Best practices in LGBT care: A guide for primary care physicians

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Outlined here is an office-based approach for addressing the unique clinical concerns of adult LGBT patients. Not all of these issues need to or should be addressed at the first visit, and the sequence in which these steps are accomplished may vary.

Step #1: Screen for mental health disorders

Lesbian, bisexual, and gay people are more likely to experience depression and anxiety. According to the results of a large meta-analysis,14 the prevalence of these conditions is 1.5 times higher in this population than in heterosexual people. Risk may vary according to group, with gay and bisexual men experiencing a higher lifetime prevalence of anxiety and depression than lesbian and bisexual women.15 Suicidal attempts are also more common in gay and bisexual men, who have a lifetime risk four times higher than that of heterosexual men.14

The risk of suicide is even higher among transgender people: 41% of surveyed transgender adults reported that they had attempted suicide, with higher rates in younger individuals.5 Risk factors include experiences of harassment or physical or sexual violence, as well as poverty, low education level, and unemployment.5 The risk of suicide in transgender people who served in the military is 20 times higher than that in the general veteran population.16

It is imperative to routinely screen LGBT patients for anxiety, depression, and suicidality and to refer them to mental health providers who are sensitive to LGBT patients’ needs and concerns. Screening tools such as the Patient Health Questionnaire-2 (PHQ2), PHQ9A, PHQ9, and Generalized Anxiety Disorder 7-item scale (GAD7) are useful in screening patients for depression and anxiety in addition to mnemonics such as SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal thoughts or ideation).17

Although the same screening tools are used in cisgender heterosexual patients, factors contributing to the experience of depression or anxiety may be directly related to gender identity, gender expression, or sexual orientation. In a 2001 study, more lesbian, gay, and bisexual people reported lifetime and day-to-day experiences with discrimination than heterosexual people, and approximately 42% attributed this in part or in total to their sexual orientation.18

Step #2: Assess for substance use

Substance use is also more common in LGBT people. Lesbian and bisexual women have higher rates of tobacco abuse, exposure to second-hand smoke, and alcohol and drug dependence.3,14 In one study, compared with heterosexual individuals, the odds of lifetime alcohol and substance use disorder was three times higher in lesbian women, and the odds of lifetime drug-use disorder was 1.6 times higher in gay men.19

In a survey of transgender people, 30% reported using tobacco compared with 20% of the US adult population, and 8% reported using alcohol or drugs to cope with mistreatment and bias.5 In a study of transgender women in San Francisco, 58% used alcohol and 43% used substances, including marijuana, methamphetamine, and crack cocaine. Substance use significantly increased the odds of testing positive for HIV.20

Clinicians should carefully question LGBT patients about their use of alcohol, tobacco, and other substances and provide counseling and assistance with cessation. Several LGBT-specific resources can be used to aid patients in their efforts, and referral to substance abuse groups that are welcoming to LGBT people may increase cessation rates.19,21

Step #3: Offer appropriate screening services

Human papillomavirus (HPV). Like heterosexual women, lesbian and bisexual women are at risk of HPV infection, which is associated with cervical cancer and genital warts.8 HPV can be transmitted in several ways, including skin-to-skin and digital-to-genital contact, as well as penile-vaginal intercourse. Lesbian and bisexual women may have acquired HPV from previous male sexual partners or from female-to-female transmission.8 In a study comparing cervical cancer screening results among lesbian, bisexual, and heterosexual women, there was no significant difference in the odds for Papanicolaou (Pap) test abnormalities and only a minor decrease in the odds of HPV infection.22 Lesbian and bisexual women should receive Pap and HPV testing according to current guidelines.

Other sexually transmitted infections, including herpes simplex virus 1, herpes simplex virus 2, Trichomonas vaginalis, syphilis, and hepatitis A, can be passed between female partners; risk may vary according to sexual practices.23 Thus, providers should not assume that lesbian women are at low risk of these infections and should screen according to current guidelines.

The US Centers for Disease Control and Prevention (CDC) recommends annual screening for Chlamydia infection for all women under age 25, as well as those at increased risk for this infection (ie, those with a new sex partner or multiple sex partners).24

Breast cancer. Studies reveal that lesbian and bisexual women are less likely to receive mammograms, and they may have several risk factors that increase their risk for breast cancer, including overweight, obesity, and excessive alcohol intake.12,18,25 Providers should discuss the risks and benefits of mammography and offer this screening service at appropriate intervals.

Screening in men who have sex with men

Men who have sex with men are at increased risk for several sexually transmitted infections, including HIV, syphilis, gonorrhea, Chlamydia, anal HPV, and hepatitis B and C.4,9 The CDC recommends annual sexual health screening that includes serologic testing for HIV and syphilis, and urine, rectal, or pharyngeal testing for gonorrhea and Chlamydia according to sexual practices.24

In contrast, routine screening for anal HPV is not currently recommended because we lack data demonstrating that screening reduces mortality rates from anal carcinoma.24,26 Nevertheless, the CDC acknowledges that some clinicians may choose to perform anal Pap testing in patients who are at high risk, and guidelines from the New York City Department of Health and Mental Hygiene suggest annual anal Pap testing in HIV-positive men who have sex with men.27

According to the results of a systematic review,28 a significant proportion of transgender women reported sexual practices that increased their risk for sexually transmitted infections, and 27.7% tested positive for HIV infection. In contrast, rates of HIV and risk behaviors were much lower among transgender men. Risk may be heightened in transgender women who have not had sexual reassignment surgery and who engage in insertive anal, vaginal, or oral intercourse.28 An awareness of an individual patient’s current anatomy and sexual practices is essential for providing appropriate counseling about sexually transmitted infections.

‘Screen what you have’

When considering screening for breast, cervical, and prostate cancer, providers should consider an individual patient’s surgical history and hormonal status. “Screen what you have” is an easy rule to help both patients and providers remember which services to consider.

Transgender men who have not had a mastectomy should discuss the risks and benefits of breast cancer screening and consider mammography as recommended by the American Cancer Society.29 Similarly, cervical cancer screening should be performed according to current guidelines, although providers should be aware that this examination can cause significant anxiety and emotional distress for the patient.30

In transgender women, guidelines for breast cancer screening for those who were previously or currently treated with hormones are lacking. The University of California-San Francisco Center of Excellence for Transgender Health recommends mammography for patients over age 50 with additional risk factors (family history, obesity, estrogen and progestin use for more than 5 years).31 Transgender women should be counseled about the risks and benefits of prostate cancer screening.

Step #4: Immunize, and promote healthy behaviors

Table 4 outlines the screening services, immunizations, and health behavior promotions that should be offered to LGBT patients.

Vaccinations. LGBT individuals should be routinely offered HPV vaccination through age 26, according to current guidelines.24 Immunization against hepatitis A and B is also recommended for men who have sex with men, if they are not already immune.24 Meningococcal vaccine should be given to men who have sex with men if they have an additional medical, occupational, or lifestyle risk factor.32

Physical activity should be encouraged, especially in lesbian and bisexual women, who are more likely to be overweight and obese.25 In a recent study,33 gay, lesbian, and bisexual youths (ages 12–22) reported 1.21 to 2.62 fewer hours of moderate or vigorous physical activity per week than their “completely heterosexual” counterparts, and were 46% to 76% less likely to participate in team sports, in part due to concerns about gender nonconformity. On the other hand, results from a recent national survey of adults ages 18 through 64 found no significant differences in physical activity according to sexual orientation.

Providers should address patients’ perceived barriers to participating in exercise programs.2

Preexposure prophylaxis against HIV. A growing number of patients and health providers are asking about preexposure prophylaxis for HIV infection. The initial CDC recommendations for the daily use of emtricitabine-tenofovir were restricted to gay and bisexual men and men who have sex with men in serodiscordant relationships or in situations where the HIV status of the patient’s partner was unknown.34 Since then, the CDC has expanded the groups who may benefit from preexposure prophylaxis.35 Assessment of the patient’s ability to adhere to a daily oral medication regimen is central to its success. Patients should be screened for hepatitis, HIV, and renal and liver function before starting emtricitabine-tenofovir and should have these tests repeated at 3-month intervals if pre-exposure prophylaxis is continued.

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