Ending LGBT invisibility in health care: The first step in ensuring equitable care

ASSESS SEXUAL BEHAVIOR TO DETERMINE RISK

In taking a history, it is important to distinguish sexual identity from sexual behavior. Physicians need to discuss sexual behavior with patients regardless of their sexual identity in order to do a risk-assessment, ascertaining what activities they engage in and to learn what they do to prevent transmission of sexually transmitted disease. In a 2006 study of more than 4,000 men in New York City,⁴ 9.4% of those who identified themselves as straight had had sex with a man in the previous year. These men were more likely to be either foreign-born or from minority racial and ethnic groups with lower socioeconomic status. They were also less likely to have used a condom. A study of lesbians reported that 77% to 91% had at least one prior sexual experience with men, and 8% reported having had sex with a man in the previous year.⁶

Once you understand more about a patient’s sexual behavior, it is important to ask how patients protect themselves from human immunodeficiency virus (HIV) and other sexually transmitted diseases. If they use condoms or latex dams, they should be asked whether they do so consistently. Many patients have the misconception that they are practicing safe sex by only engaging in oral sex and do not realize that although it is probably protective against HIV infection, it does not protect against gonorrhea, syphilis, and other sexually transmitted diseases. Although most sexually transmitted diseases are treatable, their presence increases the risk of transmission of HIV.

Counseling on safer sex should include behavioral risk-reduction approaches. Depending on what behaviors a patient already engages in and what counseling he or she would be willing to accept, one could counsel abstinence, monogamy with an uninfected partner, reducing the number of partners, low-risk sexual practices, consistent and correct use of barrier methods, ceasing to engage in at least one high-risk activity, and avoiding excessive substance abuse. Physicians should advise patients to have a proactive plan to protect themselves and their partners. Patients should also be counseled on the correct use of barrier protection and on what is available for prophylaxis in case of high-risk HIV exposure (eg, a condom breaking or postcoital HIV disclosure). Another important question is, “Do you use alcohol or drugs when you have sex, and does your partner?” because these behaviors are often associated with unsafe sexual practices.

A new dimension of care will be biomedical prevention. While there are many ongoing studies of vaginal and anal microbicides to prevent HIV infection, there are also ongoing studies of antiretroviral therapies to do so.

One important new study demonstrated the effectiveness a biomedical intervention using antiretroviral therapy to prevent HIV infection in high-risk individuals.⁷ The study showed that men who were assigned to take a combination antiretroviral medication orally on a daily basis decreased their HIV risk by almost half compared with those assigned to take a placebo. The therapy was given along with intensive behavioral counseling. While this study was done in men who have sex with men, it is a major breakthrough and suggests there will be many new approaches to preventing HIV in the future.

A guide for clinicians has not been published by any government agency at this point, but guidance for clinicians is available from the Fenway Institute at www.fenwayhealth.org.

ASSESS GENDER-IDENTITY ISSUES

One should also routinely ask about whether patients are transgender or have gender-identity concerns. Psychologists start the conversation with the following example, which can also be used by general clinicians:

“Because so many people are impacted by gender issues, I have begun to ask everyone if they have any concerns about their gender. Anything you say about gender issues will be kept confidential. If this topic isn’t relevant to you, tell me and I’ll move on.”⁸

It is important to open the door to conversation, because many transgender people see a doctor for years and the topic never comes up. When they realize that they want to change their life, no one has ever helped them deal with the issues.

If appropriate, one can also say:

“Out of respect for my clients’ right to self-identify, I ask all clients what gender pronoun they’d prefer I use for them. What pronoun would you like me to use for you?”

Once these issues have been raised, it is important to support transgender people and help them explore a number of choices, including whether they wish to undergo hormone treatment, cosmetic surgery, and genital surgery. This may not be easy for many clinicians, so it will be important to learn about resources to care for transgender individuals in your community. Resources that can be very helpful for primary care clinicians include the following:

• The World Professional Association for Transgender Health (www.wpath.org) is the oldest and most traditional source for establishing standards of care.
• Vancouver Coastal Health published a series of monographs online (https://transhealth.vch.ca) that were developed by the University of British Columbia so that transgender people could be cared for in the community by primary care clinicians.
• The Endocrine Society in the United States published guidelines in 2009.⁹

PROVIDE SUPPORT FOR ‘COMING OUT’

We should also be understanding of people’s desires and support those who are “coming out.” The desire to reveal sexual orientation to others can happen at any age, including in childhood and among those who appear to have a traditional life because they are married and have children. Sometimes people do not know how to come out and would like to discuss such issues with their doctor.