Providing Care for the Lesbian or Gay Patient

KP Edmonds, MDSJHMC Family Medicine

Objectives

• 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 lesbian woman.

• List three risk factors for suicidality in the gay and lesbian population.

Starting Point

• 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 as gay/lesbian.”

• 1.4-4.3% of US women• 2.8-9.1% of US men

Caveat

“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– Stress– Poor access to care

• Failure to address specific population needs– STI risk– Fertility concerns

• (Indirect stigmatization)

Impacts on Health

Columbia White Paper

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 satisfaction.”

GLMA Guidelines

Patient Mindset“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– Staff– Providers– Forms

• Images• Statement of non-

discrimination

Intake Forms

• “Mr./Miss/Ms./Mrs.”• “Male/Female,”

“Other”• “Marital Status”– “Married/Single”

• “Mother/Father”

Intake Forms (con’t)• Legal name• Name I prefer to be called

(if different)• Preferred pronoun?

She He

• Gender: Check as many as are appropriate Female Male Transgender Female to Male Male to Female Other (leave space for patient to

fill in)GLMA Guidelines

Intake Forms (con’t)• Current relationship

status Single Married Domestic Partnership/Civil

Union Partnered Involved with multiple partners Separated from spouse/partner Divorced/permanently

separated from spouse/partner Other (leave space for patient to

fill in)

• Living situation Live alone Live with spouse or partner Live with roommate(s) Live with parents or other family

members Other (leave space for patient to

fill in)GLMA Guidelines

Clinic Design

• Art and Posters– Inclusive images– GLBT Organizations

• Brochures– Targeted to

populations

• Magazines• Unisex bathrooms• Nondiscrimination

statement

Nondiscrimination Statement

“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

Nondiscrimination Statement

“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 national origin.”AAFP. Reaffirmend 2005.

The Sexual History

Men Who Have Sex With Men

• CDC Recommendations:– Annual STI Screening

• Syphilis• GC/C• HIV

– Hepatitis A & B Immunization

MSM Care (Con’t)• The same as for any male

including screening for:– Sexual risk– Depression/anxiety– Diet/exercise– Heart health– Intimate partner violence– Cancer– Substance use

• Plus– Hx of Hepatitis Vaccination– Anal cancer risk (HPV-

associated)

Women Who Have Sex With Women

Your patient self-identifies 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

pregnancy higher lifetime exposure to estrogen

WSW Care (con’t)

• The same as for any woman including screening for:– Sexual risk– Depression/anxiety– Diet/exercise– Heart health– Intimate partner

violence– Cancer– 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 between contact)• Washing frequently

Mental Health Concerns

Mental Health: Rates

• MSM at higher risk for:– Affective disorders– Panic Attacks– Suicide

• WSW at higher risk for:– Alcohol dependency– Drug dependency

National Household Survey of Drug Abuse

Mental Health: Suicidality

• Risk factors– GLBT Orientation– Victimization– Hopelessness– Depression– Alcohol Use– Close contact with

suicide

Mental Health: Intimate Partner Violence

• 15% of MSM (compared to 7.7%)

• 11% of WSW (compared to 30.5%)

• You have to ask!National Institute of Justice

Mental Health: Body Image

• Traditionally:– Lesbian women

thought to be protected from eating disorders or disturbed body image

– Gay men thought to be more impacted by the traditionally-female Western body image problems

Adolescent Health: Starting Early

“Are you attracted to boys, girls or both.”

In Summary• 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.

ReferencesAaron, D. J., N. Markovic, M. E. Danielson, J. A. Honnold, J. E. Janosky, and N. J. Schmidt. "Behavioral Risk Factors for

Disease and Preventive Health Practices Among Lesbians." American Journal of Public health 91.6 (2001): 972-75. Print.

Blake, S. M., R. Ledsky, T. Lehman, C. Goodenow, R. Sawyer, and T. Hack. "Gay and Lesbian Medical Association and LGBT health experts. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. San Francisco, CA: Gay and Lesbian Medical Association, 2001." American Journal of Public health 91.6 (2001): 940-46. Print.

Cochran SD, Mays VM. Relationship between Psychiatric Syndromes and Behaviorally Defined Sexual Orientation in a Sample of the US Population. American Journal of Epidemiology. 2000;151(5):516-523.

Dean et al. Lesbian, Gay, Bisexual and Transgender Health. White Paper. Center for Lesbian, Gay, Bisexual and Transgendered Health. Columbia University. 2001

Feldman, M. B., and I. H. Meyer. "Eating Disorders in Diverse Lesbian, Gay, and Bisexual Populations." International Journal of Eating Disorders 40.3 (2007): 218-26. Print.

Filiault, S. M., M. J.N Drummond, and J. ASmith. "Gay men and prostate cancer: voicing the concerns of a hidden population." Journal of Men's Health 5.4 (2008): 327-32. Print.

Gay and Lesbian Medical Association and LGBT health experts. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. San Francisco, CA: Gay and Lesbian Medical Association, 2001.

Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients. San Francisco: Gay & Lebsian Medical Association, 2004. Print.

ReferencesKatz: Comprehensive Gynecology. Chapter 9 – Emotional Aspects of Gynecology: Sexual Dysfunction, Eating Disorders,

Substance Abuse, Depression, Grief, Loss. Katz, VL, Lentz, GM, Lobo, RA, Gershensen, DM. Ed 5. 2007. Accessed via MDConsult on 08/22/09.

Lombardi, E. "Enhancing Transgender Health Care." American Journal of Public health 91.6 (2001): 869-72. Print.

Makadon, H. J. "American Journal of Public health." New England Journal of Medicine 354.9 (2006): 895-97. Print.

Marrazzo, J. M., and A. Bingham. "Sexual Practices, Risk Perception and Knowledge Of Sexually Transmitted Disease Risk Among Lesbian and Bisexual Women." Perspectives on Sexual & Reproductive Health 37.1 (2005): 6-12. Print.

Marrazzo, J. M., L. A. Koutsky, N. B. Kiviat, J. M. Kuypers, and K. Stine. "Papanicolaou Test Screening and Prevalence of Genital Human Papillomavirus Among Women Who Have Sex With Women." American Journal of Public health 91.6 (2001): 947-52. Print.

Meyer, I. H. "Why Lesbian, Gay, Bisexual, and Transgender Public Health?" American Journal of Public health 91.6 (2001): 856-59. Print.

Mravcak, S. A. "Enhancing Transgender Health Care." American Family Physician 74.2 (2006): 279-86. Print. Plumb, M. "Undercounts and Overstatements: Will the IOM Report on Lesbian Health Improve Research?" American

Journal of Public health 91.6 (2001): 873-75. Print.

Russell, S. T., B. T. Franz, and A. K. Driscoll. "Same-Sex Romantic Attraction and Experiences of Violence in Adolescence." American Journal of Public health 91.6 (2001): 903-06. Print.

Sell, R. L., and J. B. Becker. "Sexual Orientation Data Collection and Progress Toward Healthy People 2010." American Journal of Public health 91.6 (2001): 876-82. Print.

Questions?