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Fair use guidelines: This presentation was built on a skeleton of the American Medical Student Association’s LGBT Local Project in a Box presentation called.

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Presentation on theme: "Fair use guidelines: This presentation was built on a skeleton of the American Medical Student Association’s LGBT Local Project in a Box presentation called."— Presentation transcript:

1 Fair use guidelines: This presentation was built on a skeleton of the American Medical Student Association’s LGBT Local Project in a Box presentation called “LGBT 101” ( and premade slides from the Fenway Institute. You may modify the presentation without permission, but somewhere please credit both AMSA Local Projects in a Box and PRIDE in Healthcare. The Fenway Institute asks that its slides not be modified. Also, please tell us at PRIDE in Healthcare via that you are using our materials You may find more resources developed by us and by others at our blog,

2 Cultural Competency Workshop I: Overview of LGBT Health
James Lehman, MD Candidate President, PRIDE in Healthcare October 23rd and 25th, 2012

3 Outline Linguistic competency Demographic and cultural considerations
Medical issues, health disparities, and health determinants LGBT in the clinic: How to ensure positive encounters

4 Terminology There are many terms sexual and gender minorities use to describe themselves Some widely accepted; others more obscure or controversial Respect language choices and the right to self-identification LGBTQIAA+: for every letter, there are people for whom the word is an important identity The so-called LGBT community is not one monolithic entity

5 Sex versus gender Sex and gender are intertwined but distinct concepts. Sex: genetic or anatomical distinction between male and female Gender: the societal construct that is associated with men (masculinity) and women (femininity) Gender identity: internal feelings of masculine or feminine identity–or both, or neither Gender expression: outward expression of gender identity Gender identity & expression are substantially culture-dependent

6 Sexual orientation versus sexual behavior
Sexual orientation: an enduring pattern of attraction—emotional, romantic, sexual, or some combination of these—to the opposite sex, the same sex, both, or neither, and/or the genders that accompany them Sexual behavior: specific sexual practices in which one engages, including anatomical sex of partner(s) gender(s) of partner(s) body parts or accessories (toys) used use of contraception/STI protection relationship status with partner(s) Epidemiologic categories reflect behavior MSM (men who have sex with men) MSMW (men who have sex with men & women) WSW WSMW

7 Sexual Attraction Sexual Orientation Paradigm of Sexuality Sexual Behavior Biological Sex Gender Identity/ Expression

8 Lesbian Gay Bisexual Transgender Queer or questioning Intersex Asexual Allies

9 Transgender Transgender: people whose gender identity differs from sex assigned at birth Transsexual: identifies with a gender other than the birth gender, often transitions hormonally or surgically Gender Bender/Genderqueer: do not easily fit into binary gender categories; may have a mix of masculine and feminine characteristics

10 (Not Really) Transgender
Crossdresser: gender identity matches assigned gender but occasionally dresses as and may take on the mannerisms of the opposite gender Performer: dresses as the opposite sex for entertainment or for work; may or may not identify as transgender. Some are drag queens (often gay men dressing as women) or drag kings (often lesbians dressing as men) The Kinsey Sicks America's Favorite Dragapella® Beautyshop Quartet

11 Transwhatnow? MTF = male to female
Called a transwoman because she is a transgender person identifying as a woman FTM = female to male Called a transman because he is a transgender person identifying as a man Trans people almost always prefer the pronouns of their self-identified gender Some prefer gender-neutral pronouns like ze/hir/hirs/hirself

12 Intersex Someone with intermediate or atypical combinations of physical or biological features that usually distinguish female from male. Usually congenital (chromosomal or genital/gonadal) anomalies Their needs and problems overlap somewhat with LGBT, but medical and ethical issues are unique.

13 Queer (umbrella) vs. Queer (Genderqueer)
Queer can refer to all sexual/gender minorities Not mutually exclusive with LGBT+ identities Queer can be shorthand for genderqueer This is an example of reclaiming a term, making it non-perjorative Fag and dyke are sometimes used this way YMMV. Some people (especially older and rural) consider it only a slur Wait for someone to self-identify as queer first Expect it most often in younger, college-educated persons

14 Cases A 35-year-old bisexual woman describes being physically and emotionally abused by her girlfriend. You empathize and ask for the history of this abuse. She promptly admits, “I’m worried my girlfriend will out me.”

15 Cases A 74-year-old widower comes to your office with complaints of burning during urination. When you ask about his family life, he talks about his children and grandchildren. When you ask who takes care of him when he gets sick, he mentions having a roommate. He does not admit until you ask directly that he has sex with men, even though he used to be married to a woman. He says he and his roommate are in an “open relationship.”

16 Cases Your patient is a successful, well-educated gay man who would like to have a least one biological child. He and his “husband” (they are domestic partners) are very anxious about finding a fertility clinic that will be friendly to them.

17 Cases A female patient with employer-sponsored insurance has an unemployed transman domestic partner. He has not undergone sex-reassignment surgery but they scrape together enough money for hormones. They cannot afford the sex reassignment surgery and legal proceedings that are necessary so that they can get married.

18 Cases An inebriated 25-year-old gay man arrives in the ED with a laceration on his leg. He admits severe alcohol addiction and suicidal ideation. When the first-year medical student who is present for an educational activity asks whether he is interested in a recovery program, the patient responds, “I’m sure they don’t want any faggots there.”

19 Cases A baby is born with an enlarged clitoris (clitoromegaly). She has 21-hydroxylase congenital adrenal hyperplasia (CAH). How do you inform and counsel the parents?

20 Cases An intersex patient who identifies as a woman presents with a sinus infection. She is currently involved with a genderqueer individual who sits in the waiting room. You hear a PA in your clinic comment that “this place is turning into a freakshow.”

21 Cases A partnered 80-year-old lesbian who has been your patient for many years with left ventricular failure presents with orthopnea and exercise intolerance. You would like to enter her into UW Health's Heart Failure Management Program. She says that she does not want to go “because the nurses will abuse [her] if [her] partner visits” and “[her] partner won’t be able to visit if something bad happens.” She has been your patient for many years. She is very assertive and came out to you on your first visit but asked that her sexual orientation never be included in her medical record.

22 Cases A teenage female is romantically attracted to women. She is not sexually active but asks you for safe sex advice.

23 Cases Two lesbian parents arrive with their infant son for a well-child exam. Their son looks well, but they seem annoyed. When you ask whether something is wrong, they say that the receptionist asked, “Which one of you is the mother?”

24 Cases A 30-year-old married Latino man has had a few recent male casual sex partners but does not identify as gay or bisexual. He admits anal sex with most of the recent partners (but never as the receptive partner), and he always uses a condom during anal sex. He is worried because one of his male partners had a positive throat culture for Neisseria gonorrhoeae.

25 Outline Linguistic competency Demographic and cultural considerations
Medical issues, health disparities, and health determinants LGBT in the clinic: How to ensure positive encounters

26 Because sexual orientation and gender identity have not historically been included in government surveys or other large population-based surveys, and because the stigma associated with being LGBT leads to underreporting, it is impossible to know the actual percentage or numbers of LGBT people in the U.S. However, a few surveys and studies have measured sexual orientation among the US population. The Laumann study, conducted in 1992, is the best designed study to date that estimates the size/proportion of the LGB population in the United States. Some of the findings are listed in this slide. The Laumann study also gives a sense of the diversity of socio-demographic characteristics of LGB populations. For example, those who have higher educations, who live in major urban area, and who are white are more likely to identify as LGB. Hispanic and Asian men were twice as likely to report same-sex desire/attraction compared to Black and White men. From this data it became clear that there is great diversity within the sexual minority populations (geographic, racial, ethnic, age, etc.), and that it is not just one population.

27 The National Survey of Family Growth 2002 was conducted by the National Center for Health Statistics, a government agency. It compiled in-person interview data from a nationally representative sample of US males and females ages One question in the survey asked study respondents if they thought of themselves as heterosexual, homosexual, bisexual, or something else. The survey found that 4.1% of respondents identified as homosexual or bisexual. Questions about same-sex behavior were also asked. Findings are listed in the slide.

28 In 1990, the US Census began to identify households that have same-sex partners living with each other. The 2000 Census found between 600, ,000 households with same-sex partners (split about evenly between male and female households). Although survey findings show same-sex couples tend to live in metropolitan areas, a large percentage live outside the central city location (the suburbs), and 13% of couples live in non-metropolitan areas. In addition, same-sex households were observed in nearly every county in the country. This information indicates that you are likely to encounter LGBT patients no matter where you practice. It should be noted that these numbers underestimate the total number of LGB people in the U.S. since the Census does not count LGB people who are single, who do not live with partner, or who are self-identified bisexuals in opposite sex relationships. In addition, it is likely that some respondents did disclose their same-sex relationship out of fear of exposure or discrimination.

29 An increasing number of LGBT adults are choosing to have children (some lightheartedly refer to this trend as a “gayby” boom). According to an analysis (Gates and Ost, 2004) using data from the US Census 2000 and the National Survey of Family Growth (2002), approximately 27% of same-sex couples are raising children. These findings likely undercount the actual number of LGB parents in the US. Additionally, many more gay men and lesbians report the desire to birth or adopt children. Although many children of LGBT adults were conceived during previous heterosexual relationships, the number of children being born to, or adopted by people who identify as LGBT is increasing as more people “come out” at an earlier age.

30 Williams Institute, UCLA

31 To date, there are no reliable estimates of the transgender population in the US or abroad. A few studies have attempted to estimate the prevalence of transsexuals in a population using clinic data (e.g., numbers who attend clinics for surgical or medical attention). In 2007, two researchers (Olyslager and Conway) presented a re-analysis of several published studies on transsexual prevalence and determined the prevalence to be between 1:1000 and 1:2000. They also presented some more recent data that estimates the prevalence to be as high as 1:500. Until this data was presented, the most frequently quoted estimates were from a Dutch study that estimated the prevalence of MTF transsexuals at about 1 in 12,000, and FTM transsexuals at about 1 in 30,000. The use of a much broader definition of transgender (as described in previous slides) would significantly increase the prevalence estimate, but no studies or surveys have attempted to do this yet.

32 Cultural background and self-identification RACE/ETHNICITY
African American men have used SGL (same-gender loving) and on the DL (down low) as alternatives to “gay,” a white identity Hispanic heterosexually married and unmarried MSM often do not consider their behaviors homosexuality 130+ Native American peoples have defined a mixed gender identify (e.g., two-spirit)

33 Cultural background and self-identification
Up to half of lesbians are or have been heterosexually married Some WSW with female partners identify as heterosexual Older generations less likely to disclose identity Experienced criminalization Pathologization by psychiatry Fear of reparative therapy or other mistreatment

34 Cultural background and risks
Sexual minority + racial/ethnic minorities = compounded effects of discrimination and lack of privilege (minority stress) Other characteristics that affect disclosure of identity and sex behaviors: education level, income, geographic location, language, immigration status, knowledge, and cultural beliefs

35 Leading health indicators for sexual minorities
In Healthy People 2010, the Department of Health and Human Services identified ten leading health indicators (determinants) in the US population. Seven were particularly relevant to sexual and gender minorities. Physical activity Overweight and obesity Tobacco use Substance abuse Responsible sexual behavior Mental Health Injury and violence Environmental quality Immunization Access to care


37 Outline Linguistic competency Demographic and cultural considerations
Medical issues, health disparities, and health determinants LGBT in the clinic: How to ensure positive encounters

38 LGBT patient health OVERVIEW
Research disparities Health care barriers Institutional/structural Provider Patient Minority stress Biology

39 As mentioned previously, the majority of research on LGBT populations has focused on HIV/AIDS risk and treatment in gay/bisexual men. Funding for epidemiologic and clinical research on other health concerns of LGBT populations has thus far been limited. Societal bias and stigma associated with homosexuality/bisexuality, same-gender sexual behavior, and transgender identity have further restricted the ability of researchers and government surveys to access LGBT populations for surveys and studies. As a result, relatively few studies on LGBT health concerns have been conducted, and many of these studies have had to use small, convenience samples, thus limiting the generalizability of research findings, and sometimes overestimating disease and other pathology estimates (for example, studies of alcohol use that sampled men in bars). More recently (at least partly due to the IOM report and HP 2010 documents), researchers have been able to conduct a number of larger, population-based studies on sexual minorities, allowing a fuller, more accurate picture of health status and outcomes. Also, sexual orientation measures have recently been added to some government surveys. (See for a good selection of these surveys and their findings.) Although growing in number and scope, the research studies on transgender populations and their health are still extremely limited and new. Most studies have been qualitative, have used small, convenience samples, and have focused largely on HIV risk behaviors among male-to-female transsexuals who work in the sex industry. Research specifically on bisexual populations is even more rare. In general, research studies group bisexuals with lesbian and gay samples, even though the particular health behaviors and outcomes of bisexual populations may be quite different from those of lesbian and gay populations. Despite the limited scope of research on LGBT health, enough evidence has been accumulated over the last few decades to make some conclusions about disproportionate health risks and concerns for LGBT populations. The following slide provides a summary of these primary health concerns.

40 LGBT patient health MINORITY STRESS
Minority stress: Prejudice and discrimination are chronic social stressors Distal stress processes are external, including experiences with rejection, prejudice, and discrimination Proximal stress processes are internal and often the byproduct of distal stressors: concealment of minority identity, vigilance and anxiety about prejudice, and negative feelings about one’s own minority group

41 Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull September; 129(5): 674–697.

Often victims of violent physical assaults and other forms of abuse Substance abuse Unique fertility concerns Intimate partner violence Stresses resulting from depression, anxiety, suicide

43 O’Hanlan KA et al. A Review of the Medical Consequences of Homophobia with Suggestions for Resolution. J Gay Lesbian Med Assoc. 1997; 1(1):25-39.

44 LGBT health concerns LGBT Youth
Lack healthy outlets for sexual exploration Far more likely to smoke Far more likely to become homeless Verbal and physical violence Several times more likely to be threatened or injured with a weapon at school Suicide and depression Nearly 1/3 of all adolescent male suicide attempts involve a crisis over sexual orientation Supportive environments and people make all the difference I don’t know if you want to add this information of how some of these concerns can be buffered by the having a positive social environment, especially the mental health (just a suggestion). Positive family support or support networks in general help buffer (kind of common sense) – From Review of Psychiatry Vol, 21 Highlighting the importance of asking questions that determine if the patient has a supportive environment… etc.

45 LGBT health concerns LGBT Elders
2x as likely to live alone as other seniors Half as likely to have a partner 4x more likely to  have no children to assist them 50% more likely to have no close relatives to call for help when needed Increased rates of smoking, obesity, alcohol abuse, and HIV infection Delay and avoid health care

46 Lesbian health Increased risk of breast cancer Nulliparity
Less use of hormonal “birth control” Increased risk of other GYN cancers Pap intervals up to 3x longer than heteros Inactivity + obesity + smoking + stress= cardiovascular risk STIs Often ignored in WSW; screening just as important HSV, HAV and HBV, HPV, chlamydia, gonorrhea, and HIV Common vaginal infections: Yeast infections, trichomoniasis, bacterial vaginosis

47 Gay male health STIs MSM are at higher risk of both HAV (oral-fecal) and HBV (sexual contact)—Immunize! MSM youth are particularly vulnerable to STIs Illicit drug use Raises chances of unsafe sexual behavior Needle sharing directly transmits infections Eating and body image disorders Anal cancer (35x heterosexual men) Often caused by HPV, but immunocompromised men at higher risk Gay men who have receptive anal sex recommended to get anal pap smears

48 Bisexual health Often parallel risks to gay men and lesbian women
As with MSM and WSW, STIs risks reflect specific behaviors Sometimes face marginalization in LGBT community itself Women Smoke more than lesbians More mood and anxiety disorder Less often insured than lesbians Higher rate of injected drug use than lesbians Screening neglect: cholesterol, mammography Men Rarely separated from gay men in epidemiologic analysis

49 Patients may seek advice from clinicians about the magnitude of risk for HIV/STIs conferred by different sexual practices so that they can make their own choices about the risks they are willing to take. A basic guideline of risk is presented in this slide and the next. Certain STIs that are transmitted by skin-to-skin contact rather than fluid contact, such as HPV, syphilis, and herpes, can be transmitted during protected oral and genital intercourse, through skin areas not covered by a condom, such as the base of the penis or testicles. 49 49

50 With all sexual acts, tears and abrasions in mucous membranes or skin increase risk of acquiring infections. Presence of an STI can increase risk of HIV acquisition (CDC, 2008). For HIV-positive individuals, presence of an STI increases their HIV infectiousness (Wasserheit, 1992). HIV prevention activities do not correlate with reduction of high risk of STI transmission. For example, some people will engage in oral-genital sex as a risk reduction technique, but this only lowers their risk for HIV, not for most STIs. For more information on woman-to-woman transmitted STIs, go to the CDC’s website ( and Bauer and Welles, 2001 (Handout 2-B: References). Although studies show presence of certain STIs in women who report only female partners, transmission methods and prevalence require further study. With STIs transmitted by cervical fluid, such as Chlamydia, penetrative contact with a hand previously in contact with the infected cervix or with a shared sex toy is likely needed for transmission (Bauer and Welles, 2001). While there have been case reports of HIV transmission from woman to woman (e.g., Rich et al., 1993; Kwakwa and Ghobiral, 2003), there are no confirmed such cases (CDC, June 2006). 50 50

Identifying as transgender is not a mental illness. But rates of suicidal ideation are extremely high: ~50%. Gender Identity Disorder remains in the DSM-IV-TR. Victims of violence, hate crimes, and homicide more than any other group (16-60% physically assaulted, and 13-66% sexually assaulted) High levels of marijuana, crack cocaine, alcohol, methamphetamine (4-46%), and injection drug (2-40%) use Extremely high levels of joblessness and poverty Insurance plans limit access to hormones or sex reassignment surgery Refusal of care—both outright and subtle—is common

52 Transgender health Transitioning Basics
MTF (Male to Female) therapy Breast implantation Hormone therapy Genital surgery Reconstructive surgery Do not have prostate removed; still are at risk of prostate cancer FTM (Female to Male) therapy Breast reduction Still at risk of breast cancer in spite of breast reduction surgery Risk of cervical and ovarian cancer There are a wide variety of procedures and therapies that individuals may chose to transition from one sex to another. Although not every transgender person desires or is able to afford surgery, those who do require appropriate follow-up care. Those who do not still require the screenings (notably breast and prostate exams, and pap smears) for the organs they have. Pre-op or preoperative (or non-op): - A transgender person who has not had surgery - A transgender woman living as a woman who still has male genitalia - A transgender man living as a man who still has female genitalia Post-op or post operative: A transgender person who has had sex reassignment surgery

53 Hormone Therapy FTM Testosterone to stimulate masculinization MTF
Spironolactone to reduce androgen effects Estrogen to stimulate feminization Optional progesterone for breast development and additional anti-androgen effects The most widely used guidelines for the diagnosis and treatment of Gender Identity Disorders comes from WPATH, the World Professional Association for Transgender Health (formerly Harry Benjamin International Gender Dysphoria Association (HBIGDA)). It is a professional organization devoted to the understanding and treatment of gender identity disorders. They have approximately 350 members from around the world, in the fields such as psychiatry, endocrinology, surgery, psychology, sexology, counseling, law, and sociology.

54 Transgender health Standards of Care
Requires a close patient/physician relationship National Transgender Discrimination Survey (2010): 28% experienced verbal harassment in a medical setting 50% encountered providers that lacked knowledge of health care needs “Gender Identity Disorder” in DSM-IV-TR Used to justify medical treatment of transgender individuals and gain insurance coverage World Professional Association for Transgender Health (formerly HBIGDA) publishes Standards of Care. The most widely used guidelines for the diagnosis and treatment of Gender Identity Disorders comes from WPATH, the World Professional Association for Transgender Health (formerly Harry Benjamin International Gender Dysphoria Association (HBIGDA)). It is a professional organization devoted to the understanding and treatment of gender identity disorders. They have approximately 350 members from around the world, in the fields such as psychiatry, endocrinology, surgery, psychology, sexology, counseling, law, and sociology.

55 Outline Linguistic competency Demographic and cultural considerations
Medical issues, health disparities, and health determinants LGBT in the clinic: How to ensure positive encounters

56 Communication with LGBT patients in a manner that is culturally sensitive is not difficult if you listen to how your patients describe themselves and their partners, and then follow their lead. If in doubt of how to refer to your patient’s sexual identity or partner, it is okay to ask the patient what terms they prefer to use. One caveat about following your patient’s lead: sometimes people use terms for themselves that sound derogatory if coming from an outside source. For example, “faggot” or “dyke”. Again, if you are unsure if your patients would be comfortable with you using this language, ask the patient.

57 LGBT-sensitive intake form

58 LGBT-sensitive intake form

59 Another key to positive communication with LGBT patients is to avoid assumptions related to sexual and gender identity, sexual behavior, and attractions. All of these issues have been discussed in previous slides, but bear repeating in the context of communication with patients.

60 Some LGBT people who may not be part of the LGBT community, (e. g
Some LGBT people who may not be part of the LGBT community, (e.g., people who have not come out, LGBT people of color, bisexual or transgender individuals), may also be interested in a health provider with whom they can discuss LGBT-related issues.

61 Negative attitudes toward LGBT people are common: clinicians are subject to the same societal influences as everyone else and are vulnerable to believing stereotypes and making assumptions. A helpful exercise in examining one’s own beliefs is to reflect on your own reactions when someone -- a patient, colleague, friend, etc. -- tells you/has told you they are LGB or T. Exercises such as this can stimulate us to think about our deepest internal reactions to people of difference. It is easy to see how personal biases, even the ones we wish to dispose of, can interfere with the process of truly understanding a patient and establishing empathy during a clinical encounter. To the instructor: You can facilitate further small group discussion based on the attitudes assessment questions in Handout 1-B. The handout can also be used for individual reflection by course participants.

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