LGBT Healthcare

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LGBT Healthcare

• A case based workshop

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Goals

• To educate AECOM students on health issues in the
  Lesbian, Gay, Bisexual, and Transgender (LGBT)
  community during the Family Medicine Clerkship
  
• To improve the health of the Lesbian Gay,
  Bisexual and Transgender community

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Objectives

• To discuss how to interview patients about their
  sexuality in a comfortable, non-judgmental way
  
• To discuss the impact of healthcare disparities
  on the LGBT community
  
• To learn about some of the specific health care
  issues confronted by the LGBT community.

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Sexual history
WITH THE PATIENT Clarify issues of confidentialit
y Open ended questioning Use the patients words
Silences can be golden Genograms as a tool Exp
lain to the patient the routineness of your
questioning  
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Sensitive Sexual History
Some possible questions to use
  Tell me about your living situation? Who lives
with you? Who is important to you? Where do you
get your support? Who is close to you? Who wou
ld you call in an emergency?  How would you descr
ibe your sexuality?  Are you sexually active? Ha
ve you been sexually active? With men, women or b
oth? Do you have any need to discuss birth contro
l?
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Case 1

• Sal and Pal

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You are attending a family reunion. Everyone has
come home in honor of your great-grandmothers
80th birthday. Your cousin Sal is here with
another woman, Pal, who she introduces to you as
her girlfriend.   The three of you talk for a
while and the topic comes up that you are a
medical student. Pal and Sal seem a bit put off
by your chosen profession. They tell you that
doctors dont know how to take care of lesbian
patients. You ask why, whats the difference in
health care for lesbians? They both roll their
eyes, ask you to sit down, and the story begins .
. .   but first, try to think of three possible
reasons that Sal and Pal might be wary of the
medical profession.  
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Sal says   I went to the doctor a couple of yea
rs ago for a backache. The nurse asked me to fi
ll out one of those health questionnaires.
It had all these questions about sexual
activity   Are you sexually active? What typ
e of birth control do you use?
  I left it blank.   Why did Sal leave the answ
ers blank??
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Pal says   I had a different experience the fir
st time I saw my doctor. I dont have health
insurance through my job but wanted to see a
doctor because my periods had been irregular for
several years. She did a full physical. When I
got the bill for the office visit I found that
she had done a pregnancy test.
  I cant believe that she did this after I told
her that I was gay! That was a 50 bill out of my
pocket! So I just decided to deal with my
periods on my own. I have been using a
homeopathic medication and my periods are mostly
regular now.   A pregnancy test is part of the w
ork-up of irregular menses. How might the doctor
have approached the question of ordering this
test?
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Sal and Pal now trust you enough to ask more
specific health care questions, and they have a
lot of them   Should we have annual Pap smears?

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Now Sal asks   I read in a Lesbian magazine tha
t Breast Cancer is more common among lesbians.
Ever since then I have been thinking a lot about
seeing a doctor for breast cancer screening. Pal
says it is not necessary because I am only 25
have no family history of breast cancer.
  Should I start breast cancer screening early?
  I have also read that lesbians are more likely
to get yeast infections than other women?
  Is that true?
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Pal continues   What about woman-to-woman trans
mission of STDs?   Syphilis Gonorrhea Chlam
ydia
HPV Herpes Hepatitis
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Pal says   I think one of the hardest things ab
out dealing with the medical system is that they
are stuck with these old notions of family. My
family consists of Pal and me. If G-d forbid, I
became very ill, I would want Pal to be involved
in medical decision-making. It just doesnt seem
right that she cant be involved.
  What can you suggest for Pal and Sal?
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After an hour of intense conversation, your
great-grandmother stops over. As one of the 1st
female doctors in your home state you wonder how
she might respond to some of these scenarios.
  Your brother, Charlie, the family social worker
, had already clued grandma in to the
conversation. Grandma has a speech ready
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Lesbians are no different than anyone else
outside the status quo when it comes to getting
medical care. There are two issues access to
care and accurate information.
  People avoid medical care due to a fear that th
ey will be treated poorly. Unfortunately, they
often are. One patients bad experience can undo
the best efforts of many doctors.
  Confidentiality issues are difficult to deal wi
th. We dont have to put everything in the
chart. Most physicians develop their own codes
or phrases for sensitive information.
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Case 2

• M. Perez

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YOU ARE AN INTERNIST WORKING IN A PRIMARY CARE
CLINIC. YOUR MEDICAL ASSISTANT APPROACHES YOU,
CONFUSED. HES UNSURE WHICH HISTORY/PHYSICAL
FORM TO USE FOR YOUR NEXT PATIENT. HE EXPLAINS
THAT THE PATIENTS NAME IS MATHEW PEREZ BUT THAT
THE PATIENT IS DRESSED AND LOOKS LIKE A YOUNG
WOMAN. THE MEDICAL ASSISTANT SAYS HE CHECKED
WITH THE FRONT DESK TO BE SURE HE HAS THE RIGHT
CHART.   WHAT WOULD YOU DO?
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ON BEING ASKED, PATIENT REQUESTS THAT SHE IS
KNOWN AS, AND REFERRED TO, AS, MARIA
  MARIA IS HERE FOR A PHYSICAL FOR COLLEGE. SHE
REPORTS NO ACUTE PROBLEMS.   INADDITION TO ALL T
HE USUAL QUESTIONS NECESSARY IN ANY 26 YEAR OLD,
WHAT WOULD YOU PAY PARTICULAR ATTENTION TO IN THE
FOLLOWING PARTS OF THE ENCOUNTER?
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Developing Rapport

• Now that your front desk and nurse have made the
  client feel uncomfortable, what can you do to
  help build a trusting relationship?

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History?

• In addition to the usual historical questions,
  what might you ask this client?

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Physical

• What are you looking for on physical exam that
  may be different form a non transgender patient?

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Discussion/health advice

• What are the important subjects to discuss with
  this client about her health risks?

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Labs/Tests/Vaccines

• What labs would you offer?

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Resources

• Bronx Lesbian and Gay Health Resource Consortium
  1-866-4Gay Care (blghrc.org)
  
• Lesbian Gay Bisexual and Transgender Community
  Center [phone]
  
• Gay and Lesbian Medical Association (GLMA)
  [phone] (glma.org)
  
• Callen-Lorde Community Health Center 356 W 18th
  street [phone]
  

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Thanks to

• R. Beil, MD, P. Meacher MD, R. Williams, MD, F.
  Rainone, DO, F. Leanza, MD, R. Scott, MD, M.
  Levin, MD
  
• D. Myers, CSW
• A. Fornari and A. Nieto