Why Learn About LGBT Health? Why Learn About LGBT Health? • Diversity

Home , Party and play

Goals and Objectives • Review basic terms used to describe LGBT populations • Reflect on the impact of discrimination in health care based on sexual An Introduction to LGBT Health orientation and gender identity/expression on health and health access and Health Disparties • Reflect on the intersection of sexual orientation and gender Henry Ng, MD, MPH, FAAP FACP identity/expression with other socio-cultural characteristics Assistant Professor • Discuss what is known of LGBT Population Health and Health Case Western Reserve University School of Disparities Medicine MetroHealth Medical Center • Identify local, regional and national LGBT health resources Center for Internal Medicine-Pediatrics • Consider ways to advocate for health equality

Why Learn About LGBT Health? Why Learn About LGBT Health? • Diversity. . .invisible and visible. . .is good. • Economic Reality • Moral Arguments ▫ Can you select your patients? ▫ Reimbursement/Incentives tied to patient satisfaction ▫ All forms of discrimination are wrong and unjust • Professionalism • Public Health Arguments ▫ Codes of Conduct and Ethics of professional organizations ▫ Important illnesses affect LGBT populations and need to ▫ Potential Consequences with unprofessional behavior (state be addressed to improve community health boards) • However, some still reject all these arguments. ▫ LCME accreditation standard ▫ ACGME, Joint Commission standards ▫ Presidential Memorandum

Homosexuality – Historical Context Homosexuality - Historical Context • 1897 – Henry Havelock Ellis and John Addington Symonds write Sexual Inversion , the first English medical text on homosexuality

• 1952 – Homosexuality listed in the DSM-I as a sociopathic personalitydisorder • 1968 – Homosexuality reclassified in the DSM-II as a sexual deviation, • 1973 - Homosexuality removed from DSM-III as a medical diagnosis

1 Historical Homophobia Have attitudes changed? • Heterosexism/homophobia mirrors prejudices • AMA-GLMA Physician Survey held by general public (Harrison, 1996) ▫ National survey of 1121 MDs (1991) ▫ National random sample of 1,500 physicians 35% “nervous around homosexuals” involved in direct patient care 1/3 “homosexuality a threat to many of society’s basic institutions” ▫ Survey of 473 internists/FPs/GP/OB-GYN (1991) ▫ Mailed survey (X3) in 2008-2009 36% “homosexual behavior between 2 men just plain wrong ” ▫ Developed by GLMA and AMA w/ expert advisors 266 respondents Unadjusted response rate, 17.7%

9 10

Respondent Experiences Physician comfort working with… • “I have LGBT patients” Not comfortable Comfortable ▫ The average respondent reported a patient panel with: 28 lesbian patients Lesbians 3% 97% 30 gay male patients Gay men 5% 95% 8 bisexual women 5 bisexual men Bisexual men 6% 94% 1 transgender individual Bisexual women 4% 96% • “I know LGBT people” or “I have a gay friend. . .” ▫ 40% of physicians have at least 1 LGBT person in their extended MTF trans 22% 78% family ▫ 58% report at least one LGBT person as a “close friend” FTM trans 23% 77% ▫ 61% have an LGBT co-worker MSM (not gay) 10% 90% ▫ 82% have an LGBT acquaintance

Provider Education - Undergraduate A New Education Trend? • Historically little health provider training on LGBT patients • Sanchez et al (Jan. 2006) ▫ Medical school: ▫ Medical students with increased clinical exposure to Average of 3h 26 minutes exposure to LGBT health in 4 years curriculum (Wallick LGBT patients tended to perform more comprehensive and Townsend. Academic Medicine, 1992) Decreased to 2h 30 minutes in 1998 (Tesar, 1998) histories, hold more positive attitudes toward LGBT patients and possess greater knowledge of LGBT health ▫ Online Survey of 176 Allopathic or Osteopathic schools in the US (Obedin-Malivar et al, JAMA 2011) care concerns than students with little or no clinical Median reported time dedicated to teaching LGBT-related content in the entire exposure. curriculum was 5 hours • Probably can generalize to other health professions

2 Let’s Start with the Genderbread Person

Gender Identity Disorder (GID) • Medical diagnosis for Transsexualism • DSM-IV criteria: ▫ Strong, persistent cross-gender identification ▫ no perceived cultural advantages of being the other sex ▫ manifested by symptoms desire to be the other sex, frequent passing as the other sex desire to live or be treated as the other sex or the conviction that s/he has the typical feelings and reactions of the other sex. ▫ Male to Female (MTF, M2F), Transwoman ▫ Female to Male (FTM, F2M), Transman ▫ Categorized as Adult/Adol or Pediatric

3 Alternative Constructs of Gender Identity: Terminology Follows Concept

Identity Begins Here

Medical Construct Individual Construct Gender Gender Affirmation Reassignment or courtesy of AMA/Fenway Institute Transitioning

The Spectrum of Transgender Health Care. . . Terminology • Transgender care involves care in multiple domains • Homophobia ▫ Primary Care ▫ The unreasoning fear of or antipathy toward ▫ Gender Affirmation/Assertion Care (aka Transitioning) homosexuals and homosexuality. Hormonal Medication • Transphobia Surgical Procedures ▫ Mental Health Care and Social Supports ▫ The unreasoning fear of or antipathy toward ▫ Legal issues (document name changes, birth record gender transgender individuals and transgenderism changes) • Heterosexism ▫ Social issues and Transphobia/discrimination ▫ A prejudiced attitude or discriminatory practices against ▫ Domestic violence homosexuals by heterosexuals. ▫ Substance abuse ▫ View that heterosexual relationships and associations are normative

Lesbian and Gay People on Television What is LGBT? • Some terms may reflect attraction, fantasy, experience, orientation, gender identity or group affiliation ▫ i.e. Gay, Lesbian, Bisexual, Transgender • Other terms reflect behaviors only ▫ MSM (Men who have sex with Men) ▫ MSM/W (Men who have sex with Men and Women) ▫ WSW (Women who have sex with Women) ▫ WSW/M (Women who have sex with Women and Men)

4 Annals of Internal Medicine, Sept. 2006 Discordant Sexual Behavior and Self- A rose by any other name. . . Reported Sexual Identity • Queer • Pathela et al (2006) • Same Gender Loving ▫ Cross sectional, randomized telephone survey of 4193 men • Boi, Soft Boi from NYC from March – August 2003 • Thug ▫ Concurrent measures of sexual behaviors • DL/Down Low ▫ 12.4% of respondents reported sex with other men. . . but 72.8% of the MSMs identified as “straight” (8.9% of sample) • Aggressive 3.3% respondents were Gay identified • Stone butch 0.2% identified as Bisexual • “Stud” ▫ MSMs with discordant behavior/identity were more likely to • Caveats: be ▫ Different subgroups and individuals Foreign born ascribe to different labels Members of racial/ethnic minorities ▫ Not all individuals identify with a Have lower education/income specific label and its social Married connotations

Public Health Implications of Discordant Behavior/Identity Bisexuality • MSMs who do not identify with LGBT community • Often rejected by heterosexual as well as Gay and may not have access to prevention, treatment, Lesbian communities ▫ Heterosexism and “Homosexism” support and health improvement systems in place On the “Down Low” in LGBT communities. (Chapple et al, 1998) “Gay for the Day” or “Gay for Pay” ▫ Failure to promote health messages Confused “Playing on both teams” ▫ Failure to reduce risk behaviors “It’s a phase” “Spreaders of HIV and STDs”

Bisexuality ▫ Little literature dedicated to health concerns specifically of bisexual individuals Lumped in with LGBT populations Undercounted subgroup Invisibility with “heterosexual/homosexual privilege” Literature on bisexual males > females HIV treatment and prevention Drug abuse Mental health issues Tobacco abuse Eating Disorders Discrimination

5 “Triadic Therapy” • Historical Construct used in Gender “Transitioning” ▫ “Real life experience” in desired role ▫ Medical Care Hormones of the desired gender Medical management and monitoring Electrolysis vs Laser hair removal ▫ Surgery to change the genitalia and other sex characteristics. “Top and Bottom” Surgeries Feminizing surgeries (facial recontouring, tracheal shave)

Populations: Who Is LGBT? Updated Standards of Care, 7 th Edition • The World Professional Association for Transgender Health (WPATH) ▫ Flexible Clinical Guideline - diverse health needs of transsexual, transgender and gender nonconforming people ▫ Suggests letter of support from a mental health professional prior to hormone therapy and/or sex change surgery ▫ One letter for instituting hormone therapy/breast surgery ▫ Two letters generally required for genital surgery ▫ Psychotherapy not an absolute requirement for hormone therapy and surgery

A Modern Day Kinsey Scale The 10% Club – Kinsey Institute Research • Sexual Behavior in the Human Male (1948) • Sexual Behavior in the Human Female (1953) ▫ 37% of males and 13% of females had at least some overt homosexual experience to orgasm ▫ 10% of males were more or less exclusively homosexual ▫ 8% of males were exclusively homosexual for at least three years between the ages of 16 and 55. ▫ Females range of 2-6% for more or less exclusively homosexual experience/response. ▫ 4% of males and 1-3% of females had been exclusively homosexual after the onset of adolescence up to the time of the interview.

6 Who is LGBT? ▫ Various estimates on prevalence of homosexuality (identity vs. behavior vs. experience) in the US population. . . 1.1 % (Alan Guttmacher Institute, 1993). . .to. . . 14.4% of young women self-identified as either lesbian or bisexual and 5.6% of young men self-identified as either gay or bisexual (Cornell University survey, 2007) ▫ National Survey of Sexual Health and Behavior (2010) Approximately 7% of US women and 8% of US men identify as Lesbian and Gay respectively, though a greater number have had same-sex experiences

Who is LGBT? US Census Data ▫ Williams Institute Report (2011) ▫ At best, proxy for LGBT relationships ~ 3.5% of adults in the United States identify as lesbian, gay, or ▫ “Unmarried household partner” bisexual ▫ Can be same or opposite sex partner ~0.3% of adults are transgender. ▫ Census 1990 – 145,130 ~ 19 million Americans (8.2%) report same-sex sexual behavior ▫ Census 2000 – 594,691 ~ 25.6 million Americans (11%) acknowledge some same-sex ▫ American Community Survey, 2004 sexual attraction. 707,196 same sex couples identified ▫ Underestimated population ▫ National Survey of Family Growth, 2002 Fear of “Coming Out” and disclosure Measures of sexual identity, behavior and attraction Questioning Youth, People of Color, LGBT elders 4.1% of the US population aged 18 to 44 years (> 4.5 million individuals) identified as homosexual or bisexual

US Census Data

7 Framing LGBT Health Disparities Conceptual Framework • 2011 Institute of Medicine • The minority stress model calls attention to the chronic Report stress that sexual and gender minorities may experience as ▫ Minority Stress Model a result of their stigmatization; ▫ Life Course Perspective • The life course perspective looks at how events at each ▫ Intersectionality stage of life influence subsequent stages; • The intersectionality perspective examines an individual’s ▫ Social Ecology multiple identities and the ways in which they interact; Perspective and • The social ecology perspective emphasizes that individuals are surrounded by spheres of influence, including families, communities, and society.

Healthy People 2020 Topics. . .and page Healthy People 2020 numbers • Access to Health Services…2 • Heart Disease and Stroke…150 ▫ Nationwide health improvement priorities. • Adolescent Health…8 • HIV…160 • Arthritis, Osteoporosis, and Chronic Back Conditions…15 • Immunization and Infectious Diseases…166 ▫ Increase public awareness and understanding of the • Blood Disorders and Blood Safety…21 • Injury and Violence Prevention…185 • Cancer…27 • Lesbian, Gay, Bisexual, and Transgender Health * determinants of health, disease, and disability and • Chronic Kidney Disease…35 • Maternal, Infant, and Child Health…202 • Dementias, including Alzheimer’s Disease…43 • Medical Product Safety…221 opportunities for progress. • Diabetes…45 • Mental Health and Mental Disorders…225 • Disability and Health…51 • Nutrition and Weight Status…230 ▫ Provide measurable objectives and goals applicable at • Early and Middle Childhood…59 • Occupational Safety and Health…242 • Educational and Community-Based Programs…64 • Older Adults…247 the national, State, and local levels. • Environmental Health…87 • Oral Health…253 • Family Planning…106 • Physical Activity…263 ▫ Engage multiple sectors to take actions to strengthen • Food Safety…118 • Preparedness…273 • Genomics…125 • Public Health Infrastructure…276 policies and improve practices that driven by best • Global Health…127 • Respiratory Diseases…286 • Health Communication and Health Information • Sexually Transmitted Diseases…294 available evidence and knowledge. Technology…130 • Sleep Health…300 • Healthcare-Associated Infections…136 • Social Determinants of Health * ▫ Identify critical research, evaluation, and data collection • Health-Related Quality of Life and Well-Being * • Substance Abuse…302 • Hearing and Other Sensory or Communication • Tobacco Use…315 Disorders…138 needs. • Vision…331

Focus on HIV Disparities Focus on HIV Disparities

8 1. Perform an Environmental Survey ▫ Is the clinical space affirming and welcoming? Visible non- discrimination policy Advocating for LGBT Health Equality LGBT inclusive health literature/posters LGBT inclusive signage Men’s room vs. Women’s room vs. Restroom

1. Perform an Environmental Survey 1. Perform an Environmental Survey

▫ LGBT inclusive intake forms at registration ▫ LGBT media What is your gender? What is your gender? OUT Magazine Male Female The Advocate Magazine Transgendered (check one: MTF FTM) Transgender Community What is your relationship status? News Single Lesbian News Legally married Domestic partner relationship Local LGBT papers Divorced / separated Widowed Other (please specify):______

Gender of current sexual partner(s) (circle all that apply) Male Female Transgendered (please specify):______ Not currently sexually active with others

2. Conduct Interviews Using Inclusive 2. Conduct Interviews Using Inclusive Language Language ▫ Use gender neutral terms: ▫ Orientation is composed of “relationship status”, “partner,” “restroom” Attraction ▫ “What is your preferred name?” Fantasy Behavior ▫ Normalize the interview: Identification “Tell me about yourself” vs. CC ▫ Focus on sexual behavior, not orientation ▫ Ask sexual health history routinely ▫ Understand and respect the patient’s degree of “Outness” To whom has your patient disclosed? ▫ Encourage safer sex techniques ▫ Assess STI exposure ▫ Perform routine domestic violence screening

9 3. Perform Age Appropriate Routine Health Screenings 4. Learn More about LGBT Health • Blood pressure • Education Modules • Cholesterol/Heart disease risk • Smoking cessation ▫ Fenway Community Center • Hepatitis A/B vaccinations and all regular ▫ Physicians for Reproductive Choice and Health immunizations* ▫ UCSF Center of Excellence for Transgender • STD/HIV screening • Colon cancer screening Health • Hep C Screening (baby boomers) • PRIDE Clinic Elective in LGBT Health • Anal cancer* • LGBT Health Texts • Depression and mental health concerns • Substance/Alcohol abuse ▫ Fenway Guide • Domestic/Intimate Partner Violence ▫ Lesbian Health 101

5. Consider LGBT Health Research Closing Health Care Disparities • Black Gay Research Group: • Improve health provider training in caring for LGBT patients: ▫ Advancing an agenda for research, policy and ▫ Create a comfortable clinical environment service in the interests of black gay men. ▫ Screening sexual histories ▫ LGBT oriented office literature ▫ www.thebgrg.org ▫ LGBT inclusive forms ▫ Utilize national/state/local LGBT health resources • Improve caregiver training to provide culturally competent care • Promote LGBT outcomes based health research • Patient participation on LGBT focused research

LGBT Health Resources – National Organizations

www.lgbthealth.net Utilizing LGBT Health Resources www.glma.org for referrals and updated provider links Healthy People 2010 Companion Document www.pflag.org

10 LGBT HEALTH RESOURCES LGBT HEALTH RESOURCES ▫ • Lesbian Health 101 The Fenway • Suzanne L. Dibble , DNSc, RN Professor Emerita Guide To Institute for Health & Aging, Department of Social and Behavioral Lesbian, Gay, Sciences Bisexual and UCSF School of Nursing • Patricia A. Robertson , MD Transgender Professor and Endowed Chair in Obstetric and Gynecology Education Health UCSF Department of Obstetrics, www.acponline. Gynecology, and Reproductive Sciences org ($59.95)

LGBT Health Resources LGBT Health Resources ▫ Healthy People 2020 – LGBT site • Joint Commission Field • IOM LGBT Health Report Guide ▫ http://www.iom.edu/Reports/2011/T he-Health-of-Lesbian-Gay-Bisexual- http://www.healthypeople.gov/2020/topicsobjectives2 ▫ http://www.jointcommission.org/lg and-Transgender-People.aspx 020/overview.aspx?topicid=25 bt/ ▫ CDC site for LGBT Health www.cdc.gov/lgbthealth ▫ LGBT Health Channel http://www.lgbthealthchannel.com/

LGBT Health Resources – Bisexual Health LGBT Health Resources – Transgender Health

• The Task Force: Bisexual Health Report ▫ TransGender Care ▫ www.thetaskforce.org/reports_and_research/bisexual_health www.transgendercare.com ▫ World Professional Association for Transgender Health (WPATH) www.wpath.org ▫ American Psychological Association handout “Answers to Your Questions About Transgender Individuals and Gender Identity” http://www.apa.org/topics/transgender.html

11 A MODEL OF CARE: THE PRIDE CLINIC AT METROHEALTH MEDICAL CENTER Medical Home for LGBT people and their families Primary care, not STI or HIV clinic A Model of LGBT affirming Care Inclusive model ▫ One does not have to be LGBT to be a patient ▫ Care extends to patient’s children, parents, family Comprehensive Adult, Adolescent,Child Care & mental health services ▫ One Half Day a week, 4:30 to 8 PM ▫ Near West Side Cleveland MetroHealth Satellite Location

Top 10 Diagnoses

▫ General Medical Exam Dx made at time at initial ▫ Depression PRIDE Clinic visit ▫ Tobacco Abuse Dx reflect common primary ▫ Obesity care concerns Listed Dx reflect some known ▫ Gender Identity disparities in LGBT Disorder community ▫ Elevated BP w/o HTN ▫ HTN ▫ Hypercholesterolemia ▫ Gastroesophageal Reflux ▫ Allergic Rhinitis

PRIDE Clinic Staff and GSA at MetroHealth PRIDE Staff Cleveland Pride 2008

12 Questions??? In Closing. . . Thank you for your attention! • Perform routine sexual history and behavior screening • Recognize that health disparities exist for LGBT populations, the extent to which has yet to be determined • LGBT patients have unique health concerns historically not addressed in the standard medical [email protected] interview • Utilize local, state, national and web resources for your LGBT patients • Discrimination in health care is a health hazard

LGBT HEALTH RESOURCES – LOCAL/REGIONAL ▫ The Lesbian Gay Bisexual Transgender Community Center of Greater Cleveland Center Resources www.lgcsc.org ▫ Local PFLAG (Parents and Families of Lesbians and Gays) Chapter www.pflagcleveland.org ▫ TransFamily www.transfamily.org

Additional Slides Primary Care Concerns for LGBT Patients

13 Unique Health Issues for Gay, Bisexual Unique Health Issues for Lesbian, Men and MSMs Bisexual Women and WSW • Anal CA screening • Clinical breast exam and mammography ▫ Related to perianal HPV infection • Regular gynecologic care including Pap ▫ 50 – 99% of Lesbian women have had a sexual ▫ No current recommendation for screening unless HIV+ encounter with a male and thus potential exposure to ▫ Studies ongoing HPV ▫ ▫ Intimate partner infection with STI can occur safer Requires team approach (ID, PCP, Colorectal surgeon, sexual practice discussions trained Pathologist) • Duty to discuss reproductive health needs and family • Non-genital site screening for GC and CT planning ▫ Need for contraception (OCP vs. Depo-Provera vs. IUD • Recreational Drug use vs. other) • “Barebacking” and “PnP” ▫ Identified male partner vs. Sperm donor ▫ In vitro fertilization • Hepatitis A/B/C screening and immunization Finding a provider may be difficult (limited providers/bias)

Unique Health Issues for Transgender Persons • Few formal studies • Mostly convenience samples (sex workers) • Unclear what true incidence and prevalence of many health issues are • Sexual risk behaviors in MTF populations • “Pump Parties” and “Street” Physical Special Populations - Adolescents Augmentation ▫ (industrial grade silicone) • Hormonal Therapy and “purity” ▫ Internet pharmacies • Loss of insurance after Dx with GID • Mammograms, pelvic/Pap for Transmen • Mammograms, PSA and DRE for Transwomen

Adolescent Sexuality HEADS FIRST Mnemonic • “…The prevalence of homosexuality among • Home: Separation, support, "space to grow“ adolescents is unknown because gender roles and • Education: Expectations, study habits, achievement sexual identity may take years to evolve and be • Abuse: Emotional, verbal, physical, sexual acknowledged. . .Although only 1% of 12th-grade • Drugs: Tobacco, alcohol, marijuana, cocaine, others males and less than 1% of 12th-grade females • Safety: Hazardous activities, seatbelts, helmets viewed themselves as mostly or completely • Friends: Confidant, peer pressure, interaction • homosexual, 10% were unsure of their sexual Image: Self-esteem, looks, appearance • Recreation: Exercise, relaxation, TV, media games orientation .” • Sexuality: Changes, feelings, experiences, identity • Threats: Depressed or upset easily, harm to self or others

J Adol Health 1991; 12: 649-661 Goldenring and Cohen (1998)

14 Potential Psychosocial Problems of Impact of Family Rejection On LGB Gay and Lesbian Adolescents Youth Health • Social isolation • Higher rates of family rejection associated with • Running away poorer health outcomes • Prostitution ▫ LGB adolescents who reported higher levels of rejection • Substance abuse were: 8.4 times more likely to have attempted suicide • Compromised mental health 5.9 times more likely to report high levels of depression • Damaged self-esteem 3.4 times more likely to use illegal drugs • Depression 3.4 times more likely to have engaged in unprotected intercourse • Anxiety Ryan et al. Family Rejection as a Predictor of Negative Health Outcomes in White and Latino • Suicide Remafedi, G. Clin Pediatr 1985; Lesbian, Gay, and Bisexual Young Adults. 24: 481-485 Pediatrics 2009; 123; 346-352

Reproductive and Sexual Health Concerns The Young Faces of Homophobia

• Jamey Rodemeyer - 14 • Carl Walker-Hoover - 11 • Williamsville, NY • Springfield, MA • Increased incidence of high risk sexual behaviors • Suicide • Suicide - Hanging • September 19, 2011 • March 6, 2009

• Young men with partners of both sexes less likely • Asher Brown - 13 • Houston, TX • Lawrence King - 15 • Suicide - Firearms • Oxnard, CA to use condoms and more likely to have had • Sept. 23, 2010 • Murder - Firearms • Feb. 12, 2008 • Tyler Clementi - 18 multiple partners • Ridgewood, NJ • Suicide – Jumped off bridge • Eric Mohat - 17 • Sept. 22, 2010 • Mentor, OH • Bisexual and lesbian teens twice as likely to • Suicide – Firearms • Seth Walsh - 13 • March 29, 2007 • Tehachapi, CA experience unintended pregnancy • Suicide - Hanging • Sept. 19, 2010 • Sakia Gunn - 15 • Newark, NJ • Death by stabbing • Billy Lucas - 15 • Pregnancy as a means to hide sexual identity • May 11, 2003 • Greensburg, IN • Suicide - Hanging • Sept. 9, 2010 • Increased risk for STIs including HIV • Matthew Shepard - 21 • Laramie, WY • Jaheem Herrera - 11 • Murder - Beating • Dekalb County, GA • Oct. 12, 1998 • Suicide – Hanging • April 9, 2009 www.healthyteennetwork.org

Gay Men and Cancer Gay Men and Cancer • Anal Carcinoma • Kolbin et al (1996) found increased incidence of ▫ Daling et al (1987) and Beckman et al (1989) and Non-Hodgkin’s Lymphoma and Hodgkin’s several other researchers found exposure to HPV as lymphoma in gay men precursor to anal CA in MSM ▫ Cohort design study Receptive anal intercourse ▫ Records from New York City and San Francisco cancer registries and National Health index from Rectal administration of recreational drugs 1978-1990 Higher number of lifetime partners ▫ No difference in incidence of CA at other sites Higher smoking prevalence ▫ Increased NHL and Hodgkin’s related to HIV infection

15 Lesbians and Cancer MSM and HIV/AIDS • Haynes and Denenberg et al (1995) found that • 2008 statistics Lesbians are at increased risk to develop Breast ▫ 19% of MSM from 21 US cities have HIV infection cancer compared to heterosexual women. ▫ 44% of these MSM are unaware of their infection status ▫ Nulliparity ▫ African American MSM are most affected, with a disproportionate ▫ No/Rare OCP use number of incident cases in young African American MSM ▫ Increased Obesity/alcoholism • 2005 study of 5 large cities • Robertson et al (1981) noted less frequent ▫ NYC, LA, San Francisco, Baltimore, Miami gynecologic care in lesbian women ▫ 46% African American MSM HIV+ ▫ Failure to diagnose sexually transmitted infections ▫ 67% African American MSM unaware of their diagnosis ▫ Failure to screen for gynecologic malignancies

Incident HIV infections in MSM by Race/Ethnicity and Age

Youth

• 4,883 young people diagnosed in 2004 ▫ Ethnicity ages 13-25 55% infections are in African Americans 18% Hispanic ▫ MSM 14% African American MSM 7% Hispanic MSM ▫ Gender 62% male - new diagnoses from 2001-2004

Center for Disease Control and Prevention. HIV/AIDS Among Youth; CDC HIV/AIDS Fact Sheet. Web. Centers for Disease Control and Prevention. HIV Surveillance in Adolescents and Young Adults. Web (2011) Revised August 2008. http://www.cdc.gov/hiv http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm

16 Young Women

• HIV prevalence in women 16-21 50% higher than among young men of the same age during the 1990s • African American women ▫ 7 times as likely to be HIV positive as white ▫ 8 times as likely as Hispanic women • 83% of new infections are among women infected via heterosexual contact Center for Disease Control and Prevention. HIV/AIDS Among Youth; CDC HIV/AIDS Fact Sheet. Web. Revised August 2008. http://www.cdc.gov/hiv

Sullivan, L, and Fiellin, D. The Case for Routine HIV Screening and Impact of Managed Care. The American Journal Centers for Disease Control and Prevention. HIV Surveillance in Adolescents and Young Adults. Web of managed Care. (2010). 16; S345-S351. (2011) http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm

Factors Associated with HIV infection in MSM • High prevalence in HIV – “Community Viral Load” • Lack of knowledge of HIV status • Complacency about risk ▫ Younger generation, naïve of HIV epidemic ▫ False beliefs about HIV risk ▫ Consistency of risk reduction behaviors • Social discrimination and cultural issues ▫ MSM vs. Gay/Bisexual ▫ Access to prevention services and messages • Substance abuse ▫ Affecting judgment with sexual behaviors ▫ Direct risk of blood borne pathogens

17 Transgender Populations and Lesbians and HIV/AIDS HIV/AIDS • Lesbians: ??? ▫ Overrepresentation in TG community, but varies • Risk is not negligible across gender identity ▫ Although less than a quarter of the women in the National Lesbian Health Care Survey reported they ▫ Many studies of convenience samples, hard to generalize were worried about contracting STDs. . . ▫ 22-47% among urban subpopulations from several studies ▫ Bauer et al found 13% prevalence of STDs in cohort (Nemoto, et al; Xaiver et al; McCowan et al) of women with only female partners Survey of women recruited from 1997 Twin Cities • Poor self-esteem, history of rejection, Gay/Lesbian/Bisexual/Transgender Pride festival Participants asked if they had ever been diagnosed with HIV, increased risk taking behaviors, survival sex, hepatitis B, gonorrhea, syphilis, chlamydia, genital warts, genital herpes, and trichomoniasis or pelvic inflammatory disease (PID) IVDU, MTF “Pump Parties” <10% of women who reported STD history reported regular testing for STDs ▫ MTF 20-30% HIV+ prevalence ▫ FTM 2-3 % HIV+ prevalence

Gay Men and Mental Health Lesbians and Mental Health • Cochran and Mays, 2000 • National Lesbian Health Survey 1984-1985 ▫ Gay men report higher rates of depression and anxiety • Bradford et al, 1994 disorders than heterosexual counterparts ▫ 1925 Lesbians from all 50 states • Geneva Gay Men’s Health Study, 2002 ▫ Over 50% with thoughts of suicide at some time ▫ Comprehensive health survey among 571 gay men in Geneva, Switzerland ▫ 18% attempted suicide ▫ 43.7% of participants fulfilled criteria for one of five ▫ 37% abused as a child or adult DSM-IV disorders ▫ 32% raped or sexually attacked 19.2% Major depression in last 12 months ▫ 19% involved in an incestuous relationship 21.9% Specific and/or social phobia in last 12 months ▫ Nearly 1/3 used tobacco daily 16.7% Alcohol or drug dependence disorder in last 12 months >25% comorbid mental health conditions ▫ 30% drank alcohol more than once a week 35.7% had consulted a mental health provider ▫ 6% drank alcohol daily

Mental health and perceived Mental health and perceived discrimination discrimination • MacArthur Foundation National Survey of • Measures of mental health Midlife Development in the United States ▫ Mental health indicators of 5 stress-sensitive psychiatric (MIDUS) disorders ▫ Cochran and Mays, 2001 ▫ Drug and alcohol dependence ▫ Population based survey with random telephone • Homosexual and bisexual individuals reported sampling design lifetime and day to day experiences with ▫ Heterosexual N = 2844, Bisexual N = 32 discrimination more frequently than ▫ Homosexual N = 41 heterosexuals ▫ Measures of experiences in 4 domains ▫ ~42% attributed this in part or in total to their sexual Lifetime discriminatory experiences orientation Frequency of day-to-day discrimination ▫ Odds of having any psychiatric disorder increases for Reasons for discrimination any lifetime discriminatory event (OR 1.6) General effects of discrimination Multiple settings: school, work, financial services, social ▫ Or day-to-day experience of discrimination (OR 2.13) hostility ▫ Findings limited by small sample size and low power

18 Framing Gender Identity – Condition or Disorder? Lesbians and Obesity • DSM-IV: Gender Identity Disorder (GID) in • Roberts et al (1998), Seiver (1994) and children, adolescents and adults several non-randomized studies suggest ▫ Requires distress/impairment of functioning Lesbians are more likely to be overweight. ▫ Being transgender alone does not constitute a ▫ Less preoccupied with weight and body image than mental disorder heterosexual women (Seiver). ▫ Gender incongruence, dysphoria ▫ Valanais et al (2000) in comparing data from the ▫ When does treatment end? Women’s Health Initiative found that Lesbians ▫ Considered stigmatizing/pejorative consume fewer fruits and vegetables than Dysphoria vs. disorder heterosexual women.

American Psychiatric Association, 1994

Gay/Bisexual Men and Nutrition Gay/Bisexual Men and Nutrition • Very little known and variable habits reported • Kaminski et al (2004) studied body image, eating • Some studies show correlation between eating behaviors and attitudes toward exercise among gay and straight men disorders and sexual orientation among men ▫ Use of Male Eating Behavior and Body Image Evaluation (MEBBIE) (Beren et al, 1996). . . tool • while others did not (Turnbull et al, 1987 and Pope ▫ Previous studies used instruments designed to assess eating disorder symptomology in women et al, 1986) ▫ Gay men: • “Gay male gym culture” (Bernard 1998) Dieted more ▫ Response to need to appear healthy in time of AIDS Were more dissatisfied with their degree of muscularity epidemic Were more dissatisfied with their bodies in general ▫ Anabolic steroid use Were more fearful of becoming fat ▫ HIV and Hepatitis risks ▫ No difference between straight and gay men in degree of exercise or feeling guilty about missing workout

LGBT and Substance Abuse LGBT and Substance Abuse • McKirnan and Peterson (1989) • EtOH consumption rates do not seem to decrease ▫ Survey 748 Lesbians and 2652 Gay men with age as quickly as they do among ▫ Comparison of drug and alcohol use to general heterosexuals (Skinner, 1994) population • Club drugs popular among younger gay men and ▫ Higher numbers of Lesbians and Gay men use lesbians and some other groups, but prevalence alcohol, marijuana and cocaine unknown. ▫ Lesbians and Gay men did not have rates of heavy ▫ MDMA (Ecstasy, E) alcohol use higher than general population ▫ Methamphetamine (Crystal Meth, Ice, Tina) ▫ Gay men and Lesbians reported problems with ▫ Ketamine (Special K) alcohol twice as often as matched heterosexual ▫ Gamma Hydroxy Butyrate (GHB) counterparts ▫ Amyl Nitrite (Poppers)

19 Drug abuse, Sexual Risk and MSMs • Study on drug use patterns and sexual risk behavior of 13 to 21 year old MSM from1994-1997 (Remafedi, 1999) • Associations noted between unprotected anal intercourse and use of: ▫ Alcohol ▫ Marijuana ▫ *Cocaine Independent predictor of failure to use condoms ▫ Amphetamines ▫ Barbiturates ▫ Heroin ▫ LSD ▫ Volatile nitrites ▫ Tranquilizers ▫ Methaqualone

Phosphodiesterase Inhibitors and STD/HIV Risk in MSMs MTV. . .No Longer Just Music Television • Phosphodiesterase inhibitors are commonly used ▫ Methamphetamine by MSM travelers ▫ Tenofovir (Viread) • Study of 304 MSM vacationers to Key West or Rehoboth Beach (Benotsch, 2006) ▫ Viagra (Sidenafil) ▫ 1.33 unprotected anal intercourse encounters over avg of ▫ Used by some MSM for 3.6 days stay PnP (Party and Play) ▫ Over half of partners with unknown HIV status ▫ Form of pre-exposure ▫ 11% used PDE inhibitors (Viagra most common) prophylaxis ▫ Higher incidence of unprotected anal sex with PDE use ▫ No difference in rates of alcohol, cocaine ▫ No evidence of efficacy methamphetamine or other substance use between PDE ▫ No standard to use users and non-users ▫ Partners HIV status • Sildenafil (Viagra) often used with club drugs in often uncertain MSM populations (Halkitis, 2007) www.advocate.com/print_article_ektid69520.asp

LGBT and Substance Abuse LGBT and Tobacco Abuse • Transgender and substance abuse • Smoking in Lesbians is 70% higher than ▫ Very little research and unclear extent of problem heterosexual women (25.3% vs. 14.9%) ▫ Convenience samples from urban areas • Smoking in Gay men 33.2% vs. ▫ Cannot generalize ▫ ?More specific for subpopulations (MTF sex workers) heterosexual men 21.3% ▫ San Francisco DOH (1999) • Demographic risk factors MTF transsexuals drug use pattern in prior 6 months ▫ Age 35-44 THC 64% ▫ Non-Hispanic White Heroin/speed 30% ▫ Low-education attainment (< high school) Crack cocaine 21% FTM THC 43% ▫ Low household income (<$30,000)

San Francisco DOH Study 1999 Tang et al 2004

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