Carolyn Swope Halley, MD August 2006
Goal: to improve care for LGBT patients Objective: Improve understanding of the specific health risks affecting the LGBT community Objective: General understanding of the health concerns affecting a transgender person Objective: To encourage residents to be thoughtful about creating a welcoming atmosphere for LGBT patients
Is it important?
In a 2004 study of over 350 substance abuse counselors in Iowa and Chicago, counselors reported very little formal education regarding the needs LGBT clients, and nearly half had negative or ambivalent attitudes.
In a 2006 study of 248 medical students, those with increased clinical exposure to LGBT patients tended to perform more comprehensive histories, hold more positive attitudes toward LGBT patients, and possess greater knowledge of LGBT health care concerns than students with little or no clinical exposure.
Sexual Orientation Lesbian Gay WSW, MSM Bisexual Heterosexual “On the D-L” Queer
Gender Identity Transgender Transsexual Transitioning FTM/MTF Intersex Gender Identity Disorder
Barriers to Health Care
Hesitancy of health care workers to ask about sexual orientation Hesitancy of GLBT people to disclose Lack of knowledge, comfort and research regarding specific health issues Lack of insurance/partner benefits Discriminatory attitudes among health care workers
Difficulties with GLBT Research
Defining the population Measuring the size of the population Sampling a population that is both small and hidden Sampling and studying sensitive topic areas
In a 2004 pop-based study of over 40,000 Ca residents, lesbians smoked at a rate 70% higher than heterosexual women Gay men were 50% more likely to smoke than heterosexual men. Data from the 1998 WHI indicate that about twice as many lesbians as heterosexual women reported being "heavy" smokers. Almost 50% of the heterosexual women but only 2533% of lesbians reported never smoking “Project SCUM” (Sub-Culture Urban Marketing)
Early studies on alcoholism among LGBT deeply flawed In a random sample of 772 college students in the SE US, WSW were 5 times more likely to smoke, 10 times more likely to drink, and 5 times more likely to use marijuana than heterosexual women. Gay/bisexual men did not significantly differ from heterosexual men. A cross-sectional telephone survey of 2000 MSM in 4 large cities reported high levels of both recreational drug (52%) and alcohol use (85%) WHI data showed no difference in current alcohol use between lesbians and heterosexual women but a higher percentage of lesbians reported being recovering alcoholics.
Gay Men, “Tina,” and Risky Sex
Crystal meth provides increased self-esteem, increased libido, greater sexual endurance, diminished sexual inhibition, and a higher threshold for pain. Estimated that methamphetamine is 5-10 times more common in urban MSM than in the general US population About 20% of gay men in San Francisco report some meth use, as do about 15% of gay men in New York. In Chicago, nearly one in five gay men who reported using meth said they took the drug weekly. In a recent study from an LA HIV testing clinic nearly 1/3 of recent positive tests in gay men were associated with meth use. 1 in 5 MSM in Seattle who do crystal have HIV; this is 25% above HIV prevalence in MSM overall. 1 in 3 MSM who inject crystal have HIV.
According to WHI, lesbians more likely than heterosexual women to have high BMI, waist circumference, waist/hip ratio Also more likely to engage in regular exercise Higher prevalence of MI in lesbians but lower CVA & HTN
Breast Cancer Risk
Older lesbian and bisexual women have similar rates of mammogram to heterosexual women, according to WHI 2006 population based study in NY reported WSW 4 times less likely to receive mammogram Less likely to give birth by age 30 May use alcohol more Higher BMI, also higher exercise
Low parity Less OCP use Increased smoking Higher BMI No evidence either way of comparative prevalence among lesbian vs heterosexual women
Sexually Transmitted Diseases: WSW
Overall, lower risk of STD transmission In a survey of ~7000 lesbians, 77% had had 1 or more male partners
Some studies have reported that WSW may be more likely to have had unprotected IC, gay/bi male partners, and sexual contact with IDU Lesbians are less likely than bisexual or heterosexual women to be tested for STD
Sexually Transmitted Diseases: WSW
Proven transmission: herpes, HPV, trichomoniasis, Case reports: HIV, Hep B Not studied, but theoretically possible: CT/GC, syphillis Special case: BV
Cervical Cancer Risk
In a 2006 population based study in NY, WSW were ten times less likely than nonWSW to have received a timely Pap test In one study, women who reported that their health care providers were more knowledgeable and sensitive to lesbians issues were significantly more likely to have had a Pap test within the last year More likely to smoke
STD - MSM
42% of new HIV cases in MSM in US, even higher percentage in King County Re-emergent STD (syphillis, GC, CT) since 2000 in multiple cities in US In a 2000 King County study of nearly 1000 MSM, 43% of those who had anal sex reported either "never" or only "sometimes" using condoms. Among MSM surveyed at STD clinics, rectal GC or CT was found in 10.8% of HIV- and 14.7% of HIV+ men. Evidence of MSM making unprotected sex contacts on internet; prevention campaigns in chat rooms also successful.
Risks for anal cancer include anal IC and infection with multiple strains of HPV. HIV+ gay men are at significantly greater risk for anal dysplastic lesions than HIVgay men. Moreover, the risk for detection and progression of dysplastic lesions grows as the CD4+ cell count declines. ASIL risk may not decline with immune restoration with HAART
Until 1973 homosexuality was classified as a mental disorder “The research on homosexuality is very clear. Homosexuality is neither mental illness nor moral depravity. It is simply the way a minority of our population expresses human love and sexuality. Studies of judgment, stability, reliability, and social and vocational adaptiveness all show that gay men and lesbians function every bit as well as heterosexuals.” -- American Psychological Association
In the WHI study, WSW had QOL and emotional well-being scores similar to heterosexual women. In a NZ study of 946 people, men and women with same sex attraction reported significantly more suicidal ideation and selfharm. Men with same-sex attraction were also significantly more likely to report having attempted suicide. LGBT people have unique stressors: prejudice, stimatization, antigay violence
Intimate Partner Violence (IPV)
In a 2000 survey of over 8000 women, more than 11% of those in same-sex relationships reported having been raped, assaulted or stalked by a female partner (21% for hets) Fewer services Increased isolation Concern for police harrassment Protecting the community Myths -- “Women aren’t violent” Additional threats– to “out” the victim, to take children, to deport
American Psychological Association has determined that victims of hate crimes suffer the PTSD symptoms for up to five years, in comparison to two years for victims of non-bias-related crimes. Survivors of hate crimes are less likely than victims of other types of violence to report attacks against them to the police. Estimated that up to 80% of bias-crimes are never reported to the authorities
Transgender Health Concerns
Understanding of transgender health barriers Care of the initial anatomical sex Care of anatomical changes
Resulting from hormone therapy (HT) Resulting from surgery
Harry Benjamin International Gender Dysphoria Association (HBIGDA)
Standards of Care for Hormone Initiation
Able to give informed consent Informed of anticipated effects and risks Completion of either 3 months “RLE” or psychotherapy for duration specified by assessor (usually min 3 months)
Same for breast/chest surgery Standards of Care for genital/lower surgery
At least 1 yr RLE
Effects of Testosterone on FTM
a permanent deepening of the voice decreased fertility--menstrual cycles becomes irregular and eventually stop permanent clitoral enlargement mild breast atrophy (but not substantial reduction in size) increased upper body strength with exercise Facial hair growth male-pattern baldness increased sexual interest and arousal redistribution of fat from hip toward waist Development of acne, similar to male puberty
Side Effects of Testosterone
acne increased emotional sensitivity and/or instability shift of lipid profiles to male patterns which increase cholesterol and the risk of cardiovascular disease the potential to develop benign and malignant liver tumors and liver dysfunction
Effects of Estrogen on MTF
breast growth some redistribution of body fat to approximate a female body shape decreased upper body strength softening of skin decrease in body hair slowing or stopping the loss of scalp hair decreased fertility and testicular size less frequent, less firm erections
Side Effects of Estrogen
increased propensity to blood clotting (venous thrombosis with a risk of fatal pulmonary embolism) development of benign pituitary tumors infertility weight gain increased emotional sensitivity and/or instability liver disease
Sexual Reassignment Surgery: FTM
“Top Surgery”: Chest reconstruction “Bottom Surgery”: Metoidioplasty, Phalloplasty
Sexual Reassignment Surgery: MTF
Top Surgery: breast enlargement Bottom Surgery: bilateral orchiectomy, vaginoplasty Other: Tracheal shave, rounding of brow, chin surgery, jaw surgery
Encompases a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t fit the typical definitions of female or male. ISNA
Intersexuality is primarily a problem of stigma and trauma, not gender. The child is the patient, not the parents. Professional mental health care is essential. Honest, complete disclosure is good medicine. All children should be assigned as male or female, without surgery.
In most states, hospital visitation, notification, durable POA, and parental rights for nonbiological partners are not automatically granted to same-sex couples without legal action. Gay and lesbian people may be less linked to their families of origin, but often have larger social networks (“fictive kin”) Partners and friends of GLBT people have pointed time and again to the lack of rights/recognition given them in relation to visiting, decision making, and caregiving for their loved one
Developing a Welcoming Practice
Create GLBT inclusive intake and assessment Post non-discrimination policies & GLBTwelcoming posters. Have gay-targeted reading material in waiting room Become familiar with appropriate GLBT community referrals Actively reassure GLBT patients about confidentiality Encourage visibility of GLBT employees
Developing a Welcoming Practice
Talk to GLBT patients about medicolegal issues. Give friends and partners of GLBT patients privileges usually given to spouse or relative. Realize transgendered people may be particularly sensitive about disrobing. Ask trans patients which surgeries, if any, they have undergone and do screening appropriate to birth gender as well as trans-gender. Ensure GLBT employees have same benefits as other employees Ensure all staff are culturally competent
MSM & WSW have higher rates of smoking cigarettes, and probably of alcohol use WSW need PAP screening, and may not know they do Bacterial STD may be less frequent than among heterosexual women, but do exist WSW may have more risk factors for breast and ovarian cancers than heterosexual women
Unprotected sex and STD rates are increasing among urban gay men Crystal meth is widely used among MSM, and it is strongly associated with risky sex and HIV IPV occurs in the LGBT community (though less frequently than among heterosexuals) Seattle is an international center for transgendered people, and you may have them in your practice now and in the future
Provider factors including visibly welcoming atmosphere and inquiring about sexual orientation are strongly associated with disclosure among GLBT patients Disclosure is associated with regular health care use.
Seattle Counseling Services- mental health care for GLBT people Northwest Network – support for GLBT survivors of intimate partner violence Ingersoll Gender Center – support and advocacy for transgendered people Lambert House – GLBT youth center Capitol Hill Alano Club – gay 12-step groups Public Health– Seattle & King County. http://metrokc.gov/health/glbt/providers
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