#155 LGBT Health in Primary Care

June 17, 2019 | By Carolyn Chan

LGBTQ Care with Doctors Megan McNamara and Jenny Siegel

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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Credits

• Written and Produced by: Carolyn Chan MD
• Infographics: Hannah Abrams
• Cover Image: Matthew Watto MD
• Hosts: Carolyn Chan MD, Paul Williams MD, Matthew Watto MD
• Guest: Megan McNamara MD, Jenny Siegel MD
• Editors: Emi Okamoto MD, Matthew Watto MD

Sponsor

This episodes was recorded LIVE at #SGIM19 in Washington DC! Join the Society for General Internal Medicine today!

Time Stamps

• 00:00 Intro, disclaimer, guest bios
• 02:45 Guest one-liners, movie recommendations; favorite failures; Paul’s pick of the week
• 10:52 Defining terms of gender identity
• 14:20 What to do when you misgender someone or use the wrong term
• 17:10 Is it a mistake to think of the entire LGBT group as the same?
• 19:19 How to take a sexual history, the 5Ps
• 22:00 Unique clinical concerns of LGBT patients; what screening should be performed
• 24:20 Avoid focusing too much on sexuality and gender identity. Don’t forget to address their medical concerns
• 24:42 Screening for mental health disorders and asking about suicide
• 27:16 Cancer screening in transgender patients; a bit on transgener terminology; how to take an anatomy inventory
• 34:18 Vaccinations
• 37:05 Contraception considerations and VTE risk with hormonal therapy
• 41:40 Pre-exposure prophylaxis and risk of STIs
• 43:30 Impact of discriminatory state laws on LGBT mental health
• 47:32 Plugs: Fenway Health; UCSF trans health website; Guidelines from the Endocrine Society
• 49:35 Closing remarks
• 51:05 Outro

LGBT Health – Pearls for Primary Care

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.

Gender Identity Terms

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.

How do I approach these terms? What if I use the wrong term?

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 is often grouped together, is there a more nuanced approach to thinking about this diverse population?

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).  

Sexual History

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.

1. Partners
2. Parts or Practices – What body parts do you interact with?
3. Pregnancy risk
4. Past sexually transmitted infections
5. Protection

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!

Unique Clinical Concerns in LGBT health

Mental Health

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).

Cancer Screening

“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?”

LGBT Vaccine Pearls

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)

Don’t forget contraception!

Be sure to ask about pregnancy risk and patient assumptions. For example, transmen patients taking testosterone may not have periods… this is not contraception.

SGIM LGBT Health Updates

Cross-sex hormone therapy in transgender patients – VTE risk

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).   

Should we stop hormone therapy if a DVT occurs?

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.

Pre-Exposure Prophylaxis

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.

Health Policy

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.

LGBT Health – Take Home Points

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!

1. Fenway Health provides free online educational modules for LGBT health education.
2. USCF center of excellence on transgender health provides an easy to read resource for those getting started.
3. Endocrine Society Guidelines – Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline
4. World Professional Association for Transgender Health (WPATH) Guidelines

Goals and Learning Objectives

Goal

Listeners will develop an approach to caring for LGBT patients in the primary care setting.

Learning objectives

After listening to this episode listeners will…

1. Define the following gender identity terms: sex, cisgender, gender identity, genderqueer, sexual orientation, transgender, transsexual.
2. Obtain a thorough sexual history.
3. Describe an approach to address unique clinical concerns of adult LGBT patients.
4. Describe preventative care for sexual minority and transgender individuals.
5. Discuss recent evidence based updates and controversies within LGBT healthcare.

Links

Links from the show are included above.

1. The Instant Pot
2. Spartan Races
3. Meg’s movie pick:  Avengers: End Game
4. Jenny’s book pick: Less by Andrew Sean Greer
5. Paul’s movie pick: Climax
6. Carolyn’s pick of the week: Games of Thrones
7. CDC’s “5 P’s” of sexual health
8. Lunn MR, et al Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators. LGBT health. 2017. [https://www.ncbi.nlm.nih.gov/pubmed/28727950]
9. CDC Sexually Transmitted Disease Surveillance 2017 – MSM.  2017. [https://www.cdc.gov/std/stats17/msm.htm}
10. James, S. E.,et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality [https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf]
11. Toomey, RB., et al.  Transgender Adolescent Suicide Behavior. Pediatrics. 2018 [https://www.ncbi.nlm.nih.gov/pubmed/30206149]
12. Tracy JK, et al. Understanding cervical cancer screening among lesbians: a national survey. BMC Public Health. 2013 [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3693978/}
13. Bazzi AR, et al. Adherence to Mammography Screening Guidelines Among Transgender Persons and Sexual Minority Women. Am. J Public Health. 2015. [https://www.ncbi.nlm.nih.gov/pubmed/26378843]
14. Agénor M,, et at al. Sexual Orientation Identity Disparities in Awareness and Initiation of the Human Papillomavirus Vaccine Among U.S. Women and Girls: A National Survey. Ann Internal Med. 2015. [https://www.ncbi.nlm.nih.gov/pubmed/25961737]
15. CDC Adult Vaccine Guidelines, 2019. [https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html]
16. Streed CJ et. al Cardiovascular Disease Among Transgender Adults Receiving Hormone Therapy: A Narrative Review. Ann Intern Med. 2017 [https://www.ncbi.nlm.nih.gov/pubmed/28738421]
17. Nota NM, et al. Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy. Circulation. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/30776252]
18. Getahun D, et al. Cross-sex Hormone and Acute Cardiovascular Events in Transgender Persons: A Cohort study. Ann Intern Med. 2018 [https://www.ncbi.nlm.nih.gov/pubmed/29987313]
19. Høibraaten E. Hormone replacement therapy with estradiol and risk of venous thromboembolism–a population-based case-control study. Thrombosis and Haemostasis.1999. [https://www.ncbi.nlm.nih.gov/pubmed/10544901]
20. Alzaharani T., et al. Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circulation. 2019 [https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.119.005597]
21. Raifman J, et al. Association of State Laws Permitting Denial of Services to Same-Sex Couples WitH Mental Distress in Sexual Minority Adults:  Difference-in-Difference-in-Differences Analysis.Jama Psychiatry. 2019 [https://www.ncbi.nlm.nih.gov/pubmed/29799924]
22. Liu AY, et al. Preexposure Prophylaxis for HIV Infection Integrated with Municipal- and Community-Based Sexual Health Services. JAMA Intern Med. 2017 [https://www.ncbi.nlm.nih.gov/pubmed/26571482]
23. Resources; Fenway Health: https://fenwayhealth.org/the-fenway-institute/education/the-national-lgbt-health-education-center/
24. UCSF trans health: http://transhealth.ucsf.edu/protocols
25. GUIDELINE – Coleman E. et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th edition. 2012 [https://www.wpath.org/]
26. GUIDELINE – Hembree W. et al.  Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. Endo Prac. 2017 [https://www.ncbi.nlm.nih.gov/pubmed/29320642]