Build your knowledge base to improve primary care for LGBT patients! This episode is chock full of clinical pearls and updates for LGBT health from SGIM presenters, Dr. Jenny Siegel (Boston University) and Dr. Megan McNamara (Louis Stokes Cleveland VAMC). They define common gender identity terms and provide tips on how to take a sexual history. You’ll develop an approach to the unique clinical concerns of LGBT patients and learn how to phrase medical information in a gender neutral framework. This is a must listen episode for all health care providers!
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Validate patients for engaging in healthcare and try to create a welcoming environment by providing staff education on gender identity terms. Adding visual welcome signs such as rainbow stickers on badges or pins can signal your practice is welcoming to LGBT patients.
Obtain a sexual history: First ask permission before proceeding then follow the CDC’s “5 P’s” of sexual health. Ask who are your partners, with what body parts are you sexually active, assess pregnancy risk, ask about past sexually transmitted infections, and finally assess protection used.
Practice using appropriate gender identity terminology by getting in the habit of asking patients “How would you like to be addressed?”.
Mental Health: screen for anxiety, depression, intimate partner violence, and other types of violence. Ask about prior suicide attempts because the prevalence of suicidality is higher in this population.
Approach to cancer screening: “Screen what you have”. Try to screen in sensitive ways and use gender neutral language as much as possible.
Transgender health tips: To open the conversation for history taking try using phrases such as “What are you hoping for medically?” and “Tell me about who you are?” as starting points.
Vaccines: Remember 4 additional vaccines – Hep A, Hep B, HPV and meningococcal. For MSM remember – Hepatitis, HPV up to age of 26, and meningococcal in high-risk groups. For WSW, don’t forget to offer the HPV vaccine!
There are higher rates of DVT in trans women who take estrogen therapy (Nota et al, Getahun, et al). Make sure to counsel patients on smoking cessation to decrease their risk of DVT for those initiating or currently on hormone therapy.
Before we dive in, let’s define common terms. Sex is a biological distinction (ie male vs female) based on natal genitals or chromosomes. Gender identity is how an individual perceives themselves. Sexual orientation is whom an individual desires and is attracted to. Sexual behavior asks the patient how do they practice – for example men who have sex with men. Sexual identity is the “L, G, B” (lesbian, gay, bisexual).
Transgender is discordance between natal sex and gender identity. Cisgender is concordance between natal sex and gender identity. Gender nonbinary (or other terms like gender queer, gender nonconforming) are people who reject choosing the binary construct of gender. A transgender man or transman is a person assigned female at birth who identifies as a man. Transmasculine is term for a person assigned female at birth who doesn’t necessarily use the gender binary and identifies themselves as more masculine than feminine. Similarly, transgender woman and transfeminine are other terms used.
Practice using the terminology and consider opening with “How would you like to be addressed?”. Don’t avoid these terms out of nervousness of making a mistake. Make good efforts to train yourself and staff on using appropriate terminology and how to use your electronic records to reflect information (ie preferred names and gender). An office or individual can show visible support with rainbow pins and stickers on badges or within their office.
The LGBT population has a shared history of marginalization, but remember there is significant intergroup variation in these populations. For example gay men have a greater risk of sexually transmitted infections than lesbian women, but gay men higher rates of having a primary care provider in comparison (Lunn MR, et al – PCP,. CDC Stats – MSM). Transgender patients have a greater risk of psychosocial distress than the other groups (James S.E. et a l- psychosocial distress).
A tip to build patient rapport – ask permission before starting to ask about their sexual history. If the patient agrees to proceed follow the “Five P’s” of sexual health, recommended per CDC.
Expert Tips: Be careful to not make assumptions about a patient’s partner and keep things worded in a positive framework – we are here to help keep sex happy and healthy!
It’s important to screen for anxiety, depression, intimate partner violence, and other types of violence during primary care visits. For depression and suicidality screen with a PHQ-2 or PHQ-9. Ask about prior suicide attempts, because the prevalence of suicidality is high, particularly within the transgender population (Toomey 2018).
“Screen what you have” – Try to screen in sensitive ways. Sometimes we use very gendered language. Consider asking your patient how they want their natal anatomy referred to. Instead of using the term “woman’s exam” when working with a transmasculine patient, try using non-gendered language such as “You told me you have these parts, we will have to discuss the pros/cons of screening these organs.”
Consider using an organ inventory to not forget routine screening. For example a transmasculine person who has had chest reconstruction is not the same as having had a mastectomy, and there’s often residual breast tissue left behind. How you manage this is an evidence-free zone and requires a patient centered decision making conversation.
Mind the disparities – Lesbian women decrease rates of cervical cancer screening and mammography, decreased uptake of the HPV vaccine. (Tracy 2013 – cervical cancer; Bazzi 2015 – mammography, Agénor 2015 – HPV vaccine).
Transgender Health Tips
Ask “What are you hoping for medically” to open the conversation. Remember that not all transgender patients want to transition, and they may choose to express themself yet want no medical intervention. Do not assume that someone would want medications or surgery.
Say “Tell me about who you are.”
Use this as wording to help unravel the gender story. If it does not come up, consider asking, “I’m going to ask you some specific gender questions. Have you had any type of surgery that is gender affirming to you, if so what types of surgery have you had?”
Remember 4 additional vaccines! Hepatitis A, Hepatitis B, HPV and meningococcal.
For MSM (men who have sex with men)- remember to vaccinate for hepatitis A, hepatitis B, and HPV up to the age of 26. Remember conjugate meningococcal in high risk groups (HIV positive, living in close quarters, and during disease outbreaks —CDC guidelines – 2019. For WSW (women who have sex with women) don’t forget to vaccinate for HPV as this population has had decreased uptake of the HPV vaccine (Agénor 2015 – HPV vaccine)
Be sure to ask about pregnancy risk and patient assumptions. For example, transmen patients taking testosterone may not have periods… this is not contraception.
Studies suggest that there are higher rates of venous thromboembolism (VTE) in transwomen who take estrogen (Nota 2019, Getahun 2018). Make sure to discuss lifestyle changes that can mitigate risk such as smoking cessation.
For natal women on estrogen therapy, typically if a VTE occurs, it happens early in the course of treatment within the first year (Høibraaten 1999). In contrast, a study with transfeminine patients suggest that the risks of VTE persists and can increase with time. These studies show we shouldn’t be extrapolating data from natal woman to trans care. The preparations are different, the people are different (Getahun 2018).
Expert opinion: Rarely is this a scenario of absolute contraindication to continue therapy. It does require shared decision making with the patient and a discussion on other ways to mitigate risk future DVT risks…such as smoking cessation.
We know PrEP works for the prevention of HIV. Liu et. al asked the question why don’t we see more people use it? The study looked at 3 clinics and provided patients PrEP for free for 38 weeks. They found that adherence was high, 80% – 86% of patients had detectable levels of tenofovir in their bloodstream. Some populations were less likely to be adherent such as those with unstable housing and African Americans. Importantly, individuals who identified as having high risk sexual behavior were more likely to be adherent. This study suggests that interventions that address housing instability or racial disparities may increase adherence to PrEP.
Raifman 2018 looked at the impact of discriminatory state laws on those in the sexual minority. They compared states with discriminatory laws (e.g. restricted adoption, marriage license refusal) and matched them to control states. Living in states with discriminatory laws was associated with a 46% increase in mental distress among sexual minorities. Discriminatory laws impact LGBT health and are an opportunity for advocacy.
Internists can provide transgender care within their primary care practice. For those looking for a place to get started our guests provide resource recommendations. Learning how to provide care for the LGBT population is an opportunity to engage in a positive care environment with our patients!
Listeners will develop an approach to caring for LGBT patients in the primary care setting.
After listening to this episode listeners will…
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Hi Curbsiders! I'm Timmy Gocke, an Internal medicine doc for the army working in South Korea. I love your program!!! Its been a wonderful way to stay updates and current and review lots of topics that I normally don't get to see in my practice. Just listened to the LGBT episode yesterday... and today I saw a transgender female in the army. I didn't panic, I wasn't scared, because of your awesome program. Please keep up the good work!! Timmy
Hi Timmy, thanks for the great feedback- we love to hear how episodes resonate/benefit our listeners in real life...we appreciate your support of the show!
Hi Curbsiders, Thank you for your contribution to my education and competency. Your passion, expertise, and willingness to be vulnerable in asking questions is inspiring and sets a great example of how medicine should be learned and taught. Concerning this episode, I am thankful for the recommendations on immunizations, appropriate language, and cancer screenings. However, I am distraught over the inconsistencies with this episode from the majority of the other episodes. My goal in medicine is to do no harm and try to prevent, through education and resource providing, my patients from doing harm to themselves and from adverse health outcomes. Unfortunately, this episode fails to talk about the elephant in the room being hormone therapy is detrimental to the physical health of the transgender patient. In the ESG (Endocrine Society Guidelines) for hormonal treatment of gender dysphoria, it states, "They require a safe and effective hormone regimen." The mere initiation of a hormone regimen violates this principle. In medicine, why do we tell patients with anorexia nervosa that it is unhealthy and address the delusion in a healthy manner and not do the same for gender dysphoria? This would be analogous to telling a patient with anorexia nervosa that he/she is fat and encouraging he/she to continue a restriction diet that would ultimately lead to death. Sincerely, Blake Cover