Transcript Primary Health Care For LGBTQQ

Primary Healthcare For
LGBTQQT
Valerie Dzubur EdD APRN FNP-BC
Samuel Merritt University
Spring N674 2012
Objectives
 Define LGBTQQT
 Review Health Disparities for LGBTQQT Communities
 Goals for Healthy People 2020
 Identify special needs/risks/problems
 Define integrated care model SAD COST
 Identify cultural tips for comfortable care
 Discuss special needs for transgendered people to transition
using medications
LGBTQQ
 Lesbian = women who primarily want a sexual & emotional
relationship with another woman
 Gay = Men who primarily want a sexual & emotional
relationship with another man
 Bi-sex = Both men and women with both men & women
 Transgender = gender identity expression opposite from natal
gender
 Q = questioning / Q queer (not heterosexual)
 T = Two Spirited identity with both male/female character
LGBTQQT
 APRN mission to provide primary healthcare services to
underserved, at risk communities
 We want to be the primary care provider of choice
 We need to be leaders in developing new knowledge
 We need to work to influence health policy
 We need to develop partnerships across communities
LGBTQQT
 Who are we talking about
 Americans 5 – 10 % of the population
 Undercounted using 2000 numbers
 5 % of 209,128,094 = 10,456,405 people
 Living across the country in 99.3 % Counties
 3,136,921 live in committed relationships = married
 The human rights campaign estimates these numbers
represent an under count of 62 % and the numbers are ten
years old
LGBTQQA
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IOM 2012 Study in process & asking…
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State of knowledge health risks, disparities, protective factors, access to &
utilization of health care
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Developmental process across the life span
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Effects of age, ethnicity, race, geography
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Effects of social determinants and cultural factors
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Methodological challenges
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Research gaps
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Training/educational needs to advance knowledge about health concerns
LGBTQQT
 Leading health indicators
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Overweight / Obesity
Cancer
Physical Activity
Tobacco use
Substance Abuse
Responsible sexual behavior
Mental health
Injury and violence
Immunizations
Access to healthcare
LGBTQQT
 Let’s take a closer look
 Lesbians have 2 X the risk of obesity
 MSM rates of anal cancer have tripled last 30 yrs
 MTF HIV infection rates are close to 50 %
 MTF attempted suicide rate > 50 %
 Much less likely than others to have a primary care
provider over time
Causes of Disparities
 Insufficient education of healthcare professional
 Overt bias and discrimination in the system/people
 Gendered language, documentation, legal requirements
 Insurance coverage can be difficult
 Privacy concerns
 Clinic milieu
 Bathrooms
Disparities
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What do disparities look like?
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According to Healthy People 2020
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LGBT youth are 2 – 3 x more likely to attempt suicide
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And are much more likely to be homeless at some point
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Lesbians are less likely to get screened for cancer
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Gay men are at higher risk for HIV and other STIs
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Transgender people have a high prevalence of HIV / STIs
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Victimizations, mental illness, suicide, no health insurance
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Elderly are more likely to be isolated
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Have highest rate of smoking, ETOH use and other drugs
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Victims of trauma violence, bullying, abuse
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< likely to be protected by police
Healthy People 2020
 LGBTQQT
 Improve the health, safety, and well-being of lesbian, gay,
bisexual, and transgendered individuals
Across the Life Span
 Youth
 Issues are magnified
 Special concerns
 Coming out / family rejection
 Homelessness
 Substance abuse
 Mental Health – suicide risk
Across the Life Span
 Midlife / Family Issues
 Insurance
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Access to preventive care
Access to chronic disease management
 Relationships
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Marriage equality
Family of origin issues
 Becoming and being parents
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Adoption
Donor
Other ways
Across the Life Span
 Older Adults
 Financial concerns
 Social Isolation
 Hospitalization acute and long term
 Back into the closet
SAD COST Model
 S: STIs & risky sexual behaviors
 A: Attitudes of healthcare providers
 D: Depression, anxiety, suicidality
 C: Cancer Screening and risk
 C: Cardiovascular disease and risk
 O: Overweight, obesity, eating disorders
 S: Substance abuse
 T: Trauma
LGBTQQT
 Use current guidelines for leading health indicators as you
would for all other groups
 CAD, HTN, DM
 Screening for Cancers
 Lifestyle modification
 Immunizations
 Health education
 Develop a primary provider relationship
 Special focus on other risks in the history, screening, and
treatment domains SAD COST
Special Care
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Transgendered People
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Orient yourself to the gender identity of patient’s choice, do a self-check on
your language, attitude, and bias….be attentive to the way you express esteem
for others and remember identity is a core human concern for all of us.
Transgendered people are asking to be recognized for who they really are!
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History
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Blood clots
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STIs ? Last HIV Test? Results? Last risk?
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Surgeries to support transition of gender identity
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Cosmetic procedures also by lay persons – silicone
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Psychiatric events/hospitalizations
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Medications to assist with gender transition
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Source, route, dose
Special Care
 Transgendered people
 History continued
 Hepatitis A,B C status
 Immunizations Hep A & B
 Injuries – screen for abuse & violence
 Family History with emphasis on Cardiac risk
 Occupational History – sex work, source of income
Special Care
 Transgendered People
 Personal and Social History
 Legal status and name
 History of drugs and ETOH
 Relationships and social support
 Goals for transition
 Success of transition
Special Care
 Transgendered People
 Physical Exam as needed after relationship established
 Prepare the patient in advance – get permission
 Ask how to refer to anatomy i.e. genitals instead of
vagina or penis
 Check for yeast infections if binding breasts or genitals
 For silicone injections check for infection
Special Care
 Transgendered People
 Screen based on risks using current guidelines
 And an individualized risk assessment
 To interpret labs use normal lab values for natal sex until 2-yrs
after hormone therapy for transition, then use transitioned
sexual identity i.e. female values for MTF persons
 MTF
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check prolactin q 6 mos, < 25 continue therapy
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> 25 discuss decrease in estrogen dose, if > 100 stop estrogen
for 8 weeks, recheck, if still > needs MRI
Special Care
 Transgendered People
 Screening
 MTF continued
 Prostate is not removed in sexual reassignment surgery
 Review sexual risks every visit,
 screen for HIV, STIs q 6 mos, more often if sex worker
 Screen for depression, anxiety, suicide every visit
 Mammography ?
Special Care
 Transgendered People
 Screening
 FTM
 Mammography ?
 Needs pap smear as per general population
Hormones for Transition
 It takes 2 years for hormonal transition regardless of
dose
 Use is off label so get written patient consent
 Emphasize stop smoking, review & document risks for
estrogen use
 Get Baseline laboratory studies
 CBC CMP Lipids, TSH, Prolactin (MTF), HIV STI
 Recheck labs at 1 month and then q 6 months on
hormone therapy
Hormones for Transition
 See Table 39 -1 Hormone Guideline for Sex
Reassignment page 340
 MTF
 Estradiol 2 – 8 mg/d
 Spironolactone 25 – 200 mg/d (noACE)
 FTM
 Testosterone cypionate 100 – 400 mgs q 2 – 4 weeks
 Testosterone patch 2.5 mg/1 – 2 per day
Comfortable Care
 Start at the beginning – yourself
 No one is a blank slate
 If you understand your bias you can change them
 Even if you think you are clear about not being
homophobic (?) we all live in a world that presumes
heterosexuality is normal
 It has a name heteronormativity
 Self-reflection is an on-going process
Comfortable Care
 Communication Tips
 Don’t assume
 Heterosexuality
 Sexual orientation
 Sexual identity
 Sexual behavior is unchanging
Comfortable Care
 Communication Tips
 Ask people how they wish to be identified
 Always do your best to use the correct pronoun
 Use non-heterosexual language (gender neutral)
 Don’t be afraid to get personal –follow the patient’s lead
 Your good intentions help, mistakes happen
 Simple acknowledgement is good and then move on
Comfortable Care
 Create an inclusive environment
 For this you may need to be the leader
 Create a safe space
 Post and follow a non-discrimination policy
 Use Posters and handouts as a welcome message
 Use gender neutral bathrooms
 Use gender neutral intake documents
 Staff training
 Speak up about discrimination, gossip, giggling what ever
Need Help
 www.transhealth.vch.ca
 www.nickgorton.org
 Text Collins-Bride/Saxe pages 337 - 341