Apr 162014
 

One of the premier medical journals, the New England Journal of Medicine, regularly has perspective/opinion pieces. For a pre-med like me, they can be some of the most valuable pages in the journal — they can be windows into medical practice, public policy and the study and practice of medicine. I read them regularly, since my wife got me a subscription to NEJM. Most aren’t related to gender and sexual minority health, so I haven’t addressed them here much. But in the April 10th edition of NEJM, a treasure! Gilbert Gonzales did a good summary of the intersection between same-sex marriage and health.

Many health journals, including NEJM, tend to live behind a pay wall. This particular article, thankfully, is not. But in the interests of public knowledge and discourse, I wanted to summarize some of the interesting points in this article. A heads up: this is a distinctly United States-focused article.

  • Despite recent advances, roughly 60% of the US population lives in a state that prohibits same-sex marriage
  • There are significant health disparities between LGBT and heterosexual/cisgender people, as shown by the 2011 Institute of Medicine report on LGBT health (which I summarized in 3 parts at the time).
  • Discriminatory environments lead to poorer health outcomes. Example: LGBT people in states that ban same-sex marriage have higher rates of depression, anxiety, and alcohol use than straight/cis people in the same states. By the same token, states where same-sex marriage (e.g., MA and CA) was legalized show a drop in mental health care visits for some GLBT people (e.g., gay men).
  • Legalizing same-sex marriage improves access to health insurance for both same-sex spouses and children of same-sex parents.
  • The Affordable Care Act prohibits insurance companies from denying health insurance coverage because of sexual orientation, transgender identity, or pre-existing conditions like HIV.
  • The recent decision on DOMA (United States v Windsor) means couples in a same-sex marriage get taxed like other married couples. This lowers the tax burden of health care costs and health insurance.
  • Health benefits of same-sex marriage should be included in discussion of marriage equality.

All good things to point out, and good to see in such a mainstream medical journal.

We’re lucky enough that the NEJM has decided to have this article be open access. So if you can, read it to form your own opinions!

And as always…  Stay healthy, stay safe, and have fun!

Jan 022013
 

First, Do No Harm: Reducing Disparities for Lesbian, Gay, Bisexual, Transgender, Queer and Questioning Populations in California (PDF) has been published! It is a report I did some data analysis for, and it aims to “seek community-defined solutions for reducing LGBTQ mental health disparities across the state of California.” If you have the time, and I hope you do, take a look! 🙂

Oct 252012
 

LGBT youth are at elevated risk for suicide. Researchers have been looking into the risk factors for suicide in LGBT youth. Most of the studies so far have been cross-sectional; that means they only studied how things are once, at one point in time. Longitudinal studies, in contrast, measure at multiple points in time. Longitudinal studies are expensive, and risk losing track of participants, but they provide more information.

This year, the first longitudinal study of LGBT youth suicide risk factors was published. The participants were interviewed twice, a year apart. Both times, they were psychiatrically evaluated and asked about suicide attempts. They filled out questionnaires evaluating hopelessness, impulsivity, social support, gender non-conformity, age of same-sex attraction, and LGBT-related victimization.

In this sample, roughly 31.6% of the participants had attempted suicide. This is far higher than the 8% rate reported by the CDC. Seven variables were associated with previous suicide attempts: hopelessness, impulsivity, LGBT-related victimization, low family support, being younger when first feeling same-sex attraction (for LGB youth), and symptoms of either depression or conduct disorder. That is, the more hopeless or impulsive the youth, the more likely it is that they have previously made a suicide attempt. Gender non-conforming behavior and peer support did not seem to affect suicide risk. When it came to predicting future suicide attempts, the best predictor was previous suicide attempts. Youth who had previously attempted suicide had a 10 times greater risk of another attempt compared to those who hadn’t attempted suicide.

As always, these results should be accepted with caution. For example, this study did not find that gender non-conforming behavior was associated with suicidality. This is in contrast to other studies which did find an association. This study’s participants may not be representative of the population. They also had a small (ish) sample: 237 participants; 21 were transgender, and 13 had attempted suicide. Small sample sizes can limit a study’s ability to detect statistical significance. Gender non-conforming behavior may actually be associated with suicidality, but this study may not have had a large enough sample to detect it.

For me, this study brings up the question: How do we prevent suicide attempts in our LGBT youth who have already attempted suicide? They’re the most at risk for future attempts, according to this study. I don’t have a solid answer; neither do the researchers. But they do say that “The current findings underscore the need for increased prevention efforts and specifically point to the value of targeting youth who have made a prior attempt and who acknowledge their same-sex attractions at younger ages.”

Study Abstract – Full Text – Archives of Sexual Behavior

Jun 012011
 

For “older” adults, the IOM uses retirement age (around 60) as their starting age. For this group, there are no well-studied areas of health (beyond HIV/AIDS, which I don’t cover here). I’ve decided to leave the conclusion portion for another post – the last in this series.

  • Depression: Definitely more frequent in LGB elders than heterosexual elders. A very significant mental stress for this group is surviving the start of the HIV/AIDS epidemic. One study of elder gay/bisexual men found that 93% of them had known others who were HIV+ or had died of AIDS. There is no empirical data on rates of depression in elder transgender people, but it’s thought to be high.
  • Suicide/suicidal ideation: Empirical data suggest the rates of suicide are higher in LGB elders. No data on transgender elders.
  • Sexual/reproductive health: This is a rarely studied area. PCOS and its related risks may be an issue in some transgender elders. There is some indication that gay/bisexual men may be at the same risk as heterosexual men for prostate cancer. Early research implies that “lesbian bed death” may be a real phenomenon, but it’s a controversial topic. All cis-gendered women (bisexual, heterosexual, or lesbian) appear to have the same rate of hysterectomies. Sexual violence was reported on for transgender elders and it appears to be high. One study found about half of transgender elders had experienced “unwanted touch” in the past fifteen years.
  • Cancers: There are no data on cancers and transgender elders. Elder gay/bisexual men are at a higher risk of developing anal cancer (which is linked to receiving anal sex and HPV). Non-heterosexual women also appear to be at a higher risk for reproductive cancers (due to risk factors like smoking and obesity).
  • Cardiovascular health: Data appear to be conflicted. Transwomen using estrogen may be at a higher risk for venous thromboembolism (this may be because of the specific forms of estrogen used). There’s an association between transgender people getting their hormones from someone other than a doctor and poor health outcomes (e.g., osteoporosis, cardiovascular disease). The relevant transition hormones may cause long-term health problems at high doses, but no studies have really looked at this.

Risk factors include those for the younger age groups. Ageism within the LGBT communities may be an additional challenge for LGBT elders. Elders may also feel they need to hide their orientation if they move into a retirement home. Some retirement homes may also be discriminatory.  Transgender elders especially face very high threats of violence.

Some studies have found that elders felt more prepared for the aging process by being LGBT. Why? They’d already overcome huge difficulties. They’d already done a lot of personal growth. LGBT people are also more likely to have education beyond high school, and education is a well-known protective factor for the negative effects of aging. Conversely, some LGBT elders reported fewer relationship and social opportunities, being afraid of double discrimination, and problems with health care providers.

As for elder interactions with the health care system, again there’s a lot in common with younger age groups. One out of four transgender elders report being denied health care solely because they were transgender. Elders in general face problems if they need to enter assisted living homes, as some homes are discriminatory. It’s also worth noting that LGBT elder social structure is different from heterosexual social structure. LGBT elders rely much more on close friends than relatives (and/or adult children). Their chosen families are less likely to be recognized by the medical community, especially without legal paperwork.

So that’s it for what I’ll summarize from the report. Thanks for sticking around for it… this is hefty stuff.

May 262011
 

Welcome back! This part of the IOM report covers adults aged 20 to 60. There are more data available for adults than adolescents, so this part’s broken up a bit different from the last. As a reminder: GLBT (or LGBT – same meaning, different order) stands for gay, lesbian, bisexual, and transgender. I frequently do use GLB separate from T. That is intentional, not a typo. Also, the full report is available here – you can read it online for free.

The best studied aspects of health:

  • Mood/anxiety disorders: There are conflicting data here, but the consensus so far is that GLB people have higher rates of these problems. There’s almost no research on transgender people, but one preliminary study found that around half of transgender people have depression. Yikes!
  • Suicide/Suicidal ideation: LGBT people as a whole appear to be at higher risk. Bisexuals and transgender people appear to be at an even higher risk. Risk also seems to vary by age, sex, race/ethnicity, and how far out of the closet a person is.
  • Cancer: Gay and bisexual men are definitely at a higher risk for anal cancer than heterosexual men. This risk is linked to having anal HPV, which can be spread by anal sex.

Somewhat studied:

  • Eating disorders: May be more common for GLB people than heterosexuals, but we’re not sure. No data on transgender people.
  • Sexual: Gay/bisexual men don’t appear to be at an elevated risk for erectile dysfunction. Transgender people who have had sexual reassignment surgery may be at a higher risk for sexual difficulties…not entirely surprising given the potential for nerve damage from any surgery.
  • Cancer and obesity: Lesbian/bisexual women may be at a higher risk for breast cancer than heterosexual women.
  • Hormone replacement therapy -may- affect cardiovascular health, but it’s unknown.

Essentially not studied: Reproductive health (including the effects of hormone therapy on fertility for transpeople), cancer (especially in transgender patients), and cardiovascular health

Risk factors:

  • Stigma/Discrimination/Victimization: As we all know, LGBT people face these problems all the time.  Stigma is strongly associated with psychological distress. Bisexuals have reported facing discrimination from both the straight and gay communities. One study of transgender people found that 56% had faced verbal harassment, 37% had faced employment discrimination, 19% had faced physical violence.
  • Violence: LGBT people are at an elevated risk for suffering violence. LGBT people do experience intimate partner violence, but the statistics and relative risk are unknown.
  • Substance Use: LGBT people may be more likely to use substances, especially tobacco (read my previous post on this).
  • Childhood abuse: LGB may have higher rates of childhood abuse.

Potential protective factors (LGB): supportive environments, marriage, positive LGB identity, good surgical/hormonal outcomes (T)

As for access/quality of health care? Er…it’s complicated. GLB people get less regular screening (like pap smears and basic physical exams) than heterosexuals and use the emergency room more often. Two biggest obstacles to getting good health care?: problems with the health care providers. This could be perceived discrimination (thinking that someone is acting in a discriminatory way, whether that person is or not), or simply lack of knowledge on the part of the provider. One study found only 20% of physicians had received education about LGBT health issues. That’s only  one in five! I will note that this is improving – medical schools, depending on the school and its location, are starting to teach LGBT cultural competency more than they used to.

Lack of insurance is another barrier, and it especially affects transgender people. The services they need, like hormone therapy and sexual reassignment surgery aren’t covered by insurance. In addition, one study found that a third of transgender people had been treated ill by a physician.

Next time: Older Adults and conclusions…