Oct 122015
 
Human Papilloma Virus

Human Papilloma Virus

Little is known about reproductive cancer risks among cisgender lesbian and bisexual women. Cancer registries generally don’t ask about sexual orientation. Studies suggest so far that lesbian and bisexual women are less likely to get a pelvic exam and pap smear when it’s recommended. Pap smears help to detect cancer in its earlier, most easily treated and cured stages. Logically, lesbian and bisexual women may be at risk for having more developed (and potentially incurable) cancers. The data confirming that aren’t in yet, but it seems likely.

And now we have HPV vaccines. The human papilloma virus is a major cause of cervical cancer, along with anal cancer, penile cancer, and mouth/throat cancers. Human papilloma virus spreads by skin-to-skin sexual contact regardless of biological sex or gender. Along with pap smears, the HPV vaccine has been a great tool for preventing advanced cervical cancers.

This week I looked at a study of survey data from 15-25 year old women from the National Survey of Family Growth, from 2006-2010. They asked the questions: “Have you heard of the HPV vaccine?” and “Have you received the HPV vaccine?”

The results were rather spectacular. Lesbian, bisexual, and straight women had heard of the HPV vaccine. There was no difference there. However, 28% of straight women, 33% of bisexual women and 8.5% of lesbian women received the HPV vaccine.

That’s 8.5% of lesbians vs 28-33% of non-lesbian women.

Why?? Lesbians are at risk for HPV infection too!

Before looking at what the authors thought, I have some thoughts of my own.

2006, the earliest year this study had data on, isn’t too far off from when I graduated high school. I remember the sex ed class we had. We were lucky to have sex ed at all. It was a one-day class focused on the effectiveness of birth control options, how to put a condom on a banana (or maybe it was a cucumber?), and sexually transmitted diseases that can be passed between men and women in penis-in-vagina sex. There was no discussion of sexually transmitted diseases that are passed between men who have sex with men or women who have sex with women. I remember walking out of the class feeling confused and alone — what STDs were passable between women, and how can women protect themselves and their partners? Were there diseases that women could spread? Was protection warranted? I had no idea.

The study authors discuss similar problems and attributed the difference between lesbian HPV vaccine and bisexual/heterosexual HPV vaccine to misinformation. The idea that lesbian women who have never had sexual contact with men don’t need pap smears or HPV vaccines is old and incorrect, but still persists. I remember when pap smears were recommended starting at first sexual contact with men — if a woman never had sexual contact with a man then she didn’t ever need a pap, right? Wrong!

But it takes time to correct misinformation. As the authors correctly point out, important changes have happened since 2010. HPV vaccine is now recommended for all young people regardless of sex, sexual activity, sexual orientation, or gender identity. It’s not just a vaccine for a sexually transmitted disease — it’s a vaccine against some forms of cancer. Pap smears are now recommended for everyone with a cervix every 3-5 years or so.

So can you be part of the change? Help spread the word about HPV vaccine for *all* people, and pap smears for people cervixes!

The study was published in the Annals of Internal Medicine. The abstract is publicly available.

Oct 052015
 

480px-RGB_LED_Rainbow_from_7th_symmetry_cylindrical_gratingI’ve been saying for years now that the phrase “LGBT community” is insufficient when it comes to health. It’s not one community — it is multiple communities. The social issues and health issues that a gay transgender man faces every day are different from the issues a bisexual cisgender woman faces every day. There are some similarities and grouping the communities together has been politically useful. But it should never be forgotten that L, G, B, and T all face different types of health concerns and have different civil rights battles to face.

A study came out in August that has to be one of my favorites this year. Researchers in Georgia surveyed over three thousand lesbian, gay, bisexual, pansexual, transgender, gender non-conforming, and queer people. They asked about health behaviors of all kinds. And then they did statistical analysis, comparing the various genders (cis male, cis female, trans male, trans female, genderqueer) and sexual orientations (lesbian, gay, bisexual, pansexual, queer, straight). Let’s look at what they found!

  • Diet and exercise: The researchers asked about fatty foods, eating while not hungry, quantity of vegetables and fruits eaten, and about hours and types of exercise. Transgender women had the least healthy diet of all genders. As a group, they were less likely to eat many fruits and vegetables, and more likely to drink sugared drinks and eat when they weren’t hungry. Both cisgender and transgender men were also less likely to eat many vegetables compared with other groups. Genderqueer people and gay cisgender men were most likely to exercise.
  • Substance use: The researchers asked about smoking tobacco and alcohol consumption. Cisgender men were the most likely to drink alcohol, binge drink, and to drink even when they didn’t want to. Participants who identified as queer were also more likely to drink. When it came to tobacco, transgender men and straight participants were the most likely to smoke.
  • Motor vehicle risk: The researchers asked about seatbelt use, speeding, and texting while driving. No clear differences for speeding were noted. Transgender men and straight participants were most likely to drive without a seatbelt. Texting while driving varied considerably; gay and lesbian drivers were most likely to text while driving.
  • Sexual behaviors: The researchers asked about frequency of unprotected sex and sex while intoxicated. Gay men were least likely to have unprotected sex while lesbian women were most likely to have unprotected sex. When it came to sex while intoxicated, only the bisexual participants stood out as being most likely among the groups to have sex while intoxicated.
  • Violence: The researchers asked about self harm and expressing anger at others. Overall rates of interpersonal anger were very low. Transgender men and pansexual people were most likely to self harm.
  • Medical risk taking: The researchers asked about delaying medical care and not following physician advice. Transgender women were least likely to seek care; 1/3 reported that they regularly delayed seeking medical care. Both transgender women and transgender men were more likely to not follow medical advice when it was given. Bisexual people were also more likely to delay seeking medical care compared to lesbian and gay participants.

That’s a mouthful, right? There are a lot of details I left out of this summary and it still threatens to be overwhelming with detail. So how we can break this down even more simply? By talking about the conclusions.

The researchers go into some possible causes for all these different results. Maybe gay men are safer about sex because of HIV risk. Maybe transgender men eat few vegetables because of cultural expectations that “men eat lots of meat and not many vegetables.” Maybe gay and lesbian people text more while driving because of the lack of community-specific messages.

Maybe. And they’re all good thoughts.

I tend to look forward more to what we can do with these data. I’m pretty happy with this study — it’s one of the broadest I’ve seen for inclusion. Few health-oriented pieces of research include pansexual and genderqueer individuals.

It’s important to remember that these results are at the group level. Any individual person who is a gender/sexual minority will have their own health behaviors and risks. They should be evaluated and treated as individuals. From a public health perspective though, this research brings valuable data. Only by knowing what each group faces can prevention, screening, and treatment campaigns be created. Only by knowing, for example, that transgender and bisexual people avoid seeking medical care can we then examine “why?” and act to remove the barriers so that appropriate, respectful medical care is available.

So — can we change the conversation? Instead of talking about “the LGBT community”, let’s talk about “the LGBT communities”. Or, even better, “gender and sexual minority communities” — removing the alphabet soup and expanding the definitions at the same time. This research is only the tip of the iceberg. We have so much more to explore.

The paper is published online ahead of print. The abstract is publicly available.

Aug 312015
 
Psy_II

The Greek letter Psy is often used to symbolize psychology or the APA.

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 102015
 

Rainbow ribbon for LGBT+ cancer awarenessGender and sexual minority health isn’t just about HIV/AIDS, sexually transmitted infections, and mental health. It’s also about cancers, and our exposures to risk factors for cancers. Why? Because everyone can get cancer, and we all need both preventative and therapeutic health care.

Cancer is not just one disease, which is why it’s been so difficult to “cure”. Cancer is when a cell mutates and grows out of control. The cells begin to invade other tissues, and can spread throughout the body. Any cell can become cancerous. And different cancers are caused by different things and have different treatments.

A recent paper, published online ahead of print, looked at the data surrounding lesbian, gay, bisexual and transgender/transsexual (LGBT) populations and cancers. They specifically looked at cancers which may be more common in LGBT communities: anal, breast, cervical, colon/rectal, endometrial, lung, and prostate cancers.

Why might these cancers be more common in LGBT communities? Perhaps because of higher levels of risk factors like obesity, smoking, and certain infections. Or perhaps because of lack of preventative health care.

But what do the data say? What data do we even have? So far it looks like we don’t have much information. Most studies about cancers don’t ask about sexual orientation or gender identity. But let’s take the data one cancer type at a time, just as the paper did…

Anal cancer is a rare cancer of the anus. It’s primarily associated with HIV infection and HPV infection. Men who have sex with men, because they are at high risk for HIV and HPV infections, are at higher risk for anal cancer. The risks for women and transgender people are unknown. The best prevention for anal cancer is the HPV vaccine and consistent use of condoms to prevent HPV and HIV infections. Screening, to catch cancers in their most treatable state, can be done through the anal pap test. However there are no guidelines for the anal pap test and its value as a screening tool is uncertain. Treatment for anal cancer can impact not only general quality of life for survivors but sexual quality of life for men who have sex with men. The effects on sexual quality of life may be under appreciated by physicians.

Breast cancer is among the most frequently diagnosed cancers in women. Unlike with anal cancer, there are no obvious risk factors beyond being a cisgender woman. There are no data on how rates of breast cancer differ between heterosexual, bisexual and lesbian women. It is thought that bisexual/lesbian women may be at higher risk of breast cancer because of high rates of smoking, alcohol use, and obesity. Lesbian/bisexual women are also less likely to carry a pregnancy. However, it’s not known if those risk factors are actually associated with higher rates of disease. There are no data on cis or trans male breast cancer. Trans women were thought to potentially be at higher risk because of the hormones they take, but data so far seem to indicate that they’re at low risk. When it comes to screening, the best screenings so far are clinical breast exams and mammography. Women who have sex with women are less likely to receive either. Once they survive a breast cancer, women who have sex with women may be at risk for sexual side effects more than heterosexual women.

Cervical cancer is a cancer that exclusively affects cisgender women, pre-op trans men and others who have a cervix. There are no data describing how the risk for cervical cancer may be different for bisexual/lesbian women and trans men. The biggest risk for cervical cancer is HPV infection. The best prevention of cervical cancer includes the HPV vaccine and the use of barriers to prevent HPV infection. For screening, pelvic exam with pap smear at a regular interval is recommended. Women who have sex with women are less likely to receive the vaccine and less likely to receive regular screenings. Anecdotal evidence suggests that the same is true for trans men. This would leave both bisexual/lesbian women and trans men at higher risk for cervical cancer, and higher risk that if there is cancer it will be discovered at a later stage. No studies have been performed examining how women who have sex with women and trans men fare after a cervical cancer diagnosis.

Colon cancer is the third most common cancer in both men and women. Preliminary studies indicate that lesbian, gay, and bisexual cisgender people are not being diagnosed with colon cancer more frequently than heterosexual people are. There are no data on trans people. However, LGB people are more likely to have risk factors like obesity, smoking, and alcohol use. On the whole, they are also less likely to receive screenings for colon cancer. The exception is gay and bisexual men, who receive colonoscopy and sigmoidoscopy more often than heterosexual men (the authors theorize that this may be because colonoscopy and sigmoidoscopy are used to diagnose difficulties with receptive anal sex). No studies have compared side effects in LGBT survivors. However, clinicians should advise men who have receptive anal sex that treatment may impact their sexual life.

Endometrial cancer is a cancer of the lining of the uterus, which can affect any individual with that lining. There are no data on lesbian, bisexual, or transgender populations nor are there recommendations for prevention and screening for endometrial cancer. Survivor outcomes are similarly murky. However the authors note that lesbian and bisexual women, because of stigma, may seek medical care later than heterosexual women. The authors advocate for a welcoming LGBT environment for patients to facilitate early detection and treatment.

Lung cancer is the leading cause of cancer death worldwide and is primarily caused by tobacco smoke. There are no direct studies of lung cancer in LGBT populations, but LGBT people are far more likely than heterosexual/cisgender people to smoke. LGBT people, as a whole, are thus at higher risk for lung cancer. While an annual screening (via low-dose CT scan) is recommended for some long term smokers, the guidelines were not intended for LGBT patients and may not be appropriate. Outcomes and side effects are unknown for LGBT people.

Prostate cancer is a cancer that exclusively affects cisgender men and transgender women (regardless of surgical status — the prostate is not removed in surgery). HIV+ men may be at lower risk for prostate cancer, though that may be an artifact of testing. The risk of prostate cancer for trans women is unknown, but is not zero. The screening test for prostate cancer, prostate specific antigen (PSA), is of limited value, but it appears that there are no differences in screening based on sexual orientation. Treatment for prostate cancer often has sexual and bowel side effects which may affect men who have sex with men differently (particularly men who prefer receptive anal sex).

Astute readers may have noticed a trend: There are not enough data. This is a huge problem in gender and sexual minority health. We just do not know enough, particularly about topics other than HIV. While some research is going on now to try to tackle these issues, it will be a while before those results come out and get validated.

So in the mean time, what is an LGBT+ person, worried about cancer, to do? You have options! You can…

  • Find a medical provider whom you feel safe and comfortable with, and make sure you come out to them. Ask them about screening schedules for you, given your own set of risk factors. Screenings will not prevent cancer, but they will allow your physician to detect cancer in its earliest, most curable stages and could save your life.
  • Exercise, achieve/maintain as healthy a weight as you can, and eat a varied diet. All of these things will help reduce your risks.
  • Quit smoking, if you currently use tobacco. Don’t start to use tobacco if you currently don’t. All forms of tobacco cause cancer, including chew and snuff.
  • Limit alcohol consumption. Drinking a lot is associated with higher rates of some cancers.
  • Be HPV-aware, and get vaccinated if you can. Use barriers in sexual encounters to prevent both HPV and HIV infection.
  • Be as familiar with your body as you can, so that you can detect changes and notify your physician.

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

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.