1. March 9, 2016 Care of LGBTQ Population in College Health Uri Belkind, MD Clinical Director, Health Outreach to Teens (HOTT) Callen-Lorde Community Health Center

2. OBJECTIVES Identify the particular health needs of LGBT college students. Understand the importance of creating safe spaces and of the sexual history to recognize specific health needs of LGBT college students. Discuss specific health services needed to provide comprehensive care to the LGBTQ population.

3. Importance of this training Both youth and the LGBTQ community are marginalized, which is associated with increased health risks. Clinicians rarely receive training specific to LGBTQ youth. Providing LGBTQ youth-competent care is a skill.

4. Terms, definitions, acronyms… LGBTQ: Lesbian, Gay, Bisexual, Transgender, Questioning/Queer SOGI: Sexual orientation and gender identity –Sexual orientation and gender identity are two separate concepts and do not always “match”

5. Sexual Orientation Identity : a label –“I am…” LGBTQ, pansexual, asexual… Behavior : most clinically relevant –“I have sex with…” MSM, WSW, MSWM, TFSM, TMSWM… Attraction : doesn’t always align with above –“I like…”

6. Sexual Orientation: Identity NYC YRBS 2013

7. Sexual Orientation: Behavior NYC YRBS 2013

8. Gender Identity GENDER IDENTITY SEX CHROMOSOMES ANATOMY

9. Gender Identity GENDER IDENTITY SEXUAL ORIENTATION

10. Gender Identity Identity : a label – “I am…” Male, Female, Transfemale/male, Genderqueer, GNC, Non-binary… Expression : communication of one’s gender – “I appear and/or behave…” Masculine, Feminine, Androgynous Role : society’s expectations of each gender – “Be a man!”, “That’s not ladylike” Masculine, Feminine, Neutral

11. Sexuality is a Spectrum (And there are no “Should’s” or “Should not’s”)

12. Case 1. WZ 20yo Asian male STI screening Identifies as gay

13. LGBT Health Disparities Victimization Homelessness Mental health –Anxiety, Depression, PTSD –Suicidality –Eating Disorders –Substance use –High-risk sexual behaviors ↓Education

14. LGBT Sexual Health MSM have higher rates of some STIs –Gonorrhea –Primary and secondary syphilis –HIV WSW might have higher rates of: –Trichomonas –Bacterial vaginosis

15. College LGBT Sexual Health (Compared to heterosexual counterparts) MEASURE LESBIAN BISEXUAL ♀ GAYBISEXUAL ♂ #partners=↑↑↑ Oral Sex==↑↑ Vaginal Sex ↓ =↓↓↓ Anal Sex ↓ ↑↑↑ Safer sex: Oral==↑↑ Vaginal↓↓↓== Anal==== HIV Test=↑↑↑ Oswalt. 2013

16. College LGBT Sexual Health (Compared to heterosexual counterparts) STI LESBIAN BISEXUAL ♀ GAYBISEXUAL ♂ Chlamydia==== Gonorrhea==↑= Genital HSV=↑== Genital warts==↑= Hep B or C==== HIV==↑= Oswalt. 2013

17. Case 1. WZ (cont.) Multiple male sexual partners Anal and Oral sex –Versatile Condoms sometimes Doesn’t ask partners if they know their HIV status

18. HIV and LGBT Youth 1:4 new HIV infections  13-24yo Young MSM  1:5 new HIV infections Black youth  57% HIV infections in youth 20-24yo group  highest # of HIV diagnosis 2 per 1000 college students are HIV+ 1 1 ACHA-NCHA-II

19. Anal Sex and HIV risk

20. HIV Prevention Condom use –Insertive anal sex: 63% effective –Receptive anal sex: 72% effective Serosorting: 54% effective TASP: 96% effective (maybe higher) PrEP: 92% effective (maybe higher) nPEP: ? effectiveness Screening and treating other STIs

21. Mental Health Disparities Eating-related pathology (TG>G/B>F) –Diagnosis of ED –Diet pill use –Vomiting or laxative use Depression and Suicidality –Felt sad: Bisexual > GL –Attempted suicide: 3xGL, 5xBisexual –Sought MH: Non-het 2x Diemer, 2015 NYC YRBS, 2013

22. Victimization NYC YRBS, 2013 Missed school b/c felt unsafe Straight G/L Bisexual Unsure Bullied on school property Experienced physical dating violence Experienced sexual dating violence

23. Case 2. DD 18yo Hispanic female Requesting EC

24. Taking a sexual history Don’t assume: Patients are heterosexual Bisexuality is a phase Sexual orientation based on gender of partner Sexual orientation or gender identity based on appearance Sexual orientation or gender identity is the same as last visit LGBTQ patients are engaging in risky behavior LGBTQ patients have unsupportive families

25. Case 2. DD (cont.) Had a few drinks at a party last night Had consensual sex with a friend who identifies as bisexual. Didn’t use barrier protection, not on BC. DD says she came out as bisexual but thinks she identifies more as a lesbian

26. Creating safe spaces Provider sensitivity: For LGBTQ youth, the strongest predictor of disclosing orientation/ identity was discussing sexual health with their provider Recommendation to promote disclosure: “Just ask me” Lesbians who were out to their providers were more likely to receive a pap test and other preventative care Lesbian and bisexual youth are at least 2 times more likely than heterosexual youth to have unplanned pregnancies You may be one of the few people with whom they feel comfortable discussing these issues

27. Creating safe spaces First impressions are important: patients will walk in and assess for affirmation Assess and change current clinical environment - Clinic brochures and posters, health education materials - Unisex bathrooms Ensure your intake forms are inclusive of multiple gender identities and sexualities - Establishes non-judgmental attitude Advertise the cultural competency of your practice - Create and post non-discrimination, diversity policies, and confidentiality policy around clinic

28. Creating safe spaces

30. Taking a sexual history Some questions to ask everyone: Have you ever been or are you in a relationship? How old is your partner(s)? How would you describe the relationship? Have you had sex or been intimate with guys, girls, or both? If you have not had sex yet, what are your plans about sex in the future? Has anyone every touched you in a way that made you feel uncomfortable? Do you talk with your parents or other adults about sex and sexual issues?

31. Taking a sexual history Do you (or your partner) use anything to prevent getting an STI? –How often- always, most of the time, sometimes, or never? –By site Have you ever been told that you had an STI? Have you ever traded sex for money, drugs, a place to stay, or other things you need? If at risk for pregnancy: Do you (or your partner) use anything to prevent getting pregnant? Have you ever been pregnant? What happened with that pregnancy?

32. Asking about Gender and Sexual Behavior Some patients are going to be offended that you don’t assume heterosexuality or that they are cis- gender; similarly, other patients will be relieved that you don’t. “Do you consider yourself male, female, transgender or another gender?” OR “What gender do you consider yourself?” “What is your preferred gender pronoun (PGP)?”

33. Asking about Gender and Sexual Behavior If the patient is sexually active include the following questions: –Have you gone down on anyone (had oral sex) –Have you had anal sex? –Do you share sex toys? For MSM and MTF with M: “Do you top, bottom or both?” For opposite-sex partnering: “Do you have penile- vaginal sex?” For WSW and FTM with F: “Do you share sex toys?” May need to use different wording for transgender patient: “What wording do you use to describe your genitalia? I am asking so I can use the correct term when asking questions.”

34. Sexual behaviors “by site”

35. Case 2. DD (cont.) Declines birth control because she “doesn’t have sex with men very often.” Declines STI testing since this was the first time she had condom-less intercourse with a guy.

36. Case 3. SM 19yo, identifies as transmale Comes in for a physical Interested in starting masculinizing hormone therapy

37. Trans* Person whose gender identity or expression differs from their sex assigned at birth Umbrella term –MTF: Male-to-Female, Transwoman –FTM: Female-to-Male, Transmale –Gender variant, gender non-conforming, gender queer, non-binary, etc.

38. Transgender is not… A verb –You don’t transgender into… –There is no transgendering... A noun –The transgender came... –Transgenders tend to...

39. Transitioning Process and time during which a person begins to live as their new gender “Transitioning” means different things to different people 4 main aspects: –Social –Legal –Medical –Surgical People may not be interested in all aspects of transition and there is no right order on how to transition

40. TG Health care needs Knowledge is important but sensitivity even more so. It’s ok to not know, it’s not ok to not ask. Discomfort with exam especially of genitalia and breasts –“How do you refer to those body parts?” –Explain reason for exam and give patient option to refuse

41. Trans* patients Assure the patient that many are uncomfortable with the exam and that they may stop the exam at any time Provide information of why the exam is necessary Ask about PGP and terms for anatomy Discuss steps of exam before and during Maintain best practices for both anatomy and hormonal milieu

42. What more can we do? Multi-site STI testing Kent, 2005 Urine-only would have missed: 63.6% 69.6%

43. What more can we do? Trans* care: –Help patients access hormone therapy –Administer hormone injections –Teach patients to self-inject safely –Harm reduction approaches (???)

44. What more can we do? HIV+ patients: –Communicate with pt’s PMD (w/consent) –Help patients obtain medications Rx by mail Help with refills Keep meds for patients if confidentiality issues –Help patients attend f/u visits

45. What more can we do? nPEP: –Discuss with all patients, especially those at higher risk –Provide starter packs or identify nearby health centers that do –Have resources for patients that need further care (beyond starter packs)

46. What more can we do? CONTINUE TO BE ADVOCATES ON BEHALF OF OUR PATIENTS

47. THANK YOU! Care of LGBTQ Population in College Health