LGBT Cultural Competency Workshop 1: Overview of LGBT Health Discussion

1. LGBT Cultural Competency Workshop 1:Overview of LGBT Health Discussion James Lehman, MD/MPH Candidate & Nick Anderson, MD Candidate Co-presidents, PRIDE in Healthcare January 23rd and 24th, 2014

2. http://tinyurl.com/PiHTalks

3. Reflections First, let’s reflect on a few statements. Let your mind take you wherever. • I am comfortable talking with my patients about sexual behaviors other than penile-vaginal intercourse • Being gay or lesbian is a lifestyle choice • I feel uncomfortable when I see two men holding hands in public • I would be upset if someone thought I were gay or lesbian • If my child came out as transgender, I would think I did something wrong as a parent • In general, I would rather avoid offending patients rather than ask about sexual behavior • I intend to be a rural family physician, so I do not need to keep up with LGBT health issues

4. Reflections Now, let’s reflect on two questions. • Why is it challenging for us to communicate with LGBT patients? Think about this from both your perspective and that of your classmates/peers. • Why is it important to be prepared?

10. Evaluate terms • Are gender identity and sexual orientation are the same thing? • L+G+B+T = 3 orientations and 1 identity • SGM – sexual and gender minorities  emphasizes minority • “Q” or “Queer community”  emphasizes difference • What are some terms you’ve heard involving either sexual orientation or sexual identity and what does it mean? • Different terms can mean different things to different people • MSM (epi) vs. gay (social) • Some think these are synonymous and often use gay to mean MSM and gay or lesbian to mean WSW • What is sex?

11. Transwhatnow? • FTM = female to male • Called a transman because he is a transgender person identifying as a man • MTF = male to female • Called a transwoman because she is a transgender person identifying as a woman • Trans people almost always prefer the pronouns of their self-identified gender • Some prefer gender-neutral pronouns like ze/hir/hirs/hirself

12. Trans PronounsA CRASH COURSE

13. Queer (umbrella) vs. Queer (Genderqueer) • Queer can be shorthand for genderqueer, a gender identity • Queer can refer to all sexual/gender minorities • Not mutually exclusive with LGBT+ identities • This is an example of reclaiming a term, making it non-perjorative • Fag and dyke are sometimes used this way • YMMV. Some people (especially older and rural) consider it only a slur • Wait for someone to self-identify as queer first • Expect it most often in younger, college-educated persons

14. Exercise The leading cause of death in gay men is __________________? • Answer: Heart disease • HIV does not just affect gay men! But STIs are a special concern for MSM. • LGBT people have some disparities and unique needs… • …but are not from the planet Zorch

15. Medical causes of death: WI 2011

16. You’re gay? Then let’s talk about sex and ONLY sex! • Smoking up to 2x more prevalent (LGBT) • Excess alcohol (LGBT) • Weight (L) • Gyn cancers (LB) • Screening avoidance • Intimate partner violence (esp. G—why?) • Depression, anxiety, suicide ideation • What are the root causes?

17. Krehely J. How to Close the LGBT Health Disparities Gap. Center for American Progress: 2009.

18. In “Project Scum [Subculture Urban Marketing],” R. J. Reynolds tried to market Camel and Red Kamel cigarettes to San Francisco area “consumer subcultures” of “alternative life style.” R. J. Reynolds's special targets were gay people in the Castro district, where, as the company noted, “The opportunity exists for a cigarette manufacturer to dominate.”The gay Castro denizens were described as “rebellious, Generation X-ers,” and “street people.” Both the coded labeling of targets as “Generation X-ers” in the mid-1990s and as “rebellious” indicates their youth. Project Scum also planned to exploit the high rates of drug use in the “subculture” target group by saturating “ ‘head shops’ [tobacco/bong/legal psychoactives] and other nontraditional retail outlets with Camel brand.” Washington HA. Am J Public Health. 2002 July; 92(7): 1086–1095.

21. Scenario 1 A patient is referred to you for an asthma assessment. You read the referring physician’s notes, which refer to the patient as a “male”, but when you enter the room, the patient is wearing a dress and make-up. How do you begin? • How do you best document a patients sexual orientation or gender identity, especially if the patient doesn’t fit into a checkbox? • What other kinds of documentation matter?

22. Scenario 2 A 16 year-old male comes to your clinic and he appears to be very nervous. After asking a few questions, he tells you he’s scared because he finds another boy in his class attractive. • Remind that (almost) anything said will be confidential • What wouldn’t be? • Be supportive • Listen. No, really. Listen. • The presence of at least one supportive adult in a SGM’s life can reduce risk of suicide by 30% • But is he gay? Bisexual?

23. Scenario 3 An elderly lesbian patient you have been seeing for 15 years tells you her family is trying to convince her to move to an assisted living facility. She admits that she is no longer able to properly care for herself, but she is terrified of how she will be treated if she moves. • What challenges does this patient face? • What supportive factors? • What influences her views of health care? • Reflect on Gen Silent trailer

24. LGBT Elders 2x as likely to live alone as other seniors, half as likely to have a partner 4x more likely to  have no children 50% more likely to have no close relatives to call for help when needed Increased rates of smoking, obesity, alcohol abuse, and HIV infection Delay and avoid health care.

25. Scenario 4 A low SES transwoman is admitted to hospital. She is on Medicaid. The skin on her buttocks and legs is discolored. A lump of hardened silicone the size of a golf ball hangs behind her left knee (link). • Does the patient have a penis? • Does the patient have an amended birth certificate reflecting her lived gender? • What kind of review of systems does the software generate if the patient sex is “M” or “F”? • What non-medical risks does this patient face in daily life? • What is the most distal (upstream) diagnosis you could make of this patient? • Reflect on Simon’s Story.

26. Other scenarios • A 25-year-old questioning man presents with an URI. You notice symmetric anterior bruising low on his neck. • WSW patient complains of pelvic pain. Her previous physicians would not do a Pap. • Young gay man comes to an adolescent medicine clinic. He has not made a sexual debut. He claims that his family doctor would only give him heterosexual-oriented safer sex counseling.