1. LGBT Health for Third Year Students 6/24/12 Catherine Fahey

2. Goals of this talk Reminder of LGBT terminology Introduction to concepts for the wards Primary Care recommendations Legal information Welcoming Clinical Environment

3. What are gender and sexuality? Gender. Sexuality. Identity Behavior Expression Identity Biology Attraction

4. LGBT Health Being gay or lesbian is not genetically or biologically hazardous Stigmatization and marginalization, regardless of whether an individual identifies as lesbian, gay, bisexual or transgender, are the primary reasons for the health disparities in the LGBT community Sexual behavior, not sexual orientation, determines STD/STI risk Lack of health insurance or insensitive encounters with health care providers may alienate LGBT individuals

5. LGBT Health Concerns Hate crimes: victims of more violent physical assaults Substance Abuse ◦ LGBT population: 20-30% ◦ General population: 10% Unique fertility concerns Domestic Violence: similar rates of IPV among same-sex couples but less screening by health care workers

6. Care of Gay Men Care of Gay Men or MSM is essentially the same as care for straight men or MSW Issues to target ◦ Cancer risks ◦ STI risks ◦ Immunizations ◦ Substance abuse ◦ Mental Health ◦ Domestic Violence and Hate Crimes ◦ Access to Care

7. Cancer Risks Increased rate of anal carcinoma ◦ More common in HIV infected men ◦ HPV infection is the probable cause Screening is controversial ◦ One study suggests anal Pap smears for HIV men may be cost effective ◦ Evidence on outcomes is lacking HPV vaccine recommended for all boys and young men, regardless of orientation

8. STI risks Current recommendations for MSM are screening for HIV, syphilis, chlamydia and gonorrhea ◦ Little data on outcomes, recommended annual screening Increased risks for those who have multiple sexual partners, have not practiced safe sex, recently diagnosed with STD, or engage in drug abuse Counsel patients on condom use ◦ Some risk of HIV transmission with oral sex, especially if there are open mouth sores

9. HIV risks HIV incidence is increased in MSM, particularly among those who use IV drugs Annual HIV testing for MSM ◦ More frequent for those engaging in high risk behaviors Educate patients on availability of post- exposure prophylaxis in the event of an individual unsafe encounter

10. Immunizations In addition to routine immunizations, hepatitis A and B vaccines are recommended HPV quadrivalent vaccine has been approved for young men

11. Substance Abuse Smoking is more common among gay men, especially among younger gay men ◦ Counsel and assist in smoking cessation Alcoholism may be more prevalent Drugs of abuse do not vary from the heterosexual population

12. Mental Health Increased rates of suicide among gay youth ◦ Ideation and attempts are 3 to 7 x increased Increased incidence of body image and eating disorders Increased violent experiences, possible anxiety and fear of coming out

13. Domestic violence, sexual assault and hate crimes IPV occurs among homosexual couples at the same rate as heterosexual couples Some studies suggest gay men are the most frequent victims of violence

14. Access to Care Open and nonjudgmental approach to patients Educational materials targeted to the LGBT community Inclusive forms White coat pins

15. Primary Care of Lesbian Women Limited population studies on health issues ◦ Studies suggest WSW are more likely to  smoke, drink alcohol, have a high BMI, ◦ less likely to  have children, use OCP, and preventative screening

16. Drug Abuse Smoking: 28.7% of lesbians, 26.9% bisexual compared to 12.2% of the general population Alcohol: 4.5% lesbian, 2.3% heterosexual women

17. Screening Lower rates of screening for cervical cancer ◦ May be related to perception that WSW have lower risk of HPV Increased age-adjusted risk for breast cancer ◦ Bisexual women have the highest rate of breast cancer ◦ WSW may obtain mammograms and clinical breast exams at lower rates Higher theoretical risks of ovarian cancer ◦ Screening recommendations are controversal

18. Sexually Transmitted Diseases Infectious agents can be transmitted in any exposure to bodily fluids Risk varies based on practices and number of partners Association between BV and history of female partners ◦ High rates of concordance between partners Safe sex tips: avoid mucous membrane contact with a partners blood or vaginal secretions and washing sex toys between uses

19. Chronic Stress Sexual minorities, particularly elderly lesbians, may experience higher levels of chronic stress as a result of their lifelong stigmatization from their sexual identity Impact on their mental health and health outcomes

20. Legal Issues for LGBT patients While LGBT couples do have the right to marry or obtain domestic partnerships in some states, this varies by state, and does not guarantee recognition in other states Written recognition may be needed for partners for health care, survival benefits, child raising, etc

21. Legal Health Care Issues Patient must designate their partner as their health care power of attorney ◦ Patient and partner should have a copy, as should the physician and any alternate healthcare proxy Visitation rights ◦ All hospitals that accept Medicare and Medicare must allow all patients to designate who may visit them while in the hospital, regardless of the legal relationship between the patient and visitors ◦ Encourage patients to do that in advance in case they are not mentally capable during their stay

22. Additional considerations Durable power of attorney for finances ◦ Springing power of attorney goes into effect only if the individual is incapacitated Health Care Power of Attorney for minors ◦ Non-legal parent has the ability to make decisions in health care of child Living wills or advance directive Health Care Power of Attorney for each partner

23. LGBT parenting Legal parent is established by blood, marriage or adoption Consent custody order ◦ One parent sues the other for custody Written Parenting Agreement ◦ One legal parent, both have rights and responsibilities Death of legal parent voids power of attorney ◦ Include a guardianship provision in a will

24. Laws pertaining to LGBT individuals Adoption Laws ◦ Any adult can petition to adopt ◦ Unmarried couples cannot jointly petition to adopt ◦ No explicit prohibition of same sex partner adopting partner’s child ◦ Precedents exist to use sexual orientation to deny, restrict or modify custody and visitation Gender Identity ◦ NC will issue new birth certificate if a physician certifies an individual has undergone sex- reassignment surgery

25. NC Laws pertaining to LGBT individuals Hate Crimes ◦ Gender identity is not protected ◦ Sexual orientation is not protected Employment Non-discrimination ◦ Gender Identity is not protected ◦ Sexual orientation is not protected Marriage ◦ No marriage for same sex couples ◦ Does not honor marriages of same-sex couples from other jurisdictions

26. Insurance No laws prohibit private employers from offering partner health insurance and other benefits ◦ DOMA affects federal taxes  Partner benefit coverage is taxed as income ◦ Certain state marriage amendments have been interpreted to limit state governments

27. Welcoming Environment Office and hospital environment Posters, brochures, symbols, restrooms Office and hospital staff Trainings, LGBT staff, non-discrimination Inclusive forms and language Patient-physician interaction Rapport, sensitivity, openness, confidentiality, non-judgment Providing resources and referrals

28. Inclusive Forms and Language Forms “Relationship,” “partner,” “parent or guardian,” fill-in for gender/ orientation, asking gender identity and birth sex and pronoun Non-assuming, non-judgmental Gender-neutral, non-heteronormative Mirror the patient’s words.

29. References and Resources Human Rights Campaign UpToDate ◦ Primary care of men who have sex with men ◦ Primary care of lesbians GLMA Fenway Health Institute National Coalition for LGBT Health

30. Questions?