Episode 103 - Caring for LGBTQ+ Patients

Episode 103: Caring for LGBTQ+ Patients. 

Salwa, Pat, and Dr. Arreaza explain how to care for patients who identify themselves as LGBTQ+. Answered questions include, what screenings are needed? Any special needs? 

Introduction: LGBTQ+ Information.  
By Hector Arreaza, MD. 

Recently the media has been flooded with information about LGBTQ+. If you wonder what LGBTQ+ means, it means lesbian, gay, bisexual, transgender, queer or questioning, and the “+” sign acknowledges other orientations such as asexual, intersex, and more. June was designated as “pride month”. I think we have received more information within the last year than in the previous century. Many people consider this an overrepresentation of the calculated 3.5% to 8% of the population who identify themselves as LGBTQ+, many others consider this a revolution to promote equality in our society by reaffirming gay rights, while others consider this a part of an agenda to destroy the “American way of living” or even the US Armed Forces. 

You can come to your own conclusion about the origin and validity of this movement, but as medical providers, especially as family medicine providers, we must be prepared to care for any patient we encounter, including members of the LGBTQ+ community, and treat them with the same respect and compassion as any other patient. This episode was done to increase your awareness of this topic and motivate you to keep learning about it. By the way, there are now specific fellowships you can take to become more specialized on this topic, and you can find more information on the American Medical Association website.[3] 

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

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Caring for LGBTQ+ patients. 

By Salwa Sadiq-Ali, MS IV Ross University School of Medicine, and Pattamestrige Perera, MS IV, American University of the Caribbean. Comments by Hector Arreaza, MD.

 

Salwa: So, I was browsing the internet as we all do these days and I came across a short film, The Clinic, by a Canada-based organization, the Get REAL movement. Have you heard about this Dr. Arreaza? 

Arreaza: No, I haven’t, but this sounds interesting. What was the film about? 

Salwa: Essentially, it’s about LGBTQ+ patients and how healthcare is not inclusive. The film shows two patients with the same concern, one of which is from the LGBTQ+ community. It goes on to show how they are treated differently by the physician. 

Arreaza: That’s not how it should be. Unfortunately, healthcare disparity is very real, especially in minority groups like the LGBTQ+. One study found that 3.5% of Americans identify as lesbian, gay, or bisexual and 0.3% identify as transgender. They also found that these individuals are more likely to get poor care because of stigma and lack of awareness. 

Salwa: Exactly! And since June is PRIDE month, I thought this would be a great topic! Especially because we as students or healthcare providers don’t learn too much about this in school or training. 

Arreaza: I think that’s a great idea. I’ve heard a lot about PRIDE celebrations and the memorials that are held. How about we start with what exactly is PRIDE?

Pat: PRIDE is a celebration, a movement. It’s celebrated to commemorate the 1969 Stonewall Riots or Uprising. The riots began after the police raided a gay club in New York City leading to almost a week of violent clashes. This event marked the beginning of the gay rights movement as we know it today. 

Arreaza: And today PRIDE is celebrated with parades and many hold memorials for members of the community who were victims of hate crimes. By the way, you can listen to our episode 14, “Gender Diversity”, to learn about the definitions of gender, sexual orientation, and more.

Pat: As you said earlier, LGBTQ+ individuals are part of a minority group and face discrimination. 

Arreaza: Let’s talk about the health care gaps the “community” faces. Tell us more. 

Salwa: Yes absolutely! Let’s get into it! Did you know that LGBTQ+ youth are at a higher risk for substance abuse, STDs, cancers, cardiovascular disease, obesity, bullying, isolation, rejection, anxiety, depression, and suicide in comparison to the general population? 

Arreaza: The AAFP says suicide rates are 4 times higher among LGBTQ+ and even higher among trans youth compared to heterosexual youths. Also, members of the community, specifically men who have sex with men, are at a much higher risk of being affected by HIV/AIDS.

Pat: In fact, family physicians, and all primary care providers, are key to providing care for the LGBTQ+ community and the special needs of the community including gender-affirming care. 

Arreaza: So, what should primary care providers do?

Salwa: That’s a great question! First, let’s go back to the basics. Bedside manners are key. Being open and welcoming will open the door for you to find relevant health information. Having open conversations and being empathetic and mindful will help you build that patient-doctor relationship you want to have with your patients. I’ll share a story from when I was rotating in surgery. I had a transgender patient in the clinic, male to female. That’s what is called a transgender woman. When I was reviewing the chart, I couldn’t tell what pronouns the patient used. The first thing I did when I got into the room was to ask, “What pronouns would you like me to use?”. Even though she was wearing a mask I could tell that her face lit up just by looking at her eyes, and she said, “Thank you, that was very kind of you to ask.” Small things like this can really make a difference. 

Arreaza: And that’s becoming a routine question when our medical assistants encounter a patient for the first time. Their preferred pronoun is listed next to the patient’s name. What about the other health issues for LGBTQ+ patients? What should we do for that?

Salwa: For the other concerns – depression, anxiety, suicide, and more – follow the current guidelines for cisgender patients (cisgender patients are those who identify themselves with their gender assigned at birth). The AAFP and USPSTF have screening guidelines in place that can be utilized to help determine what someone may need further management for. 

Pat: The PHQ9 – a screening questionnaire for depression – will help you determine if you need to start treatment for depression or refer to behavioral health. There’s a similar questionnaire for anxiety – the GAD 7. 

Salwa: When I was doing my psychiatry rotation, I had a transgender male patient who didn’t have a support system. His family had essentially rejected him, and he was so isolated that he became depressed and suicidal. So, I’d say ask your patients about bullying, their support system, ask them about their friends. Maybe even talk to their parents if the patient is a minor, if they consent you to do so, or refer to family therapy. 

Pat: And of course, there is STD testing, HPV vaccination, obesity and related comorbidity screening, PAP smears for anyone with a cervix, maybe even consider an anal PAP smear when appropriate.

Arreaza: Beverly Hills rotation: A gynecologist for men.

People at increased risk of anal cancer:
-Men who have sex with men
-Iatrogenic immunosuppression (e.g., solid organ transplant recipients, long-term oral corticosteroids)
-Women with a history of cervical, vulvar, or vaginal SIL (also termed intraepithelial neoplasia) or cancer
-Women with a history of cervical HPV 16 infection
-Individuals with a history of anogenital warts

Pat: Depression is important to detect on time given the higher rate of suicide in this population, aside from following current guidelines, are there any unique health-related questions we should ask our LGBTQ+ patients? I hope you guys said yes! two common health topics are gender-affirming care and complications related to chest binding. Dr. Arreaza, have you had any patient encounters for gender-affirming care?

Arreaza: Yes actually. I’ve had a few patients who requested gender-affirming care. It requires a multi-disciplinary care team. You must consider hormone replacement, mental health, and surgeries. At the primary care level, you are there as the patient’s support system to help them navigate through everything and provide them with all the information. Hormone replacement is generally done by an endocrinologist or by a primary care provider who has been trained to do it. Of course, when appropriate, we will refer the patients to surgeons for certain procedures. 

Salwa: Exactly! Individuals who, from my understanding, are transgender or non-binary, as in they identify as males but tend to have female sexual characteristics such as breasts, may do something called chest binding. It involves compressing the breast tissue with a wrap to have a more masculine gender expression. Usually, individuals will use commercial binders, elastic bandages, duct tape, or plastic wrap. When you have a patient who practices chest binding, it’s important to address safe practices. They commonly develop dermatological conditions like acne, scarring, fungal infections. But they can also develop other complications like chronic pain, restrictive respiration, rib fractures, syncope, lightheadedness, and heartburn. 

Pat: A study showed that 88.9% of participants experienced a negative side effect of binding, but only 15% sought care. Cleveland Clinic suggests that individuals use a commercial, breathable binder or a sports bra. It’s also important to stay hydrated, have at least one day a week when a binder is not used, and avoid using a binder while sleeping. Most importantly, if you experienced any side effects, to get help from a doctor. 

Arreaza: Asylum seekers due to sexual orientation is possible. People in different parts of the world suffer persecution due to their sexual orientation. LGBTQ+ individuals are target for “killings, sexual and gender-based violence, physical attacks, torture, arbitrary detention, accusations of immoral or aberrant behavior, denial of the rights to assembly, expression and information, and discrimination in employment, health, and education in all regions around the world.

Pat: So, I think we covered most of it. Do you two think we mentioned the important parts?

 

Salwa: On that note, we want to end this podcast with a small message to LGBTQ+ individuals

listening in. We want you to know that you are not alone and that you matter.

And if you’re listening right now and know someone who is LGBTQ+, check in on them and let

them know how much they mean to you.

 

Pat: We encourage you to go to your PCP and talk to them about your concerns and how you’re doing. And we encourage all PCPs, all healthcare providers even, to implement these principles when encountering their LGBTQ+ patients.

 

Arreaza: If you do not feel comfortable caring for LGBTQ+ patients, you can refer them to a provider with the knowledge and skills to care for them.

 

Available Resources:

The Center for Sexuality and Gender Diversity in Kern CountyPFLAG Bakersfield ChapterBakersfield LGBTQ+The Trevor Project (have crisis counselors available to help)National Suicide Hotline (1-800-273-8255)National LGBTQ TaskforceSAGE - Services and Advocacy for LGBTQ+ EldersTransgender Law Center

 

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Conclusion: Now we conclude our episode number 103 “Caring for LGBTQ+ Patients.” Remember to screen your patients for conditions related to their gender assigned at birth but take into consideration the effects of hormones in those who have changed their gender. While caring for LGBTQ+ patients, remember to apply the same ethical principles you apply to the rest of your patients: beneficence, non-maleficence, autonomy, and justice. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Salwa Sadiq-Ali, and Pat Perera.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

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References:

Powell, Lauren. We Are Here: LGBTQ+ Adult Population in United States Reaches At Least 20 Million, According to Human Rights Campaign Foundation Report, December 9, 2021, Human Rights Campaign, hrc.org, https://www.hrc.org/press-releases/we-are-here-lgbtq-adult-population-in-united-states-reaches-at-least-20-million-according-to-human-rights-campaign-foundation-report, accessed on June 30, 2022. 

 

How Many People are Lesbian, Gay, Bisexual, and Transgender? UCLA School of Law Williams Institute, April 2011, https://williamsinstitute.law.ucla.edu/publications/how-many-people-lgbt/

 

National LGBTQ+ Fellowship Program, American Medical Association Foundation, https://amafoundation.org/programs/lgbtq-fellowship/

 

Guidelines on International Protection No. 9, United Nations High Commission for Refugees, unhcr.org, published on October 23, 2012, online at: https://www.unhcr.org/509136ca9.pdf, accessed on June 30, 2022. 

 

The Clinic, short film. The Get Real Movement, thegetrealmovement.com, https://www.thegetrealmovement.com/theclinicfilm. Accessed on June 30, 2022. 

 

June is LGBT Pride Month, Youth.Gov, https://youth.gov/feature-article/june-lgbt-pride-month, accessed on June 30, 2022.

 

Stonewall Riots, The History Channel, history.com, https://www.history.com/topics/gay-rights/the-stonewall-riots, Accessed on June 30, 2022. 

 

Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus. 2017 Apr 20;9(4):e1184. doi: 10.7759/cureus.1184. PMID: 28638747; PMCID: PMC5478215. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478215/

 

Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ+) Health, American Academy of Family Physicians, accessed on June 30, 2022. https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/equality/BKG-LGBTQ+Health.pdf.

 

Creating a welcoming clinical environment for lesbian, gay, bisexual, and transgender (LGBT) patients, rainbowwelcome.org, https://www.rainbowwelcome.org/uploads/pdfs/Creating%20a%20Welcome%20Clinical%20Environment%20for%20LGBT%20Patients.pdf

 

Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study. Cult Health Sex. 2017 Jan;19(1):64-75. doi: 10.1080/13691058.2016.1191675. Epub 2016 Jun 14. PMID: 27300085. https://pubmed.ncbi.nlm.nih.gov/27300085/

 

Moffa, Jamie. Chest Binding: A Physician’s Guide, Pride in Practice, April 6, 2019. https://www.prideinpractice.org/articles/chest-binding-physician-guide/

 

Cleveland Clinic Health Essentials, How to Bind Your Chest Safely, July 26, 2021, https://health.clevelandclinic.org/safe-chest-binding/