Care of the lesbian or gay patient

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Overview of the evidence and guidelines regarding care of the lesbian or gay patient. Geared towards medical residents.

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  • Focusing specifically on GL population as the transgendered population is a separate discussion.
    Will freely alternate between using “gay” and “MSM” as well as between “lesbian” and “WSW.” Follow the language that your patient uses.
  • Definition from Columbia White Paper
    High end of population estimates represent the population that has ever had a same-sex sexual experience.
    “In August [Arizona’s] legislature…passed a provision containing a more narrow definition of dependents for the purposes of determining benefit eligibility for state employees. The provision, which passed the legislature over the summer as part of a budget bill, specifies that benefits will  be granted only to "a spouse, a child under the age of 19, or a child under the age of 23 who is a full-time student.“
    A similar restriction was voted down by Arizonans in the 2006 general election.
    Update: ruled as a possible contract violation by AZ Attorney General’s office so won’t take effect until October 2010 to give time for employees to have reset expectations and adequate planning.
  • Most focus on direct and specific population needs
    I add indirect to include: perception of heteronormativity of medical care, embarrassment resulting from heteronormative forms (strict gender apportionment, strict definitions of partnerships), etc.
  • Among individuals aged 18 to 59, for example, 21.8% of homosexuals and bisexuals reported that they had an unmet health care need in 2003, nearly twice the proportion of heterosexuals (12.7%).  (Canadian Health Survey)
  • …Additionally, clinicians unaware of their patients’ sexual orientation may fail accurately to diagnose, treat, or recommend appropriate preventive measures for a range of conditions. While more research is needed on the effects of communication related to sexual orientation and medical care, small surveys suggest that successful communication and ease of sexual orientation disclosure may positively affect health risks and screenings.
  • 1998 nursing students: 8-12% “despised,” 5-12% found them “disgusting,” 40-43% though they should keep their sexuality to themselves.
    The impact of heteronormativity.
    Should we, directly and through our behavior, encourage this population to “keep their sexuality to themselves.”
  • About more than just aesthetics. It’s about ensuring a lack of heteronormativity in all of the manners in which a patient population interacts with your office.
  • Sex/Gender: blank line, check box for “transgender”
    “Relationship Status” + “Partnered”
    “Parent”
    Confidentiality statement? The information covered, Who has access to the medical record, How test results remain confidential, Policy on sharing information with insurance companies, Instances when maintaining confidentiality is not possible (GLMA Guidelines)
  • This is just a sample so, obviously, this can quickly become very complicated.
  • “CHW does not discriminate on the basis of race, gender, marital status, national origin, religion or veteran status.”
  • Topics to include in a staff training program should include:
    1 Use of appropriate language when addressing or referring to patients and/or their significant others
    2 Learning how to identify and challenge any internalized discriminatory beliefs about LGBT people
    3 Basic familiarity with important LGBT health issues (e.g., impacts of homophobia, discrimination, harassment, and violence; mental health and depression; substance abuse; safe sex; partner violence; HIV/STDs)
    4 Indications and mechanisms for referral to LGBT-identified or LGBT-friendly providers
    Now that we’ve encouraged openness from our patients in an indirect, nonverbal way, it’s time to learn more about them.
  • 44% are not out to their PCP.
    This does not encompass the full spectrum of health risks to the MSM population nor would it be absolutely necessary for every MSM patient.
    Other considerations: (1) minority group stigma with the added consideration of racial/ethnic groups, (2) the effect of lower SES, (3) lack of access to health insurance and (4) homophobia and harassment.
    A 1998 analysis of data from the General Social Survey, the 1990 Census and the Yankelovich Monitor indicated that gay and lesbian people earn less than their heterosexual counterparts.5 African-American gay and bisexual men are disproportionately affected by homelessness, substance abuse, and sexually transmitted diseases, all correlated with a lower socioeconomic status.6 Native American/Alaskan gay and bisexual men are at both economic and geographical disadvantages when considering access to prevention messages.7 While A&PI communities are often stereotyped as highly educated and economically successful, one demographic profile of a major urban area found that by per capita income, APIs make 19% less than the general population and about 20% of A&Pis live in poverty.8 (Columbia White Paper)
  • Added risk factors: lack of social support, possibly higher incidence of eating disorders (increased risk for full syndrome bulimia, subclinical bulimia and any subclinical eating disorders); higher rates of smoking (rates 50% higher than the general population), alcohol and substance use.
    17% more likely than gen pop to develop anal cancer leading some to perform anal pap smears in MSM patients who engage in anal sex. The lack of treatment modalities for concerning results on a pap has lead the CDC to recommend against the practice at this time.
  • 45% are not out to their PCP. 20-30% do not have health insurance.
    Key factor: avoidance or underutilization of healthcare 2/2 past experiences or false beliefs.
    HPV can be passed between women depending upon their sexual practices (digital stimulation, sexual adjuncts). A high percentage will also have had sexual contact with a man at some point in their lives.
  • Obesity: norms in the WSW population, less internalization of mainstream ideal (as a population, however, have a better body image).
    Smoking: ~200% higher than gen pop
    High estrogen exposure: conflicting research on whether or not there is a higher rate of cancer as a result, but it is a commonly cited risk factor.
    The lower rates of recommended screening services and higher prevalence of obesity, smoking, alcohol use, and lower intake of fruit and vegetables among these women compared with heterosexual women indicate unmet needs that require effective interactions between care providers and nonheterosexual women.
  • Mammograms on age-appropriate schedule.
    Pap smear schedule may require a certain level of clinical judgment.
  • Barriers: dental dam, split open non-lubricated condom, Saran Wrap (not clinically proven).
    Lesbianlife:
    Use warm water and hand soap, antibacterial is preferred.
    Silicone dildos can be set in boiling water for two minutes or run through your dishwasher.
    Rubber dildos absorb more dirt than silicone, so you should use condoms with rubber dildos. Wash with hot water and soap between uses.
  • Homosexuality removed from DSM in 1973 and ego-dystonic homosexuality was removed in 1986.
    Higher rates of mental disorders, substance use and suicide.
    Complicated relationship between psychological constructs and sexual risk taking behavior (including ego dystonic sexuality, sensation seeking, alcohol/drug use, emotion-focused coping, hopelessness and suicidal tendencies).
    KFF:
    Three quarters (74%) of lesbians, gays and bisexuals report having been the target of verbal abuse, such as slurs or name-calling, because of their sexual orientation. Gay men (82%) and lesbians (79%) are significantly more likely to say they have been the target of verbal abuse than those who identify as bisexual (52%).
    About one third (32%) say they have been the target of physical violence, either against their person or property, because someone believed they were gay or lesbian.
  • “Social and behavioral research is beginning to explore the concept of resilience to identify strengths that may promote health and healing. Resilience involves the interaction of biological, psychological, and environmental processes. LGBT people are enmeshed in stressful situations throughout their lives.”
  • The numbers disagree as to whether there are higher rates of suicide in the gay and lesbian population. Some argue that there is a higher prevalence of suicidal ideation but a similar incidence of completed suicide.
  • Raped, physically assaulted or stalked.
    Very few studies, small numbers.
    National Institute of Justice (DOJ)/CDC, National Violence Against Women Survey. 2000
  • Several, flawed studies have demonstrated a greater-than-expected prevalence of gay men amongst males with eating disorders. They did not, however, control for important factors such as existence of depression or social stressors.
    More recently, researchers have described these theories as sexist.
  • Higher risk of exposure to violence (and more likely to need subsequent treatment). Risk for suicidality. Greater proportion of high risk behavior. ?Eating disorders?
    Gay, lesbian, bisexual, or not sure youth report a significantly increased frequency of suicide attempts. Sexual orientation has an independent association with suicide attempts for males, while for females the association of sexual orientation with suicidality may be mediated by drug use and violence/victimization behaviors.
    GLB youth who self-identify during high school report disproportionate risk for a variety of health risk and problem behaviors, including suicide, victimization, sexual risk behaviors, and multiple substance use. In addition, these youth are more likely to report engaging in multiple risk behaviors and initiating risk behaviors at an earlier age than are their peers. These findings suggest that educational efforts, prevention programs, and health services must be designed to address the unique needs of GLB youth.
  • Care of the lesbian or gay patient

    1. 1. Providing Care for the Lesbian or Gay Patient KP Edmonds, MD SJHMC Family Medicine
    2. 2. Objectives • Describe two impacts of the gay or lesbian experience on health. • Explain two ways in which a welcoming environment can be created in the office. • Demonstrate the taking of a thorough sexual history. • Describe two unique concerns in the healthcare of the gay population. • Describe the cervical cancer screening schedule for a lesbian woman. • List three risk factors for suicidality in the gay and lesbian population.
    3. 3. Starting Point • A lesbian or gay person “is one with an orientation toward people of the same gender in sexual behavior, affection, or attraction, and/or [those who] self-identify as gay/lesbian.” • 1.4-4.3% of US women • 2.8-9.1% of US men
    4. 4. Caveat “LGBT persons vary in sociodemographic characteristics such as cultural, ethnic, or racial identity; age; education; income; and place of residence. They are also diverse in the degree to which their LGBT identities are central to their self-definition, their level of affiliation with other LGBT people, and their rejection or acceptance of societal stereotypes and prejudice.” Journal of Public Health. 2001.
    5. 5. Impacts on Health • Direct stigmatization – Exposure to violence – Stress – Poor access to care • Failure to address specific population needs – STI risk – Fertility concerns • (Indirect stigmatization)
    6. 6. Impacts on Health Columbia White Paper
    7. 7. Why Should We Ask? “Disclosure of sexual orientation in the health care setting is crucial to the provision of appropriate, sensitive, and individualized care. Failure to establish rapport and communication between physicians and patients is associated with decreased levels of adherence to physician advice and treatment plans, and decreased rates of satisfaction.” GLMA Guidelines
    8. 8. Patient Mindset “I suppose I see a hospital as a sort of heterosexual kind of place.” “You fear, you’re frightened of the judgmental attitude of the doctor. You’re frightened that he might not have your best interest at heart. Better to be silent about it all, and not create waves.” Filiault, et al. 2008.
    9. 9. Creating a Welcoming Environment • Power of language – Staff – Providers – Forms • Images • Statement of nondiscrimination
    10. 10. Intake Forms • “Mr./Miss/Ms./Mrs.” • “Male/Female,” “Other” • “Marital Status” – “Married/Single” • “Mother/Father”
    11. 11. Intake Forms (con’t) • • • Legal name Name I prefer to be called (if different) Preferred pronoun?  She  He • Gender: Check as many as are appropriate       Female Male Transgender Female to Male Male to Female Other (leave space for patient to fill in) GLMA Guidelines
    12. 12. Intake Forms (con’t) • Current relationship status Single Married Domestic Partnership/Civil Union Partnered Involved with multiple partners Separated from spouse/partner Divorced/permanently separated from spouse/partner  Other (leave space for patient to fill in)        • Living situation Live alone Live with spouse or partner Live with roommate(s) Live with parents or other family members  Other (leave space for patient to fill in) GLMA Guidelines    
    13. 13. Clinic Design • Art and Posters – Inclusive images – GLBT Organizations • Brochures – Targeted to populations • Magazines • Unisex bathrooms • Nondiscrimination statement
    14. 14. Nondiscrimination Statement “This office appreciates the diversity of human beings and does not discriminate based on race, age, religion, ability, marital status, sexual orientation, sex, or gender identity." AMA Policy D-65.996 modified and reaffirmed in BOT Report 11, A-07
    15. 15. Nondiscrimination Statement “The AAFP opposes all discrimination in any form, including but not limited to, that on the basis of actual or perceived race, color, religion, gender, sexual orientation, gender identity, ethnic affiliation, health, age, disability, economic status, body habitus or national origin.” AAFP. Reaffirmend 2005.
    16. 16. The Sexual History
    17. 17. Men Who Have Sex With Men • CDC Recommendations: – Annual STI Screening • Syphilis • GC/C • HIV – Hepatitis A & B Immunization
    18. 18. MSM Care (Con’t) • The same as for any male including screening for: – – – – – – – Sexual risk Depression/anxiety Diet/exercise Heart health Intimate partner violence Cancer Substance use • Plus – Hx of Hepatitis Vaccination – Anal cancer risk (HPV-associated)
    19. 19. Women Who Have Sex With Women Your patient selfidentifies as a lesbian, does she need a pap smear? How often?
    20. 20. WSW Care (con’t) • Risk factors for disease – Higher rate of obesity – Higher rate of smoking and substance use – Lower rates of pregnancy  higher lifetime exposure to estrogen
    21. 21. WSW Care (con’t) • The same as for any woman including screening for: – – – – – Sexual risk Depression/anxiety Diet/exercise Heart health Intimate partner violence – Cancer – Substance use
    22. 22. WSW Care (con’t) • Safer sex practices – Use of dental dams or other oral-genital barrier – Latex/non-latex gloves – Care of sexual adjuncts • Not sharing • Using male condoms (and changing condom in between contact) • Washing frequently
    23. 23. Mental Health Concerns
    24. 24. Mental Health: Rates • MSM at higher risk for: – Affective disorders – Panic Attacks – Suicide • WSW at higher risk for: – Alcohol dependency – Drug dependency National Household Survey of Drug Abuse
    25. 25. Mental Health: Suicidality • Risk factors – – – – – – GLBT Orientation Victimization Hopelessness Depression Alcohol Use Close contact with suicide
    26. 26. Mental Health: Intimate Partner Violence • 15% of MSM (compared to 7.7%) • 11% of WSW (compared to 30.5%) • You have to ask! National Institute of Justice
    27. 27. Mental Health: Body Image • Traditionally: – Lesbian women thought to be protected from eating disorders or disturbed body image – Gay men thought to be more impacted by the traditionally-female Western body image problems
    28. 28. Adolescent Health: Starting Early “Are you attracted to boys, girls or both.”
    29. 29. In Summary • The process of learning about our patients starts long before we see them. • We can all probably do better with our sexual history taking. • Like in all patients, the health care that we provide to our gay and lesbian patients should be tailored based upon who they are and what they do. • Start asking the questions early.
    30. 30. References Aaron, D. J., N. Markovic, M. E. Danielson, J. A. Honnold, J. E. Janosky, and N. J. Schmidt. "Behavioral Risk Factors for Disease and Preventive Health Practices Among Lesbians." American Journal of Public health 91.6 (2001): 972-75. Print. Blake, S. M., R. Ledsky, T. Lehman, C. Goodenow, R. Sawyer, and T. Hack. "Gay and Lesbian Medical Association and LGBT health experts. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. San Francisco, CA: Gay and Lesbian Medical Association, 2001." American Journal of Public health 91.6 (2001): 940-46. Print. Cochran SD, Mays VM. Relationship between Psychiatric Syndromes and Behaviorally Defined Sexual Orientation in a Sample of the US Population. American Journal of Epidemiology. 2000;151(5):516-523. Dean et al. Lesbian, Gay, Bisexual and Transgender Health. White Paper. Center for Lesbian, Gay, Bisexual and Transgendered Health. Columbia University. 2001 Feldman, M. B., and I. H. Meyer. "Eating Disorders in Diverse Lesbian, Gay, and Bisexual Populations." International Journal of Eating Disorders 40.3 (2007): 218-26. Print. Filiault, S. M., M. J.N Drummond, and J. ASmith. "Gay men and prostate cancer: voicing the concerns of a hidden population." Journal of Men's Health 5.4 (2008): 327-32. Print. Gay and Lesbian Medical Association and LGBT health experts. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. San Francisco, CA: Gay and Lesbian Medical Association, 2001. Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients. San Francisco: Gay & Lebsian Medical Association, 2004. Print.
    31. 31. References Katz: Comprehensive Gynecology. Chapter 9 – Emotional Aspects of Gynecology: Sexual Dysfunction, Eating Disorders, Substance Abuse, Depression, Grief, Loss. Katz, VL, Lentz, GM, Lobo, RA, Gershensen, DM. Ed 5. 2007. Accessed via MDConsult on 08/22/09. Lombardi, E. "Enhancing Transgender Health Care." American Journal of Public health 91.6 (2001): 869-72. Print. Makadon, H. J. "American Journal of Public health." New England Journal of Medicine 354.9 (2006): 895-97. Print. Marrazzo, J. M., and A. Bingham. "Sexual Practices, Risk Perception and Knowledge Of Sexually Transmitted Disease Risk Among Lesbian and Bisexual Women." Perspectives on Sexual & Reproductive Health 37.1 (2005): 6-12. Print. Marrazzo, J. M., L. A. Koutsky, N. B. Kiviat, J. M. Kuypers, and K. Stine. "Papanicolaou Test Screening and Prevalence of Genital Human Papillomavirus Among Women Who Have Sex With Women." American Journal of Public health 91.6 (2001): 947-52. Print. Meyer, I. H. "Why Lesbian, Gay, Bisexual, and Transgender Public Health?" American Journal of Public health 91.6 (2001): 856-59. Print. Mravcak, S. A. "Enhancing Transgender Health Care." American Family Physician 74.2 (2006): 279-86. Print. Plumb, M. "Undercounts and Overstatements: Will the IOM Report on Lesbian Health Improve Research?" American Journal of Public health 91.6 (2001): 873-75. Print. Russell, S. T., B. T. Franz, and A. K. Driscoll. "Same-Sex Romantic Attraction and Experiences of Violence in Adolescence." American Journal of Public health 91.6 (2001): 903-06. Print. Sell, R. L., and J. B. Becker. "Sexual Orientation Data Collection and Progress Toward Healthy People 2010." American Journal of Public health 91.6 (2001): 876-82. Print.
    32. 32. Questions?

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