1. health and fitness

LGBT Health
Health of
Lesbian/Bisexual
Women and
Trans Men
May 3rd, 2013
UNC Chapel Hill
School of Medicine
LGBT sensitivity is important for physicians as a
matter of policy and of professionalism with coworkers and patients.
LGBT patients have specific health concerns and
experience health disparities, primarily due to
stigma, discrimination, and barriers to health
care.
In order to provide effective health care to LGBT
patients, physicians should be familiar with
these concerns, disparities, and the population.
A review
Attraction
Biology
Gender
Sexuality
LGBT language
gay – primarily attracted to same gender
lesbian – woman primarily attracted to other women
bisexual – person attracted to both men and women
queer, as a sexual orientation – person attracted to
one or more genders along the spectrum
queer community – umbrella term for gender/sexual
minorities
transgender – identifies as gender different from
assigned gender
transwoman – assigned male, identifies female (MTF)
transman – assigned female, identifies male (FTM)
In this session
Health concerns and disparities in
lesbian/bisexual women
Health care of transmen
Education on topics specific to these groups
This session is not intended to establish stereotypes of
lesbian or transgender patients. We will discuss
patterns shown so far in the (limited) research.
It is up to you, the physician, to create an environment
in which your patient can disclose to you, and then to
use this information to assess what is important for
your patient.
Case #1:
14yo female patient coming in
for annual check-up. You have
noted that she started
experiencing puberty last year.
What questions would you ask
about her sexuality, and how?
Defining Lesbian
Attraction?
Behavior?
Identity is the definition commonly used in
epidemiological research and most affirming for
your patient.
1-5% of the female population
70% are WSW, 30% are WSMW
Diverse in race, age, education, income, geography
Lesbian youth
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Increased risk of sexual, psych, physical abuse
More likely to report early drinking
4x higher likelihood of substance use
Twice as likely to attempt suicide
Protective factors include family connectedness, other
adult caring, school safety – similar protective factors to
other populations
Lesbian youth
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Approaching sexual
orientation (as a physician):
Non-assuming
Non-judgmental
Emphasizing confidentiality
Going forward:
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Sexual identity can still change
Should still get HPV vaccine as recommended
Still need safer sex and contraceptive education
Sexual
function
Sexual behaviors in WSW (and largely for WSM):
Oral-vaginal
genital-genital
digital-vaginal
vaginal toys, oral-anal
Anal toys digital-anal
BDSM
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Sexual function
(the other side)
23% of lesbians with sexual dysfunction - only 3% of them saw
a physician.
Common to all women: May have decreases in desire,
arousal, lubrication, pleasure, orgasm with increased age.
Effects are less pronounced with higher relationship
satisfaction.
Case #2:
25yo female patient comes in
with odorous, white vaginal
discharge.
What questions do you ask
about her sexual
history/behavior?
STIs in
lesbians
Common STIs – BV, chlamydia, HSV, HPV, lice, trich
Less common – gonorrhea, hep, HIV, syphilis
Risk factors for BV – smoking, # partners, partner with BV,
shared sex toy, receptive oral-anal
- 23% concordance of BV with partner.
Safer sex tips
Avoiding blood, vaginal fluid, breastmilk.
Wearing gloves or fingercots.
Using condoms or cleaning sex toys.
Dental dams or plastic wrap.
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IPV in lesbian relationships
30-40% of lesbians have experienced IPV
– compared to 35% of women in the general population
The perpetrator is often older.
- Pattern of being perpetrator or victim may change.
Additional hiding or intimidation if victim is not out – may
be more prevalent in first relationships after coming out
Lesbians tend to go to support groups,
counseling, and shelters, but least
frequently to neighbors, attorneys,
physicians.
Case #3:
28yo female patient comes in with
fatigue, and she thinks it’s because
she wakes up early in the morning
and can’t fall back asleep.
What other clinical information would
you like?
What screening questions would you
ask? What parts of her social history
would you inquire about?
Mental health
Conflicting evidence on how prevalence of depression in
lesbians compares to general population.
Some studies report higher self-esteem in lesbians
compared to straight women.
Bisexual women often have poorer mental
health more often than lesbian and
heterosexual women.
Alcohol use
Bars in the lesbian community – similar to the role
of bars in other communities, can have both positive
and negative outcomes
For lesbians who do seek help with alcoholism, 74%
of relied on additional supports outside of AA, but:
Many alcohol treatment centers do not offer LGBTspecific services or have negative attitudes
towards LGBT patients, or are not familiar
with LGBT issues like internalized homophobia
Need to consider when referring patients
Smoking
Higher prevalence of smoking in lesbian/bisexual
women (25-30%) compared to straight women
(15-20%)
May be associated with advertisements targeted
to LGBT community
Often begins during adolescence
when many lesbians are
coming out
Nutrition/exercise
Being overweight in the lesbian community may result
from unclear mechanisms that require individualized
patient counseling
Unclear mechanisms – greater acceptance of large
body size, social induction, rejection of “thin” aesthetic
Cancer
Lower rates of getting Pap smears, clinical breast exams,
and maybe mammograms
Breast cancer risks
smoking, nulliparity, obesity (postmeno), alcohol,
no breastfeeding
Ovarian cancer risks
increased BMI, nulliparity, no OCP
Endometrial cancer risks
increased BMI, nulliparity
Cervical cancer risks
HPV, smoking
Case #4:
35yo female patient says she
doesn’t feel like getting a Pap
smear since she’s been
monogamous with her female
partner for over 10 years.
Would you recommend a Pap
smear? How would you counsel
her?
Reproductive health
Some lesbians do want birth control.
15-30% are sexually active with men.
Increased rate of unintended pregnancy in lesbian
and questioning female youth.
(Review: Don’t make assumptions)
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Oral contraceptives may decrease risk
of ovarian/uterine cancer, and can also
treat endometriosis, PCOS,
dysmenorrhea.
Pregnancy options
Studies show:
50% of lesbians want to be parents.
30% of these become biological mothers.
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Insemination by known or unknown donor
(Intrauterine > cervical )
Intercourse
Co-maternity
Adoption/foster
Planning for pregnancy should be encouraged
for ALL women.
Blood work (rubella, HIV, CF)
Prenatal vitamins 3mo before conception
Decisions about various parental roles
Legal advice
Pregnancy difficulty
Lesbians postpone childbearing longer,
resulting in increased miscarriages,
abnormal karyotypes, decreased fertility.
Recommended that lesbian couples
using IUI who fail to impregnate after
3-6 months see an infertility specialist
Increased incidence of postpartum
depression.
Case #5:
28yo patient wants to have a child
with her female partner, but they
want to wait 5+ years until they’re
completely ready.
What are their options? How
would you counsel them?
Hospital/ end-of-life care for lesbians
As of 2008, North Carolina allows patients to designate visitors
regardless of legal status  Is the law always followed?
Helpful documentation
Durable health care power of attorney
(true for any non-married couples)
Out-of-hospital DNR form
Last will and testament
Instructions in event of death
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Hospice and nursing facility care: concern about homophobia,
treatment, discrimination, child custody, etc.
25% of survivors experienced complicated grief over loss of a
life-partner, especially if not out.
- Compared to only 6-15% of survivors in general population
Gender expression
Reversible options:
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Clothing/hair/make-up
Voice/manner
Prosthetics/binders
Name/pronoun
Does not require a medical provider or expensive care;
may not be as "passable," may still feel discordant
‘Real-life experience’ (RLE) usually required for
further therapy.
e.g., 3mo rec before hormones, 3mo req
before top surgery, 1 yr req before bottom
Guidelines for Transition
World Professional Association for Transgender
Health (WPATH)
formerly Harry Benjamin Internat’l Gender Dysphoria
Association (HBIGDA)
Vancouver Coastal Health
Trans Care Project
The Endocrine Society
Options for Transition
Gender expression
Hormones
Surgery
Chest (top)
Genital (bottom)
Cosmetic
Vocal
Psychotherapy
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Often required or recommended before hormone therapy
or surgery
Intended to ensure readiness and minimize regret
after surgery, and establish relationship with health care.
Assess state and development of gender identity,
gender concerns, co-existing problems. Explore options
for gender expression, identity management, social
support.
Diagnosis of Gender Identity Disorder may be required
for further therapy
- Pathologizes  preference for gender dysphoria
Often perceived as a hoop to jump through, loss of
autonomy, transphobic discrimination; but can be a
source of support during a serious life change.
Testosterone
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Increase muscle, reduce fat
Increase facial hair/acne
Increase libido,
Enlarge clitoris, vaginal/breast atrophy
Decrease fertility, cease menstruation
Deepen voice
Side Effects
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Hormone therapy
for FTM
Excessive acne
Weight gain, salt retention
Sleep Apnea
Increased RBC/polycythemia
Decreased HDL, variable effects on LDL
Scalp hair loss
Hormone therapy for FTM
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Administered through injections, gels, patches, pills
Pros:
• Closer match between appearance and self-perception
with identity
• Reversible
Cons:
• Expensive
• Continual treatment
• Genitals can still be a source of dysphoria
Highly recommended to consult a medical provider
before/during
Adolescents can take puberty-delaying hormones before
deciding hormone therapy or surgery
Surgeries
Gender Affirmation, Sex Reassignment, Genital Reconstruction
Breast removal or reduction.
Hysterectomy/oophorectomy, vaginectomy, metaidioplasty,
phalloplasty, scrotoplasty
Best "treatment" for gender identity disorder
Cons: expensive, irreversible, surgeons/surgeries are not
perfect (loss of sensation)
Rhinoplasty
Chin/jaw implants
Pectoral implants
Liposuction
Surgeries
Elective Bilateral Mastectomy –
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Removal or reduction of the breasts (reduction
mammoplasty, “top surgery”)
Incision made near nipple, tissue and fat removed from
under the skin to shape into “masculine” chest
Option to have skin grafted from existing nipple to create a
new “male-like” nipple
Few complications, length varies per patient
Reduction mammoplasty is often all a FTM needs to
comfortably assume a new gender role and pass in
society.
Surgeries
Metoidioplasty –
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Creation of a penis by extending the clitoris that has been
significantly enlarged by testosterone hormone use
Skin around the clitoris is removed so that the clitoris can extend
from the pubic region and appear as a penis.
The resulting penis is smaller than the average size of an adult
male penis and its use in sexual intercourse is limited.
Option to have the urethra lengthened, which makes it possible to
urinate while standing. This requires removal of the vagina.
Fat of the pubic area is typically removed and the skin pulled tighter
around the area, creating a more male-like appearance.
The vaginal opening is closed and the skin of the vaginal labia
(lips) is used to create a scrotum. Inflatable expanders are placed in
the scrotum either during or after surgery in order to expand the skin
of the newly created scrotum. Once expanded, the scrotum can
accommodate testicle implants.
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Surgeries
Phalloplasty (free flap phalloplasty) 
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Constructing a penis from the inner forearm skin (nondominant
side) and vaginal tissue
Forearm skin is grafted along with its nerves, arteries, and veins
and formed around a plastic catheter tube, which will serve as the
urethra and allow for urination. The forearm skin is used to create
the shaft, glans (head), and urethra.
Nerves of the clitoris are attached to the grafted nerves and will
grow into the penis after surgery.
Skin and tissue of the vaginal labia is used to create a scrotum.
The procedure may take 3 hours or more. After 6 to 9 months of
healthy recovery, cosmetic testicle implants can be inserted in the
scrotum. Erectile implants, those used in men with impotence
(erectile dysfunction), can be added to achieve erection in the new
penis.
Hardening of the urinary tract and tissue death in the new penis are
complications of phalloplasty.
Health Care of Transmen
Assessing for readiness or desire for
transition with hormones or surgery
Monitoring hormone therapy and side fx
Ask about how they’re acquiring and
injecting.
May still need contraceptive education if
having sex with male-bodied persons
Should still be getting Pap smears if the
patient has a cervix
Screening for drug/alcohol use, mental
health, STI, violence etc.
Trans persons are at even higher risk.
Tips for gyn exam of transman
Do not assume anything about the
patient’s sexual orientation or behavior.
Tips for gyn exam of transman
Split the exam into two parts - clothed
interview and gowned physical, maybe
even as two appointments.
Tips for gyn exam of transman
Allow them to bring a friend for support,
distraction.
Tips for gyn exam of transman
Ask if they have had penetrative sex before they may like to try using the speculum on
themselves first.
Give the patient time to see pictures of a Pap
being done, hold a speculum, etc.
Tips for gyn exam of transman
Be sensitive and respectful about the words
you use. Ask how the patient refers to his
genitals.
‘internal/external genitals’ instead of cervix and
labia, ‘healthy ’ or ‘normal for you’
If the patient does not want an internal exam, you
can still perform an external exam, provide
education about cervical health, and build a
trusting relationship.
Tips for gyn exam of transman
Don’t turn the patient into a teachable
moment for you or your students.
Tips for gyn exam of transman
Transmen on testosterone may have an
enlarged clitoris and atrophic cervix and
fewer secretions.
Include a note for the lab with any gyn
samples.
Case #6:
A new patient comes into your
office for a check-up.
You notice that they’ve circled
“M” under “Gender: M/F” on
your intake form.
Something about your patient’s
appearance makes you think
they might be transgender.
Does it matter? How do you
ask?
What is the appropriate care
for this patient?
Creating a welcoming environment
Office and hospital environment
Posters, brochures, symbols, restrooms
Office and hospital staff
Trainings, LGBT staff, non-discrimination
Inclusive forms and language
Patient-physician interaction
Rapport, sensitivity, openness, confidentiality, non-judgment
Providing resources and referrals
Inclusive forms and language
Forms
“Relationship,” “partner,” “parent or guardian,” fill-in for
gender/ orientation, asking gender identity and birth sex
and pronoun
Non-assuming, non-judgmental
Gender-neutral, non-heteronormative
Mirror the patient’s words.
Take-home messages
Lesbian/bisexual and transmale communities
have specific health disparities and concerns,
possibly sharing a common cause.
Physicians should be aware of these issues in
order to serve their patients better.
It is important for these communities to feel
comfortable accessing needed health care and
to disclose their gender/sexual identity.
Some resources
GLMA, Fenway Health Institute,
National Coalition for LGBT Health
Lesbian Health & Research Center
Lesbian Health 101: A Clinician’s Guide
Suzanne Dibble RN and Patricia Robertson MD
National Center for Lesbian Rights (legal)
LesbianSTD.com (safer sex)
Checkitout.ca and Checkitoutguys.ca (Pap
smears)
Center of Excellence for Transgender Health
Acknowledgements
Alice Chuang, Krishna Foust (Ob/gyn rotation)
Terri Phoenix, Danny Depuy (UNC LGBTQ)
Dinushika Mohottige, Perry Tsai (QSA)
Questions?
Abigail Liberty
[email protected]