A Discussion Around LGBTQ+ health

When the topic of specific medical care for LGBTQ+ patients comes up, people often ask “Why?”. Why is there a need for this specification? Why are there special clinics for LGBTQ+ people in Tel Aviv, New York, and Berlin? These are all cities with a very high population of people from the community, therefore with high awareness and sensitivity to that community.

This blog is a summary of the webinar “A discussion around LGBTQ+ health”, led by Dr. Zucker, an Infectious diseases specialist and the first to specialize in LGBTQ+ medicine at Icahn School of Medicine at Mount Sinai, New York.

The term LGBTQ+ is an umbrella term for Lesbian, Gay, Bisexual, Transgender, Queer. Over the years, many more terms have fallen under this colorful umbrella which is why the plus sign has been added. The term LGBTQ+ medicine means medical care that specifically revolves around that community, their specific needs, and raising awareness within that community. 

Don’t ask, Don't tell - No more!

When the topic of LGBTQ+ specific medical needs comes up, there are many who ask why there's a need to be aware of the patients’ sexual orientation and gender identity. Why is there a need for a specialization focusing on LGBTQ+ health? The answer to this is split into two.

First, the LGBTQ+ community is less likely to seek out medical care. This may relate to their fear of "coming out" to medical staff. These people will often seek medical attention only once the symptoms are so severe that they usually need to be taken to the hospital. Even in “gay-friendly” cities like New York and Tel Aviv, it only takes one bad encounter with someone less accepting to make people more hesitant to seek medical care the next time.

The second part has more to do with the future of medicine and where it is headed. Medicine is becoming more and more personalized. In the past, we had only general specializations such as orthopedics and cardiology. Nowadays, orthopedics might continue to specialize in spinal surgery and cardiologists may specialize in Interventional cardiology. The same approach should and is being applied to LGBTQ+ health. Medical providers administrating hormonal treatment to a transgender patient should be able to adjust the patient’s HIV prevention and treatment plan accordingly to minimize any drug-drug interactions and adverse effects. The medical provider should be also able to take into consideration possible substance issues, vaccinations and more. Until recently, there was never a structured syllabus and specialization for this kind of medical care.

A deep dive into LGBTQ+ medicine

This blog’s purpose isn’t to just explain the “why”, but also the “what” and “how”. We cannot cover all of the topics in one blog post. Instead, we will focus on a few main topics that were introduced in the webinar. The main goal is to open our eyes and help all of us cultivate a more understanding mindset when seeing a patient from the LGBTQ+ community.

Pre-exposure prophylaxis (PrEP) 

According to the Centers for Disease Control and Prevention (CDC), an antiretroviral medication (containing tenofovir and emtricitabine) will reduce the chances of contracting HIV via sexual contact by 99%^[1] if taken as prescribed. It is important to note that, yes, it does require a prescription, but any health care provider licensed to write prescriptions can prescribe PrEP.

According to the “Global PrEP Network”, oral PrEP use is increasing globally, with a 70% increase in usage from 2017 to 2018 alone!^[2]

Unfortunately, not everyone who might benefit from this drug receives it. For instance, In the USA it is estimated that out of the 1.1 million potential candidates, only 8% are receiving PrEP^[3]. This disparity might be because of the patient’s lack of knowledge or because the patient might need to “out” themselves to their medical provider to receive the prescription.

Sexually Transmitted Infections (STIs)

When speaking about STIs we mainly refer to syphilis, chlamydia trachomatis (LGV & non-LGV), neisseria gonorrhoeae, and mycoplasma genitalium. As a healthcare provider, if a heterosexual male asks you for an STI test, you will be usually correct in sending him for a urine and blood test. Would you medically treat men who have sex with men (MSM) the same way? The correct answer is no. Both chlamydia and gonorrhea, are “site-specific” infections, meaning if the patient had oral sex we will do a pharyngeal swab and if they had anal sex we will do a rectal swab. Even now, in many countries, the guidelines for STI screening don’t acknowledge the difference between patients from the LGBTQ+ community. The best approach in this case is to explain these tests and openly ask your patient about their sexual encounters to determine the screening tools that will provide the most accurate results.

The increased use of PrEP led to a decrease in the use of condoms which might increase the risk of contracting an STI^[4,5]. This combined with the lack of knowledge of many medical providers regarding the appropriate screening tests to order, has led to many people thinking they are healthy because of a negative urine test. In actuality, a rectal or pharyngeal swab would have indicated otherwise.

The lesbian community

The word LGBTQ+ represents many different groups of people. Assuming that they all share the same problem is a mistake. Each group has its own unique features.

The lesbian community suffers higher rates of breast and cervical cancer than their heterosexual counterparts. One of the main reasons for this is the low rates of lesbian women who undergo prevention and screening tests compared to their heterosexual counterparts^[6,7]. In addition, evidence shows that the lesbian community suffers more from obesity, substance abuse, and smoking^[8].

The bisexual community and their unique concerns 

As my bisexual identifying friend always tells me, just because they enjoy both worlds doesn’t mean they don’t have their own unique problems. According to one study, bisexual people have higher rates of mental health issues and suicide when compared to the other members of the LGBTQ+ community^[9]. Additionally, they experience body image issues, eating disorders, and substance abuse. According to studies, in the USA more than half of the LGBTQ+ community identifies as bisexual^[10].

The transgender community and hormone therapy 

When interacting with a transgender patient (or any patient) for the first time, don’t be afraid to ask what pronouns to use when addressing them. This simple question will make both of your lives easier and less awkward. Avoid the term “biological gender”. Instead, ask about their assigned gender at birth and ask them about their current gender identity. If this information wasn’t noted before, add it to their file to better prepare the next medical provider.

According to a study conducted in the USA, less than 1% of Americans identify as transgender^[10]. Despite the general misconception, most transgender people do not undergo gender reassignment surgery^[11]. Some of them choose only to take hormones. There are many discussions regarding the age a person can start undergoing hormonal therapy. If they do start during puberty, the medical provider will administer reversible therapy with a gonadotropin-releasing hormones agonist. The medical provider will administer testosterone based regimen for transgender men, and estrogen based regimen for transgender women. For transgender women who are taking estrogen, there is an associated risk of venous thromboembolism; to reduce this risk, androgen lowering agents (e.g. spironolactone) may be added which will allow reducing the estrogen dose.

For more info on how to interact and communicate better with a transgender patient, check out my previous blog post “How to Provide LGBTQ+ Patients With the Best Care Possible” and check out this article published by the New England Journal of Medicine.

LGBTQ+ Fellowship

In 2015 Dr. Zucker was sent to Berlin to conduct research in Cardiology. During his visit, he stumbled upon his first LGBTQ+ medical center. The Berlin medical center took care of 25,000 people. Once back in Israel, he started taking more interest in transgender health, HIV, STDs and preventative care. He joined the Gan Meir LGBTQ+ clinic in Tel Aviv in 2017. His interests led him to specialize in infectious diseases. Nowadays, Dr. Zucker is the first medical provider in the world sub-specializing in LGBTQ+ medicine at Mount Sinai hospital in New York. In addition, Dr. Zucker started a program called “Party Keepers” in Israel. The program trains non-medical people in how to correctly provide first aid to someone who has overdosed during a party. He is now starting a similar program in New York.

If you have reached this far in the blog I hope you will agree that even if in 10, 20, or 30 years, being queer will be so normal it’s boring. The medical attention given to the LGBTQ+ community should still be specific and targeted to provide the best medical care possible. 

About Omer

Omer Rott is a fourth-year medical student at Masaryk University, Brno, located in the Czech Republic. A Regional Lead in the Osmosis Medical Education Fellowship program, he is interested in Pediatrics. During his free time, Omer enjoys reading, baking, photography, and playing board games with his friends. 

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References

1. Cottrell ML, Yang KH, Prince HMA, et al. A Translational Pharmacology Approach to Predicting Outcomes of Preexposure Prophylaxis Against HIV in Men and Women Using Tenofovir Disoproxil Fumarate With or Without Emtricitabine. J Infect Dis. 2016;214(1):55-64.
2. https://www.who.int/news-room/feature-stories/detail/global-data-shows-increasing-prep-use-and-widespread-adoption-of-who-prep-recommendations
3. Siegler AJ et al. Distribution of active PrEP prescriptions and the PrEP-to-need ratio, US, Q2 2017. 25th Conference on Retroviruses and Opportunistic Infections (CROI 2018), Boston, abstract 1022LB, 2018.
4. Kojima, N., D.J. Davey, and J.D. Klausner, Pre-exposure prophylaxis for HIV infection and new sexually transmitted infections among men who have sex with men. AIDS, 2016. 30(14): p. 2251-2.
5. Nguyen, V.K., et al., Incidence of sexually transmitted infections before and after preexposure prophylaxis for HIV. AIDS, 2018. 32(4): p. 523-530.
6. Dana L. Brandenburg PsyD, Alicia K. Matthews PhD, Timothy P. Johnson PhDM & Tonda L. Hughes PhD and RN and FAAN (2007) Breast Cancer Risk and Screening: A Comparison of Lesbian and Heterosexual Women, Women & Health, 45:4, 109-130, DOI: 10.1300/J013v45n04_06
7. J. Kathleen Tracy, Alison D. Lydecker, and Lynda Ireland.Journal of Women's Health.Feb 2010.229-237.http://doi.org/10.1089/jwh.2009.1393
8. Weisz, V. K. (2009). Social justice considerations for lesbian and bisexual women's health care. Journal of Obstetric, Gynecologic & Neonatal Nursing, 38(1), 81-87.
9. Chan RCH, Operario D, Mak WWS. Bisexual individuals are at greater risk of poor mental health than lesbians and gay men: The mediating role of sexual identity stress at multiple levels. J Affect Disord. 2020;260:292-301. doi:10.1016/j.jad.2019.09.020
10. Gates, G. J. (2011). How Many People are Lesbian, Gay, Bisexual and Transgender? UCLA: The Williams Institute. Retrieved from https://escholarship.org/uc/item/09h684X2
11. Table 1, Nolan, I. T., Kuhner, C. J., & Dy, G. W. (2019). Demographic and temporal trends in transgender identities and gender confirming surgery. Translational andrology and urology, 8(3), 184–190. https://doi.org/10.21037/tau.2019.04.09