Sep 142015

A cluster of studies came out this week looking at different aspects of mental health for gay, lesbian, and bisexual people. Rather than do a deep dive on each one I thought it’d be fun to do a birds eye view of all of them and talk about the results as a group. Ready?

Why look at mental health in lesbian, gay and bisexual (LGB/GLB) people at all, and why might their health be different from their straight peers? Because of minority stress! If you’re a long time reader of the blog that term may sound familiar. Minority stress is the concept that solely by being a minority in a culture you have a higher level of stress. That stress is even worse when you’re a minority that is discriminated against. It’s also worse if you are a member of multiple minorities. Stress is associated with certain mental illnesses, including eating disorders, substance use/abuse, depression, and anxiety. Stress also makes it harder to cope with life’s everyday events.

So what about these studies?

Study #1 looked at disordered eating patterns in young women and compared that eating between gay, bisexual, and straight men and women. The researchers didn’t look at diagnoses or treatments of eating disorders directly. Instead, they screened patients in a primary care clinic for eating patterns and thoughts about eating that are associated with eating disorders. The researchers found that gay and bisexual men were at higher risk for disordered eating than heterosexual men. Among women, bisexual women were at higher risk for disordered eating than both lesbian and straight women.

Study #2 looked at both mental and physical health in LGB and heterosexual people seeking treatment for substance use. They found that gay and bisexual men and women were more likely to have a psychiatric diagnosis (in addition to substance use) than their heterosexual peers. Gay and bisexual men and women were also more likely to have psychiatric prescription medications. Gay/bisexual men and bisexual women, but not lesbian women, were more likely to be receiving psychotherapy and were more likely to have physical health problems and to be using health care services. Anywhere from 1/2 to 3/4 of LGB people seeking substance abuse treatment have had other psychiatric diagnoses, indicating that there is a potential need for additional care beyond substance abuse treatment in LGB people.

Study #3 examined the effects of domestic violence in same sex and opposite sex couples. The researchers found that domestic violence in same sex couples resulted in more symptoms of depression and physical violence than in opposite sex couples.

What does all this mean, and how do we think about this?

First, these studies add to the research that shows that gay, lesbian, and bisexual people are at higher risk for mental health difficulties than their heterosexual peers. However, they add an interesting wrinkle. Gay and bisexual men and bisexual women may be at higher risk than lesbian women. We’ll have to wait for more studies to come out to see if this is a true difference, or just a random quirk of the data. But it’s an interesting thought.

And secondly, that people in same-sex relationships may fare worse when domestic violence happens than people in opposite-sex relationships. This is likely because of the lack of resources and public awareness around domestic violence than anything to do with the relationship itself.

What do you think about these studies?

Sep 072015

In its August 27th issue, the New England Journal of Medicine (NEJM) published a paper reviewing primary health care needs of men who have sex with men. NEJM is one of the most prestigious American medical journals. It was home to the first paper detailing HIV infection in gay men. It’s one of the two major medical journals that my class has been urged to read weekly — part of our professional development as medical students.

What kinds of things does this review article recommend? And was it complete? Let’s take a look…

First is the recommendation to discuss a comprehensive and open sexual history. This should not stop at the classic “Are you sexually active?” question, but ask how the patient self identifies (gay, bisexual, etc), the kinds of sexual activity, the forms of protection used and the consistency with which they are used. Why? Because of HIV. Other sexually transmitted infections are a concern as well, but the big fear is HIV. Of all new infections in the United States each year, just under 2/3 are among men who have sex with men.

Other infections to be wary of include gonorrhea and chlamydia, Hepatitis A/B/C, and HPV. There has also been a rise in meningitis infections among gay men, caused by the bacterium Neisseria meningitidis. Of these infections, hepatitis A, hepatitis B, HPV, and meningitis all have vaccines. Where possible, men who have sex with men should be vaccinated against these diseases. HIV and hepatitis C have no vaccine. To prevent them, barriers such as condoms and gloves can be used in sexual encounters and screening tests should be performed. Pre-exposure prophylaxis and antiretroviral therapy for HIV+ individuals can also be helpful for preventing HIV spread, but cannot and should not replace barriers.

Thankfully, this article was not all about the sex lives of men who have sex with men. Too often the lives of gay and bisexual men are distilled down to just their sex lives, particularly because of HIV. The author points out that men who have sex with men should be screened for substance use, depression and anxiety. However, they stop there. While asking about tobacco, alcohol and illicit drugs is very important, there are other important aspects of the lives of gay and bisexual men that should be addressed. In particular, I would ask about…

  • Social support and living situation, particularly among young gay/bi men and older gay/bi men. Young men are at higher risk for being homeless because of family discrimination. Bullying also happens frequently among young gay/bi men. Older men may have lost their support group during the 1980s-1990s and may be facing the challenge of growing old alone. LGBT elders may face the prospect of going “back into the closet” to receive nursing home care.
  • Domestic violence. Same-sex domestic violence is under reported and specific resources are scarce.
  • History of assault or violence. Violence against men perceived to be gay/bi can have lifelong health consequences, including post traumatic stress disorder.
  • Attempts to self harm or suicide. These must never be ignored, no matter who one is talking to.
  • Diet and exercise. Eating disorders are known to occur in gay/bi men. Diet may be poor and exercise may be too low or too high, depending on the individual and his situation.

Yes, screening for HIV and other sexually transmitted diseases is important. And this article did bring some specific health issues to a large audience. However it’s important not to distill men who have sex with men down to a cluster of diseases. Let this article be a spark for discussion, and not the be-all and end-all of primary care for men who have sex with men.

What do you think? Did I miss anything important in the things I would add?

A preview of the paper is publicly available.

Aug 312015

The Greek letter Psy is often used to symbolize psychology.

The American Psychological Association has released a 55-page document detailing guidelines for psychologists treating transgender and gender non-conforming individuals. To my knowledge, this is the first such document the APA has published. It’s a huge milestone in trans mental health care.

APA guidelines provide standards for both trainees and practicing psychologists on the expected conduct of psychologists. They’re used in both introductory and continuing education.

In this document, the APA lists out the following guidelines (note that TGNC stands for “transgender/gender non-conforming”):

  1. Psychologists understand that gender is a non‐binary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth.
  2. Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.
  3. Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.
  4. Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.
  5. Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well‐being of TGNC people.
  6. Psychologists strive to recognize the influence of institutional barriers on the lives of TGNC people and to assist in developing TGNC‐affirmative environments.
  7. Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well‐being of TGNC people.
  8. Psychologists working with gender questioning and TGNC youth understand the different developmental needs of children and adolescents and that not all youth will persist in a TGNC identity into adulthood.
  9. Psychologists strive to understand both the particular challenges that TGNC elders experience and the resilience they can develop.
  10. Psychologists strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychological effects of minority stress.
  11. Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans‐affirmative care.
  12. Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of TGNC people.
  13. Psychologists seek to understand how parenting and family formation among TGNC people take a variety of forms.
  14. Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to TGNC people and strive to work collaboratively with other providers.
  15. Psychologists respect the welfare and rights of TGNC participants in research and strive to represent results accurately and avoid misuse or misrepresentation of findings.
  16. Psychologists seek to prepare trainees in psychology to work competently with TGNC people.
This is all excellent.
There is a history of psychologists attempting to change gender identity through conversion therapy or other coercive means. The APA’s statement, in effect, states very strongly that attempts to change gender identity should not be attempted. Instead, the APA is embracing the ethical treatment of transgender people and of affirming transgender and gender non-conforming people.
Do these guidelines mean anything for you if you’re receiving therapy? Possibly. Talk with your therapist, whether you’re trans or cis, to make sure they’ve seen the updated guidelines. If you’re receiving therapy that is not within these guidelines, consider talking with your therapist about these guidelines or seeking another therapist.
And spread the word! The document itself is publicly available as a PDF.
Aug 172015

715px-715px-Sunbedoff_largeA new study finds that gay and bisexual men use tanning beds more frequently than straight men. The use of tanning beds is strongly associated with skin cancers, especially melanoma (the most dead form of skin cancers).

Campaigns to dissuade people from using tanning beds usually target straight women, as they’ve been the most frequent users of tanning beds. These new data show that gay and bisexual men use tanning beds just as frequently as straight women. Lesbian and bisexual women were less likely than straight women to use tanning beds.

Tanning beds should not be used for cosmetic reasons. While many perceive a tan as “healthy” or enjoy the experience of tanning, tanning damages the skin and raises the risk of skin cancer.

Want to read the study for yourself? It’s publicly available!