Transcript presentation slides - New Jersey College Health

Care of LGBTQ Population
in College Health
Uri Belkind, MD
Clinical Director, Health Outreach to Teens (HOTT)
Callen-Lorde Community Health Center
March 9, 2016
OBJECTIVES
• Identify the particular health needs of
LGBT college students.
• Understand the importance of
creating safe spaces and of the sexual
history to recognize specific health
needs of LGBT college students.
• Discuss specific health services
needed to provide comprehensive
care to the LGBTQ population.
Importance of this training
• Both youth and the LGBTQ community are
marginalized, which is associated with
increased health risks.
• Clinicians rarely receive training specific to
LGBTQ youth.
• Providing LGBTQ youth-competent care is a
skill.
Terms, definitions, acronyms…
• LGBTQ: Lesbian, Gay, Bisexual,
Transgender, Questioning/Queer
• SOGI: Sexual orientation and gender
identity
– Sexual orientation and gender identity are
two separate concepts and do not
always “match”
Sexual Orientation
• Identity: a label
– “I am…”
• LGBTQ, pansexual, asexual…
• Behavior: most clinically relevant
– “I have sex with…”
• MSM, WSW, MSWM, TFSM, TMSWM…
• Attraction: doesn’t always align with above
– “I like…”
Sexual Orientation: Identity
NYC YRBS 2013
Sexual Orientation: Behavior
NYC YRBS 2013
Gender Identity
GENDER
IDENTITY
SEX
• CHROMOSOMES
• ANATOMY
Gender Identity
GENDER
IDENTITY
SEXUAL
ORIENTATION
Gender Identity
• Identity: a label
– “I am…”
• Male, Female, Transfemale/male,
Genderqueer, GNC, Non-binary…
• Expression: communication of one’s gender
– “I appear and/or behave…”
• Masculine, Feminine, Androgynous
• Role: society’s expectations of each gender
– “Be a man!”, “That’s not ladylike”
• Masculine, Feminine, Neutral
Sexuality is a Spectrum
(And there are no “Should’s” or “Should not’s”)
Case 1. WZ
• 20yo Asian male
• STI screening
• Identifies as gay
LGBT Health Disparities
• Victimization
• Homelessness
• Mental health
–
–
–
–
–
Anxiety, Depression, PTSD
Suicidality
Eating Disorders
Substance use
High-risk sexual behaviors
• ↓Education
LGBT Sexual Health
• MSM have higher rates of some STIs
– Gonorrhea
– Primary and secondary syphilis
– HIV
• WSW might have higher rates of:
– Trichomonas
– Bacterial vaginosis
College LGBT Sexual Health
(Compared to heterosexual counterparts)
MEASURE
LESBIAN
BISEXUAL ♀
GAY
BISEXUAL ♂
#partners
=
↑
↑
↑
Oral Sex
=
=
↑
↑
Vaginal Sex
↓
=
↓↓
↓
Anal Sex
↓
↑
↑↑
↑↑
Oral
=
=
↑
↑
Vaginal
↓↓
↓
=
=
Anal
=
=
=
=
=
↑
↑
↑
Safer sex:
HIV Test
Oswalt. 2013
College LGBT Sexual Health
(Compared to heterosexual counterparts)
STI
LESBIAN
BISEXUAL ♀
GAY
BISEXUAL ♂
Chlamydia
=
=
=
=
Gonorrhea
=
=
↑
=
Genital HSV
=
↑
=
=
Genital warts =
=
↑
=
Hep B or C
=
=
=
=
HIV
=
=
↑
=
Oswalt. 2013
Case 1. WZ (cont.)
• Multiple male sexual
partners
• Anal and Oral sex
– Versatile
• Condoms sometimes
• Doesn’t ask partners
if they know their HIV
status
HIV and LGBT Youth
• 1:4 new HIV infections 13-24yo
• Young MSM 1:5 new HIV infections
• Black youth  57% HIV infections in youth
• 20-24yo group  highest # of HIV diagnosis
• 2 per 1000 college students are HIV+1
1ACHA-NCHA-II
Anal Sex and HIV risk
HIV Prevention
• Condom use
– Insertive anal sex: 63% effective
– Receptive anal sex: 72% effective
• Serosorting: 54% effective
• TASP: 96% effective (maybe higher)
• PrEP: 92% effective (maybe higher)
• nPEP: ? effectiveness
• Screening and treating other STIs
Mental Health Disparities
• Eating-related pathology (TG>G/B>F)
– Diagnosis of ED
– Diet pill use
– Vomiting or laxative use
• Depression and Suicidality
– Felt sad: Bisexual > GL
– Attempted suicide: 3xGL, 5xBisexual
– Sought MH: Non-het 2x
Diemer, 2015
NYC YRBS, 2013
Victimization
Straight
Missed school b/c felt unsafe
G/L
Bullied on school property
Bisexual
Unsure
Experienced physical dating violence
NYC YRBS, 2013
Experienced sexual dating violence
Case 2. DD
• 18yo Hispanic female
• Requesting EC
Taking a sexual history
• Don’t assume:
Patients are heterosexual
Bisexuality is a phase
Sexual orientation based on gender of partner
Sexual orientation or gender identity based on
appearance
• Sexual orientation or gender identity is the same
as last visit
• LGBTQ patients are engaging in risky behavior
• LGBTQ patients have unsupportive families
•
•
•
•
Case 2. DD (cont.)
• Had a few drinks at a
party last night
• Had consensual sex with a
friend who identifies as
bisexual.
• Didn’t use barrier
protection, not on BC.
• DD says she came out as
bisexual but thinks she
identifies more as a
lesbian
Creating safe spaces
• Provider sensitivity:
• For LGBTQ youth, the strongest predictor of disclosing
orientation/ identity was discussing sexual health with their
provider
• Recommendation to promote disclosure: “Just ask me”
• Lesbians who were out to their providers were more likely to
receive a pap test and other preventative care
• Lesbian and bisexual youth are at least 2 times more likely
than heterosexual youth to have unplanned pregnancies
• You may be one of the few people with whom they feel
comfortable discussing these issues
Creating safe spaces
• First impressions are important: patients will walk in
and assess for affirmation
• Assess and change current clinical environment
- Clinic brochures and posters, health education materials
- Unisex bathrooms
• Ensure your intake forms are inclusive of multiple
gender identities and sexualities
- Establishes non-judgmental attitude
• Advertise the cultural competency of your practice
- Create and post non-discrimination, diversity policies, and
confidentiality policy around clinic
Creating safe spaces
Creating safe spaces
Taking a sexual history
• Some questions to ask everyone:
• Have you ever been or are you in a relationship?
• How old is your partner(s)? How would you describe
the relationship?
• Have you had sex or been intimate with guys,
girls, or both?
• If you have not had sex yet, what are your plans
about sex in the future?
• Has anyone every touched you in a way that
made you feel uncomfortable?
• Do you talk with your parents or other adults
about sex and sexual issues?
Taking a sexual history
• Do you (or your partner) use anything to prevent
getting an STI?
– How often- always, most of the time, sometimes, or never?
– By site
• Have you ever been told that you had an STI?
• Have you ever traded sex for money, drugs, a
place to stay, or other things you need?
If at risk for pregnancy:
• Do you (or your partner) use anything to prevent
getting pregnant?
• Have you ever been pregnant? What happened
with that pregnancy?
Asking about Gender and
Sexual Behavior
Some patients are going to be offended that you
don’t assume heterosexuality or that they are cisgender; similarly, other patients will be relieved that
you don’t.
• “Do you consider yourself male, female,
transgender or another gender?”
OR
• “What gender do you consider yourself?”
• “What is your preferred gender pronoun
(PGP)?”
Asking about Gender and
Sexual Behavior
If the patient is sexually active include the following questions:
– Have you gone down on anyone (had oral sex)
– Have you had anal sex?
– Do you share sex toys?
• For MSM and MTF with M: “Do you top, bottom or both?”
• For opposite-sex partnering: “Do you have penilevaginal sex?”
• For WSW and FTM with F: “Do you share sex toys?”
May need to use different wording for transgender patient:
“What wording do you use to describe your genitalia? I am
asking so I can use the correct term when asking questions.”
Sexual behaviors “by site”
Case 2. DD (cont.)
• Declines birth control
because she “doesn’t
have sex with men very
often.”
• Declines STI testing since
this was the first time she
had condom-less
intercourse with a guy.
Case 3. SM
• 19yo, identifies as transmale
• Comes in for a physical
• Interested in starting masculinizing
hormone therapy
Trans*
• Person whose gender identity or
expression differs from their sex
assigned at birth
• Umbrella term
– MTF: Male-to-Female, Transwoman
– FTM: Female-to-Male, Transmale
– Gender variant, gender non-conforming,
gender queer, non-binary, etc.
Transgender is not…
• A verb
– You don’t transgender into…
– There is no transgendering...
• A noun
– The transgender came...
– Transgenders tend to...
Transitioning
• Process and time during which a person
begins to live as their new gender
• “Transitioning” means different things to
different people
• 4 main aspects:
–
–
–
–
Social
Legal
Medical
Surgical
People may not be interested in all
aspects of transition and there is no
right order on how to transition
TG Health care needs
Knowledge is important but sensitivity even
more so. It’s ok to not know, it’s not ok to not
ask.
• Discomfort with exam especially of genitalia
and breasts
– “How do you refer to those body parts?”
– Explain reason for exam and give patient
option to refuse
Trans* patients
• Assure the patient that many are
uncomfortable with the exam and that they
may stop the exam at any time
• Provide information of why the exam is
necessary
• Ask about PGP and terms for anatomy
• Discuss steps of exam before and during
• Maintain best practices for both anatomy
and hormonal milieu
What more can we do?
• Multi-site STI testing
Urine-only would have missed:
Kent, 2005
63.6%
69.6%
What more can we do?
• Trans* care:
– Help patients access hormone therapy
– Administer hormone injections
– Teach patients to self-inject safely
– Harm reduction approaches (???)
What more can we do?
• HIV+ patients:
– Communicate with pt’s PMD (w/consent)
– Help patients obtain medications
• Rx by mail
• Help with refills
• Keep meds for patients if confidentiality issues
– Help patients attend f/u visits
What more can we do?
• nPEP:
– Discuss with all patients, especially those
at higher risk
– Provide starter packs or identify nearby
health centers that do
– Have resources for patients that need
further care (beyond starter packs)
What more can we do?
CONTINUE TO BE ADVOCATES
ON BEHALF OF OUR PATIENTS
Care of LGBTQ Population in
College Health
THANK YOU!