1. Primary Healthcare For LGBTQQT
This presentation is about primary healthcare, health protection and promotion, and screening for Lesbian, Gay, Bi-sexual, Transgendered, Queer ,Questioning, and Two Spirited people.
Valerie Dzubur EdD APRN FNP-BC
Samuel Merritt University
Spring N

2. Objectives Define LGBTQQT
Review Health Disparities for LGBTQQT Communities
Goals for Healthy People 2020
Identify special needs/risks/problems
Define integrated care model SAD COST
Identify cultural tips for comfortable care
Discuss special needs for transgendered people to transition using medications
The objectives for this presentation are that the FNP student will be able to
Define LGBTQQT
Review Health Disparities for LGBTQQT Communities
Goals for Healthy People 2020
Identify special needs/risks/problems
Define integrated care model SAD COST
Identify cultural tips for comfortable care
Discuss special needs for transgendered people to transition using medications

3. LGBTQQ
Lesbian = women who primarily want a sexual & emotional relationship with another woman
Gay = Men who primarily want a sexual & emotional relationship with another man
Bi-sex = Both men and women with both men & women
Transgender = gender identity expression opposite from natal gender
Q = questioning / Q queer (not heterosexual)
T = Two Spirited identity with both male/female character
Terminology:
Lesbian = women who primarily want a sexual & emotional relationship with another woman ( notice that does not say a women who has never had sex with a man)
Gay = Men who primarily want a sexual & emotional relationship with another man
Bi-sex = Both men and women with both men & women
Transgender = gender identity expression is opposite from natal gender
Q = questioning / Q queer (not heterosexual)
T = Two Spirited identity with both male/female character
Human sexual behavior and sexual orientation don’t always match, it is a life long process, a continuum, and sexual changes moves in more than one direction, so sexual behavior and sexual orientation are not stable /unchanging over a life. Don’t make assumptions – ask about behaviors when you are assessing risks for health protection. You can use a both developmental and behavioral approach in thinking about risks. For example a questioning teen will have different set of issues, risks, and needs than a 50 year old gay man in a committed relationship i.e. married.

4. LGBTQQT
APRN mission to provide primary healthcare services to underserved, at risk communities
We want to be the primary care provider of choice
We need to be leaders in developing new knowledge
We need to work to influence health policy
We need to develop partnerships across communities
APRN mission to provide primary healthcare services to underserved, at risk communities
We want to be the primary care provider of choice
We need to be leaders in developing new knowledge
We need to work to influence health policy
We need to develop partnerships across communities

5. LGBTQQT Who are we talking about Americans 5 – 10 % of the population
Undercounted using 2000 numbers
5 % of 209,128,094 = 10,456,405 people
Living across the country in 99.3 % Counties
3,136,921 live in committed relationships = married
The human rights campaign estimates these numbers represent an under count of 62 % and the numbers are ten years old
Who are we talking about
Americans 5 – 10 % of the population
Undercounted using 2000 numbers
5 % of 209,128,094 = 10,456,405 people
Living across the country in 99.3 % Counties
3,136,921 live in committed relationships = married
The human rights campaign estimates these numbers represent an under count of 62 % and the numbers are ten years old

6. LGBTQQA IOM 2012 Study in process & asking…
State of knowledge health risks, disparities, protective factors, access to & utilization of health care
Developmental process across the life span
Effects of age, ethnicity, race, geography
Effects of social determinants and cultural factors
Methodological challenges
Research gaps
Training/educational needs to advance knowledge about health concerns
There is an IOM 2012 study in process now asking…
What is the state of knowledge, health risks, disparities, protective factors, access to & utilization of health care for LGBTQQA folks
What are the Key Developmental processes for LGBTAAQ people, across the life span, how is it different from other groups
What are the effects of age, ethnicity, race, geography
And what are the effects of social determinants and cultural factors, for example we know that because of extreme discrimination transgender people are at high risk for dropping out of school, being homeless, being a victim of violence and other trauma, being unemployed, being rejected from family, isolated from normal support systems and so forth. Once we get a clearer picture of the effects of these social and cultural determinant we will be better able to intervene in a very bad predictable spiral to the bottom of the society.
There are Methodological challenges in reaching marginalized groups.
The Research gaps are large.
We do know however that we need to start with educating healthcare professionals to better meet the needs of the community and to advance the science

7. LGBTQQT Leading health indicators Overweight / Obesity Cancer
Physical Activity
Tobacco use
Substance Abuse
Responsible sexual behavior
Mental health
Injury and violence
Immunizations
Access to healthcare
Although it is important to understand the specific and sometime special needs of defined groups i.e. LGBTQQT in this discussion, we need to keep in mind that all the other things we know and do for people in general apply as well …so let’s start again leading health indicators and think about how they pertain to this group. The indicators are:
Overweight / Obesity
Cancer
Physical Activity
Tobacco use
Substance Abuse
Responsible sexual behavior
Mental health
Injury and violence
Immunizations
Access to healthcare
So we should ask what is the rate of obesity, cancer, physical activity, smoking habits, access to healthcare, immunizations rates, substance abuse and so forth in the LGBYQQT community. And when we ask this question properly we will discover there are important differences that need attention by any of us involved in the healthcare system

8. LGBTQQT Let’s take a closer look Lesbians have 2 X the risk of obesity
MSM rates of anal cancer have tripled last 30 yrs
MTF HIV infection rates are close to 50 %
MTF attempted suicide rate > 50 %
Much less likely than others to have a primary care provider over time
For Example
Let’s take a closer look
Lesbians have 2 X the risk of obesity
MSM rates of anal cancer have tripled last 30 yrs
MTF HIV infection rates are close to 50 %
MTF attempted suicide rate > 50 %
Much less likely than others to have a primary care provider over time

9. Causes of Disparities
Insufficient education of healthcare professional
Overt bias and discrimination in the system/people
Gendered language, documentation, legal requirements
Insurance coverage can be difficult
Privacy concerns
Clinic milieu
Bathrooms
There are many causes for these disparities
Insufficient education of healthcare professional
Overt bias and discrimination in the system/people
Gendered language, documentation, legal requirements
Insurance coverage can be difficult
Privacy concerns
Clinic milieu
Bathrooms

10. Disparities What do disparities look like?
According to Healthy People 2020
LGBT youth are 2 – 3 x more likely to attempt suicide
And are much more likely to be homeless at some point
Lesbians are less likely to get screened for cancer
Gay men are at higher risk for HIV and other STIs
Transgender people have a high prevalence of HIV / STIs
Victimizations, mental illness, suicide, no health insurance
Elderly are more likely to be isolated
Have highest rate of smoking, ETOH use and other drugs
Victims of trauma violence, bullying, abuse
< likely to be protected by police
What do disparities look like when you pull back the onion skin?
According to Healthy People 2020
LGBT youth are 2 – 3 x more likely to attempt suicide
And are much more likely to be homeless at some point
Lesbians are less likely to get screened for cancer
Gay men are at higher risk for HIV and other STIs
Transgender people have a high prevalence of HIV / STIs
Victimizations, mental illness, suicide, no health insurance
Elderly are more likely to be isolated
Have highest rate of smoking, ETOH use and other drugs
Victims of trauma violence, bullying, abuse
< likely to be protected by police

11. Healthy People 2020 LGBTQQT
Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgendered individuals
The goals for Healthy People 2020 include:
LGBTQQT
Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgendered individuals

12. Across the Life Span Youth Issues are magnified Special concerns
Coming out / family rejection
Homelessness
Substance abuse
Mental Health – suicide risk
Thinking developmentally:
Youth
Issues are magnified
Special concerns
Coming out / family rejection
Homelessness
Substance abuse
Mental Health – suicide risk

13. Across the Life Span Midlife / Family Issues Insurance Relationships
Access to preventive care
Access to chronic disease management
Relationships
Marriage equality
Family of origin issues
Becoming and being parents
Adoption
Donor
Other ways
Midlife / Family Issues
Insurance
Access to preventive care
Access to chronic disease management
Relationships
Marriage equality
Family of origin issues
Becoming and being parents
Adoption
Donor
Other ways

14. Across the Life Span Older Adults Financial concerns Social Isolation
Hospitalization acute and long term
Back into the closet
Older Adults
Financial concerns
Social Isolation
Hospitalization acute and long term
Back into the closet

15. SAD COST Model S: STIs & risky sexual behaviors
A: Attitudes of healthcare providers
D: Depression, anxiety, suicidality
C: Cancer Screening and risk
C: Cardiovascular disease and risk
O: Overweight, obesity, eating disorders
S: Substance abuse
T: Trauma
The SAD COST Model can help us remember some of the special issues and concerns:
S: STIs & risky sexual behaviors
A: Attitudes of healthcare providers
D: Depression, anxiety, suicidality
C: Cancer Screening and risk
C: Cardiovascular disease and risk
O: Overweight, obesity, eating disorders
S: Substance abuse
T: Trauma

16. LGBTQQT
Use current guidelines for leading health indicators as you would for all other groups
CAD, HTN, DM
Screening for Cancers
Lifestyle modification
Immunizations
Health education
Develop a primary provider relationship
Special focus on other risks in the history, screening, and treatment domains SAD COST

17. Special Care Transgendered People
Orient yourself to the gender identity of patient’s choice, do a self-check on your language, attitude, and bias….be attentive to the way you express esteem for others and remember identity is a core human concern for all of us. Transgendered people are asking to be recognized for who they really are!
History
Blood clots
STIs ? Last HIV Test? Results? Last risk?
Surgeries to support transition of gender identity
Cosmetic procedures also by lay persons – silicone
Psychiatric events/hospitalizations
Medications to assist with gender transition
Source, route, dose
For us to provide the special care the is called for when working with transgendered people
Transgendered People
Orient yourself to the gender identity of patient’s choice, do a self-check on your language, attitude, and bias….be attentive to the way you express esteem for others and remember identity is a core human concern for all of us. Transgendered people are asking to be recognized for who they really are!
History
Blood clots
STIs ? Last HIV Test? Results? Last risk?
Surgeries to support transition of gender identity
Cosmetic procedures also by lay persons – silicone
Psychiatric events/hospitalizations
Medications to assist with gender transition
Source, route, dose

18. Special Care Transgendered people History continued
Hepatitis A,B C status
Immunizations Hep A & B
Injuries – screen for abuse & violence
Family History with emphasis on Cardiac risk
Occupational History – sex work, source of income
Transgendered people
History continued
Hepatitis A,B C status
Immunizations Hep A & B
Injuries – screen for abuse & violence
Family History with emphasis on Cardiac risk
Occupational History – sex work, source of income

19. Special Care Transgendered People Personal and Social History
Legal status and name
History of drugs and ETOH
Relationships and social support
Goals for transition
Success of transition
Transgendered People
Personal and Social History
Legal status and name
History of drugs and ETOH
Relationships and social support
Goals for transition
Success of transition

20. Special Care Transgendered People
Physical Exam as needed after relationship established
Prepare the patient in advance – get permission
Ask how to refer to anatomy i.e. genitals instead of vagina or penis
Check for yeast infections if binding breasts or genitals
For silicone injections check for infection
Transgendered People
Physical Exam as needed after relationship established
Prepare the patient in advance – get permission
Ask how to refer to anatomy i.e. genitals instead of vagina or penis
Check for yeast infections if binding breasts or genitals
For silicone injections check for infection

21. Special Care Transgendered People
Screen based on risks using current guidelines
And an individualized risk assessment
To interpret labs use normal lab values for natal sex until 2-yrs after hormone therapy for transition, then use transitioned sexual identity i.e. female values for MTF persons
MTF
check prolactin q 6 mos, < 25 continue therapy
> 25 discuss decrease in estrogen dose, if > 100 stop estrogen for 8 weeks, recheck, if still > needs MRI
Transgendered People
Screen based on risks using current guidelines
And an individualized risk assessment
To interpret labs use normal lab values for natal sex until 2-yrs after hormone therapy for transition, then use transitioned sexual identity i.e. female values for MTF persons
MTF
check prolactin q 6 mos, < 25 continue therapy
> 25 discuss decrease in estrogen dose, if > 100 stop estrogen for 8 weeks, recheck, if still > needs MRI

22. Special Care Transgendered People Screening MTF continued
Prostate is not removed in sexual reassignment surgery
Review sexual risks every visit,
screen for HIV, STIs q 6 mos, more often if sex worker
Screen for depression, anxiety, suicide every visit
Mammography ?
Transgendered People
Screening
MTF continued
Prostate is not removed in sexual reassignment surgery
Review sexual risks every visit,
screen for HIV, STIs q 6 mos, more often if sex worker
Screen for depression, anxiety, suicide every visit
Mammography ?

23. Special Care Transgendered People Screening FTM Mammography ?
Needs pap smear as per general population
Transgendered People
Screening
FTM
Mammography ?
Needs pap smear as per general population

24. Hormones for Transition
It takes 2 years for hormonal transition regardless of dose
Use is off label so get written patient consent
Emphasize stop smoking, review & document risks for estrogen use
Get Baseline laboratory studies
CBC CMP Lipids, TSH, Prolactin (MTF), HIV STI
Recheck labs at 1 month and then q 6 months on hormone therapy
It takes 2 years for hormonal transition regardless of dose
Use is off label so get written patient consent
Emphasize stop smoking, review & document risks for estrogen use
Get Baseline laboratory studies
CBC CMP Lipids, TSH, Prolactin (MTF), HIV STI
Recheck labs at 1 month and then q 6 months on hormone therapy

25. Hormones for Transition
See Table Hormone Guideline for Sex Reassignment page 340
MTF
Estradiol 2 – 8 mg/d
Spironolactone 25 – 200 mg/d (noACE)
FTM
Testosterone cypionate 100 – 400 mgs q 2 – 4 weeks
Testosterone patch 2.5 mg/1 – 2 per day
See Table Hormone Guideline for Sex Reassignment page 340
MTF
Estradiol 2 – 8 mg/d
Spironolactone 25 – 200 mg/d (noACE)
FTM
Testosterone cypionate 100 – 400 mgs q 2 – 4 weeks
Testosterone patch 2.5 mg/1 – 2 per day

26. Comfortable Care Start at the beginning – yourself
No one is a blank slate
If you understand your bias you can change them
Even if you think you are clear about not being homophobic (?) we all live in a world that presumes heterosexuality is normal
It has a name heteronormativity
Self-reflection is an on-going process
Start at the beginning – yourself
No one is a blank slate
If you understand your bias you can change them
Even if you think you are clear about not being homophobic (?) we all live in a world that presumes heterosexuality is normal
It has a name heteronormativity
Self-reflection is an on-going process

27. Comfortable Care Communication Tips Don’t assume Heterosexuality
Sexual orientation
Sexual identity
Sexual behavior is unchanging
Communication Tips
Don’t assume
Heterosexuality
Sexual orientation
Sexual identity
Sexual behavior is unchanging

28. Comfortable Care Communication Tips
Ask people how they wish to be identified
Always do your best to use the correct pronoun
Use non-heterosexual language (gender neutral)
Don’t be afraid to get personal –follow the patient’s lead
Your good intentions help, mistakes happen
Simple acknowledgement is good and then move on
Communication Tips
Ask people how they wish to be identified
Always do your best to use the correct pronoun
Use non-heterosexual language (gender neutral)
Don’t be afraid to get personal –follow the patient’s lead
Your good intentions help, mistakes happen
Simple acknowledgement is good and then move on

29. Comfortable Care Create an inclusive environment
For this you may need to be the leader
Create a safe space
Post and follow a non-discrimination policy
Use Posters and handouts as a welcome message
Use gender neutral bathrooms
Use gender neutral intake documents
Staff training
Speak up about discrimination, gossip, giggling what ever
Create an inclusive environment
For this you may need to be the leader
Create a safe space
Post and follow a non-discrimination policy
Use Posters and handouts as a welcome message
Use gender neutral bathrooms
Use gender neutral intake documents
Staff training
Speak up about discrimination, gossip, giggling what ever

30. Need Help www.transhealth.vch.ca www.nickgorton.org
Text Collins-Bride/Saxe pages
Text Collins-Bride/Saxe pages