OBJECTIVES
Understand the social and medical context in which lesbian, gay, bisexual, and transgender (LGBT) patients seek health care.
Describe major medical and psychosocial concerns in LGBT patients.
Summarize strategies to promote culturally appropriate care for LGBT patients.
Dr. Nguyen is in the middle of her busy family practice clinic. She enters the room to see her new patient “Mr. John S.” and is puzzled to see the notation “due for Pap” among the reminder notations. The patient is male appearing and appears quite apprehensive and angry. Dr. Good asks what can she do to help and Mr. S explains with some hesitation that he is a transgender man and has female anatomy and therefore requires a Pap smear. His previous medical provider was uncomfortable with this and suggested that Mr. S. see a “gay friendly” doctor. Dr. Good was listed on a Web site so Mr. S made an appointment but is now upset because the front desk staff had loudly stated, “there must be a mistake, it says here you need a Pap smear” and then began to stare at Mr. S and laugh nervously.
INTRODUCTION
Lesbian, gay, bisexual, and transgender (LGBT) Americans and Western Europeans now experience a degree of equality, visibility, and support that was unimaginable in the past. LGBT people are much more visible in the media, workplaces, schools, government, places of worship, and a host of other settings. As LGBT people have gained visibility, equality, and support throughout our society, they have received increasing attention in health care and health education.
Health-care providers are likelier than ever before to be personally acquainted with someone LGBT and to have a general familiarity with LGBT experiences and concerns. Consequently, health-care providers must be equipped to offer truly welcoming, knowledgeable, and sensitive care to LGBT patients, who face particular challenges in health care. This chapter describes the health-care concerns of LGBT patients and explains how health professionals can best address them, creating optimal medical outcomes and building relationships of comfort and trust.
“LGBT” TERMINOLOGY
Optimal care for LGBT patients begins with an understanding of those to whom the “LGBT” acronym refers. This chapter uses “lesbian” to refer to women primarily attracted to other women; “gay” to refer to men primarily attracted to other men; “bisexual” to refer to those attracted to both men and women; and “transgender” to refer to two groups: those who identify with and transition to a gender other than the one assigned to them at birth, and those who express gender differently from prevailing norms in our society. In other words, the terms “lesbian,” “gay,” and “bisexual” refer to sexual orientation, while “transgender” refers to gender identity or gender expression. A patient who is transgender could have any sexual orientation: heterosexual, lesbian, gay, or bisexual. For this reason, laws and policies prohibiting discrimination against LGBT people are often worded to forbid discrimination related to both sexual orientation and gender identity and expression.
CREATING A WELCOMING ENVIRONMENT FOR LGBT PATIENTS
While estimates of the number of LGBT Americans vary for a host of reasons, it is entirely safe to say that LGBT people live in every area of the country and are well represented in every subgroup of Americans (e.g., ethnic/racial minorities, religious faiths, income classes, rural/suburban/urban dwellers).1 Health-care providers may not know which or how many of their patients are LGBT, but all will treat LGBT people in the course of their careers, regardless of their location or professional role.
It is critical for providers to remember that any patient could be LGBT, whether or not she or he matches stereotypes of LGBT people. For example, a male patient who refers to himself as “married” could be wedded to another man. A woman who resembles a provider’s grandmother could well say that she is a lesbian. A young male athlete, who has previously mentioned only sexual relationships with women, may say that he has recently become sexually active with men. And a woman whose husband has accompanied her to take notes on future treatment may indicate that she was “assigned male” at birth. In all of these situations, it is critical not only that health care be unaffected by learning a patient’s LGBT status but also that provider–patient rapport remains strong after LGBT status becomes known. In fact, the moment in which a patient’s LGBT status becomes known to a health professional is a critical and sensitive one. Even with much progress toward LGBT equality nationwide, it often is not easy for LGBT people to be “out,” particularly in settings like health care, where they may feel especially vulnerable.
When a patient does choose to come out, or when a health-care provider otherwise becomes aware that a patient is LGBT, it is important for the provider to signal that care will not be negatively affected. A warm smile or nod, a friendly greeting to a newly introduced same-sex spouse or partner, or a response such as “Thank you for sharing that—I know it’s not always easy” can greatly ease LGBT patients’ worries about how they will be treated. In fact, a sense that their provider is “friendly” can do much to encourage them to pursue needed care and to help create the trust and rapport that improve health outcomes.
DISCRIMINATION CONCERNS
Despite much progress for LGBT Americans, they continue to be concerned about discrimination in health-care and other settings. This is particularly true for transgender individuals, who have gained visibility and discrimination protection much more recently and on a more limited basis than LGB people. For example, one national survey of LGBT people about their health-care perceptions and experiences2 found that 28% of LGB, 35% of HIV+, and 73% of transgender respondents believed they would be treated differently in health care because of their sexual or gender identity. In addition, significant percentages of respondents reported having experienced discrimination in health care because of their LGBT status, including verbal harshness, physical roughness on the part of some health-care providers, and aversion to physical contact on the part of others. Another national survey revealed that these phenomena are particularly common for transgender patients, who may additionally experience unduly long waits for care, confidentiality violations, “gawking,” biased comments, challenges to bathroom use, and interviews and exams unrelated to their actual complaints.3
Behavior such as this in health-care settings may run afoul of state laws that forbid discrimination related to sexual orientation and gender identity and expression. In addition, the Joint Commission in the United States calls on accredited hospitals to prohibit such discrimination,4 and growing numbers of health-care facilities are voluntarily instituting policies that ban discrimination and embracing practices that promote LGBT patient-centered care and extend a welcome to LGBT patients.5 The policies and practices recommended in the following table can do much to welcome LGBT patients, assure them of equity and inclusion, and build comfort and trust (Box 32-1).
Box 32-1. Recommended Policies and Practices for Health Professionals
Any patient could be LGBT or have LGBT family members:
Use inclusive language with all patients (e.g., ask a female patient about a possible “partner” rather than “boyfriend” or “husband,” and ask a young person about his “family,” rather than “mom and dad”).
Respond warmly on learning that patients, colleagues, or employees are LGBT, so that they do not fear bias or discomfort.
Use LGBT patients’ own language for themselves, rather than substituting other terms.
Be sure not to make assumptions about individual LGBT patients based on stereotypes about LGBT people.
Ask sensitively for more information if an LGBT patient uses phrases or mentions practices that are unfamiliar.
Adopt history and intake records that allow LGBT patients.
To indicate they are partnered (rather than requiring “single” if they are not married)
Refer to “parent/guardian” (rather than “mother” and “father”)
To indicate transgender status and/or preferred name and pronoun.
Create a welcoming online and/or in-person environment by providing links or brochures about LGBT health, including LGBT images and symbols on webpages and walls, and posting LGBT-inclusive nondiscrimination policies where both patients and employees can readily see them.
Have helpful referrals at hand for LGBT patients, including national and local groups providing targeted support for youth, families, elders, veterans, smokers, people of color, HIV+ people, actual and would-be parents, transgender individuals, and others.
Signal support for LGBT patients by joining a directory of LGBT-friendly health-care providers, advertising via LGBT Web sites and publications, and/or displaying an “ally” pin, card, or sign.
Arrange LGBT education (including lectures, brown bags, films, Web sites, and publications) for employees and colleagues.
Seek out information about general and health-related LGBT topics by surfing Web sites, reading books and publications, and talking with LGBT friends.
MEDICAL CARE FOR LGBT PATIENTS
Lesbians comprise between 1% and 4% of female patients,6 and although many do not verbally disclose to their health providers their sexual orientation, most lesbians prefer that their health providers do know their orientation. Gay men face numerous health threats that need to be seen in their historical, cultural, and behavioral context. Historical stigmatism, discrimination, and rejection set the stage for psychological distress and substance misuse. The medical world has not always welcomed gay men, and in many parts of the world, good and safe care is difficult or impossible to come by. The increasing number of transgender, transsexual, and gender nonconforming people seen in health-care settings requires that health care providers understand how to manage them.
Most research studies in lesbian health are based on self-identification rather than sexual behavior. Of the patient cohort that self-identifies as lesbian, about 30% are sexually active with men as well as with women; hence, it is important to consider counseling for prevention of unintended pregnancy. However, this counseling needs to be done in a sensitive manner, as intensive birth control counseling without regard to identified sexual orientation is often described as a reason that lesbians do not go back for follow-up visits to a provider. It is important to know that about 90% of all lesbians have had sex with men at some time in their lives. Whether or not a lesbian woman has sex with men, she may be interested in having a child, so preconception counseling should be offered to all lesbians (see the following subsections).
Lesbians can have sexually transmitted infections (STIs), acquired through either their female or male partners. Chlamydia in young women is a public health epidemic, and can cause infertility in later years due to asymptomatic tubal scarring. Many public health departments recommend annual chlamydia and gonorrhea screening in all women younger than 26 years who are sexually active. There is one study that reported young adult lesbians had a higher prevalence of chlamydia infection than the heterosexual female cohort, mostly attributed to the observation that the lesbians had more sexual partners (some of whom were male) than the comparison heterosexual group.7 HIV testing is now recommended for all women at least once in their lifetime. When lesbian patients are seen for the first time, if they have ever had sex with men, they should have age-appropriate gonorrhea and chlamydia screening, and all should have at least a one-time test for HIV. Further testing can then be individualized based on sexual behavior risk.
There have been rare but validated cases of HIV infection transmitted between women. Safer sex techniques have not been studied in lesbians; however, use of the female condom during high-risk times of menstruation, not sharing sex toys, and avoiding anal sex/tearing may be prudent at any time, and are strongly recommended in lesbian couples who are discordant for the HIV virus. Bacterial vaginosis can be transmitted between lesbian sexual partners. Infections that do not resolve or recur with treatment require evaluation of the partner. Genital herpes can also be transmitted between female sexual partners, and usual heterosexual precautions can be used with lesbians who have genital herpes.
Lesbians tend to delay screening tests than heterosexual women, and women who self-identify as bisexual lag behind lesbian in screening rates.8 Lesbians do exercise more than heterosexual women, but neither group exercises enough to meet national goals.9 Lesbians have increased body mass index (BMI) about 1.5–2.0 times the frequency of increased BMI in heterosexual women, placing overweight/obese lesbians at increased risk for cancer, diabetes, and cardiovascular disease.10
With the exception of breast cancer, cancer in lesbians has not been well studied. Breast cancer occurs at a slightly higher rate in lesbians than in other women. Lesbians probably get mammograms at the same rate as heterosexual women but have fewer clinical breast exams. Risk factors for lesbians for breast cancer are the same as in heterosexual women. The increased risk may be related to an increased prevalence of alcohol use, higher BMI, higher incidence of smoking, and lower rates of childbearing and breastfeeding than among heterosexual women.
Since most lesbians have had sex with men at some point of time in their life, and because human papillomavirus (HPV) can be transmitted between women, Pap smears for cervical cancer screening are recommended according to the same professional society guidelines as for heterosexual women.
Increasing numbers of lesbians are childbearing, though often at an older age than heterosexual women. This means lesbians are at increased risk for infertility as well as at a possible increased risk of hypertension and diabetes in pregnancy, and their babies may have higher rates of birth defects. All women who plan pregnancies or who may get pregnant should have preconception counseling to include review of vaccinations and serologic testing for immunity for common infections that can cause fetal defects, review of medications and family genetic history, and advice on daily vitamins with folic acid (at least 0.4 mg/day), especially in the 3 months prior to conception. The majority of lesbians who are planning to become pregnant choose insemination from an anonymous donor for conception; however, some lesbians use known donors (e.g., male donor from the partner’s family) or co-parent with men (e.g., a gay or heterosexual male friend[s]). Some lesbians in couples use “co-maternity” in which one lesbian donates an egg, it is mixed in the in vitro fertilization lab with sperm, and the embryo is placed into the uterus of her partner, such that both share biologically in the pregnancy.
There are many ways for LGBT parents to structure their families. State laws need to be considered when choosing a method of conception, especially regarding parental rights of the sperm donor if the conception or insemination occurs outside a physician’s office. A potential lesbian parent should be encouraged to consult with a local family attorney prior to conception if possible. The National Center for Lesbian Rights has important information for potential LGBT parents (www.nclrights.org). Most fertility practices are now accessible for lesbian clients. Adoption is governed by state laws and may or may not be an option for a single lesbian parent-to-be or those in a couple.
Many studies have now been done on the outcomes of children raised by lesbian parents. They verify that the emotional, psychological, and physical well-being of children raised by lesbians equals or exceeds that of children raised by heterosexual parents.11
Lesbians have higher rates of depression compared with heterosexual women, particularly if they belong to a racial minority. Other types of mental illness are probably present at the same prevalence as for heterosexual women. Domestic violence rates are probably the same for lesbian couples as for heterosexual women.12 Many women including lesbians have been sexually assaulted in the past. Studies have documented slightly increased rates of childhood sexual abuse in lesbians.13
The increased rate of depression has been attributed to the daily homophobia that many lesbians experience.14 Lesbians are comparatively more likely than heterosexual women to use psychotherapy than medications for treatment of their depression. A recent study revealed that there was an increased rate of attempted suicide in LGB persons who sought out religious or spiritual counseling, compared with those who used mental health or medical treatment services.15 Therefore, it is critical that lesbians do not get referred to homophobic therapists or mental health clinics.
Lesbians have increased rates of smoking, alcohol consumption, and substance use. A complete history therefore needs to be taken, and if injection drugs have ever been used then appropriate hepatitis and HIV testing should be done.16 Their smoking rate is two to three times that of heterosexual women,17 so they should be screened for cigarette smoking at each medical visit. Referrals for drug and alcohol treatment, just as for all mental health referrals, need to be sensitively made. Many lesbians are in recovery, but not all Alcoholics Anonymous (AA) or other recovery groups or programs are welcoming to lesbians. In large cities, it is often possible to find lesbian AA and other recovery and support groups.
Sexual expression became incredibly risky with the spread of HIV, and much of gay male health is currently centered on prevention and management of HIV infection. It is important to be aware that not all men who have sex with men (MSM) identify as gay, and that there may be unique issues for MSM who identify as bisexual or heterosexual. Bisexual men and women may experience less social support than their homosexual or heterosexual peers, not feeling fully accepted by either community. This section addresses some of the challenges to health experienced by gay men, MSM, and bisexual men and provides an overview of priorities in their care.
The majority of gay men do not experience problems with mental health. However, anxiety and depression likely do occur at a higher rate than in the general population, up to 1.5 times more frequently in some studies (see the Institute of Medicine’s 2011 report on LGBT health for an overview of the study of mental health in LGBT communities).18 The risk of suicide in LGBT teens has been well publicized in the United States, and an elevated risk likely persists into adulthood, with an overall lifetime risk of suicide more than twice as high as for heterosexuals.
It is important to note, however, that not all studies have found higher rates of psychological distress across the board in gay as compared to straight men. Measures of well-being such as happiness and job satisfaction reveal similar findings for men across the sexuality spectrum. The relationship between sexual orientation and mental health is nuanced—for example, Bostwick et al19 found gay men had a higher prevalence than heterosexual men of any lifetime mood disorder (42.3% vs. 19.8%) and of any lifetime anxiety disorder (41.2% vs. 18.6%). These rates, however, were mediated by the degree of same-sex attraction: men (and women) reporting exclusive same-sex attraction reported lower rates of psychological stress than did those with less exclusive attraction or behavior. Bisexuality was associated with the highest rates of mood disorders. Regardless of where people fall on the spectrum of sexuality, the mental health of LGBT populations will likely improve in parallel with advances in societal support and acceptance.
Substance misuse and abuse is also more prevalent in gay men and MSM. Smoking may be up to twice as common among gay men as heterosexual men, and black gay or bisexual men have almost double the smoking prevalence of heterosexual black men (62% vs. 34%).20 Data are mixed on the rates of drug and alcohol use by gay men—studies have found higher levels of both use and dependence. Heavy marketing of cigarettes and alcohol to the gay community encourages overuse. Use of the acronyms “PNP” (party and play) and “Chem Friendly” in personal adds by men seeking a male partner reflects a culture where drugs and sex are commonly linked.
Of particular concern is the use of drugs or alcohol to negotiate and facilitate unprotected sex. Among black MSM who do not identify as gay, drug and alcohol use or exchange play a significant role in promoting unprotected sex. A study of men in methamphetamine and cocaine addiction programs found that within the first few months of treatment, the number of reported sex partners fell from a mean of approximately seven to one per month. In the same study, unprotected anal intercourse decreased from 70% to 24% of encounters.21 MSM accustomed to sex while using stimulants often describe sex without drug use as lacking pleasure and excitement.22 This experience has direct implications for treatment and relapse prevention programs.
HIV education and prevention efforts depend first on understanding risk. Risk remains disproportionately high among MSM, and in particular among younger MSM and racial and ethnic minorities. Although MSM represent less than 10% of the US male population, in 2010 they accounted for 78% of new HIV infections among men and 63% of all new infections. While the overall incidence of HIV infection in heterosexuals and injection drug users in the United States has stabilized or declined, there has been a 12% increase in the rate of new infections among MSM. Young black MSM account for 55% of new infections in young men, and Latino/Hispanic men are infected at 2.9 times the rate of white men.22
In 2011, an estimated 18% of all MSM were infected. Thirty-four percent of these men were unaware of their infection, and those who did not know their HIV status were more likely to have unprotected sex.23
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