LGBTQ HEALTH: WHO, WHAT, WHERE

AND WHY WE SHOULD CARE

LAURA C. HEIN PHD, RN, FAAN

 OBJECTIVES

• Introduce you to LGBTQ terminology

• Discuss historical and contemporary health concerns of the
LGBTQ community
• Discuss facilitators and barriers to health
• Present current legal and regulatory standards related to
LGBTQ health with recommended practice protocols
• Is your facility compliant?
DEFINITIONS LGBTIQ

• Gay, Lesbian
• Exclusive physical and emotional attraction to members of one’s own
sex

• Bisexual
• Physical and emotional attraction to members of both sexes

• Transgender (gender identity)

• A person who feels his or her body is not the sex it should be,
regardless of transformational hormone or surgical status

• Cis-Gender
• A person whose gender identity matches their sex at birth
Transgender
(gender identity) LGBTIQ

• MtF = Male-to-Female (she) transwoman

• Born with male anatomy, female gender

• FtM = Female-to-Male (he) transman

• Born with female anatomy, male gender
Definitions LGBTIQ

• Intersex
• The vogue term for hermaphrodite. People born with the
sexual characteristics of both sexes

• Questioning
• People who suspect they might be LGBT, but are not yet
certain

• Queer
• Inclusive term of the LGBTIQ community
• Unique paradigm
PREVALENCE - 9 MILLION LGBT PEOPLE IN THE
U.S.

Homosexual (gay/lesbian is preferred term)

• 3.4% self-identify as LGBT (Gates & Newport 2012)
• 1 in 5 - 20.8% of males in the U.S. reported either
homosexual behavior or homosexual attraction since
age 15 (Sell, Wells & Wypij, 1995)
• 17% of women and 6% of men have engaged in same-sex
behavior. However, 7% of women and 4% of men identify as
gay or bisexual (Copen et al. 2016).

Remember there are 320 million people in the U.S.

TRANSGENDER POPULATION
SIZE

• ~1.4 million adults self-identify as trans in the

U.S.
• Crissman et al. 2017; Flores et al., 2016; Meerwijk & Sevelius, 2017
GENDER NON-CONFORMITY OR GENDER
DYSPHORIA
GENDER NON-
CONFORMITY
• the extent to which a person’s
gender identity, role, or
expression differs from the
cultural norms prescribed for
people of a particular sex (IOM,
2011 definition)
GENDER DYSPHORIA
• discomfort or distress that is
caused by a discrepancy between
a person’s gender identity and that
person’s sex assigned at birth (and
the associated gender role and/or
primary and secondary sex
characteristics) (WPATH, 2011)
TRANSGENDER HEALTH –
YOUTH
• Protections under Title VII and Title IX of the Civil
Rights Act. Affirmed by DOJ filing in G.G. v.
Gloucester County School Board (2015). Case on appeal
to SCOTUS. Oral arguments Feb. 2017.

“There is a public interest in ensuring that all

students, including transgender students, have the
opportunity to learn in an environment free of sex
discrimination.” (DOJ)
TRANSGENDER HEALTH –
RESTROOM ACCESS
• April 8, 2015 – EEOC has ruled that an
employers refusal to allow a transgender
employee access to restrooms consistent with his
or her gender is sex discrimination under Title
VII.
• EEOC case: Lusardi v. AMRDEC
WHAT ABOUT SCHOOL? TITLE
IX
• Title IX protects students, faculty and employees
from sex discrimination in any federally funded
education program or activity.
• However… schools are still not safe.
 EARLY SOCIAL TRANSITION

• Child lives as gender that matches their identity

• Trial run - name, attire, social roles at school, in community
• Reversible
• Family decision whether to disclose to others or not

• Approx. 25% of children who were assessed for gender dysphoria

grew up to be cis-gender gay vs. transgender.
 CHILDREN AND YOUTH

• EARLY medical and mental health services

• Family support is critical to positive health outcomes
• Puberty experienced congruent with gender (delay until
sure)
• Reduces need for later medical interventions
• Prevents unwanted sex characteristics (i.e. breasts)
• Decreases stress, anxiety, depression
REPARATIVE THERAPY

• = Efforts to change the sexual orientation or gender identity

• Condemned by all mainstream professional organizations as
harmful including the APA, AMA, Am Acad of Pediatrics,
AAN, ISPN etc.
• Related to depression, anxiety and suicide

• George Rekers (prof emeritus from USC SOM) – published

case where he conducted reparative therapy. This is what
he did….
PUBERTY BLOCKING – GNRH
AGONISTS
• Ideally begun in Tanner 2 stage (early start of puberty).
• Can begin in Tanner 3-5 – goal is to stop puberty/ prevent
secondary gender characteristics i.e. height, breasts etc.
• GnRH Agonists - Leuprorelin; Triptorelin; Goserelin;
Histrelin implants
• Very expensive. Cost is between $500 and $1500 month.
• Insurance rarely covers this cost

• Effects are totally REVERSIBLE

IRREVERSIBLE HORMONE
EFFECTS
• ESTROGEN • TESTOSTERONE
• Breast development • Uterine atrophy
• Nipple enlargement • Facial and body hair
• Loss of erection • Deepened voice
• Testicular atrophy • Clitoral enlargement
• ? sterility • ? sterility
FIRST DO NO HARM….
There is harm related to NOT intervening
• Suicide ~ 44%
• Depression
• Anxiety
• Homelessness
• ETOH, drug use
• Sex work
• HIV
OVERREPRESENTED HEALTH
PROBLEMS

• HIV/ AIDS
• Trauma/ Victimization
• Mental Health Concerns
• Addictions

• Is this because they’re LGBT? –or- because of the

context within which LGBT people must exist?
HIV/ AIDS

• A missing generation of gay men due to AIDS

• HIV+ the norm in some areas
• Homelessness/ poverty – survival sex
• Street hormones (trans)
TRAUMA/ VICTIMIZATION

• Parental abuse
• Increased prevalence of verbal and physical abuse and heightened
suicidal ideation among those who disclosed their s.o. to their
families

• Hate crimes
MENTAL HEALTH –
DEPRESSION & ANXIETY

Additional stress d/t image management

related to s.o./g.i.
• LGBT children often grow up in a society
that says that they should not exist and/or
should not act on their feelings.
• These societal mores can be internalized = internalized
homophobia
 DEPRESSION

• Prevalence of depression 17.2% higher than in U.S.

adult men in general
• Distress & depression associated w/:
• lack of a partner;
• not identifying as gay, queer, or homosexual;
• experiencing multiple episodes of antigay violence
in the previous 5 years; and
• very high levels of community alienation

Mills 2004
LGBT YOUTH VICTIMIZATION

• 25% of gay youth (16% lesbian) have been threatened

or injured with a weapon on school property.
• 3x higher than hetero rate for boys; 4x higher than hetero
for girls.

• 13% gay (16% lesbian) youth didn’t go to school

because of safety issues (O’Malley, 2014)
• 3x the hetero rate

Sample was of YRBS HS students

 MENTAL HEALTH - SUICIDE

• LGB youth = 30% attempted

suicide (double the hetero
rate)
• School bullying increased the
risk of suicide (Bouris et al, 2016)
TRANSGENDER SUICIDE

U.S. TRANS/GQ DATA

ADDICTIONS

• Young LGBT (most prevalent) Ecstacy: MDMA

• Lesbian/ female Bi – principally ETOH

• Gay/ MtF Transgender –
• Ecstasy (and other Rave drugs)
• Risk = hyperthermia;
• Poppers (amyl nitrate) – enhanced
sexual experience
• Risk = an MI, priapism
CDC RECOMMENDATIONS FOR
SCHOOLS TO SUPPORT LGBTQ
HEALTH

1. Identify “safe spaces”

2. Prohibit harassment and bullying
3. Facilitate access to health & psych providers not on school
property who are LGBTQ affirming
4. Encourage professional development on safety for all students
5. Provide health education curricula with inclusive terminology
Demisse et al., 2013
CASE 1

• A 15yo questioning female student presents to the school nurse asking

him to sponsor a Gay Straight Alliance (GSA) at their school. The best
school nurse answer:
A. “yes, of course I’ll sponsor a GSA”
B.“I’d like to but I’ll need to talk to the principal first”
C.“I think I’d like to talk to your parents first – we’ll be back in touch”
D.“You really need to talk to our school psychologist about this”
SC CODE 59-32-30A(5)
LOCAL SCHOOL BOARDS TO IMPLEMENT
COMPREHENSIVE HEALTH EDUCATION PROGRAM;
GUIDELINES AND RESTRICTIONS

• (5) The program of instruction provided for in this

section may not include a discussion of alternate
sexual lifestyles from heterosexual relationships
including, but not limited to, homosexual
relationships except in the context of instruction
concerning sexually transmitted diseases.
CASE 2
• 30yo transman who initiated social gender affirmation 5 years ago,
chest construction at 25yo, testosterone from 25-28yo. He grew a beard
and stopped taking T. Beard growth persisted. No menstruation for 5
years. He would like the option to become pregnant in the future
because he wants children but has legal concerns related to adoption.
As the NP you first:
A.Conduct an exam and draw labs
B.Conduct an exam, draw labs and refer to endocrinology
C.Conduct an exam, draw labs and refer to GYN
YOUR PATIENT WANTS TO
TRANSITION – NOW WHAT? The pdf is free

1. Google “WPATH
Guidelines”
2. Refer to a Psych NP or
other mental health
provider
3. Start hormone therapy

www.wpath.org
RESEARCH ON HORMONES – IS IT
SAFE?

FTM MTF

• No increase in CAD found in 876 • Increased risk of CAD at

FTM pts (Gooren, 200) high doses.
• Increased risk of CA at low
doses
• If prior MI – PO estradiol
does not incr. or decr. risk for
further emboli
WPATH Standards of Care

The criteria for hormone therapy are as follows:

•Persistent, well-documented gender dysphoria;
•Capacity to make a fully informed decision and to
consent for treatment;
•Age of majority in a given country (if younger,
follow the Standards of Care outlined in section
VI);
•If significant medical or mental health concerns
are present, they must be reasonably well
controlled
 Rx information taken from
Cavanaugh 2016
HORMONES FTM - OPTIONS

• Injectable Testosterone
• Testosterone Enanthate or Cypionate 100-200 mg IM q 2 wks (20 -22g x 1 ½” needles)

• Transdermal Testosterone
• Androderm TTS 2-8mg daily
• Topical testosterone gels in packets and pumps, multiple formulations (Testim, Androgel)
5 to 10 gm (50 to 100 mg of testosterone) applied topically daily
• Axiron 2% pump gel for axillary application 1 pump to each axilla daily

• Testosterone Pellet
• Testopel- implant 6-10 pellets q 3 to 6 months

• Buccal Testosterone
• Striant 30 mg buccal system q 12 hours
TESTOSTERONE

RISKS MONITORING

• Baseline CBC, CMP, lipids,

•  HDL  triglycerites
renal panel, fasting glucose
•  insulin resistance • 3 month, then Q 6-12 mo
•  sleep apnea • CBC, liver enzymes,
serum testosterone
• Infertility
• Q 6-12 mo
• Mental health • Lipid profile, HbA1c
changes
HORMONES MTF OPTIONS
• Oral Estrogen
• Estradiol (estrace) 2-6mg PO or SL daily(can be divided into BID dosing)
• Premarin (conjugated estrogens) 1.25-10mg PO daily (can be divided into BID dosing)

• Transdermal estrogen (preferred for 40yo)

• Estradiol patch 0.1-0.4mg twice weekly

• Injectable Estrogens [NOTE – shortage right now]

• Estradiol valerate5-20mg IM q2 weeks
• Estradiol cypionate2-10mg IM weekly

• Antiandrogens
• Spironolactone (aldactone) 50-400mg PO daily (can be divided into BID dosing)
• Finasteride (Proscar) 2.5-5mg PO daily

• Progestins – increase breast development, but CV risk, weight gain & depression
MTF – ESTROGEN
RISKS
• CAD weight triglycerides
• libido glucose tolerance
• Gallbladder ds
• Infertility
• Mental health changes
• Spronolactone carries risks of
hypotension, hyperkalemia and
renal insufficiency
MONITORING
• Baseline – CBC, CMP, lipids,
renal, fasting glucose,
testosterone, prolactin
• 6mo. – serum testosterone &
estradiol
• If on spironolactone
• 1 mo. then 3mo. – lipids, lytes,
creatinine, glucose
 MTF SURGICAL OPTIONS (~30%)

• Removal of scrotum & penis

• Creation of vagina, labia, clitoris &
mons
• Breast augmentation
• Tracheal shave
• Facial feminization
• Brow
• nose

Taken from Schechter 2017 p.37

FTM SURGICAL OPTIONS (~30%)

• Phalloplasty with urethral • Chest reconstruction

reconstruction & creation
of scrotum (uncommon)
STAGED SURGERIES

• Genital FtM • Chest Contouring FtM

• Tissue removal from donor • Mastectomy
site • Revision of prior surgery to
• Urethral reconstruction decrease scarring and
• Implant prosthesis remove arm flaps
YOU’RE AN ORG LEADER/ MANAGER
WHAT CAN YOU DO?

• Know the law and standards related to LGBTQ

patients
• Train your staff – receptionist to CNO
• Work on the culture of your organization to make it
safe.
Joint Commission Standards (2011)

• The patient-centered communication standards for

Hospitals (CAMH).
• Elements of performance 28 and 29 under
RI.01.01.01, require access to a support person and
non-discrimination of care.

The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and FamilyCentered Care
for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL, Oct. 2011.
LGBTFieldGuide.pdf.
RI.01.01.01 ELEMENT 29

“No longer considered to be simply a patient’s

right, effective communication is now accepted
as an essential component of quality care and
patient safety.”
HOSPITAL VISITATION

• January 2010 Centers for Medicare and Medicaid

Services (CMS) regulation required hospitals to
permit patients to designate visitors & prohibits
discrimination in visitation based on so/gi. 42
C.F.R. § 482.13
• Compliance with requirements for Medicare Conditions of
Participation (CoPs)
HOSPITAL VISITATION

• July 2011 Joint Commission standard – prohibition on

discrimination based on orientation or gender identity.
• “Prohibit discrimination based on age, race, ethnicity,
religion, culture, language, physical or mental
disability, socioeconomic status, sex, sexual
orientation, and gender identity or expression.”
RI.01.01.01 EP29 (p.48 of Joint Commission LGBT
doc).
CMS – EQUAL COVERAGE TO CARE
IN THE SAME NURSING HOME AS A
SPOUSE

• Aug. 29, 2013 - CMS announced the guarantee of

Medicare coverage applies to ALL spouses regardless
of sexual orientation.
• Prior to this same-sex spouses with Medicare Advantage plans were not
eligible to live in the same nursing home as their spouse.
FMLA
• All spouses are now covered under FMLA if the employer is FMLA
covered. (3/15 injunction against same sex spouses dissolved by SCOTUS
Obergefell ruling)

FMLA may be used for

• The birth of a child, adoption or foster parent;
• To care for a spouse, son, daughter, or parent who has a serious health
condition;
• For a serious health condition that makes the employee unable to perform the
essential functions of his or her job; or
• For any qualifying exigency arising out of the fact that a spouse, son,
daughter, or parent is a military member on covered active duty or call to
covered active duty status.

http://www.dol.gov/whd/regs/compliance/whdfs28.pdf
AFFORDABLE CARE ACT

• Section 1557 – Civil Rights provisions of

the Act.
• Applies civil rights protections to the Health
Insurance Marketplace created by the ACA – and
includes LGBT people
ACA & PREVENTIVE CARE

May 2015 DOL Guidance on the ACA confirms

•Plans cannot limit sex-specific preventive
services by gender identity. If a provider orders
the service it is considered appropriate.

http://www.dol.gov/ebsa/faqs/faq-aca26.html
THE LAW

SC ANTI- TRANSGENDER BILL

• S.1203 defeated May 4, 2016
TITLE IX -
EDUCATION
• Grimm v. Glouchester
(2015)
TITLE VII - EEOC • Appealed to SCOTUS

• Macy v. Holder (EEOC, 2012) – • Administrative guidance

gender non-conformity = gender.
 HOW DO I FIND AN
AFFIRMING PROVIDER?

GLMA.org
•Then click on: Resources – For Patients – Find a Provider
•A searchable provider directory (location, specialty,
transition care etc.).

Provider Directory at the Harriet Hancock LGBT

Center
RESOURCES

Locally
• Harriet Hancock LGBT Center
• IRIS = LGBT group on campus
Nationally
• The Trevor Project – suicide hotline for LGBT youth www.thetrevorproject.org 1-866-
488-7386
• Trans Lifeline http://www.translifeline.org 1-877-565-8860
Providers GLMA.org
https://glmaimpak.networkats.com/members_online_new/members/dir_provider.asp
HOW CAN AN LGBT PERSON KNOW IF
SOMEONE IS SAFE TO TALK TO?

• Go with your instincts

• If you get a bad vibe from someone – trust your instincts and get out of
there.

• Look for these symbols

WHAT WE CAN DO AS NURSES

• Be Authentic
• Encourage Authenticity in others
• Share
• Be flexible, scootch over a little, share the bench ≈ share the power
LAURA C. HEIN PHD, RN, FAAN
HEIN@SC.EDU