Best Practices in LGBT Primary Care

1. Best Practices in LGBT Primary Care Marvin Alviso, MD May 17, 2019

2. Disclosure • I have no conflicts of interest or relationships to disclose

3. 32 y/o female for her first well woman exam at the request of her insurance

4. 32 y/o female, identifies as a lesbian for her first well woman exam at the request of her insurance.

5. Objectives • Define LGBT terminologies including gender, sex and sexual orientation • Identify unique primary health care needs of the LGBT population • Provide recommendations in creating a welcoming environment for the LGBT

6. LGBT TERMINOLOGIES

7. LGBT Population The percentage of LGBT adults increased from 3.5% in 2016 to 4.5% in 2017 ( 11 Million ) Rise in LGBT identification mostly among millennials 5.1% of women identify as LGBT vs 2.9% of men LGBT identification is lower among older individuals https://content.gallup.com/origin/gallupinc/GallupSpaces/Production/Cms/POLL/on1561nppeqws12bwzqaia.jpg

8. SEX ≠ GENDER IDENTITY ≠ SEXUAL ORIENTATION

10. LGBTQQIA – Lesbians Gay Bisexual and Transgender, Queer, Questioning, Intersex & Asexual • MSM – Men who have sex with men • WSW – Women who have sex with women • Transgender female – assigned male at birth who identifies as a female ( transwoman ) • Transgender male – assigned female at birth who identifies as a man ( transman ) • Same Gender Loving ( SGL ) – an alternative term for gay and lesbian, almost exclusively used in African American communities

11. ADDRESSING THE HEALTH NEEDS OF LGBT PATIENTS

12. STEP 1: Screen for Mental Health Disorders • Homosexuality was removed as mental illness in 1973 ( DSM III) • LGBTQ individuals are almost 3x more likely than others to experience a mental health condition such as major depression or generalized anxiety disorder. 

13. STEP 1: Screen for Mental Health Disorders • LGBQ adults have a two-fold excess risk of suicide attempts compared to other adults. • Among transgender adults, the lifetime prevalence of suicide attempts is 40%. • Suicide risk in LGBTQ people is thought to be highest during the teen years and early 20s. • In 2015, more than 4.5 times as many LGB-identified high school students reported attempting suicide in the past 12 months compared to non-LGB students (29.4% vs 6.4%)

14. STEP 1: Screen for Mental Health Disorders • Coming out – process by which an LGBT person accepts and discloses his or her sexual orientation or gender identity • Dual Stigma – Having a psychiatric diagnosis while also being gay. • It is imperative to routinely screen LGBT patients for anxiety, depression and suicidality

15. STEP 2: Assess for Substance Abuse • The odds of lifetime alcohol and substance use disorder was three times higher in lesbian women • The odds of lifetime drug use disorder was 1.6 times higher in gay men • Lesbian and bisexual women have higher rates of tobacco abuse, exposure to second hand smoke and alcohol and drug dependence

16. STEP 2: Assess for Substance Abuse • National surveys show that 23.9 – 38.5% of LGBT individuals smoke compared to 16.6 -25.3% of heterosexual respondents • For a subpopulation of MSM, recreational drug use is common. One survey found high rates of marijuana, inhaled alkyl nitrates, cocaine, ecstasy and amphetamine use • For unclear reasons, abuse is highest among bisexual

17. STEP 2: Assess for Substance Abuse • In a survey of transgender people, 30% reported using tobacco compared with 20% of the US adult population • 8% reported using alcohol and drugs to cope with mistreatment and bias

18. STEP 3: Offer appropriate screening services HUMAN PAPILLOMA VIRUS ( HPV) • Cervical cancer screening and HPV vaccination should be offered according to established guidelines regardless of woman’s sexual orientation or practices OTHER SEXUALLY TRANSMITTED INFECTIONS • Transmission between women has been reported for trichomonas, HIV, HPV, HSV, Hep C, syphilis, chlamydia and BV BREAST CANCER SCREENING

19. STEP 3: Offer appropriate screening services ANAL HPV • Routine screening for anal HPV is not currently recommended because we lack data demonstrating that screening reduces mortality rates from anal carcinoma SCREENING IN MSM • MSM are at increased risk for several sexually transmitted infections including HIV, syphilis, gonorrhea, chlamydia, anal HPV, and hepatitis B & C

20. Gonorrhea and Chlamydia https://www.cdc.gov/std/stats17/figures/13.htm https://www.cdc.gov/std/stats17/figures/27.htm

21. Syphilis and HIV https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics https://www.cdc.gov/std/stats17/figures/48.htm

22. STEP 3: Offer appropriate screening services • SCREEN WHAT YOU HAVE is an easy rule to help both patients and providers remember which services to consider • Transgender men still need breast cancer screening and cervical cancer screening • Transgender women breast cancer recommendation is 50 + 5 years or more on HRT

23. STEP 4: Immunize and Promote Healthy Behaviors VACCINATIONS • LGBT individuals should be routinely offered HPV vaccination. ( Age 9-45 ) • Immunizations against Hepatitis A and B is also recommended for men who have sex with men.

24. STEP 4: Immunize and Promote Healthy Behaviors • Meningococcal vaccine should be given to MSM if they have an additional medical, occupational or lifestyle risk factor

25. STEP 4: Immunize and Promote Healthy Behaviors PHYSICAL ACTIVITY • Should be encouraged especially in lesbian and bisexual women who are more likely to be overweight and obese • LGBT youths reported 1.21 to 2.62 fewer hours of moderate or vigorous physical activity per week than their non-LGBT counterparts • And were 46-76% less likely to participate in team sports

26. STEP 4: Immunize and Promote Healthy Behaviors PREEXPOSURE PROPHYLAXIS AGAINST HIV (PrEP)

27. PrEP • PrEP, or pre-exposure prophylaxis, is daily medicine that can reduce your chance of getting HIV.

28. PrEP • Daily PrEP reduces the risk of getting HIV from sex by more than 90%. Among people who inject drugs, it reduces the risk by more than 70%. • The risk of getting HIV from sex can be even lower if you combine PrEP with condoms and other prevention methods. • It takes 21 days to have protective levels in the vagina and blood and 7 days to have protective levels in the rectal area.

29. STEP 4: Immunize and Promote Healthy Behaviors www.prepmeidaho.com

30. STEP 5: Initiate or continue hormone therapy for transgender individuals • Hormone therapy often improves the quality of life for patients who desire to have their physical appearance align more closely with their gender identity. • Moreover, abruptly stopping hormone therapy can have significant psychological consequences

31. Gender Dysphoria A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following • A marked incongruence between one’s experienced gender and primary and/or secondary sex characteristics • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of marked incongruence with one’s experience/expressed gender • A strong desire for the primary/secondary sex characteristics of the other gender

32. A strong desire to be of the other gender • A strong desire to be treated as the other gender • A strong conviction that one has the typical feelings and reactions of the other gender B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify if with disorder of sex development Specify if Post transition

33. Gender Affirming Care • Medical • Surgical The two main principles of hormone therapy • Reduce endogenous hormone levels and their associated sex characteristics • Replace with hormones of the preferred sex

34. Criteria for Hormone Therapy • Persistent, well documented dysphoria • Capacity to make a fully informed decision and to consent for treatment • Age of majority in a given country • If significant medical or mental health concerns are present, they must be reasonably well-controlled

35. Feminizing Hormone

36. Masculinizing Hormone

37. Goals of therapy Transgender female Estradiol 100-200 pg/mL Testosterone < 55 ng/dL Transgender man Testosterone 320 -1000 ng /dL ( 450 ng/dL )

38. STEP 6: Screen for intimate partner violence • IPV refers to physical, sexual, and psychological harm by a current, or former partner or spouse. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Intimate-Partner-Violence-and-Sexual-Abuse-among-LGBT-People.pdf

39. STEP 6: Screen for intimate partner violence • IPV is uniquely challenging for LGBT people. Forced disclosure ”outing”, may result in additional psychological violence and harm. • Judicial system may not understand dynamics of same-sex domestic violence, may discount it altogether. • Female survivors may find that their same sex abusers have the same access to resources and shelters that they do

40. STEP 6: Screen for intimate partner violence • Police are 10-15x as likely to make a dual arrest in cases of same-sex domestic/intimate partner violence than in heterosexual ones (NCAVP, 2009). • Judges are more likely to issue mutual restraining orders to same-sex partners • LGBT individuals who experience abuse may have difficulty finding a safe shelter. 61.6% of survivors who sought shelter were denied access. (NCAVP, 2011).

41. CREATING A WELCOMING ENVIRONMENT FOR LGBT PATIENTS

42. Creating a welcoming environment • The first step is to create an environment inclusive of LGBT people. • LGBT patients often scan an office for clues to help them determine what information they feel comfortable sharing with their health care provider

43. Establish gender neutral bathrooms and avoid restroom signage that specifically designates one gender to another • Waiting room reading materials and bulletin boards should include materials of interest to the LGBT community

44. Create initial patient intake forms that collect information on the patient’s preferred name, pronoun, gender identity, sex assigned at birth, partner and other family members

46. 32 y/o female, identifies as a lesbian for her first well woman exam at the request of her insurance.

47. Suggested questions for obtaining sexual history • Are you sexually active ? • With whom do you have sex, men, women or both? • What parts of your body do you use when you have sex with your partner(s) ? • Do you practice safer sex? With primary partners? With casual partners? • How do your partners identify their gender or sexual orientation

48. In Summary • There are no LGBT specific disease. • While LGBT individuals are at increased risk for mental and substance abuse disorders, certain health conditions vary by group • Lesbian and bisexual women are at increased risk for overweight, obesity, tobacco use, drug and alcohol disorders • Annual screening for HIV, syphilis, chlamydia, and gonorrhea should be offered to MSM • Screen what you have is a rule that can help physicians to consider appropriate screening services

49. References Guidelines-and-Protocols-for-Comprehensive-Primary-Care-for-Trans-Clients-2015.pdf http://sherbourne.on.ca/wp-content/uploads/2014/02/Guidelines-and-Protocols-for- Comprehensive-Primary-Care-for-Trans-Clients-2015.pdf Makadon et al. Fenway Guide to Lesbian, Gay, Bisexual, And Transgender Health. 2nd. Edition American College of Physicians, Philadelphia, 2015 Mcnamara MC, Ng H. Best practices in LGBT care: A guide for primary care physicians. Cleve Clin J Med. 2016;83(7):531-41. NIDA. (2017, September 5). Substance Use and SUDs in LGBT Populations. Retrieved from https://www.drugabuse.gov/related-topics/substance-use-suds-in-lgbt-populations on 2019, April 27

50. https://www.mentalhelp.net/mental-health-in-the-lgbt-community/https://www.mentalhelp.net/mental-health-in-the-lgbt-community/ https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx https://www.nami.org/NAMI/media/NAMI-Media/Infographics/MulticulturalMHFacts10-23-15.pdf https://www.mdedge.com/ccjm/article/109822/adolescent-medicine/best-practices-lgbt-care-guide-primary-care-physicians https://assets2.hrc.org/files/assets/resources/HEI-2018-FinalReport.pdf?_ga=2.229793050.749782844.1555796885-893070247.1555796885 https://www.lgbthealtheducation.org/wp-content/uploads/Screening-for-IPV-in-Primary-Care-Webinar.pdf