Mar 162015
 

170px-Rod_of_Asclepius2.svgBeing a gender or sexual minority (GSM) is not only difficulty and tricky for patients — it can also be a challenge for medical providers. Medicine can be a particularly conservative field, depending on location and specialty. Lives are, after all, often at stake.

Despite recent advances it appears that some 40% of lesbian, gay and bisexual medical students are hiding their sexual minority status in medical school. Among transgender medical students, 70% were hiding their identity. All because of fear of discrimination.

That fear has been, and still is, warranted. From medical providers transitioning and losing their practices, to medical students losing their residency slots, to LGBT health student organizations fighting to exist, LGBT providers face similar discrimination as our patients.  Similar happens for other gender and sexual minority health care providers, though we lack statistics. At a meeting of kink-identified mental health care providers, one attendee noted a high level of vulnerability for the clinicians. Being “outed” could lose them their jobs or even trigger legal action.

To some extent, discretion among health care providers is warranted. Most people don’t want to know about their clinician’s (or coworker’s) personal lives. And most GSM providers don’t actually want to share those most intimate details. It’s where the line is that can be distressing — how much information is too much? Can I discuss my wife when other women clinicians are discussing their husbands? How exactly do you notify your fellow clinicians or patients about a change in gender pronouns or name? How can a clinician use information gained from intimate encounters to help patients, without revealing too much? It’s a balance we constantly seek. Sometimes mentors are there and can help. Other times we figure it out as we go along.

Yet we bring a lot to the table, as minorities. Like many racial and ethnic minorities, there are pressures and issues that affect GSM people more than the majorities. We bring that knowledge with us to the research we choose to perform, the communities we participate in, and each and every patient encounter.

We as clinicians and future clinicians need to have the support in order to be appropriately open about our gender and sexual minority status. Our patients and clients must know they can be safe and honest with us so they can receive the most complete and respectful care possible.

Some progress has been made already. There’s an association for LGBT medical professionals. There’s an association for kink psychological research. There’s an association for transgender health. All of which allow student members and provide mentoring. Many other organizations exist too. Some US medical schools are working with their students to provide a safe and welcoming environment where these issues can be explored. The American Association of Medical Colleges recently launched a program to enhance education surrounding LGBT and intersex health care. The American Medical Association also has an LGBT Advisory committee.

I’m proud to say that my medical school has been accepting and supportive of its gender and sexual minority patients, and that clinics in the area of my medical school are seeking to expand their care to be more inclusive of LGBT patients. Support exists for both those seeking medical care, and those seeking to provide that care. It’s only the beginning.

Aug 022014
 
Rural vs Non-rural

Rural vs Non-rural

This study used a convenience sample of transgender individuals and compared mental health factors between trans people living in rural and non-rural areas in the United States.

Why would health and health care differ between rural and suburban or urban trans people? A number of possible factors, including…

  • Transportation issues.
  • Overall difficulty accessing health care. Fewer physicians, fewer hospitals. Few big research or teaching hospitals.
  • Possibly less social support for healthy lifestyles. Depending on the community, support of a healthy lifestyle may be less. Rates of tobacco use, alcohol drinking may be high and access to exercise and a fruit/vegetable-focused diet may be low
  • Less accepting physicians. Rural areas are traditionally more socially conservative, possibly resulting in higher rates of transphobia. Open-minded physicians may not have the resources to learn about transgender health care, and access to specialists is limited in rural areas
  • Smaller minority communities. With a smaller population, and transportation time, it’s much harder to form a supportive LGBT or trans community. Social support and information sharing may be very limited.

The vast majority of transgender health centers are in urban areas including San Francisco, Los Angeles, New York City, Seattle, Boston, Washington DC, and Philadelphia. Resources in places like the middle of rural New Mexico are few. But that doesn’t mean people in such rural places don’t need care too.

This research used the internet, advertising on mailing lists, journals, and forums, to recruit and survey trans people in all areas. They ended up with a very large sample for a trans study: 1,229 people! What determined whether a person lived in a rural or non-rural area? The participants self-selected an option – and if they selected “rural” or “small town” for their location they were classified into “rural”. Other options (suburban and urban) were classified “non-rural”.

What did they measure? Basic demographics, substance use, mental health (including anxiety, depression, somatization, and self-esteem), and sexual risk behaviors. That last one – sexual risk behaviors – was specifically narrow, focusing only on protected vs unprotected penetration with a penis.

The results were fairly clear.

For trans women, there was no different in mental health between rural women and non-rural women. But trans men were statistically significantly more likely to have depressive or anxiety symptoms, low self-esteem, and other similar mental health problems if they were rural than if they weren’t rural.

There were no significant differences in substance use for either trans men or trans women. There were no differences in sexual risk behavior either.

Some interesting, and some disturbing, statistics that came out of this:

  • 25-27% of trans women reported a previous suicide attempt vs 38-40% of trans men.
  • 7-10% of all trans people in the study reported binge drinking alcohol in the past 3 months. 7-13% used an illicit substance other than marijuana in that same time frame.
  • 42-45% of trans women reported unprotected penile sex with either a primary or non-primary partner, vs 16-21% of trans men (in the past 3 months)

This study isn’t perfect. It was internet-based and used a convenience sample, so it may not reflect the larger trans population. It also used a broad definition for transgender at times, including those who cross dress for reasons other than gender identity. The fact that it was internet-based means that people who do not use computers or have access to the internet weren’t included. Still, it was the first of its time and its methods were fairly sound given these restrictions.

So what can we conclude?

  • First, something that we knew before: Trans people are in need of compassionate, open-minded mental health care and medical care no matter where they live.
  • Second: That trans men living in rural ares may be faring worse than their urban and suburban brothers.
  • Third: That rates of suicide are still unacceptably high for all trans people
  • Fourth: That trans people, especially trans women, are still at unacceptably high risk for HIV and other STDs via unprotected sexual contact.

What can we do about all of this?

Rural health care is a challenge for both physical and mental health. Telemedicine options continue to be in development. Education and outreach efforts must continue within trans communities. Those who work in physical and mental health, whether rural or urban, must understand that transgender populations face specific stressors and have specific health needs. Efforts to educate all providers, such as WPATH’s mailing list and Trans Line, must continue to be available and probably should expand.

This paper was published in the Journal of Homosexuality and is publicly available.

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…