Chapter 66: Caring for Lesbian, Gay, Bisexual, & Transgender Patients

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.

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.

General Considerations

Any publication on LGBT health that omitted mention of HIV would be incomplete, but thorough coverage of the topic is covered in a separate chapter.

Gay men constitute the largest number of AIDS cases in the United States. Recent literature suggests increased rates of unprotected anal intercourse (“barebacking”) among certain gay populations. This trend may be due in part to decreased fear of HIV in the era of highly active antiretroviral therapy (HAART). Young gay men, those who use the Internet to meet sexual partners, and those with substance abuse problems, particularly those who use crystal meth, ecstasy, and Viagra, are at greater risk. Increasingly, African American and Hispanic men are disproportionately affected. Another quickly growing HIV-positive population is African American women who have unprotected sex with African American male partners that are on the “down low” or secretly having unprotected sex with men. Increased stigma associated with homosexuality in ethnic minority communities may drive individuals at risk to hide, complicating efforts at diagnosis and treatment.

Prevention

Until an effective vaccine is available, behavioral interventions are the best means to stop the spread of HIV. Physicians should screen all patients for risk behaviors (eg, unprotected intercourse, multiple partners, concurrent sex and substance use, injection drug use) and should intervene to reduce risk and test for HIV in patients with a positive risk history, repeating testing periodically if risk behaviors continue. Pursue a “harm reduction” strategy if it is impossible to eliminate all risk (eg, stopping needle sharing until drug abuse can be stopped, keeping condoms available when sex with a new partner is possible). Since patients engaging in risky behaviors rarely will volunteer information about their risk, physicians must proactively assess each patient’s risk and intervene when needed.

Postexposure prophylaxis (PEP) may be beneficial for HIV-negative individuals exposed to HIV. The data supporting antiretroviral treatment following sexual exposure are limited, extrapolated from occupational exposure data and vetted by expert guidelines recommended to initiate a 4-week regimen of PEP as soon as possible after a significant exposure to HIV. The benefit of treatment started >72 hours after exposure is limited. Combinations of antiretroviral agents similar to those used in treating HIV may be used, with similar adverse effects. PEP is not 100% effective in preventing HIV seroconversion.

Clinical Findings

Physicians should consider and test for HIV in at-risk individuals who present with routine viral infection symptoms. Patients with acute HIV infection present with symptoms that are generally indistinguishable from common viral infections, including fever (96%), adenopathy (74%), pharyngitis (70%), rash (70%), and other nonspecific symptoms (see Table 14-2). HIV viral load tests (eg, PCR) become positive 1–2 weeks before routine (antibody-based) HIV tests and may be useful in diagnosis (as distinct from screening).

Latent HIV infection may remain essentially asymptomatic for years. Generalized lymphadenopathy may persist for years. Its disappearance may indicate clinically significant immune system decline, marked by nonspecific symptoms such as fevers, weight loss, and diarrhea. Early immune dysfunction results in diseases such as herpes zoster or persistent vaginal candidiasis. Without effective antiretroviral treatment, almost all patients will progress to one or more AIDS-defining illnesses.

Treatment

Patients infected with HIV require a comprehensive care plan that involves skilled physicians, ancillary health services, pharmacologic therapy, and access to social and other support services. Excellent resources exist to guide physicians in the detailed management and care of patients with HIV/AIDS (see next section). The family physician’s role in HIV care will be determined by the knowledge, skill, comfort level, and personal preferences of the physician, as well as the accessibility of referral physicians. Family physicians may serve primarily in case finding, by testing and referring patients found to be HIV-positive, or may assume full responsibility for comprehensive management of HIV and its complications. Current research supports all HIV-positive patients should start HAART treatment regardless of CD4 count or viral load.

General Considerations

Human papillomavirus (HPV), likely leading to condyloma, genital warts, or epithelial dysplasia, is the most commonly transmitted STI.

Gonorrhea, chlamydia, and nonchlamydial nongonococcal urethritis (NGU) are common problems in sexually active gay men. As each of these may cause asymptomatic infection, periodic screening may be useful to detect clinically silent disease. Antibiotic resistance to Neiseria gonorrhea has become so ubiquitous that the only remaining first-line treatment is ceftriaxone, and fluoroquinolones are no longer recommended for treatment in MSM. Herpes simplex and syphilis most commonly cause genital ulcer disease (GUD) in heterosexual and homosexual men.

Enteritis and proctocolitis may be caused by an STI via oral-anal contact. Enterobactericiae and Giardia lamblia are a common cause and should be included in the differential diagnosis of enteritis and proctocolitis in MSM, as well as CMV in the HIV-positive patient. Unprotected receptive anal intercourse can lead to the tenesmus, rectal pain, and bleeding of proctitis, in which the most common pathogens are Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and herpes simplex virus.

Oral stimulation of a man’s penis, mistakenly thought to be a “safe” sexual practice, may be an independent risk factor for urethral and pharyngeal gonorrhea and nonchlamydial NGU; it has been implicated in HIV transmission, and has been associated with localized syphilis epidemics in gay men. Syphilis epidemics have also been associated with high-risk sexual activity among HIV-positive men.

Some researchers have shown comparable rates of STIs between lesbians and heterosexual women. Infections, including bacterial vaginosis (BV), candidiasis, herpes, gonorrhea, and human papillomavirus infections, can be contracted by lesbians. One series found a 2.5-fold increase in BV among lesbians compared to heterosexual women, often showing similar vaginal flora between female ­partners.

Human herpes virus type 8 (HHV8) has been shown to predispose people to Kaposi’s sarcoma. Ten studies assessed the prevalence and correlates of HHV8, with most concluding that MSM have disproportionally higher HHV8 infection rates than do comparison groups.

Hepatitis C virus is a risk factor for non-Hodgkin’s lymphoma and hepatocellular carcinoma. Surveillance data suggest that hepatitis B and C viral infections have increased over time in MSM, whereas it has decreased in the general population. In addition, hepatitis C is an emerging coinfection in HIV-infected MSM regardless of IVDU.

Prevention

Counseling has been shown to reduce risk behaviors, and patients reporting high-risk behaviors or those diagnosed with an STI should receive or be referred for individual or group counseling. Additionally, MSM patients engaging in sex outside a mutually monogamous relationship should receive periodic STI screening, as should women having sex with men and women (see Chapter 14 for screening recommendations and other information about STIs). If not immune, gay men should be vaccinated against hepatitis A and hepatitis B.

Patient Education

Patients diagnosed or suspected to have an STI should be informed of transmission methods and how to reduce infection risk. Such patients should also be informed of specific treatment, if any, as well as potential coinfection with other sexually transmissible agents. Patients should be counseled to contact sex partners; in lieu of this, the physician or health department may notify partners.

General Considerations

Human papillomavirus is a pervasive infection, manifesting in >100 viral types that infect various parts of the human body. Head and neck cancers can be caused by HPV, although current research shows that the risk of oral HPV infection did not differ by sexual orientation. HPV types that infect the genitalia carry varying risk for dysplasia and neoplasia. The types that cause the most visually apparent warts are usually the types with least risk for dysplasia. Conversely, the types causing clinically inapparent disease carry high dysplastic risk.

Sexual orientation and receptive anal intercourse appear to be independent correlates of condyloma and anal intraepithelial neoplasia. Interestingly, one study even showed that anal HPV was more transient in men who have sex with women (MSW) but more persistent in MSM. Most available evidence demonstrates that MSM have a higher prevalence of anal HPV infection than do comparison groups regardless of HIV status. In addition, it appears that both HIV infection and receptive anal intercourse are significant correlates of anal squamous intraepithelial lesions, and the prevalence of anal cancer was higher in MSM with HIV than in women and heterosexual men.

Prevention

Secondary prevention via Pap smear remains the cornerstone of screening. One study of lesbians revealed that 25% of respondents had not had a Pap test within the past 3 years, and 7.6% had never had a Pap test. Lesbian patients may mistakenly believe themselves to be less susceptible to cervical cancer than heterosexuals or bisexuals, even though one study showed 79% reported previous sexual intercourse with a man. Even in women reporting no prior sex with men, HPV DNA and squamous intraepithelial lesions (SILs) may be found in ≤20% of patients. Thus cervical Pap smears supplemented with HPV DNA testing should be performed routinely using the American Society of Colposcopy and Cervical Pathology guidelines. Individuals with abnormal screening tests should receive colposcopy or anoscopy and subsequent follow-up as indicated by findings.

A gay man’s risk of anal squamous cell carcinoma is equivalent to the historical risk of cervical cancer that women faced prior to the advent of Pap screening. Anal HPV DNA is very prevalent in gay men—one study detected it in 91.6% of HIV-positive and 65.9% of HIV-negative men. HIV exacerbates HPV effects, and is associated with more prevalent HPV infection and higher-grade anal intraepithelial neoplasia (AIN). Screening HIV-positive homosexual and bisexual men for AIN and anal squamous cell carcinomas with anal Pap tests offers quality-adjusted life expectancy benefits at a cost comparable with other accepted clinical preventive interventions. Because the observed increased incidence of anal cancer does not appear to be due solely to HIV infection, high-resolution anoscopy and cytologic screening of all MSM with anal condyloma and other benign noncondylomatous anal disorders is supported by current knowledge.

No consensus guidelines exist on screening for AIN and anal cancer in men who have sex with men, regardless of HIV status. Because of the ubiquitous prevalence of HPV in the HIV-positive population, baseline cytology and yearly anal cancer screening using Pap smears for all HIV-positive MSM is recommended. Current research is conflicted on the cost-effectiveness of screening all MSM using anal Pap smear, although current expert recommendations suggest screening HIV-negative MSM every 2–3 years, similar to cervical cancer screening recommendations.

Taking an anal-rectal sample for cytology (ARC) is a simple procedure. It does not require the use of an anoscope. No special preparation is needed for the patient, although the patient may be advised to refrain from receptive anal intercourse or the use of intraanal preparations before examination.

An ARC sample can be collected with the patient in the lateral recumbent position lying on one side, with the knees drawn up toward the chest. To collect an ARC sample, a tap water–moistened Dacron swab is used. The Dacron swab is inserted approximately 5–6 cm into the anal canal past the anal verge, into the rectal vault. This is done without direct visualization of the anal canal. Firm lateral pressure is applied to the swab handle as it is rotated and slowly withdrawn from the anal canal, inscribing a cone-shaped arc. Care should be taken to ensure that the transition zone is sampled. A swab or smear of the perianal skin is an unsatisfactory sample for ARC. Avoid using cotton swabs on a wooden stick because the handle may break and splinter during collection.

For liquid-based cytology, the swab is then placed in the preservative vial and agitated vigorously several times to release the cellular harvest. If liquid-based cytology is not available, the swab can be smeared onto a glass slide and then spray-fixed as per the procedure for conventional cervical Pap smears. The lab requisition should be labeled as a rectal Pap smear.

Experimental vaccination has been shown to prevent infection with some types of HPV commonly associated with cancer development and demonstrated to prevent genital warts. A quadrivalent vaccine against HPV is licensed and recommended for both females and males aged 9–26 years. Additional discussion of HPV appears in Chapter 14.

General Considerations

Alcohol, psychoactive drug, and tobacco use appear to be more widespread in gay men and lesbians than in the general heterosexual population. Several studies suggest that lesbians and bisexual women consume more alcohol and use other psychoactive substances more than heterosexual women. A recent meta-analysis found risk ratios of 4.0 and 3.5 for alcohol and substance dependence, respectively, among WSW and WSMW as compared to WSM. Another review of tobacco use found smoking rates among adolescent and adult lesbians, gays, and bisexuals to be higher than in the general population. Methamphetamine use has reached epidemic proportions in some gay male populations, and routine history taking should include a question regarding current and past use of this drug.

Alcohol use has been associated with high-risk sexual behavior (eg, unprotected anal and oral intercourse). Gay men who have unprotected anal intercourse are more likely to have a drinking problem than gay men who do not have unprotected intercourse, and unprotected intercourse after drinking is more common with nonsteady sexual partners.

Drug use is also associated with increased high-risk sexual behaviors. Such drugs include hallucinogens, nitrate inhalants, and cocaine and other stimulants. Drug use during high-risk sex is common. However, associations between drug use and high-risk sexual behavior exist only for current use, not past drug or alcohol use. Providing adequate treatment to patients with substance abuse problems can diminish their subsequent risk of acquiring HIV and other STIs.

In some venues, the prevalence of illicit drug use and associated high-risk sexual activity is dramatic, with use of substances such as MDMA or Ecstasy approaching 80% of the population. Men who attend “circuit parties”—a series of dances or parties held over a weekend that are attended by hundreds to thousands of gay and bisexual men—should be considered at high risk for concurrent illicit substance use and should be counseled accordingly.

Anabolic steroid use is a problem among a subset of gay men. One British study of >1000 gay men recruited from five gymnasiums found that 13.5% of the study population used anabolic steroids, and users were more likely than never users (21% vs 13%) to report engaging in unprotected anal intercourse, increasing their risk for HIV infection.

Pathogenesis

Several theories have been proposed to explain the increased substance use seen in LGBT patients. The observed behavior has been explained in various ways—a maladaptive coping strategy to deal with societal bias against homosexuality; a consequence of bars serving as a primary social gathering place for lesbians and gay men; a genetic predisposition to substance abuse linked to genes coding for same-sex attraction; a coping method for dealing with stresses such as fear of HIV infection, lack of social support, fear of discrimination in housing or employment, and rejection by family or friends on the basis of sexual orientation; or something else. Research to date has not explained causation.

Reasons for steroid use are more straightforward: to modify the patient’s musculature to conform more closely to an idealized male form. Significant social pressures may drive patients to resort to steroids to achieve an idealized masculine physique, and for these patients substantial support and counseling may be required to overcome steroid abuse.

Prevention & Treatment

Prevention, clinical findings, complications, and treatment of substance abuse in LGBT populations are similar to these management considerations in heterosexual populations (see Chapter 56 for further discussion). However, modification of standard treatment approaches to reflect LGBT culture may enhance treatment effectiveness. Differences to consider with this population include the prevalence of methamphetamine use, and its association with high-risk sexual behavior among some groups of gay men; concomitant use of sildenafil (Viagra) or other treatments for erectile dysfunction; and “club drugs” (eg, MDMA or Ecstasy, amphetamines, γ-hydroxybutyrate, ketamine). Erectile dysfunction treatments, either with or without other substance use, are associated with high-risk sexual behavior.

General Considerations

Feelings of stigmatization, internalized homophobia (the direction of society’s negative attitudes toward the self), and actual experiences of discrimination or violence contribute to LGBT distress. A study of HIV-infected men, which may be relevant to all gay men, found that men who did not demonstrate traditional gender identity were more likely to have current symptoms of anxiety and depression and to have had a lifetime history of depression. Depression has also been linked to an HIV diagnoses and the AIDS epidemic.

Well-designed studies with valid sampling techniques demonstrate that suicidal ideation, attempts at suicide, and completed acts of suicide are more common in gay, lesbian, and bisexual youth than in their heterosexual counterparts. Population-based research demonstrates significantly higher rates of suicidal symptoms and suicide attempts among men who reported having same-sex partners than those who reported having exclusively opposite-sex partners. A recent meta-analysis indicates a fourfold increase in lifetime suicide attempt prevalence among gay and bisexual men as compared to heterosexual men. Other investigators demonstrate similar findings (eg, in a study of twins in which one brother reported same-sex partners after age 18 and the other did not). Suicidality has been linked to the process of “coming out,” or revealing one’s homosexual orientation to others. Thus, physicians caring for gay adolescents or adults disclosing their sexual orientation to others should be especially sensitive to symptoms or signs suggesting any increase in suicide risk.

One study of lesbians considered predictors of depression and looked at relationship status, relationship satisfaction, social support from friends, social support from family, “outness” (degree to which the woman publicly shared her sexual orientation), and relationship satisfaction. Lack of social support from friends, poor relationship satisfaction, and lack of perceived social support from family were significant predictors of depression.

Prevention

Well-being is enhanced during later stages of gay identity development, which suggests that facilitation of an individual’s synthesis of his or her gay identity may alleviate depressive symptoms. Conversely, in HIV-positive men, concealment of homosexuality is associated with lower CD4 counts and depressive symptoms, lending further support to the idea that facilitating gay identity development may alleviate or prevent depression in some patients, and in so doing, better equip them to maintain their health.

Clinical Findings

Symptoms and signs of depression in lesbian female and gay male patients are very similar to those in heterosexual populations (see Chapter 52). Although depression is often associated with decreased sexual activity, one study of gay men revealed that 16% had heightened sexual interest while depressed. Predictors of depression in lesbians (eg, lack of social support from friends, relationship status dissatisfaction, and lack of perceived social support from family) are similar to predictors for heterosexual women.

Cancer Screening

All LGBT patients require the same age- and gender-appropriate cancer screening as heterosexual and non-gender-variant patients. As discussed above, cervical cancer screening should be offered to lesbian women, and anal cancer screening to men with a history of receptive anal intercourse, particularly if they are coinfected with HIV, although there remains insufficient evidence to universally recommend the anal Pap at this time.

Since breast and ovarian cancers may be more common in nulliparous or uniparous women, it may be more common in lesbians, but well-designed, prospective studies are lacking. One study compiling survey data from almost 12,000 women found lesbians had greater prevalence rates of obesity and alcohol and tobacco use, and lower rates of parity and birth control pill use. Another study confirmed higher prevalence of nulliparity, and also found higher prevalence of other health risk factors, including high daily alcohol intake, higher body mass index, and higher prevalence of current smoking.

In transgender patients, it is important to screen according to current anatomy as well as use of hormonal therapy. For example, many male-to-female (MTF) transgender patients are at risk for both prostate and breast cancers, and female-to-male (FTM) transgender patients often require screening for breast, uterine, cervical, endometrial, and ovarian cancers. As in any patient population, tobacco and alcohol use among LGBT patients increase risk for malignancy.

Erectile Dysfunction

Studies have demonstrated that erectile dysfunction is more common in homosexual than in heterosexual men, although overall prevalence was still <4%. Related, gay men also report higher levels of performance anxiety (eg, more likely to agree with the statement “If I feel I’m expected to respond sexually, I have difficulty getting aroused”) than do heterosexual men. This was true even when men reporting erectile dysfunction were excluded from analysis. Erectile dysfunction is more common in HIV-positive homosexual men than in HIV-negative homosexual men. Declines in serum testosterone have been associated with HIV infection, suggesting one possible etiology for his difference.

Contraception & Reproductive Health

Assuming that all women of reproductive age need contraception risks alienating lesbian patients, who may consequently decline to disclose their sexual orientation. However, lesbians who are sexually active with men may be interested in obtaining contraceptives.

Lesbian patients may also be, or wish to become, mothers and so may welcome a discussion of reproductive options. Parenthood options available to lesbians and gay men include adoption, artificial insemination, surrogacy, or heterosexual intercourse. Existing evidence suggests that gay men and lesbians have parenting skills comparable to heterosexual parents. Special considerations that may arise for lesbian and gay parents include the children’s awareness of lesbian and gay relationships, heterosexism, and homophobia. When compared with children of heterosexual parents, children of gay men and lesbians seem to be no different in significant variables measured, including their sexual or gender identity, personality traits, and intelligence. Despite this, gay men and lesbians may face unjustified barriers in their attempts to become foster and adoptive parents. Issues that warrant physician awareness include parental legal rights and durable power of attorney; gestation and pregnancy; choice of surrogate, sperm, or egg donor; possible HIV risk; and routine preconception and prenatal care. Physicians caring for lesbians and gay men wishing to become parents should maintain information about appropriate referrals to facilitate this process.

Terminology

Terminology can be problematic when describing transgender individuals. Transgender, used as an umbrella term, can have multiple meanings—either individuals who transcend culturally defined categories of gender in some way, or individuals experiencing incongruence between their perceived and observed gender. Transsexual often refers to an individual who has undergone partial or complete sex reassignment surgery (SRS). Intersex individuals are born with both male and female sexual characteristics and organs, such that unambiguous assignment of male or female sex at birth is not possible. “Gender queer” is a term characterizing an individual who doesn’t identify as either male of female or accept the gender binary.

The term male-to-female (MTF), or as the transgender community feel as the more appropriate term, “transwoman” describes individuals born with male genitalia who presents as a male regardless of hormone or surgical intervention; the reverse is true for female-to-male (FTM) individuals, or “transman.” Additional ways to characterize the biological, social, psychological, and legal identity of transgender individuals have been described. The best approach to caring for an individual patient is to determine how they wish to be addressed and understand how they conceptualize their gender.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnosis of gender dysphoria communicates the emotional distress that can result from “a marked incongruence between one’s experienced/expressed gender and assigned gender. Individuals who experience the strongest feelings of dissonance between their gender identity and their physical appearance believe the quest for full hormonal and surgical sex reassignment is vital because they actually feel “trapped” in an anatomically incorrect body. Currently, transgender people include cross-dressers, female and male impersonators, transgenderists and bigender persons (identify as both man and woman), and transsexuals who have or will undergo SRS. Limited research into the etiology of gender dysphoria suggests that it may be multifactorial, including anatomic brain differences between transsexual and nontranssexual individuals, and differences in parental rearing. Regardless of etiology or classification, transgender patient needs are increasingly recognized as valid and deserving attention from healthcare educators, researchers, policymakers, and clinicians of all types.

Treatment

A multidisciplinary team experienced with transgender care may be the most critical element in providing superior care and therapy. Some patients choose partial medical or surgical treatment, finding that living with physical components of both genders best addresses the dissonance caused by their birth physiognomy. Others use extensive medical and surgical treatment to physically manifest their “internal” gender as fully as possible. Current literature on the health needs of transgender patients focuses on psychological and psychiatric evaluation and treatment, SRS, and hormonal therapy. Although common practice is to delay initiating SRS until the patient is at least 18 or 21 years of age, treatment in adolescence is well tolerated for carefully selected individuals, does not lead to postoperative regret, and may prevent psychopathology seen in individuals forced to delay therapy. Patients considering SRS should undergo psychological evaluation by a therapist experienced in working with this population.

Intensive psychological counseling, hormonal treatment, and living in the role of the desired gender for a period of ≥1 year should precede surgical treatment. Surgical treatment can involve the breasts, genitalia, and larynx. The right to such treatment, even in health systems receiving government funding, has been sanctioned by courts. Because each patient is unique, surgical approaches must be tailored to individual patients, and patients seeking SRS should be referred to teams experienced with these procedures.

Primary care is an ideal setting for transgender healthcare, given that primary care physicians are knowledgeable of and often experienced with the administration of estrogens (for menopausal care and contraception), testosterone (for androgen-deficient states such as with human immunodeficiency virus), and testosterone-blocking medications (for hirsutism and prostatic disease), and are aware of important mental and social health issues.

Hormonal treatment is often employed in both genders. Cross-sex hormonal treatment may have substantial medical side effects, so the smallest doses needed to achieve the desired result should be used. Outcome studies suggest that known complications of hormonal therapy such as galactorrhea and thromboembolic events occur, but that the incidence of complications can be held to acceptable levels with careful attention to regimens used. Extensive experience with hormonal therapies in transsexual patients indicates that hormonal therapy, particularly if transdermal formulations are used, does not cause increased morbidity or mortality; monitoring luteinizing hormone levels in MTF transsexuals may increase the benefit-to-risk ratio by limiting hormone-related bone loss.

Lesbian and gay adolescents growing up in a loving, supportive environment develop and mature in a manner similar to their heterosexual counterparts. However, lesbian and gay adolescents may be vulnerable to parental wrath and withdrawal of support on disclosure or suspicion of their homosexual orientation. In certain instances, this can initiate a chain of events that leaves the youth homeless and vulnerable. Lacking employable skills, some homeless gay youths may resort to prostitution or “survival sex” to support themselves.

Gay youths have an increased risk for suicide compared with their heterosexual peers. In addition, population-based surveys of adolescents indicate that lesbian and gay adolescents report being physically abused ≤2 times as often as their heterosexual peers, and sexually abused ≤10 times as often as heterosexual adolescents. Despite this, homosexual adolescents are generally more similar to than different from their heterosexual peers, face many of the same challenges, and have great potential to mature into healthy and happy adults.

Physicians caring for families need to be aware of the possibility that the typical adolescent struggle to establish identity may be compounded when a teen recognizes his/her sexual orientation, particularly when this occurs in a potentially hostile environment. Physicians can play a vital role in helping adolescents—and their families—find acceptance. Parental support can dramatically reduce the adverse effects of “coming out” and the potential risk for suicide, and can increase the likelihood of healthy psychological development and maturation.

Older lesbians and gay men developed and matured in a different social milieu, when society was less tolerant of homosexuality and the consequences of being gay or lesbian included even greater threats to the individual’s social and family relationships, housing, and livelihood than exist today. Thus, older patients may be even less willing to disclose their homosexual orientation to physicians, and may have special healthcare needs that would go unrecognized if the physician did not take a thorough sexual history. Incorrect assumptions about geriatric patient sexuality may lead physicians to inaccurately identify risk behaviors and to implement appropriate education or screening tests. Physicians should know that many older lesbians and gay men remain sexually active, with older gay men reporting less condom use than their heterosexual counterparts.

Although not extensive, research suggests that many lesbians and gay men successfully navigate the aging process and remain connected and involved in life. In fact, the challenges that being gay presents may cause individuals to face the challenges associated with aging more successfully than their heterosexual counterparts.

One aspect of being gay or lesbian that may be overlooked in caring for a patient’s medical needs is the role of family and social networks in providing support and sustenance to the LGBT patient. In this context, family often includes individuals unrelated by biological ties. A useful concept is that of “family of origin,” which consists of parents, siblings, and others with whom one shares a blood relation, contrasted with “family of choice,” which includes those close friendship relationships that endure over time and incorporate the same types of support and emotions often associated with idealized views of the traditional family. The family of a lesbian or gay patient, including her/his partner, is a vital part of the individual’s health and can serve as a source of both stress and support, just as with heterosexual patients. Physicians caring for gay men and lesbians need to assess the resources and stressors that exist within the family, as defined by the patient.

The American Academy of Pediatrics (AAP) has come out in support of gay marriage, saying that research indicates “that there is no causal relationship between parents’ sexual orientation and children’s emotional, psychosocial and behavioral development.” The AAP also endorses adoption and foster parenting by gays and lesbians.