Sex Positive Primary Care ft. David Alajajian, MD

Sex Positive Primary Care ft. David Alajajian, MD

***DISCLAIMER: KB ONLY***

This podcast is a series of interviews with medical providers, mental health professionals, community members and advocates. Each interview represents the opinions of the individual. Individuals may use different terminology than what you’re used to. The intention is to educate not discriminate, and we welcome positive and constructive feedback. Please keep in mind; this is not a replacement for medical care or advice. I am simply presenting my views along with educational information that will be both evidence based research and external networks that have an impact on LGBTQI and nonbinary health care. Consult your provider for any medical or mental health concerns. My name is Kerin “KB” Berger and welcome to Queer MEDucation!

***INTRO MUSIC***

***INTRO TO EPISODE: KB ONLY***

Hello and welcome to our pilot episode of Queer MEDucation, a platform to educate medical professionals and the general population on LGBTQI and nonbinary health care. So many LGBTQI and nonbinary individuals are constantly asked sexual history and past medical history questions that are not applicable. Today’s episode will highlight creating a sex positive environment in a primary care setting with a physician practicing in Los Angeles, California. Thank you for joining us and I hope you enjoy this interview.

***INTERVIEW: KB AND DAVID ALAJAJIAN***

KB:                  Hey, what's up? It's KB. I'm here with a very special guest today. I'm going to allow this person to introduce themselves.

DA:                  Hey. I'm David, Alajajian. I'm a primary care doctor, internal medicine and I specialize in taking care of the LGBT population.

KB:                  Awesome. And where are you practicing currently?

DA:                  I work at a practice called Pacific Oaks medical group. It's technically in Beverly Hills, close to West Hollywood.

KB:                  How long have you been there?

DA:                  Um, it's about a year and a half now.

KB:                  Awesome. And tell us a little bit about Pacific Oaks and kind of how you got from your training to that particular setting.

DA:                  Um, so I did internal medicine residency at, um, a residency program in Long Island, at Northwell Health, um, Hofstra Northwell School of Medicine to be exact. And I was looking to move back to Los Angeles with my partner at the time. And, um, I signed up with a recruiter and I had just told them, hey, I'm looking for a primary care practice because I'm passionate about preventative medicine. And they said, well, here, we'll set you up with a bunch of interviews. And, um, they said, you know, one day they called me and they said, well, you know, there's this practice that's been around since the 80s, and, uh, we're having problems finding the ideal person for this practice because a lot of people are uncomfortable working with gay population. Would you feel comfortable, um, interviewing with them and I just lit up and I said, you know what, um, this would maybe be a perfect match for me because not only would I feel comfortable, I feel like there's a lot of life experiences that I've had that I would find as an asset to that practice. So when I went and interviewed there, I learned that Pacific Oaks was actually, um, started in 1979 by a couple of doctors who, um, uh, felt like the needs of the gay community weren't being met by some other practices, that there was a lot of discrimination. People wouldn't handle HIV positive blood at the time. And it had, you know, uh, blossomed during the AIDS crisis and now still lives on. Um, although with some different directions.

KB:                  Did you ever see yourself kind of going in that direction or even know about this particular specialty?

DA:                  You know, I really didn't know that this was even a career option going through medical school and through residency because I felt that there was a paucity of experiences for me to to see lgbt medicine and then to also see mentors and role models in those roles. So it was really very life changing for me, um, to discover this. And I was kind of surprised that I'd never been exposed to it in any capacity.

KB:                  Yeah. And I think that's pretty common. Um, as most of our listeners have gotten through medical profession professional training, um, that people just didn't really know that this even existed or exists in very particular settings. Um, but I think that's changing more and more now. Hence how your recruiter found you, which is amazing.

DA:                  Yeah.

KB:                  If you don't mind telling the listeners a little bit about your background prior to medical school, like your journey to becoming a physician.

DA:                  Um, so, um, I grew up in a very sort of traditional Armenian family where it was expected that you were going to go into some form of the sciences. And so I, um, and there was a very heavy sort of emphasis on, um, going into something that has like an academic leaning towards it. And, um, I did my undergrad at UC Berkeley where I studied molecular and cell biology and I also found things like virology and immunology really, really cool. You know, how the immune system fights against different, uh, pathogens and stuff like that. And that made me want to work at a lab at UCLA for a couple of years where I did, um, immunotherapy research. And I realized that there's really cool information out there, but I didn't, uh, get that human interaction that I was really longing for working in a lab. I really wanted to be able to take all the cool scientific innovations and be able to translate that to people and see how that could change people's lives and see how that fits into people's lives. So that's what kind of, um, uh, made me want to go to med school.

KB:                  And were you, um, out during your training? During medical school and residency?

DA:                  Yes, I was, but, um, uh, I guess there's different sort of degrees of out and in retrospect I'm realizing that I was struggling, um, uh, through being 100% comfortable with all aspects of my life at that time. Yeah.

KB:                  Meaning like separate from medicine and your training?

DA:                  Yeah, I, um, so for example, um, if I were put on the spot, I would identify as gay, uh, but I'd be concerned about people's in, um, reactions, uh, while I was going through training. And so I tried to keep my personal life pretty private.

KB:                  I see. Yeah. Did you ever have any negative experiences or is more just a feeling of sticking out in a negative way?

DA:                  What I felt going through medical school and then going through residency was, um, um, you know, medicine is a very conservative field in general and there are certain, there are certain perspectives and viewpoints, um, that permeate the medical field, um, that aren't as sex positive as, um, uh, um, I would have liked it to have been, there weren't as many, um, lgbt mentors for me and I did hear a lot of negative comments and, um, the, some of that probably comes from lack of education. Uh, but I do think that there's a lot to be done in terms of medical education and graduate measured medical education in terms of building cultural competency. Um, I think the medical field approaches gay people in a medicalized or problemize sort of way. Um, so how does, how does, how do certain behaviors pose an STD risk? How is this a high risk population? Not how is this a community? How do they interact when they're not here? And that could be stigmatizing, that could be oppressive. And there was a lot of opportunities here to turn that around. So

KB:                  Absolutely. I think like one thing that Queer MEDucation tries to do via instagram and this podcast is to try to destigmatize, um, not only the queer community but also the medical community. I mean, I think you're a 100% right. It's, you know, I've heard stories and been in clinics where you'd have a patient who is HIV positive and everybody has to know that that person is HIV positive. When reality is that the most basic OSHA training will tell you to take precautions around anybody. And as we know through our training and our, our, our experiences is that most people who are HIV positive are undetectable and not transmissible anyway, where sometimes you go into these medical settings and you're surprised that physicians and, and, and uh, nurse practitioners and dos and nps are not aware of that. It's, it's shocking,

DA:                  Right, it is. And I remember being in groups of medical students or groups of residency groups and being prepared that, you know, you're about to enter the room of an HIV positive person, they're gay, um, make sure you, um, you know, make sure you censor yourself in a certain way and prepare yourself. You're about to meet people that, you know, we don't know a hundred almost. We don't a hundred percent approve their behaviors or something like that. And so the cultural competency was sort of presented in a way how to avoid a PR disaster, not how to understand and be part of other patients, which is pretty concerning. Um, uh, for the medical professional, the profession in general is just sort of the way that we distance ourselves from patients, um, can be, it's a little unfortunate.

KB:                  It is unfortunate and so much of a, where that's created is from, um, ignorance but also lack of resources and you know, completely ignoring the problem in the eighties and nineties to the point where the community really stepped up. Um, and it was just immediately stigmatized in medicine and it's still continuing, which is sort of baffling being in 2018.

DA:                  Right. And, and there's this perspective from the, from the viewpoint of doctors that when there's gaps, when we have to build bridges, it's the patient's gap. There's a, there's a lack of education, a lack of knowledge. They need to be taught. So for example, the lgbt community needs to be taught about std risks because they don't know enough. So doctors need to reach out and teach them that their behaviors are wrong or need to be remediated in some way. Or this resident, um, me, for example, I was pulled apart, um, um, from the group various times during my training and told that my mannerisms or my communication style or the way that I was dressing wasn't what their standards of, or their vision of what a doctor should be like. And a lot of these are very heavily influenced by heteronormative values. They're not, they don't necessarily have a scientific basis. Um, and it, if not sort of corrected, it could be discriminatory, you know?

KB:                  So it sounds like, it was. I'm sorry to hear that. Yeah. One of my rotations I used to wear, um, I used to wear ties and uh, when I went to my pediatrics rotation, I'd dress up really fun because they were kids and they were fun and the kids, they just loved it. And you could see the parents, some of the parents would kind of give you some interesting looks because I had pretty short hair and was more of a uh, quote masculine dresser at the time. And the kids, they would just ask very simple questions, why are you dressed like a boy? And I would say because I like to, and then we would just move on with our lives. It was such a beautiful thing.

DA:                  That is beautiful.

KB:                  Yeah. And I think it's really interesting what you're saying like this, just bringing it back, you know, because we're, you know, generally medical and is that, where is this standard coming from? Is it even relevant? And what is the necessity to conform to this sort of a white coat, um, standard?

DA:                  Where do you doctors and other medical health professionals have to, in bridging that gap, have to educate themselves about the different communities that they're treating. You know, maybe medical students should get extra credit for going to a gay bar or something like that, just to see what the environments are like and what the situations are like. Um, uh, because a lot of it comes from a place of ignorance or lack of knowledge. And so when we do talk about that lack of knowledge, patient education, I think it's more, you know, doctor education to be honest.

KB:                  For sure, for sure. No, I think you bring up a great point. I mean, I think historically, um, medical providers were just put on a pedestal and um, you know, kind of the all knowing beings and, and you know, things change so quickly. We have so much information now that it's almost hard to keep up as medical professionals. Whereas 60 years ago, you know, we didn't have half the technology, so it was a little bit easier to say, you know, I'm 100% sure the answer is this or that when we just, we have so much now. Um, so I feel like it's, it's, it's an interesting time to be a medical professional. And I know we've talked to this when we hung out last week, but this concept of shifting the mentality of we don't necessarily know everything and that's the point of all of us learning together. What has been like your, your transition to this very different sort of practice and how has that been for you?

DA:                  So initially when I started working at Pacific Oaks, I realized too, that I am treating people who are in the same lifestyle demographic age as I am. And that was a very new experience to me because I was much more used to treating, uh, patients who are much older than myself and also, uh, uh, people with a lot more comorbidities. Um, I'm the a lot more disease states. Um, and suddenly I'm seeing young, healthy, um, gay, bisexual, lesbian patients who are just getting preventative medicine and are coming here for advice and those sort of standards that I was brought up in, in residency, um, standards of professionalism suddenly came into question because I would have patients go to my boss and complain and say, you know, we think this new doctor that you hired is a little bit stuck up and a little bit, um, a little bit dry, you know, um, he seems to be our age and relatable, but we can't really get into conversations with him, like real life things and sort of a switch went off in my head and I realized, you know, the way that I talk to friends and the way that I talk to family, if I just bring that into the clinic and just be real with my patients, it's going to go a lot further than me to be sterile and detached the way I'd been taught to be. And there was a complete transformation. And, um, how I, um, interacted with my patients in how I was received and people started opening up to me. People started telling me things that I never thought that they would share with anyone, very personal things. And I was actually in the position where I could research this stuff and actually give them good advice about what to do, um, in real life scenarios. So it was amazing because I suddenly felt that work is bleeding into life and, um, and I can really tap into, um, um, my passion for taking care of this community but also my interest and, um, uh, my own personal life experiences. So that was really cool.

KB:                  That's awesome. And, um, since you've kind of switched, how has that been with your patient interactions?

DA:                  Um, I think very, very, very positive. I think that, um, uh, people always, especially in a primary care doctor who you establish a long term relationship with you, we're looking for trust. Um, uh, I feel especially when you're in, um, the lgbt community or any marginalized community where you've had certain experiences where people haven't 100% made you feel comfortable. Um, whenever you feel comfortable in sharing some of the things that you, you know, you're not going to be judged about, um, there's more trust with your doctor. And, um, with that honesty and trust comes more information and um, um, that's where, that's where the magic really happens.

KB:                  I completely agree. I mean, I think like the, you know, we all learn medicine the same way. There's standards, there's protocols. Um, but people don't, your patients don't see you because you were number one in your class or you had the highest board score. Um, they see you and continue to see you because they develop a relationship with you and, uh, uh, trust with you. That is very special. I think. So I think people forget that sometimes. Probably, you know, when you're immersed in that academic setting like you were describing, it's, you know, you're almost trained like, this is how I'm supposed to be some sort of robot. And then you get out there and patients give you feedback. Like you got it. It's like mind blowing. And, and how positive that was for you as a professionals. Sounds incredible.

DA:                  Oh yeah, definitely that sense of satisfaction and that sense of, oh my gosh, you know, I was the person that, that person needed at that moment. It's huge. It really propels you. It's, it could be really addicting to people describe medicine as being an addicting, especially primary care as being, having this addicting quality to it where you never really come home from work. And I'm having the pleasure of finally experiencing that.

KB:                  Yeah, that's awesome. It, it's definitely the medical dream, that's for sure. Um, so, um, tell our listeners a little bit about kind of the, uh, practice and maybe I'm kind of how you create that sex positive or just general openness at Pacific Oaks.

DA:                  So what I've noticed is that, um, just given our life experiences and, um, the environments that we all grew up and, um, being part of a sexual minority was normalized only to a certain extent. So you see gay characters, lesbian characters, um, gender nonconforming characters in movies, and they typically fit into certain roles and you don't see the whole spectrum of the diversity, especially the diversity of sexual expression, Um, um, just by going through life. And so people have learned, um, and are in the process of unlearning how to censor themselves and censor themselves with their doctor. And so my strategy and trying to elicit kind of that diversity is bringing up scenarios and examples. So for example, if I think that someone is highly sexually active and um, um, has had multiple partners, I'll bring up an example, and, I'll say, you know, sometimes people go to places like white party or another sex party and they'll have sex with like 20 different people. Um, but I'll see those patients commonly and then I'll std test them the following week. Do you fall into this category? And it kind of normalizes it. I feel like it giving it breath like that, giving it life like that, um, makes the person to understand, hey, I know I'm from planet earth. I know the situations you're in, the people that, you know, they also come to me, so don't feel weird about this because people are concerned that they're going to be judged for their behaviors or that their behaviors are unusual. I want them to know that it's totally usual. It's very usual.

KB:                  For sure. For sure. And it's hard to know, you know, because I work in a sexual health clinic so people come in and they know what they're comfortable talking about, of course in it, in context to the provider that they feel comfortable with. But um, you know, I think in primary care is sometimes it is a little bit more challenging to open up that conversation when you have a whole bunch of other things to get through, like all of your screenings and, and what not. Um, so I think that's really a great tactic to kind of make it, um, uh, applicable to just the regular world setting.

DA:                  Yeah. I can't tell you how often I 'll get a new patient and they're here just for a regular health screening, a yearly physical. And I bring up something like, um, you know, sexual practices. And I ask them, well, do you need to be on PREP for example? And just the fact that I know about PREP that I even mentioned it so casually an entire dialogue, we'll start from that and the purpose of the visit will completely change and it'll just become a sexual health visit. And at the end of that, I'll get a comment like I never felt so comfortable sharing with my doctor. Um, all my sexual health stuff, I can't believe that you brought that up. And that's kind of unfortunate that other doctor's offices, it's not, you know, we learned so much in medical school and in training about how to elicit sexual history, but I think there's an art form to it and everyone has their own style.

KB:                  Absolutely. Absolutely. So there's lots of different listeners out there. Why don't you tell them a little bit about PREP since you brought it up and you know why that would be pertinent, pertinent questioning in your particular practice.

DA:                  So PREP is a medication. It's a combination. It's actually a combination of two medications in one pill that was previously, or it's still part of HIV treatment, but that one pill by itself is now used, um, as a once a day medication to help lower the risk of HIV transmission and people who are considered, uh, to be at risk. Um, so taking PREP once a day, um, uh, um, you know, over a period of time and being exposed to HIV, you know, lowers, the risk of, um, uh, actually getting HIV and um, it's a very, it's a very great sort of breakthrough in that, um, our hope is that it's going to help along with other things. Um, eliminate, eradicate lower the overall global HIV burden, which is huge.

KB:                  For sure. And what patients would you kind of bring that up with or what gives you the sense that a patient might be a good candidate for PREP?

DA:                  So in some of the, in some of the studies looking at PREP, um, uh, people who were prescribed PREP, um, you really saw that people were very good at, um, uh, having insight into their own sort of HIV risk. So when they looked at PREP compliance and then they looked at sexual behavior, they saw that people were very good at gauging just how much they were putting themselves at risk. And so, um, so I go by the patients, you know, own personal sexual history. And where I start to advise is when I see that there's a lot of condomless sex with partners who's HIV status is unknown. Um, uh, yeah, the multiple, multiple sexual partners with um, uh, people with unknown HIV status. And I'll add a little amendment to that is that, you know, we, we were taught in medical school to, you know, sort of advise people to, you know, ask your sexual partners about their most recent std testing. And I've found that it's not all always the most effective way for them to get good sexual histories from their partners because sometimes it's a conversation ender, you know, when you ask somebody, hey, have you been HIV tested? You might get a yes and then that's it. That's a conversation ender. There's not a lot of quality to that conversation. So I've also been advising people to, you know, ask more detailed questions. When did you get tested? Um, uh, why did you get tested? How many people have you been with since last time that you got testing? Um, which adds a little bit more contoured to that territory. I feel

KB:                  Definitely. And there's so many different, uh, ways to provide your partners with, um, a std and HIV information. Now I'm like, I know there's apps out there where you can have all your testing, a lot of clinics, um, use different resources like Health Vana or other kinds of standardized, um, services so that people can actually pull up results with the date and the information. Um, so partners can kind of be on the same page.

DA:                  Yeah. And there's anonymous texting services that text, uh, multiple partners telling them that they may have been exposed to an STI, um, you know, sort of prompting them to go get tested then or treatment.

KB:                  And I want to commend you on, um, the way you talked about prep because I think again, when you're in your medical school or, or medical training programs, when you, generally, most of them are present Truvada in the context of your infectious disease, a lecture when you're talking about men who have sex with men. Um, and, and the reality is that anyone who's having condomless sex with multiple partners is at risk for HIV. It doesn't matter how you identify, um, uh, with your, your sexual orientation or your gender identity. Um, really the risk comes from the type of sex that you're having, how much sex you're having and the partners that you're having. Um, so, so I, I thank you for, for being very, um, uh, politically correct when talking about that because I think so many people, just, even when you read the CDC, you know, it all, it says, you know what men who have sex with men, men who have sex with men, IV drug users, sex workers, and it's like, well, 20% of new diagnoses are cisgender heterosexual women. And, um, just because, and, and I know we can, we talked about this will be hung out, but just because somebody says that they're married doesn't mean that they're monogamous. So that's a whole other conversation piece.

DA:                  And also, you know, in terms of, um, you mentioned, um, new HIV diagnoses and cisgender women. Um, I also really bring up the conversation of, you know, how safe people feel in their relationships, especially when we're talking about, um, sex workers, people who are non monogamous, you know, are they being forced into these situations? Do they feel like they're, uh, how empowered do they feel in these situations? Um, in terms of, um, you know, the topic of consent, um, I think it always has to accompany the safe sex conversation. Um, uh, so, so, so that's another piece.

KB:                  Definitely. What are some recommendations for some of your clients who maybe have multiple partners or maybe are having more condomless sex besides, uh, pre exposure prophylaxis? What are some other medical recommendations you would make for those people?

DA:                  So, I'm so happy you asked this question because going through residency, I was taught to advice people to, um, minimize the number of partners they have as much as possible. And I always found that recommendation to be lacking a, because I don't think that it has a sex positive leading, you know, sex positivity is about encouraging different sexual experiences and trying to promote their safety at the same time, not trying to make sexual experiences heteronormative, um, necessarily monogamous necessarily for procreation, but also that sex is pleasurable and it's a vital part of people's health, wellbeing and happiness. And so there's a little bit of a conflict there. And so how do you turn that into a politically correct medical recommendation? You know, uh, this end, the spectrum is from have no sex whatsoever because there is an infinitesimal, std risk associated with any sex versus have very risky sex. Um, without being tested. So my recommendation is, um, finding good ways of having very open dialogues with new sex partners. And my firm belief is that sex is safer, um, more consensual and more pleasurable if there's a lot of dialogue and communication about, you know, the, the, you know, what's on the table, what's not on the table, you know, um, what risk is this associated with and what's your status going into it? And what do you plan to do coming out of it? So I encourage my patients to have those types of open dialogues. Um, and the way an open dialogue starts like that is by setting a good example. So I tell people, you know, volunteer your own personal information first, um, show that you care about your sex partners, health and wellbeing, you know, tell them, hey, listen, I got tested August 22nd. Um, my gonorrhea and chlamydia were negative then, but I've had one partner since then. I don't suspect that I got anything from that partner, but you never know. And now it's November. And, um, let's have, you know, we're planning on having oral sex. Um, I don't typically have anal sex, but if we do, I'm going to use a condom. Something very detailed like that. Um, uh, in order to give your partner as much information as you can and also show that you care about their wellbeing. Um, so, so, so that's my top sort of recommendation in terms of how to have the safe sex talk.

KB:                  I love that. Do you find that patients are receptive or come back with, you know, positive and or negative feedback with that information?

DA:                  So some patients receive that information very well. I had a very honest conversation with a patient this past week who is HIV positive and he revealed to me that he was very anxious about having the HIV positive conversation with the types of sex partners, uh, that he's having because, um, A: um, uh, HIV positive people are still unfortunately sometimes stigmatized or treated differently when they revealed their status. And B: there's very little information out there about, um, uh, not, I should rephrase that. There is information out there, but the widespread knowledge about, you know, undetectable status meaning untransmissable the level of trust you need with someone before, um, you could trust it, they're undetectable. Um, is, is, is it different sort of conversation. And so it wasn't as well received, but it opened up this whole dialogue about, um, how do I feel accepted as an HIV positive person among my sex partners? And it, it, it, it got the gears grinding a little bit so, so I found it to be very, very positive.

KB:                  That's awesome. I mean, unfortunately, yes, there's still a huge stigma. Um, and that's one of the things we're trying to do through this platform is really to dissolve that as much as possible because people that work in this particular field, that have worked in this particular field know that people who are undetectable, who've been in relationships for many years with HIV negative people, um, that the HIV negative people never seroconverted. So we've, this information has been kind of known for awhile if you worked in the field, but now the CDC is finally expressed that. That expression, unfortunately, and fortunately by organizations like the CDC will help destigmatize. Definitely. Yeah. Um, so any other medical recommendations for our patients that you'd recommend? I mean, for example, I know for y'all through the CDC, for men who have sex with bed or men who have sex with that of women, um, certain vaccinations are recommended. Um, how do you go about making sort of, uh, alternative preventative recommendations with your patient population?

DA:                  So a couple of, um, avenues that I feel, um, are lacking in terms of preventative care for these populations. One is, um, Gardasil or the, um, the vaccination to prevent HPV or the virus that causes genital warts, rectal and throat cancer. Um, um, seems to have really over the past 10 to 20 years, um, reached, um, the female population in terms of preventing cervical cancer. But, um, many men have missed this vaccination, especially men who are having multiple male, um, sex partners. And so I bring this conversation up because now there's a new recommendation to extend the vaccination period up to, um, the mid forties. Um, uh, I don't know if insurances are 100% following suit. Um, which is a little bit problematic, but for a patient population, I'm here in Los Angeles. I always put it in it in these terms. We live in a city where we pay $140 for a yoga class or we paid $12 for an energy drink. So if you think about your, if you think of your longterm health and how this vaccination is going to prevent cancer, I think that, um, um, even if insurance is ended up or the payers and if not not covering the expenses, you know, it might be worth the investment to be protected against, um, the ninth, the strains of HPV. Um, so that's one, uh, um, a recommendation did I kind of have a dialogue about, uh, the other one is hepatitis A vaccination, which, Uh, there was a recent outbreak in San Diego, um, about a year ago, um, and the homeless population. But, um, uh, because of its fecal oral transmission, um, actually anyone who has oral, anal intercourse, it should be vaccinated for hepatitis A. And again, um, if you're traveling to areas that are prone to hepatitis A, it might be a win win. Um, so, uh, people often traveled to South America or Southeast Asia and um, um, it's a sort of good to hit two birds with one stone. So those are a couple of things that I bring up in my conversations pretty regularly.

KB:                  Yeah. Is Hepatitis A something you would get, um, or let the listeners know what, you know, is that something you would get, is that part of your regular vaccination schedule as a kid or is that something you have to seek out?

DA:                  So I've found, um, that um, despite recommendations, um, many people have missed hepatitis A vaccines. They would, so you would a, you would, you would standardly not get this as a kid. You would not get it growing up as a kid, you would, no one would have said, oh, you're a five. Let's give you the hepatitis A vaccine. So no on that one. And second of all, a lot of people have not gotten the hepatitis B vaccination or gotten screened for Hepatitis C. There is a recommendation that if you were a baby boomer and to be screened for Hepatitis C, but, um, oftentimes when you go to your, um, um, std, checks you get gonorrhea, chlamydia, syphilis checked. Um, Hepatitis A, B, C, it's hit and miss depending on where you go and who you see. Yeah,

KB:                  For sure. And how does, um, Hepatitis A, B and c correlate to, um, sexual health?

DA:                  Um, so hepatitis A, hepatitis B and C are, um, sexually transmitted. They could also be transmitted through blood. Uh, but the way that we talk about it as we talk about their sexual transmission, and so, um, uh, bodily bodily fluids like semen can transmit these viruses, which I end up infecting your liver. And longterm, they could cause liver failure, liver, liver cancer, and longterm consequences. But found out early they could be treated. Uh, hepatitis C could be cured. Uh, but hepatitis B has a vaccine that prevents you from getting it at all. Um, there's an interesting thing with hepatitis B and PREP because PREP has this effect of if you're infected with hepatitis B at the time that you stopped taking your PREP, you're in, you're in danger. So, so that's an important thing to have tested if you haven't already and you happened to be on PREP.

KB:                  Yeah. So a lot of times with the routine starting, um, labs that you'll get when you do start prep, um, not only will you get a metabolic panel and sti testing, but you also get a hepatitis panel, which will include a hepatitis B screening for infection, um, in addition to A and C as well. But, um, what, um, what David's talking about is when you are on PREP and, and, uh, so, so Truvada is also used to treat hepatitis B. If you go off of your Truvada, not knowingly having hepatitis B, you can have what's called a rebound infection and it actually can cause a death. So a very important, um, to talk to your provider when you are starting prep to make sure of the testing that you're actually getting is appropriate. So that's a really good point. Yeah.

DA:                  And I've seen that situation, the rebound, um, um, and, and it's quite severe. So it's important to, to, to bear in mind where when you, especially now that prep is being offered by some online services. I'm not sure how thorough their screening and informed consent processes, but it's very important to bear that in mind.

KB:                  Yeah. And also I've had patients come in who start prep, um, through the, um, some online services, which are obviously some are better than others. And there with the followup was actually lacking, meaning they had a positive result and then did not find out for a little bit. So really important to stay on top of your own health before anybody else's.

DA:                  Absolutely.

KB:                  Um, so, um, you know, I know we talked a lot about, um, kind of sex in general. I did want to touch a little bit about, um, maybe different communities that you're seeing that aren't necessarily discussed, you know, on the CDC or whatever his website. Um, I know that you have told me a little bit that some of the patients populations that you see as part of the poly community. And I kind of wanted to kinda hear a little more about that and tell our listeners a little more about that.

DA:                  So, you know, I do see a lot of patients who, um, uh, don't fall into the sort of heteronormative sort of, um, uh, cultural norms that we're all familiar with and um, seek out a more sort of sex positive environment for their primary care and in a lot of aspects, um, uh, they share a lot of things in with the gay community. It's great that there's the, the medical term MSM or men who have sex with men because, um, although we might not see this sort of popularized in the media, there is the gay community men who have sex with men, but there's a large number of men who identify as street who have male partners occasionally. And so hence that term. Um, of course that term doesn't give justice to the LGBT community and all their struggles in history and what not. But it's important to recognize and realize that, um, there is sort of a very heterogeneous, um, population of people out there practicing many different kinds of sexualities. And so I see polyamorous couples, um, who identify as straight and they may have, um, male or female, uh, partners. Um, and, uh, in terms of std risk, std screening, std education, it's important to sort of evoke all this knowledge that we've learned from treating the gay community and extended to, um, uh, an increasing proportion of the street community.

KB:                  Yeah. Again, and I think, you know, one thing that I've, uh, you know, as a patient myself, notice when I'm in, you know, and, uh, um, somebody taking a medical history on me and they'll ask, you know, are you single? Are you married? And do you know if I say, Hey, I'm married more often than not. Um, the, the conversation completely shifts assumingly, that I am monogamous, for example. Um, so, and, and so many people are not. And, um, I think, you know, especially in the primary primary care setting, you have such an opportunity to not only protect the patient in front of you but also their po, their marriage partner, especially if they're in a poly relationship. I mean, I think you have a dual duty there

DA:                  Right and sometimes one of the partners is monogamous with their husband or wife, but maybe their husband or wife. Um, I had a patient and I, I kinda, I kind of find this unfortunate that, you know, the way that this information is presented to the provider is little apologetic and almost, you know, explaining once often think, you know, before our visit is over, I just wanted to let you know that my husband has a boyfriend. And I said, that's totally fine that you could share that with me. But I just wondered, I wish that we could create an environment where that information is, you know, people feel more comfortable expressing that information. And you know, I kind of internalize that experience and said, you know, I should ask a little bit more direct questions I should ask. You know, we always worry about offending and saying, you know, like, well, you're married. Does that mean you only have sex with your husband? But we need to really get over that and say, and be able to ask those questions because so many people, um, uh, live a very different spectrum of lifestyles then that we were accustomed to just growing up. And it's just the reality,

KB:                  Right? And it's, you know, it's so amazing how media has such a big effect. You know, what you see on tv isn't necessarily the norm to everybody. Um, yeah. You know, depending on how you live and what your life is like. So it's, it's the same when it comes to sex and marriage and all that. Um, but I think it's so important to protect your partners, uh, especially if your ear married or in a relationship with someone else and you're open and they think it's crucial to be able to present the conversation of sexual history in a way that, um, because we're so used to getting defensive about it by nature of our expression in our experiences, but being able to, um, really presented as a, I'm asking these questions because I need to know them so we can better your health outcomes.

DA:                  Yeah. And I think part of that is maybe just more normalizing the concept of sexual networks and, um, you know, just putting that out there and saying that, hey, everyone has their sexual network. Um, it's not infinitely large the way that, you know, it's been depicted in the media that the gay community has this infinitely large sexual network. The literally all have sex with each other. That's not true. Um, they're limited and they're not infinitely small where it's just a husband and a wife. The way you know, tv would like you to think, it's just, it's everything in between.

KB:                  Exactly. And that's what makes medicine so exciting, um, to me at least, is that you never know what's going to come in the room. And that's part of, you know, not only do we like to take care of people, but I think we also are problem solvers at heart and, and, and in mind. So, you know, the more differences the better. Right.

DA:                  Absolutely.

KB:                  Yeah. Um, is there any other particular populations or groups of individuals that you see that you kind of want the listeners to know about or have more recommendations about?

DA:                  Um, so, um, I think that we covered, um, you know, a few different sexual minorities. One, a group of people that, you know, I would typically not lump into sexual minority is half of our population is women and women's health is a huge, um, um, area. Um, that is, I guess for lack of a better word, lacking. Um, and you know, now that there's, you know, fears about a funding for planned parenthood, um, I'm seeing more women, um, in need for basic primary care, uh, including, you know, just pap smears, mammograms, breast exams, and, um, I think that women's health, um, is an area that I'm very unfortunately is now becoming a health disparity and, um, uh, you know, half of our population is becoming a sexual minority. Uh, just kind of bizarre, but that's a, that's a big a population that I take care of is just women for their, uh, women's health issues. Um,

KB:                  When you say women, do you mean like cisgender heterosexual women or

DA:                  They're heterosexual women, but also just women, women who need their annual pap smears, mammograms, um, um, std checks and, um, everything else that's, we know, women's health related.

KB:                  Yeah, for sure. I think that's a really great point. Um, even in our clinic we've noticed, I think since planned parenthood as has, maybe the funding has gone down, people can't afford to go there anymore. Um, and they've been coming to see us a lot more. Um, and you're right, the resources are totally lacking. I mean, one example of, of a, I feel a disparity is in the topic of bacterial vaginosis. I mean, we've known about it forever. It's a chronic problem sometimes for, for, um, anyone who has a vagina basically. And, um, there's no research being done on how to fix this problem that is a continuously a problem. So, um, yeah, I think that's a great point. And hopefully, um, the funding, you know, unfortunately it takes a public health problems to get the funding. Um, I mean, I think we're seeing this with std rates, but unfortunately I don't think the funding's coming out of that, but yeah...

DA:                  And that's what happens is, um, um, uh, groups become, you know, blamed for these outbreaks and um, above the, uh, moralistic sort of messages usually tied to it with them, which, um, and it comes down to economics. Really? Yeah. Shot costs $400. And insurance doesn't pay for it. You know, you can't turn around and say, Oh, it's your community that's causing a syphilis outbreak. It might be that, oh, we didn't prioritize it. We didn't value it as a society and we didn't take care of it.

KB:                  Absolutely. While we're seeing that right now, that's for sure. I think I saw about four cases of secondary syphilis on Fridays clinic and it's just everywhere right now.

DA:                  It's alarming, but, but, but what's even more alarming is, uh, you know, uh, I mean you work in a different setting than I do, but I commonly run into the problem where, um, uh, people's insurances deny, um, that the injection that's curative of um, uh, syphilis and, um, uh, people are finding that they have to pay out of pocket or try to search around for a limited resources, a free clinics and, um, um, stayed with the disease state longer than they should. So.

KB:                  Right. Which is this making everything worse in terms of health outcomes for our patients. So do you have any particular advice for other primary care or internal medicine practitioners on how to create more of a sex positive environment for their practice?

DA:                  Yes. So, um, I would say having done this for only about a year and a half, um, I have learned a lot, even coming from the LGBT community, I had a lot to learn and I still have a lot to learn. But having images, um, you know, even, um, non traditional couples, um, in, um, I didn't know in your lobby, in your hallways, um, having, um, thinks about resources posted on bulletin boards, uh, creates a more sex positive environment. I'm talking about sex in a very de stigmatized way in a very normalized way, creates a sex positive environment and um, uh, but you know, get close to your patients. You don't have to distance yourself. You know, it's one thing to be diplomatic and polite. It's another thing to be distant and cold and clinical, um, or sterile. So, and there's a fine line there.

KB:                  For sure. For sure. Um, so just to kind of wrap things up, why do you feel like your job is important? Loaded question.

DA:                  Yeah, I think that my job is important because I reach out to, um, a group of people who otherwise wouldn't get the same information, the same care delivered in the same way. Um, and at a time where there's a big need for it. Stds are on the rise. Um, the need for taking care of, um, uh, this group of people is becoming more and more and more. And um, historically, uh, um, uh, the group's been marginalized and stigmatized by the medical community and I think we owe it to them.

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