Medical and Mental Health

Goals

At the completion of this module, the participant will have an understanding of health issues unique to the LGBT population and primary preventative health care best practices to care for these patients.

Objectives

In order to reach this goal, the participant will have:

Pre-Test

  1. Lesbians are not exposed to HPV, have a lower incidence of cervical cancer, and therefore do not need PAP smears as frequently as heterosexual women.
    • True
    • False
  2. The rate of new cases of HIV in MSM (men who have sex with men) :
    1. Is dropping steadily due to universal acceptance of safe sex practices.
    2. Dropped initially, but has been rising recently along with the rates of infection with other STDs.
    3. Now lower than the rate in lesbians
    4. Is of less concern now that effective and safe treatments for HIV exist.
  3. HPV is:
    1. Not found in lesbians
    2. Associated with cervical dysplasia and cancer in all women, including women who have never had sex with men
    3. Associated with higher rates of anal carcinoma in MSM
    4. Only transmitted by penile-vaginal penetration.
  4. Rates of alcohol and tobacco use in the LGBT community:
    1. Are lower due to the large number of gay-friendly 12-step groups.
    2. May be a risk factor for cardiovascular disease in gay men and lesbians
    3. Are higher in gay men and lower in lesbians than the general population
    4. Are a subject of controversy due to flaws in existing research and the lack of inclusion of sexual orientation in large population based government studies.

Health Issues in the LGBT Community

LGBT persons are people first and foremost, with the same primary care issues and needs as others across the life cycle. The LGBT community is highly diverse, and any discussion of health risks and behaviors runs the risk of overgeneralization or even stereotyping, leading to questionable assumptions.   Compounding this risk are the methodological difficulties of researching a relatively small minority who are subject to bias and discrimination, and therefore reluctant to cooperate. The challenges of research in this population and the dearth of information are reviewed elsewhere (Harcourt 2006, Dean 2000). Boehmer, in 2002, reviewed all MEDLINE citations in the years 1980-1999 and found only 0.1% referred to LGBT health.   Of those articles, the majority (56%) dealt with the topic of men who have sex with men (MSM) and HIV/AIDS.

While health risk is conferred or mitigated by behavior, environment, and genetics, not by sexual orientation per se, primary care clinicians should be aware of the importance of taking a thorough, non-judgmental sexual history. The CDC suggests that the "5 P's" are key to a sexual history: PARTNERS, PREVENTION (of STDs), (sexual) PRACTICES, PAST (history of STDs) and (prevention of) PREGNANCY. In taking a sexual history, clinicians need to understand the distinction between sexual identity and sexual behavior, and avoid using sexual identity as shorthand for sexual behavior. Terms for sexual preferences and practices differ across cultural, generational, and ethnic groups. Although it is a good place to start, a routine inquiry into patients' sexual identities may fail to identify many individuals whose sexual practices can affect their primary care needs. Just asking patients about their sexual identity ("Are you gay?") may also lead to misunderstanding patients who define their identities in ways that differ from prevailing cultural definitions.

The Department of Health and Human Services, in its 2010 HealthyPeople.gov report, recognized gay men and lesbians as one of the 6 most underserved minority groups in America. Despite this recognition, sexual orientation was not assessed in many of the initiatives in this document (Harcourt 2006), and the 2005 Midterm Report on Progress does not mention the LGBT community.

Most surveys consistently show that primary care providers do not inquire about their patients' sexual identity or practices. Patients also report reluctance to disclose that information, due to concerns of confidentiality and possible negative reactions by their physician (Dean 2000). As more employers become self-insured and thereby gain access to their employees' health information, concern about confidentiality and discrimination may increase. There is some validity to these concerns. Surveys show a high rate of negative reactions and disapproval when the patient does disclose their sexual orientation to their doctor. LGBT individuals report delaying or avoiding treatment due to concerns about their access to respectful care, even in large, presumably gay-friendly metropolitan areas (Harcourt 2006). The quality of the relationship between doctor and patient demonstrably affects compliance and overall outcomes of treatment. Thus gay men and lesbians, particularly if they are closeted, are at risk for poorer outcomes when they do seek care.

HIV/AIDS

The Human Immunodeficiency Virus (HIV) is the infectious agent responsible for the Acquired Immunodeficiency Syndrome (AIDS). The spread of HIV has had an enormous impact on world health. Unprotected sex with someone already carrying HIV has accounted for the majority of cases of HIV infections worldwide, with contacts between people of the opposite sex accounting for more cases than same-sex contacts globally. However, the pattern of transmission varies significantly between countries. In the US and Europe, the LGBT population has been particularly impacted. The subpopulation of "Men who have sex with men" (MSM) is the largest category of individuals affected in the US. Since the beginning of the epidemic, almost 300,000 MSM with AIDS have died, including an estimated 6,863 in 2009. As of 2009, 64% of all new cases in the US were estimated to be due to sexual transmission in MSM (CDC).

The Centers for Disease Control (CDC) estimates 1.2 million people in the US are living with HIV infection. One in five (20%) of those people are unaware of their infection. Despite increases in the total number of people in the U.S. living with HIV infection in recent years (due to better testing and treatment options), the annual number of new HIV infections has remained relatively stable. However, new infections continue at far too high of a level, with approximately 50,000 Americans becoming infected with HIV each year. After the initial epidemic, thanks to knowledge about the virus and risk factors for it's transmission, the sexual practices of MSM changed considerably; however, rates of new HIV infection remain disproportionately high among younger black and Hispanic MSM (Catania 2001, CDC). MSM should be counseled regarding safer sexual practices and methods of avoiding infection with HIV. If seronegative, they should be screened annually. Those men reporting higher risk behavior, such as multiple partners, unprotected receptive anal or oral sex, sharing needles, or sex with partners who are sharing needles, should be screened even more frequently (every 3-6 months). Patients should also be educated about the possible synergistic effect of other STDs on HIV transmission and its frequent co-occurrence with these infections (Makadon 2006).

Clinicians make an error if they assume that lesbians have no history of sexual contact with men. In one survey of self-identified lesbians 77% had 1 or more male sexual partners in their lifetime, and 6% in the prior year. There are case reports of transmission of HIV and Hepatitis B between women. There are particular reasons why lesbians might be at high risk. Women who have had sex with women appear to have higher rates of unprotected sex when having sex with men (both vaginal and anal), more sexual contact with bisexual or homosexual men, and more sexual contact with IV drug users when compared with exclusively heterosexual women (Mravcak, 2006).

The AIDS epidemic has been devastating, but what was once a nearly certain fatal diagnosis has become a chronic disease in many areas of the world. There is enormous variability in the course of infection among individuals. Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype. After the diagnosis of AIDS, if treatment is not available, survival ranges between 6 and 19 months. For those living with HIV, highly active antiretroviral therapy (HAART) has been the standard treatment for people with HIV/AIDS. Many questions regarding the long-term prognosis and possible side effects of this therapy remain, as does the question of emerging drug resistance. HAART appears to be associated with alterations in body fat distribution and blood lipid levels, both of which may raise the long-term risk for cardiovascular disease (Dean 2000). Implementation of HAART raises the life expectancy for a newly diagnosed young adult to 20–50 years (Maggiolo & Leone 2010). Although the timing of when to begin HAART is still controversial, early and aggressive treatment seems imperative for the most successful outcome.

Hepatitis

"Hepatitis" refers to any inflammation of the liver and also refers to a group of viral infections that affect the liver. The most common types are Hepatitis A, Hepatitis B, and Hepatitis C. Viral hepatitis is the leading cause of liver cancer and the most common reason for liver transplantation. An estimated 4.4 million Americans are living with chronic hepatitis; most do not know they are infected. Vaccines exist for Hepatitis A and B. Patients should be routinely screened, and if negative should be routinely counseled to receive vaccinations. Men who have sex with men (MSM) are at elevated risk for Hepatitis A and B. Despite the availability of safe and effective vaccines, many MSM have not been adequately vaccinated against viral hepatitis. Approximately 15–25% of all new Hepatitis B virus (HBV) infections in the United States are among MSM. (CDC) The Advisory Committee on Immunization Practices recommends Hepatitis A and Hepatitis B vaccination for MSM. Because of higher rates of infection among this population. The CDC also recommends testing MSM for chronic HBV infection.

Other STDs

Other STD’s are of particular concern the LGBT population. Notifiable disease surveillance data on syphilis and data from the Gonococcal Isolate Surveillance Project suggest that some STDs in MSM, including men who have sex with both women and men, are increasing. Because STDs and the behaviors associated with acquiring them increase the likelihood of acquiring and transmitting HIV infection. The rise in STDs among MSM may be associated with an increase in HIV diagnoses among MSM (CDC). This is both a primary public health concern and also a worrisome marker of unsafe sexual practices associated with transmission of HIV. The current recommendation is that MSM should be screened yearly for gonorrhea, syphilis, and Chlamydia. High-risk behavior is an indication for more frequent screening and education.

HPV is sexually transmitted, associated with genital and anal warts, and is a well known cause of cervical cancer. Emerging evidence connects HPV with anal cancers in men (see below).

The myth that lesbians are either at low or no risk for STDs is increasingly being debunked. Transmission of herpes, genital warts associated with HPV, and trichomoniasis has been proven to occur between female partners. Transmission is theorized but has not been studied in Chlamydia, gonorrhea, and syphilis.. Despite these risks, lesbians and bisexual women are screened less frequently for STDs, and are not given recommendations for safer sexual practices by their physician (Mravcak 2006).

Cancer

MSM have higher rates of non-Hodgkin lymphoma and Kaposi's sarcoma associated with HIV infection. HAART has reduced the incidence of KS but not non-Hodgkin's lymphoma. In addition, the median survival is lower for HIV positive MSM with lymphoma than in the general population. There is also an increased rate of Hodgkin's disease in MSM, but the evidence connecting this with HIV is not clear (Koblin 1996).

MSM have higher rates of anal carcinoma associated with infection with the HPV virus, independent of HIV status. HPV and ASIL prevalence is higher still in HIV positive men (Koblin, 1996). HIV positive MSM should have yearly anal PAP tests, and those who are HIV negative should be screened every 2-3 years. The FDA recently approved HPV for use in women ages 16-25 a vaccine against the 4 most common oncogenic types of HPV. It is under study for the MSM population and recommendation to vaccinate may be expanded to at risk men in the future (Makadon 2006).

Some studies show higher rates of breast and cervical cancer in WSW. This association is controversial due to flawed data collection. Many studies show that lesbians are less likely to receive routine PAP screens or clinical breast exams (Harcourt, 2006). HPV associated cervical dysplasia has been found in women who have never had sex with a male partner. WSW should be screened with PAP and for HPV as per the established recommendations for all women, and vaccinated against HPV when appropriate. They should have regular pelvic and breast exams as well. The rate of mammogram screening does not appear to differ in WSW vs. heterosexual women. It is unclear whether theoretical risks for breast cancer, such as nulliparity, translate into higher rates of breast cancer in WSW. Theoretically, WSW also have an increased prevalence of known risk factors for ovarian cancer (higher BMI, fewer or no pregnancies, less use of OCP and HRT); whether there is an actual increase is not known (Mravcak 2006).

Tobacco

MSM have higher rates of tobacco use. Lesbian and bisexual women have higher rates of tobacco use, perhaps even higher than MSM. Use of tobacco is associated with increased risk for coronary and peripheral vascular disease, obstructive lung disease, lung cancer, and various other health problems (Harcourt 2006). People with nicotine dependence should be encouraged to stop, or at the very least to reduce the amount of nicotine they consume. There are several pharmacological interventions that have been demonstrated to increase the success rates of those attempting to quit. In addition to that, a number of psychosocial interventions have demonstrated efficacy. It should also be noted that in terms of morbidity and health risks, while nicotine is by no means benign, it is not nearly as toxic as the delivery system (cigarettes, or cigars). Nicotine replacement therapy is both efficacious and even if it extends beyond the recommended duration, is far safer than continued use of cigarettes.

Substance Abuse

Studies of the rates of substance use are notoriously difficult to ascertain in a consistent and reliable manner, despite heroic and thoughtful efforts. The preponderance of evidence indicates that rates of use of alcohol and illicit drugs are higher in lesbians and gay men. This higher rate may be the result of a number of factors. Gay men, lesbians, and transgender individuals are subjected to higher degrees of stress than their straight counterparts. Certain aspects of LGBT culture revolve around drugs and alcohol, marketing efforts from some drug and alcohol companies specifically target gays and lesbians. The barriers to appropriate health care, stigma, and access may be even higher in terms of substance abuse treatment than in the general population. Relatively high toleration or normalization of casual substance use within an individual’s LGBT social circles and/or socio-sexual network may also present a challenge to recovery from a substance use disorder.

Substance abuse is considered by many leading health experts to be the number one factor in preventable health problems and mortality. Lesbians and gay men should be routinely screened for alcohol and substance use disorders. In addition, particularly as drug and alcohol use is associated with high-risk sexual behaviors and adversely affects other chronic diseases.

The “commonly” abused substances should of course not be ignored. The clinician who works with this population is advised to become familiar with some substances, licit or illicit that may be not as commonly used in the general population. Among these are the “Club Drugs”: Ecstasy or Molly (usually thought to be synonyms for MDMA, though analysis of drugs sold as Ecstasy and Molly often finds a mix of various other substances), ketamine, and GHB. Other newer “trending” drugs include "bath salts" (various cathinone derivatives or analogues including mephedrone and methylone).

Psychiatric illness

Most authors agree that MSM and WSW have higher prevalence of depression, anxiety, suicidal ideation, and PTSD. The links between psychiatric illness and other chronic illnesses are increasingly recognized. Psychiatric illness in GLB patients would then be expected to worsen medical co-morbidity such as diabetes and coronary artery disease.

Violence

MSM and WSW have higher rates of experiencing violence, including hate crimes and domestic abuse (Dean 2000). Routine screening for exposure to violence is recommended in this group as it is in the general population.

Legal issues

Establishing a patient's wishes regarding extraordinary or end of life care and medical decision-making is a routine recommendation for primary care preventative health, although one that is not uniformly followed. This already complex situation is further complicated by the inability of LGBT persons to legally marry, a right that would automatically guarantee one's partner access and participation in one's care.   In cases of incapacity, biological relatives can have greater legal status than a long-term partner with tragic results. LGBT persons should be counseled to seek legal advice or to use standard health care directives to establish their wishes and to designate their medical decision makers.  

Fertility issues for WSW

It is estimated that gay and lesbian parents are raising between 6 and 14 million children. As more lesbians are making the decision to have children, they may contact their PCP for referral or information about insemination services or other assisted reproductive technology (ART) (Mamo 2007). It is not known whether WSW are at higher risk for infertility. Mravcak (2006) notes that women considering ART should also be routinely referred for legal counseling regarding establishing legal relationships with the non-biologic parent and clarifying parental rights of known sperm donors.   Case law in this area is evolving and inconsistent across states.

Transgender Patients

Transgender (TG) or "Trans" refers to a broad spectrum of cross-gendered behavior and identification, including transsexualism and transvestitism. Individuals with intersex conditions are sometimes erroneously considered to be a part of this group. Health care clinicians frequently assume that a transgender status signifies a homosexual orientation, which may or may not be the case.

Health care clinicians' negative attitudes towards TG patients are common and often more overtly expressed than attitudes against lesbians and gays. Transphobic bias also exists in the GLB community. Research regarding TG patients is sparser and more flawed than that about LGB populations. Transgender individuals experience high rates of negative experiences with health care providers. A lack of culturally sensitive care, such as continuing to refer to TG individuals by the incorrect pronoun when speaking to them or in their medical records, may lead these patients to avoid seeking care. TG persons tend to have lower socioeconomic status and reduced access to health insurance as well. If unable or unwilling to seek care, they may find illicit sources of hormonal treatments to aid in their transition, and may be at similar risk for exposure to HIV and hepatitis as IV drug users (Lombardi 2001).

Transgender individuals frequently report being the victim of violent hate crimes, and should be screened for exposure to violence.

Transgender individuals have much higher rates of substance abuse, depression, anxiety, previous suicidal ideation or attempts, and psychiatric hospitalization than average. This level of psychiatric morbidity would be expected to have deleterious effects on health overall, particularly chronic conditions sensitive to stress such as cardiovascular disease and diabetes.

Male to female transsexuals

Male to female transsexuals undergo a range of therapies to alter their gender including surgical alteration of breasts and genitals and taking exogenous hormones to create female secondary sexual characteristics. Treatment with exogenous estrogen is associated with higher rates of deep venous thrombosis (DVT) (usually in the lower extremity) leading to pulmonary embolism as well as other health problems such as mood lability, weight gain, liver disease, and benign pituitary tumors. In one study the incidence of DVT in TG women was 20 times the background rate). Smoking contributes to this risk. There have been several case reports of breast cancer in TG women as well (Dean 2000). Estrogen therapy and reassignment surgery also obviously result in infertility, and biologic males considering the transition may want to consider sperm banking if they want to consider parenthood in the future.

There are reports of extremely high rates of HIV seropositivity in TG women. TG women are less likely than the general population to engage in safer sexual practices as well (Lombardi 2001).

Female to male transsexuals

Transgender women transitioning to male gender may undergo surgery to alter breasts and genitalia and take virilizing hormones. Exogenous testosterone is known to increase cholesterol, lipids, heart disease, mood lability, liver disease and tumors, hair loss, and acne. (Dean 2000).   Smoking further elevates these risks.  

Post-Test

More than one answer may be correct.
  1. MSM:
    1. Have higher rates of ASIL and anal carcinoma due to oncogenic HPV exposure
    2. Do not need HIV or STD screening if they report condom use or monogamy
    3. Delay or avoid seeking care due to concerns about discrimination and negative reactions from health care clinicians
    4. Should be screened annually for HIV, syphilis, Chlamydia, and gonorrhea.
  2. Male to female transgender patients after transition:
    1. Routinely report negative interactions with health care clinicians
    2. Have a lower incidence of DVT than the general population
    3. Take estradiol supplements, theoretically raising their risk of breast cancer
    4. Have a higher rate of HIV and unsafe sexual practices compared to MSM.
  3. WSW (women who have sex with women):
    1. Don't require HIV screening
    2. Need yearly PAP, pelvic, and breast exams
    3. Have never been documented to transmit STDs
    4. By definition never have sex with men
  4. Female to male TG patients after transition:
    1. Should still be referred to as "she" in the medical record to reflect the biological reality
    2. Are taking estrogen supplements
    3. Are at higher risk for mood lability, liver damage, dyslipidemia, and cardiovascular disease
    4. Use tobacco at higher rates, adding to the cardiovascular risk

References

Antiretroviral Therapy Cohort Collaboration. 2008. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet 372 (9635): 293–9.

Catania J et al. 2001. Men who have sex with men. American Journal of Public Health.

Dean L et al. 2000. Lesbian, gay, bisexual, and transgender health: Findings and concerns. Journal of the Gay and Lesbian Health Association 4(3):101-51.

Harcourt J. 2006. Current issues in lesbian, gay, bisexual, and transgender (LGBT) health: Introduction. Journal of Homosexuality 2006;51(1):1-11.

Laumann EO et al. 1994. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press.

Lombardi E. 2001. Enhancing transgender health care. American J Public Health 91(6): 869-72.

Maggiolo F, Leone S. 2010. Is HAART modifying the HIV epidemic? The Lancet 376(9740):492 - 493.

Makadon H et al. 2006. Optimizing primary care for men who have sex with men. J American Med Assn 296(19):2362-65.

Mamo L. 2007. Queering reproduction:   Achieving pregnancy in the age of technoscience. Durham: Duke University Press.

Mravcak S. 2006. Primary care for lesbians and bisexual women. American Family Physician 74(2): 280-6.

Perlman G, Drescher J. 2005. A gay man's guide to prostate cancer. New York: Harrington Park Press.

UNAIDS, WHO. 2007. 2007 AIDS epidemic update.

Links

Lesbian health issues from the National Women's Health Information Center

Mautner Project : The National Lesbian Health Organization

Health Concerns for Gay Men

HIV / AIDS Information & Resources

Top 10 issues for LGTB patients to discuss with their healthcare provider

Gay and Lesbian Medical Association (GLMA) Guidelines for Care of LGBT Patients