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
Providing Care for the Lesbian
or Gay Patient
KP Edmonds, MD
SJHMC Family Medicine
• 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
• List three risk factors for suicidality in the gay and
• 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
• 1.4-4.3% of US women
• 2.8-9.1% of US men
“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.
Impacts on Health
• Direct stigmatization
– Exposure to violence
– Poor access to care
• Failure to address
– STI risk
– Fertility concerns
• (Indirect stigmatization)
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
“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.
Creating a Welcoming Environment
• Power of language
• Statement of nondiscrimination
Intake Forms (con’t)
Name I prefer to be called (if
Gender: Check as many as are
Female to Male
Male to Female
Other (leave space for patient to fill in)
Intake Forms (con’t)
• Current relationship status
Domestic Partnership/Civil Union
Involved with multiple partners
Separated from spouse/partner
Other (leave space for patient to fill
• Living situation
Live with spouse or partner
Live with roommate(s)
Live with parents or other family
Other (leave space for patient to fill
• Art and Posters
– Inclusive images
– GLBT Organizations
– Targeted to populations
• Unisex bathrooms
“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
“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
AAFP. Reaffirmend 2005.
Men Who Have Sex With Men
• CDC Recommendations:
– Annual STI Screening
– Hepatitis A & B
MSM Care (Con’t)
• The same as for any male
including screening for:
Intimate partner violence
– Hx of Hepatitis Vaccination
– Anal cancer risk (HPV-associated)
Women Who Have Sex With Women
Your patient selfidentifies as a lesbian,
does she need a pap
smear? How often?
WSW Care (con’t)
• Risk factors for disease
– Higher rate of obesity
– Higher rate of smoking
and substance use
– Lower rates of
lifetime exposure to
WSW Care (con’t)
• The same as for any
– Substance use
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
• Washing frequently
Mental Health: Rates
• MSM at higher risk for:
– Affective disorders
– Panic Attacks
• WSW at higher risk for:
– Alcohol dependency
– Drug dependency
National Household Survey of Drug Abuse
Mental Health: Suicidality
• Risk factors
Close contact with
Mental Health: Intimate Partner
• 15% of MSM (compared
• 11% of WSW (compared
• You have to ask!
National Institute of Justice
Mental Health: Body Image
– Lesbian women thought to
be protected from eating
disorders or disturbed
– Gay men thought to be
more impacted by the
Western body image
Adolescent Health: Starting Early
“Are you attracted to
boys, girls or both.”
• 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.
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and Transgender (LGBT) Health. San Francisco, CA: Gay and Lesbian Medical Association, 2001.
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Abuse, Depression, Grief, Loss. Katz, VL, Lentz, GM, Lobo, RA, Gershensen, DM. Ed 5. 2007. Accessed via MDConsult on 08/22/09.
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