Who is Lesbian, Gay, Bisexual, or Transgender?
Assuming the most recent data to be correct, 5–9% of men are gay and 3–4% of women are lesbian. Kinsey’s original reports put these numbers at 10% for men and 2–6% for women. A recent international review reports that ≤15% of men report same-sex sexual activity at some time during their lives. An additional small percentage of the population experiences gender identity disorder or identify as transgender. These numbers suggest that physicians will provide care for lesbian, gay, bisexual, or transgender (LGBT) patients regardless of geographic location, or the ethnic, religious, socioeconomic, or gender demographics of their practice, and perhaps without knowing.
ESSENTIALS OF DIAGNOSIS
The first step in providing high-quality healthcare to LGBT patients is a thorough and sensitive sexual history.
History forms can facilitate this, if items include options relevant for LGBT patients, for example, “marital status” should include options for domestic partner.
Comprehensive information about behavior is necessary as a foundation for optimal education and health screening.
Knowing which patients are LGBT is the first and most important step in providing superior care—even if patients do not self-identify as LGBT but engage in same-sex sexual encounters. Accomplish this by taking a thorough and sensitive sexual history with all new patients and any time sexual behavior may be relevant to diagnosis and management.
Taking the Sexual History
The process of taking a sexual history begins with creating a safe environment. As sexual and gender-variant minorities, many LGBT people have faced discrimination and may fear sharing the details of their sexual lives with a healthcare provider. To further complicate matters, many healthcare providers may avoid discussing sexuality and sexual orientation details with patients, especially with adolescents, because often physicians do not feel they have the skills needed to address issues of sexual orientation. By providing literature in the office relevant to LGBT patients and by displaying positive, reassuring symbols (eg, a rainbow flag or equal sign), physicians can help their patients feel more at ease. History forms should include the full range of patient responses and not contain wording that ignores LGBT patients’ lives; such forms could facilitate conversation about sensitive topics. Physicians can overcome their own discomfort by routinely taking sexual histories.
The goal of taking a sexual history is to identify behaviors that can affect a patient’s health. Whether a man who has sex with men (MSM) self-identifies as gay or bisexual is important for understanding his social and psychological situation, but less relevant in terms of screening for and treating organic disease processes. It is worth prefacing all sexual history taking by informing the patient that the discussion will remain entirely confidential, and that the reason why each question must be answered in full, although the questions may seem too personal and invasive, is so that the physician can provide the best, most personalized care possible.
Physicians can help their patients be forthcoming about behaviors by guaranteeing privacy, excusing family members and partners from the room (after first receiving the patient’s consent to do so), and being mindful of the assumptions they make about their patients. For example, married heterosexual women may have sexual encounters with women, and self-identified lesbians have often had sexual encounters with men. Not all male-to-female (MTF) transgender people are sexually active with men, or at all. Many elderly patients remain sexually active well into their senior years. Compassionate, thorough discussion of a patient’s behavior can help clarify and demystify assumptions that healthcare providers make on the basis of superficial traits or stereotypes of LGBT patients. After introducing the topic, many clinicians begin the sexual history by asking, “Are you sexually active?” This question is a good starting point, but fails to address past behavior. In addition, patients may have variable definitions of what constitutes “being sexually active.” These ambiguities should be addressed by carefully listening to patients’ responses and following up with more specific questions.
The second question often used by practitioners is, “Are you sexually active with men, women, or both?” Asking this emphasizes behaviors are emphasized over labels, and no assumption is made about sexual orientation. Providing a list of options instead of asking patients to fill in the blanks, makes it easier to give voice to important medical information and communicates the physician’s receptivity to hear any answer.
Regarding current and former partners, the distinct sexual behaviors in which the patient has participated should be elucidated. It is these behaviors (eg, penile-vaginal intercourse, receptive or insertive anal intercourse, oral-vaginal intercourse, oral-anal intercourse), and whether barrier protection was used during intercourse, that will help determine screening and other management decisions. Without asking about specific behaviors, regardless of the fact that the gender of partners may be known, therapeutic decisions will be based on potentially incorrect assumptions.
In addition, it may be useful to identify the number of current and past partners, regardless of whether those relationships were monogamous, whether barrier protection is always used (keeping in mind that condoms are often not used properly), and whether patients and their partners have a history of sexually transmitted infection. This information is useful for approximating risk of disease exposure, and may identify ongoing risk behaviors that need attention.
A physician must understand how a patient’s sexual or gender identity affects her/his life at home, at work, and in the community. In addition, all patients who are sexually active with opposite sex partners, regardless of their sexual identity, should be asked whether they are interested in birth control. All LGBT patients should be screened for experiences with domestic violence or hate crime. Because the increased rates of substance abuse and dependence in some LGBT populations, the entirety of the social history should be completed, addressing the use of tobacco, alcohol, cocaine, methylenedioxymethamphetamine (MDMA; Ecstasy or Molly), methamphetamines (crystal meth), prescriptions (including opiates, benzodiazepines and stimulants), hormones, hallucinogens, marijuana, and intravenous drugs
It is only by identifying behaviors that physicians can appropriately screen, risk-stratify, effectively educate, and provide optimal care for their patients. Individuals who are members of a sexual or gender-variant minority group are often less obvious in their identity than those of other types of minority groups. Human behavior or gender expression does not always clearly align with gender norms of male and female.
For the purposes of this chapter and in the interest of simplicity, we will refer to gay men and lesbians as if they were single populations. However, this is a gross oversimplification of very complex and diverse human behavior. The LGBT population is heterogeneous, composed of individuals, couples, and families of all genders, ages, and socioeconomic, ethnic, religious, political, and geographic backgrounds. It is for this diversity that the rainbow flag was chosen as an LGBT symbol. This diversity also serves as the complex social context of patients’ lives that, in turn, shapes their experience of health and disease.
Who Is Gay? What Is Bisexual?
The complexity of human sexual behavior defies simple categorization. Sexual orientation manifests as fantasies, desires, actual behavior, and self- or other-identified labels. For example, a man could think of himself and describe himself as heterosexual, engage in sex with men and women in equal numbers, and in his sexual fantasies focus almost exclusively on male images; a simple label fails to capture the reality of his sexuality. Even when considering only sexual behaviors, differences may exist between actual versus desired, past versus present, admitted versus practiced, and consensual versus forced.
In the medical setting, asking about a patient’s label (eg, “Are you gay or bisexual?”) importantly assesses her/ his self perception, but may fail to identify medically significant information. Many individuals who engage in same-gender, high-risk sexual behaviors do not self-identify as gay or bisexual. MSM may be at increased risk for sexually transmitted infections (STIs) compared with men who have sex with women only. Women who have sex with men and women (WSMW) may have an increased risk for STIs and substance abuse compared with either women who have sex with women (WSW) or women who have sex with men only. Differentiation would not be possible by asking a patient only if she identifies herself as lesbian, as both WSMW and WSW may identify themselves as lesbian.
Little specific literature exists describing the characteristics of bisexual men and women separate from either strictly heterosexual or homosexual persons. Research studies that include bisexual-identified individuals typically group them with homosexual patients during statistical analysis, limiting information about bisexuality as distinct from heterosexuality or homosexuality. Historically, research focusing on LGBT patients frequently suffers from definitional differences that limit cross-study comparisons, small sample size, population sampling bias, and other shortcomings. Changing societal attitudes, improved research methodology, and increased resources are improving our knowledge gaps.
Homophobia, Heterosexism, & Sexual Prejudice
Homophobia is defined as an irrational fear of, aversion to, or discrimination against homosexuality or homosexuals. Heterosexism is the belief that heterosexuality is the natural, normal, acceptable, or superior form of sexuality. Sexual prejudice encompasses negative attitudes toward an individual because of that person’s sexual orientation. In their most extreme manifestation, homophobia and sexual prejudice result in physical violence and murder. Evolving societal attitudes may diminish such threats, but homophobia and its behavioral manifestations remain a significant threat to health.
Homophobia is dangerous. One survey of physicians found that 52% observed colleagues providing substandard care to patients due to sexual orientation. In another study, 37% of young gay men reported anti-gay harassment in the previous 6 months, resulting in increased suicidal ideation and diminished self-esteem. In HIV-seropositive gay men who were otherwise healthy, HIV infection advanced more rapidly, exhibiting a dose-response relationship, in participants who concealed their homosexual identity. A study of 1067 lesbians and gay men found that feelings of victimization resulting from perceived social stigma were a significant contributor to depression. A study of 912 Hispanic men found that experiences of social discrimination were strong predictors of suicidal ideation, anxiety, and depressed mood.
Overcoming prejudices and eliminating discriminatory practices are fundamental to healthcare for all patients. Bias against LGBT individuals seems to respond more effectively to experiential interventions (eg, interaction with LGBT individuals) than to rational interventions (eg, information dissemination). In a clinical setting, physicians can communicate acceptance and support with posters showing same-sex couples, stickers depicting a rainbow flag or equals sign, and a visible nondiscrimination statement stating that equal care is provided to all patients, regardless of age, race, ethnicity, physical ability or attributes, religion, sexual identity, and gender identity.
The perceived tolerance (or intolerance) strongly influences LGBT patients’ willingness to disclose sexual orientation and details of their personal lives. A patient’s sexual practices affects risk for various diseases and can influence disease screening and diagnostic evaluation, so honest discussion of the patient’s sexual and social life is vital to promote optimal health. A physician who fails to identify an LGBT patient’s sexual orientation may not adequately counsel or diagnose a patient and may compromise delivery of quality medical care. Incorrect assumptions about patients can have similar adverse outcomes (Table 66-1). Using simple conversational techniques, and mastering a very manageable amount of medical information, will allow family physicians to provide superior care to LGBT patients.
Table 66-1.Pitfalls in caring for gay and lesbian patients. ||Download (.pdf) Table 66-1.Pitfalls in caring for gay and lesbian patients.
|Assumption ||Solution |
|Assumption about sexual orientation: Many patients are neither exclusively heterosexual nor exclusively homosexual. ||Learn to inquire about sexual orientation in a nonjudgmental manner that recognizes the range of human diversity and apply this learning to all patients. |
|Assumptions about sexual activity: Lesbian and gay male patients may have numerous different sexual partners, be in a monogamous relationship, be celibate, or vary in patterns of activity over time. ||Take a specific, sensitive sexual history from all patients. |
|Assumptions about contraception: The need for contraception arises from a wish to prevent pregnancy from heterosexual intercourse, regardless of the patient’s gender identity, sexual orientation, or label. ||Inquire about need (rather than assuming need) or lack of need for all patients. Tailor recommendations to patient’s needs. |
|Assumptions about marriage: Lesbians and gay men may have been, and may still be, married to persons of the opposite sex. In some states and countries, they may be married to same-gender partners and may use the terms “partner” or “husband/wife” to refer to their spouse. ||Inquire about significant relationships for all patients. Use the same terminology that your patients choose. |
|Assumptions about parenting: Lesbian and gay male couples are often interested in and choose to bear and raise children. ||Inquire about parenting wishes and choices, and be prepared to discuss options. |