1. LGBTQ Health: Who, What, Where and Why We Should Care
Laura C. Hein PhD, RN, FAAN

2. Objectives Introduce you to LGBTQ terminology
Discuss historical and contemporary health concerns of the LGBTQ community
Discuss facilitators and barriers to health
Present current legal and regulatory standards related to LGBTQ health with recommended practice protocols
Is your facility compliant?

3. Definitions Gay, Lesbian Bisexual Transgender (gender identity)
LGBTIQ
Gay, Lesbian
Exclusive physical and emotional attraction to members of one’s own sex
Bisexual
Physical and emotional attraction to members of both sexes
Transgender (gender identity)
A person who feels his or her body is not the sex it should be, regardless of transformational hormone or surgical status
Cis-Gender
A person whose gender identity matches their sex at birth

4. Transgender (gender identity)
LGBTIQ
MtF = Male-to-Female (she) transwoman
Born with male anatomy, female gender
FtM = Female-to-Male (he) transman
Born with female anatomy, male gender

5. Definitions Intersex Questioning Queer LGBTIQ
The vogue term for hermaphrodite. People born with the sexual characteristics of both sexes
Questioning
People who suspect they might be LGBT, but are not yet certain
Queer
Inclusive term of the LGBTIQ community
Unique paradigm

7. Prevalence - 9 million LGBT people in the U.S.
Homosexual (gay/lesbian is preferred term)
3.4% self-identify as LGBT (Gates & Newport 2012)
1 in % of males in the U.S. reported either homosexual behavior or homosexual attraction since age 15 (Sell, Wells & Wypij, 1995)
17% of women and 6% of men have engaged in same-sex behavior. However, 7% of women and 4% of men identify as gay or bisexual (Copen et al. 2016).
Sell, Wells, and Wypij, (1995) surveyed 3,931, 16 to 50 year old people across three countries and found that 20.8% of males in the United States reported either homosexual behavior or homosexual attraction since age 15.
Remember there are 320 million people in the U.S.

8. Transgender Population size
~1.4 million adults self-identify as trans in the U.S.
Crissman et al. 2017; Flores et al., 2016; Meerwijk & Sevelius, 2017

9. Gender Non-conformity or gender Dysphoria
the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (IOM, definition)
discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (WPATH, 2011)

10. Transgender Health – Youth
Protections under Title VII and Title IX of the Civil Rights Act. Affirmed by DOJ filing in G.G. v. Gloucester County School Board (2015). Case on appeal to SCOTUS. Oral arguments Feb
“There is a public interest in ensuring that all students, including transgender students, have the opportunity to learn in an environment free of sex discrimination.” (DOJ)

11. Transgender Health – Restroom Access
April 8, 2015 – EEOC has ruled that an employers refusal to allow a transgender employee access to restrooms consistent with his or her gender is sex discrimination under Title VII.
EEOC case: Lusardi v. AMRDEC

12. What about School? Title IX
Title IX protects students, faculty and employees from sex discrimination in any federally funded education program or activity.
However… schools are still not safe.

13. Early social transition
Child lives as gender that matches their identity
Trial run - name, attire, social roles at school, in community
Reversible
Family decision whether to disclose to others or not
Approx. 25% of children who were assessed for gender dysphoria grew up to be cis-gender gay vs. transgender.

14. Children and youth EARLY medical and mental health services
Family support is critical to positive health outcomes
Puberty experienced congruent with gender (delay until sure)
Reduces need for later medical interventions
Prevents unwanted sex characteristics (i.e. breasts)
Decreases stress, anxiety, depression

15. Reparative therapy
= Efforts to change the sexual orientation or gender identity
Condemned by all mainstream professional organizations as harmful including the APA, AMA, Am Acad of Pediatrics, AAN, ISPN etc.
Related to depression, anxiety and suicide
George Rekers (prof emeritus from USC SOM) – published case where he conducted reparative therapy. This is what he did….

16. Puberty blocking – GnRH Agonists
Ideally begun in Tanner 2 stage (early start of puberty).
Can begin in Tanner 3-5 – goal is to stop puberty/ prevent secondary gender characteristics i.e. height, breasts etc.
GnRH Agonists - Leuprorelin; Triptorelin; Goserelin; Histrelin implants
Very expensive. Cost is between $500 and $1500 month.
Insurance rarely covers this cost
Effects are totally REVERSIBLE
STRONG support by deVries group that early blocking of puberty with hormone replacement is associated with no adverse events, no suicides and no use of street hormones.

17. Irreversible Hormone effects
ESTROGEN
Breast development
Nipple enlargement
Loss of erection
Testicular atrophy
? sterility
TESTOSTERONE
Uterine atrophy
Facial and body hair
Deepened voice
Clitoral enlargement
? sterility

18. First do no harm…. There is harm related to NOT intervening
Suicide ~ 44%
Depression
Anxiety
Homelessness
ETOH, drug use
Sex work
HIV

19. Overrepresented Health Problems
HIV/ AIDS
Trauma/ Victimization
Mental Health Concerns
Addictions
Is this because they’re LGBT? –or- because of the context within which LGBT people must exist?

20. HIV/ AIDS A missing generation of gay men due to AIDS
HIV+ the norm in some areas
Homelessness/ poverty – survival sex
Street hormones (trans)

21. Trauma/ Victimization
Parental abuse
Increased prevalence of verbal and physical abuse and heightened suicidal ideation among those who disclosed their s.o. to their families
Hate crimes

22. Mental Health – Depression & Anxiety
Additional stress d/t image management related to s.o./g.i.
LGBT children often grow up in a society that says that they should not exist and/or should not act on their feelings.
These societal mores can be internalized = internalized homophobia

23. Depression
Prevalence of depression 17.2% higher than in U.S. adult men in general
Distress & depression associated w/:
lack of a partner;
not identifying as gay, queer, or homosexual;
experiencing multiple episodes of antigay violence in the previous 5 years; and
very high levels of community alienation
Mills 2004

24. LGBT Youth Victimization
25% of gay youth (16% lesbian) have been threatened or injured with a weapon on school property.
3x higher than hetero rate for boys; 4x higher than hetero for girls.
13% gay (16% lesbian) youth didn’t go to school because of safety issues (O’Malley, 2014)
3x the hetero rate
Sample was of YRBS HS students
N=528

25. Mental Health - Suicide
LGB youth = 30% attempted suicide (double the hetero rate)
School bullying increased the risk of suicide (Bouris et al, 2016)

26. Transgender Suicide 42% attempted suicide
U.S. Trans/GQ Data
42% attempted suicide
Those who reported moderate to severe rejection by their family were more likely to attempt suicide (OR 2.0 to 3.2 respectively) (Drapeau, 2015)

27. Addictions Young LGBT (most prevalent)
Hein - Safe?
Addictions
Young LGBT (most prevalent)
Lesbian/ female Bi – principally ETOH
Gay/ MtF Transgender –
Ecstasy (and other Rave drugs)
Risk = hyperthermia;
Poppers (amyl nitrate) – enhanced sexual experience
Risk = an MI, priapism
Ecstacy: MDMA
Ecstasy = a stimulant and psychedelic
Distortion in time and perception. Enhanced tactile sensation.
Poppers – dilation of blood vessels

28. CDC Recommendations for SCHOOLS to support LGBTQ health
Identify “safe spaces”
Prohibit harassment and bullying
Facilitate access to health & psych providers not on school property who are LGBTQ affirming
Encourage professional development on safety for all students
Provide health education curricula with inclusive terminology
Demisse et al., 2013
Identify “safe spaces” such as a counselor’s office, designated classroom, or student organization where LGBTQ youth can receive support from administrators, teachers, other school staff, or other students.
2. Prohibit harassment and bullying based on a student’s perceived or actual sexual orientation or gender expression.
3. Facilitate access to providers not on school property who have experience delivering health services, including human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing, counseling, and reproductive healthcare, to LGBTQ youth.
4. Facilitate access to providers not on school property who have experience in providing social and psychological services to LGBTQ youth.
5. Encourage staff members to attend professional development on safe and supportive school environments for all students, regardless of sexual orientation, gender identity, or gender expression.
6. Provide health education curricula or supplemental materials, i.e., HIV, STI, or pregnancy prevention information relevant, to LGBTQ youth (e.g., curricula or materials that use inclusive language or terminology).
What is SC law related to this?

29. CASE 1
A 15yo questioning female student presents to the school nurse asking him to sponsor a Gay Straight Alliance (GSA) at their school. The best school nurse answer:
“yes, of course I’ll sponsor a GSA”
“I’d like to but I’ll need to talk to the principal first”
“I think I’d like to talk to your parents first – we’ll be back in touch”
“You really need to talk to our school psychologist about this”

30. SC Code A(5) Local school boards to implement comprehensive health education program; guidelines and restrictions
(5) The program of instruction provided for in this section may not include a discussion of alternate sexual lifestyles from heterosexual relationships including, but not limited to, homosexual relationships except in the context of instruction concerning sexually transmitted diseases.

31. Case 2
30yo transman who initiated social gender affirmation 5 years ago, chest construction at 25yo, testosterone from 25-28yo. He grew a beard and stopped taking T. Beard growth persisted. No menstruation for 5 years. He would like the option to become pregnant in the future because he wants children but has legal concerns related to adoption. As the NP you first:
Conduct an exam and draw labs
Conduct an exam, draw labs and refer to endocrinology
Conduct an exam, draw labs and refer to GYN
What are the concerns re: an exam?
What labs to you draw?
Is there a SAFE endocrinologist or GYN in SC?
How do you support and council him?
How can you support his goals that are inconsistent with a binary M/F?
You may need to know a little more about caring for a trans client.

32. Your patient wants to transition – now what?
The pdf is free
Google “WPATH Guidelines”
Refer to a Psych NP or other mental health provider
Start hormone therapy
The psych referral is only because you need a diagnosis of Gender dysphoria before there’s even a remote chance of insurance coverage.
Hormone Therapy - guidelines

33. Research on hormones – is it safe?
FTM
MTF
No increase in CAD found in 876 FTM pts (Gooren, 200)
Increased risk of CAD at high doses.
Increased risk of CA at low doses
If prior MI – PO estradiol does not incr. or decr. risk for further emboli

34. WPATH Standards of Care
The criteria for hormone therapy are as follows:
Persistent, well-documented gender dysphoria;
Capacity to make a fully informed decision and to consent for treatment;
Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI);
If significant medical or mental health concerns are present, they must be reasonably well controlled
Therapy is no longer an absolute requirement prior to hormone therapy or surgery.

35. Hormones FtM - Options Injectable Testosterone
Rx information taken from
Cavanaugh 2016
Hormones FtM - Options
Injectable Testosterone
Testosterone Enanthate or Cypionate mg IM q 2 wks (20 -22g x 1 ½” needles)
Transdermal Testosterone
Androderm TTS 2-8mg daily
Topical testosterone gels in packets and pumps, multiple formulations (Testim, Androgel) 5 to 10 gm (50 to 100 mg of testosterone) applied topically daily
Axiron 2% pump gel for axillary application 1 pump to each axilla daily
Testosterone Pellet
Testopel- implant 6-10 pellets q 3 to 6 months
Buccal Testosterone
Striant 30 mg buccal system q 12 hours

36. Testosterone  HDL  triglycerites  insulin resistance  sleep apnea
Risks
Monitoring
Baseline CBC, CMP, lipids, renal panel, fasting glucose
3 month, then Q 6-12 mo
CBC, liver enzymes, serum testosterone
Q 6-12 mo
Lipid profile, HbA1c
 HDL  triglycerites
 insulin resistance
 sleep apnea
Infertility
Mental health changes

37. Hormones MtF options Oral Estrogen
Estradiol (estrace) 2-6mg PO or SL daily(can be divided into BID dosing)
Premarin (conjugated estrogens) mg PO daily (can be divided into BID dosing)
Transdermal estrogen (preferred for 40yo)
Estradiol patch mg twice weekly
Injectable Estrogens [NOTE – shortage right now]
Estradiol valerate5-20mg IM q2 weeks
Estradiol cypionate2-10mg IM weekly
Antiandrogens
Spironolactone (aldactone) mg PO daily (can be divided into BID dosing)
Finasteride (Proscar) 2.5-5mg PO daily
Progestins – increase breast development, but CV risk, weight gain & depression

38. MtF – Estrogen Risks monitoring
CAD weight triglycerides
libido glucose tolerance
Gallbladder ds
Infertility
Mental health changes
Spronolactone carries risks of hypotension, hyperkalemia and renal insufficiency
Baseline – CBC, CMP, lipids, renal, fasting glucose, testosterone, prolactin
6mo. – serum testosterone & estradiol
If on spironolactone
1 mo. then 3mo. – lipids, lytes, creatinine, glucose

39. MtF Surgical Options (~30%)
Removal of scrotum & penis
Creation of vagina, labia, clitoris & mons
Breast augmentation
Tracheal shave
Facial feminization
Brow
nose
All surgery resulting in sensate and functional changes. The Schechter 2017 citation discusses this in detail.
Creation of a vagina can occur in three ways: 1) penile inversion vaginooplasty; 2) intestinal transplantation; or 3) nongenital flaps (l
last choice)
Breast augmentation – for either transition will require areola and nipple augmentation
Facial feminization: brow lift. Reduction of the dorsal hump on the nose. Upper lip shortening.
Taken from Schechter 2017 p.37

40. FtM Surgical Options (~30%)
Phalloplasty with urethral reconstruction & creation of scrotum (uncommon)
Chest reconstruction
Testicular implants require a second surgery

41. Staged Surgeries Genital FtM Chest Contouring FtM
Tissue removal from donor site
Urethral reconstruction
Implant prosthesis
Chest Contouring FtM
Mastectomy
Revision of prior surgery to decrease scarring and remove arm flaps

42. You’re aN ORG leader/ Manager What can YOU do?
Know the law and standards related to LGBTQ patients
Train your staff – receptionist to CNO
Work on the culture of your organization to make it safe.
So what are these laws/ standards

43. Joint Commission Standards (2011)
The patient-centered communication standards for Hospitals (CAMH).
Elements of performance 28 and 29 under RI , require access to a support person and non-discrimination of care.
The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and FamilyCentered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL, Oct LGBTFieldGuide.pdf.

44. RI Element 29
“No longer considered to be simply a patient’s right, effective communication is now accepted as an essential component of quality care and patient safety.”

45. Hospital visitation
January Centers for Medicare and Medicaid Services (CMS) regulation required hospitals to permit patients to designate visitors & prohibits discrimination in visitation based on so/gi C.F.R. §
Compliance with requirements for Medicare Conditions of Participation (CoPs)
Rule prompted by Langbehn v. Jackson Memorial Hospital (2010). US District Court of FL. dismissed the case. President Obama did not.

46. Hospital Visitation
July 2011 Joint Commission standard – prohibition on discrimination based on orientation or gender identity.
“Prohibit discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.” RI EP29 (p.48 of Joint Commission LGBT doc).
Langbehn v. Jackson Memorial Hospital
November 2010 Department of Health and Human Services releases new regulations governing the treatment that LGBT patients and their families should receive in federally funded hospitals across the nation. The new regulations require hospitals to have written visitation policies; to inform patients of their right to designate visitors, including a same-sex spouse or domestic partner; and to not discriminate with respect to visitation rights based on sexual orientation, gender identity, and other characteristics.

47. CMS – Equal coverage to care in the same nursing home as a spouse
Aug. 29, CMS announced the guarantee of Medicare coverage applies to ALL spouses regardless of sexual orientation.
Prior to this same-sex spouses with Medicare Advantage plans were not eligible to live in the same nursing home as their spouse.

48. fmla
All spouses are now covered under FMLA if the employer is FMLA covered. (3/15 injunction against same sex spouses dissolved by SCOTUS Obergefell ruling)
FMLA may be used for
The birth of a child, adoption or foster parent;
To care for a spouse, son, daughter, or parent who has a serious health condition;
For a serious health condition that makes the employee unable to perform the essential functions of his or her job; or
For any qualifying exigency arising out of the fact that a spouse, son, daughter, or parent is a military member on covered active duty or call to covered active duty status.

49. Section 1557 – Civil Rights provisions of the Act.
Affordable Care Act
Section 1557 – Civil Rights provisions of the Act.
Applies civil rights protections to the Health Insurance Marketplace created by the ACA – and includes LGBT people

50. ACA & Preventive Care May 2015 DOL Guidance on the ACA confirms
Plans cannot limit sex-specific preventive services by gender identity. If a provider orders the service it is considered appropriate.

51. The LAW
SC Anti- Transgender bill
Title IX - Education
S.1203 defeated May 4, 2016
Grimm v. Glouchester (2015)
Appealed to SCOTUS
Administrative guidance
TITLE VII - EEOC
Macy v. Holder (EEOC, 2012) – gender non-conformity = gender.

52. How do I find an affirming provider?
GLMA.org
Then click on: Resources – For Patients – Find a Provider
A searchable provider directory (location, specialty, transition care etc.).
Provider Directory at the Harriet Hancock LGBT Center

53. Resources Locally Harriet Hancock LGBT Center
IRIS = LGBT group on campus
Nationally
The Trevor Project – suicide hotline for LGBT youth
Trans Lifeline
Providers GLMA.org

54. How Can an LGBT person Know if Someone is Safe to Talk to?
Go with your instincts
If you get a bad vibe from someone – trust your instincts and get out of there.
Look for these symbols

55. What We Can Do as nurses Be Authentic Encourage Authenticity in others
Share
Be flexible, scootch over a little, share the bench ≈ share the power
Services and health-care providers can be a source of safety or victimization.
Inversely, if LGBT people perceive services or providers to be discriminatory and/or unsafe, they are unlikely to use these services.

56. Laura C. Hein PhD, RN, FAAN Hein@sc.edu