Gender and Sexual Minority Healthcare Satisfaction in CT

Diane Verrochi, MSN, RNDonna Caplin, MSN, RN

Amanda KlattJay Palica

By the end of this Roundtable session, participants will be able to ◦ Recognize and utilize culturally sensitive language

related to gender and sexual minority persons◦ Evaluate the degree to which health services are

responding appropriately to gender and sexual minority healthcare needs

◦ Develop an action plan to improve access to culturally and clinically competent primary prevention and healthcare

Objectives

Gender and Sexual Minority Terminology

Gender assigned at birth – one of the first assessments after birth: “it’s a boy” or “it’s a girl,” actually an assessment of biological sex but often conflated with gender

Gender identity – a person’s internal sense of what gender best describes them

Gender minority – a person whose gender identity is different than the gender they were assigned at birth

Cisgender – adjective describing a person whose gender identity is in alignment with the gender they were assigned at birth

Transgender – adjective describing a person who is a gender minority, sometimes abbreviated to “trans”

Trans man – person assigned female at birth, identifies as male Trans woman – person assigned male at birth, identifies as female Genderqueer, non-binary, gender fluid – a person whose gender identity

is neither strictly male nor strictly female(Keatley, Deutsch, Sevelius, & Gutierrez-Mock, 2015, Table 17-1, p. 462-3)

Terminology - Gender

Sexual minority – person with any sexual orientation other than heterosexual

Sexual orientation identity – whether a person is drawn/attracted to form intimate relationships with others of the same gender, other genders, or not at all

Sexual identity – how one describes one’s sexuality

Sexual behavior – who one has sex with (men who have sex with men or MSM, women who have sex with women or WSW, etc.)

(Sell, 2007)

Terminology – Sexual Orientation

Homosexual or gay – person who identifies their sexual attraction as exclusively to those whose gender is the same as their own (American Psychological Association [APA], 2008)

Lesbian – woman who identifies her sexual attraction as exclusively to other women (APA, 2008)

Bisexual – person who identifies their sexual attraction to more than one gender (APA, 2008)

Pansexual – person who identifies as being attracted to all genders (Bisexual.org, 2013)

Asexual – person who does not experience sexual attraction (Bogaert, 2006)

Terminology – Sexual Orientation Identity

Background

Little population-level data available due to lack of tracking

Community Assessments in CT to date do not include gender and sexual minority demographic information (DPH, 2015)

The Institute of Medicine (IOM) has identified many health disparities for gender and sexual minority persons (IOM, 2010).

Background - Data

Very recent mandate from the Centers for Medicare & Medicaid Services (CMS) for EMRs to facilitate data collection on gender and sexual minorities as part of Meaningful Use (CMS, 2015).

Patients may still be reluctant to disclose sexual orientation or gender identity due to fear of maltreatment.

Future Data Collection

The Study

Qualitative: focus groups and interviews Recruitment methods – network/snowball

sampling◦ Fliers◦ Social media◦ Targeted recruitment at a gender and sexual

minority-focused event

Methods

Participant Demographics - Age

20-29 30-3940-4950-5960-69

Gender0

2

4

6

8

10

12

14

16

MaleFemaleBlank

Participant Demographics - Gender

Do you identify as transgender?

yesnoskip

Participant Demographics – Gender Identity

Sexual Orientation0

1

2

3

4

5

6

7

8

gaylesbianbisexualpansexualflexualsapiosexualqueerheterosexual

Participant Demographics – Sexual Orientation

CaucasianAsian/Pacific Islander

Participant Demographics - Race

Do you feel that your health and wellness needs are being met by existing local services?

Do you feel comfortable disclosing your sexual orientation or gender identity to your providers?

Have you ever had any specifically positive or negative experiences disclosing your sexual orientation to a healthcare provider?

Which area services do you find the most helpful? Are there any area health services that you find less helpful? Which health and wellness needs do you feel are not being

met? Did you experience any injuries or health challenges during

the recent weather events such as Hurricane Sandy or the blizzard commonly referred to as “Nemo”?

The Questions

Perception that healthcare providers are not knowledgeable about gender and sexual minority health issues, especially related to gender transition.

“Of course it’s appropriate to know your HIV status, but they don’t ask every straight person that or every person who doesn’t identify their sexual orientation right away, but they just make this assumption, ‘Uh-h! This person’s probably HIV-positive.”

Participant responses – common themes

One participant reported having to travel substantial distances for HIV care.

Another stated the rural nature of Eastern CT is a barrier for healthcare access in general.

A third stated, “I had to travel to New Haven to find an available clinician … I think folks in lower income areas are gonna have trouble with transportation … you can’t take a med cab from Willimantic to Hartford.”

Participant responses – Concerns

Regarding calling a transgender patient by their birth name when it doesn’t correspond to their gender presentation: “When you’re just, like, outed to everyone in the waiting room, makes it extremely uncomfortable.”

“The worry I have is like, EMTs. You know, when we dial 911, because you don’t have any choices there in that … you know, who comes to the door.”

Participant responses - Concerns

“Non-binary transitions are something that generally, like, the medical field has no understanding about … gender dysphoria doesn’t have … isn’t always going from one box to the other.”

“… if you are not using the gender pronouns that fit [in charting/notes] … you’re not really integrating that at a level that I think is facilitative for, like, actually being able to work with [a transgender patient].”

Participant responses - Concerns

Implications

Is there really a difference in HIV care quality in different locations of CT?

What health services need to be available for youth?

What is the quality of senior services and senior housing available to gender and sexual minority elders?

Implications – Assessment Needs

Apparent reluctance in this population to participate in this research, which has implications for self-reporting of health data and gender/sexual minority status.

Faith groups often allies in public health outreach, may not be universally so for this population.

Implications - Barriers

Inclusive preparation for all healthcare staff Specialized clinics with adequate

transportation access

Implications - Approaches

A few Known Disparities

Gay and bisexual men at heightened risk for skin cancer secondary to indoor tanning (Mansch, M., Katz, K., Linos, E., Chren, M., & Arron, S., 2015).

Lesbian and bisexual women at heightened risk for breast cancer secondary to reduced incidence of pregnancy (IOM, 2011, p. 205).

Transgender persons at higher risk for poverty, employment and healthcare discrimination, physical violence, abuse during childhood, intimate partner violence, suicidal ideation/attempt (Reisner, White, Bradford, & Mimiaga, 2014).

Known Disparities

Screenings Often missed for Gender and Sexual Minority

Persons

Cervical Pap for transgender men w/cervix Prostate screening for transgender women Mammography for lesbian and bisexual

women

Screenings Often Missed

Cervical pap: same guidelines for anyone who has a cervix, regardless of sexual orientation/behavior or gender identity (Daskalakis, Radix, & Mayer, 2015, p. 301)

Anal pap: no official guidelines for people who practice receptive anal sex, but recommendation of annual for those HIV+ and every 3-5 yrs for those HIV- (Daskalakis et al, 2015, p. 301-302)

Mammography: transgender women age 50+ with risk factors such as past or current hormone use >5yrs, family history, screen every 1-2 yrs (Feldman & Spencer, 2015, p. 486)

Prostate-specific antigen (PSA): not recommended for any usual-risk population, and may be artificially low in transgender women with past or current hormone use (Feldman & Spencer, 2015, p. 489)

Digital rectal exam for colorectal and/or prostate cancers: annual after age 50 for all usual-risk persons, remembering transgender women retain the prostate gland even after gender-affirming surgery. (Feldman & Spencer, 2015, p. 489)

Screenings

Common Medical and Surgical Interventions to

Affirm Transgender Identities

People who are transgender may take some of the following medications:

Estrogen: estradiol Anti-androgen: spironolactone, cyproterone

acetate GnRH agonist: Degarelix  Testosterone: oral, parenteral, transdermal

(Hembree et al, 2009, p. 19)

Hormone Therapies for Transgender Persons

Top surgery: reconstructive chest surgery to masculinize or feminize the chest◦ Double-mastectomy with nipple grafting◦ Periareolar/keyhole procedure◦ Liposuction◦ Breast augmentation

(Chyten-Brennan, 2014, p. 276-278)

Surgical Interventions for Transgender Persons

Gender-affirming surgery (GAS) Gender-confirming surgery (GCS) Gender reassignment surgery (GRS) Sex reassignment surgery (SRS) May refer to any transition-related surgery,

often used interchangeably.

(Chyten-Brennan, 2014)

Surgical Terminology

Bottom surgery: alterations to genitals and/or internal reproductive organs◦ Orchiectomy, removal of testicles◦ Vaginoplasty, creation of a vagina◦ Metoidioplasty, increase of clitoris/phallus length◦ Phalloplasty, creation of a penis◦ Scrotoplasty, creation of a scrotum◦ Hysterectomy and salpingo-oopherectomy,

removal of uterus, fallopian tubes, and ovaries

(Chyten-Brennan, 2014, p. 278-283)

Surgical Interventions for Transgender Persons

Head and Neck Procedures◦ Facial feminization surgery◦ Tracheal shave◦ Hair transplant

(Chyten-Brennan, 2014, p. 283-285)

Surgical Interventions for Transgender Persons

Cost: proposed rule for nondiscrimination in health care would improve health insurance access for transgender healthcare (HHS, 2015).

Provider availability: a study participant related extreme difficulty finding knowledgeable providers in CT or even in US.

Barriers to Medical and Surgical Interventions for Transgender Persons

American Psychological Association. (2008). Answers to your questions: For a better understanding of sexual orientation and homosexuality. Washington, DC: Author. [Retrieved from www.apa.org/topics/lgbt/orientation.pdf.] Bisexual.org. (2013). Questions & Answers. Retrieved October 15, 2015, from http://bisexual.org/?qna=what-is-the-difference-between-bisexual-and-terms-like-pansexual-polysexual-omnisexual-ambisexual-and-fluid Bogaert, A. F. (2006). Toward a conceptual understanding of asexuality. Review Of General Psychology, 10(3), 241-250. doi:10.1037/1089-2680.10.3.241 Centers for Medicare & Medicaid Services, Department of Health and Human Services. (2015, October 16). Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 through 2017. Retrieved October 16, 2015, from https://www.federalregister.gov/articles/2015/10/16/2015-25595/medicare-and-medicaid-programs-electronic-health-record-incentive-program----stage-3-and Chyten-Brennan, J. (2014). Surgical Transition. In Erickson-Schroth, L. (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. New York, NY: Oxford University Press. Daskalalkis, D.C., Radix, A., and Mayer, G. (2015) Sexual health of LGBTQ people. In Makadon, H., Mayer, K., Potter, J., & Goldhammer, H. (2015). The Fenway guide to lesbian, gay, bisexual, and transgender health (2nd ed.). Philadelphia: American College of Physicians. Department of Health and Human Services. (2015). Fact Sheet: Nondiscrimination in Health Programs and Activities Proposed Rule. Retrieved October 16, 2015, from http://www.hhs.gov/ocr/civilrights/understanding/section1557/nprmsummary.html

References

Feldman, J., and Spencer, K. (2015). Medical and surgical management of the transgender patient: What the primary care clinician needs to know. In Makadon, H., Mayer, K., Potter, J., & Goldhammer, H. (2015). The Fenway guide to lesbian, gay, bisexual, and transgender health (2nd ed.). Philadelphia: American College of Physicians. Hembree, W.C., Cohen-Kettenis, P., Delemarre-van de Waal, H.A., Gooren, L.J., Meyer III, W.J., Spack, N.P., Tangpricha, V, and Montori, V.M. (2009). Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline. Retrieved October 15, 2015, from https://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical Practice Guidelines/Endocrine-Treatment-of-Transsexual-Persons.pdf Institute of Medicine. (2011). The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press.Keatley, J, Deutsch, M, Sevelius, J, and Gutierrez-Mock, L. (2015). Creating a foundation for trans health: identities and healthcare needs. In Makadon, H., Mayer, K., Potter, J., & Goldhammer, H. (2015). The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health (2nd ed.). Philadelphia, PA: American College of Physicians.Mansch, M., Katz, K., Linos, E., Chren, M., & Arron, S. (2015). Association of skin cancer and indoor tanning in sexual minority men and women. Journal of the American Medical Association Dermatology. doi:10.1001/jamadermatol.2015.3126. Retrieved October 15, 2015, from http://archderm.jamanetwork.com/article.aspx?articleid=2453327Office of the National Coordinator for Health Information Technology. (2015, October 1). 2015 Edition Health Information Technology (Health IT) Certification Criteria, Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications Final Rule. Retrieved October 15, 2015, from https://www.healthit.gov/sites/default/files/factsheet_draft_2015-10-06.pdf Reisner, S. L., White, J. M., Bradford, J. B., & Mimiaga, M. J. (2014). Transgender health disparities: Comparing full cohort and nested matched-pair study designs in a community health center. LGBT Health, 1(3), 177-184. Sell, R. (2007). Defining and measuring sexual orientation. In Meyer, I. (2007). The Health of Sexual Minorities: Public Health Perspectives on Lesbian, Gay, Bisexual, and Transgender Populations. New York, NY: Springer. State of Connecticut Department of Public Health. (2015). Connecticut Hospital Community Health Needs Assessments. Retrieved October 16, 2015, from http://www.ct.gov/dph/cwp/view.asp?a=3902&q=552718

References