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LGBT Health and Health Disparities in Adolescent and Pediatric Health Care Henry Ng, MD, MPH, FAAP, FACP Associate Professor Case Western Reserve University School of Medicine Center for Internal Medicine-Pediatrics at MetroHealth Medical Center


Disclosures I

have no conflicts of interest to disclose. No 'off-label' uses of medications will be discussed.


Patient Case : KG Actual patient.  Visit conducted in Spanish.  KG, a 15-year-old Hispanic girl, comes for a posthospitalization follow-up visit.  She has been seen her twice in the past for asthma and the common cold.  She was hospitalized for 4 days in the pediatric intensive care unit for an apparent drug overdose.  She ingested 30 tablets of ibuprofen (Motrin).  She was medically stabilized and was discharged home. 


KG Continued    

 

She is asked how she is feeling and what led up to her taking the pills. KG reports she felt sad and upset because another girl at school had "broken up with her." On further interview, KG reports attraction to females, but does not yet identify as lesbian, nor has she been sexually active with males. With her permission, her mother is interviewed, who reports awareness and support of her daughter's same-sex attractions and relationship. Her mother is concerned for KG's ongoing depression. The clinician leaves and considers the resources available to assist KG in the community.


Goals and Objectives  

Review terms used to describe sexual orientation and gender identity (“LGBT 101”) Recognize health issues and health disparities of children and youth who appear non-gender conforming or are Lesbian, Gay, Bisexual Transgender or Questioning (LGBTQ) Recognize psychosocial and developmental issues pertaining to sexual orientation and gender identity (ABP ITE content areas) Recognize local, state and national resources for pediatric patients related to sexual orientation


Why Learn About LGBT Health?  Diversity. 

Is both visible and invisible

 Moral 

Arguments

All forms of discrimination are wrong and unjust

 Public 

..

Health Arguments

Important illnesses affect LGBT populations and need to be addressed to improve community health

 Some

individuals may be biased and reject all these arguments.


Why Learn About LGBT Health?  Economic Reality  Can you select your patients?  Reimbursement/Incentives tied to patient satisfaction  Professionalism  Codes of Conduct and Ethics of professional organizations  Potential Consequences with unprofessional behavior (state boards)  LCME accreditation standard  ACGME, Joint Commission standards  Presidential Memorandum


Historical Homophobia 

1869 – Karl Maria Kertbeny coins Homosexuality in his campaign against German sodomy laws

1897 – Henry Havelock Ellis and John Addington Symonds write Sexual Inversion, the first English medical text on homosexuality 

1952 – Homosexuality listed in the DSM-I as a sociopathic personality disorder

1968 – Homosexuality reclassified in the DSM-II as a sexual deviation,

1973 - Homosexuality removed from DSM-III as a medical diagnosis


Provider Education - Undergraduate 

Historically little health provider training on LGBT patients 

Medical school: 

Average of 3h 26 minutes exposure to LGBT health in 4 years curriculum (Wallick and Townsend. Academic Medicine, 1992)

Decreased to 2h 30 minutes in 1998 (Tesar, 1998)

Online Survey of 176 Allopathic or Osteopathic schools in the US (Obedin-Malivar et al, JAMA 2011) 

Median reported time dedicated to teaching LGBT-related content in the entire curriculum was 5 hours

image courtesy of LGBT Medical Education Research @ Stanford: http://med/standford/edu/lgbt/


From: Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education JAMA. 2011;306(9):971-977. doi:10.1001/jama.2011.1255

Figure Legend:

Lesbian, gay, bisexual, and transgender (LGBT)–related topics taught during the required curriculum (N = 132 survey respondents). HIV indicates human immunodeficiency virus; STI, sexually transmitted infections; DSD, disorders of sex development; IPV, intimate partner violence; and SRS, sex-reassignment surgery. Date of download: 11/13/2013

Copyright © 2012 American Medical Association. All rights reserved.


A New Education Trend? 

Sanchez et al (Jan. 2006) 

Medical students with increased clinical exposure to LGBT patients tended to perform more comprehensive histories, hold more positive attitudes toward LGBT patients and possess greater knowledge of LGBT health care concerns than students with little or no clinical exposure.

Can probably generalize to other health professions training


Homophobia in Medicine 

Heterosexism/homophobia mirrors prejudices held by general public 

National survey of 1121 MDs (1991) 

35% “nervous around homosexuals”

1/3 “homosexuality a threat to many of society’s basic institutions”

Survey of 473 internists/FPs/GP/OB-GYN (1991) 

36% “homosexual behavior between 2 men just plain wrong”


Challenges to Care 

Societal Homophobia/Transphobia

Lack of provider education and experience

Lack of provider knowledge of health resources

Lack of culturally competent providers

Geographic Isolation

Lack of evidence based medicine (more to come about this)


Terminology Let’s Start with the Genderbread Person


LGBTQIA. . .and more letters


One Pulse


Adolescent Populations: Who is LGBT?


Kinsey Institute Research  Sexual

Behavior in the Human Male (1948)  Sexual Behavior in the Human Female (1953)  37%

of males and 13% of females had at least some overt homosexual experience to orgasm  10% of males were more or less exclusively homosexual  8% of males were exclusively homosexual for at least three years between the ages of 16 and 55.  Females range of 2-6% for more or less exclusively homosexual experience/response.  4% of males and 1-3% of females had been exclusively homosexual after the onset of adolescence up to the time of the interview.


A Modern Day Kinsey Scale


Adolescent Sexuality 

“…The prevalence of homosexuality among adolescents is unknown because gender roles and sexual identity may take years to evolve and be acknowledged. . .Although only 1% of 12th-grade males and less than 1% of 12th-grade females viewed themselves as mostly or completely homosexual, 10% were unsure of their sexual orientation.”

J Adol Health 1991; 12: 649-661


LGBT Youth Self-identification 

“Students were most likely to endorse same-sex attractions, followed by fantasies and experiences, and then were least likely to describe themselves as homosexual” (Remafedi et al, 1992)

Youth coming out younger and identifying orientation earlier


LGBT Youth of Color 

Sexuality holds different meaning within cultures and ethnicities

Challenges

 Identity

development

 Integration

of sexual and gender identity

 Consolidation

 Racism

with race and ethnicity

and bias within larger LGBT community

 Homophobia/Transphobia

within own ethnic

communities Ryan, C. LGBT Youth: Health concerns, services and care. Clinical Research and Regulatory Affairs. 2003, 20(2):137-158.


Little Research on LGBT Youth of Color 

168 publications from 1972-1999 on health and mental health concerns of LGBT youth

16 on LGBT youth of color 

3 book chapters

4 empirical studies

9 additional articles on social service/provider training needs of transgender youth

Ryan, C. A Review of the Professional Literature & Research Needs for LGBT Youth of Color. Washington, DC: National Youth Advocacy Coalition, 2002


Empower Youth to Create Change


Busting Binary Identities


Adolescent Perspectives as Health Consumers


Adolescent Comfort Zone   

Boekeloo et al (1996) Study of youth age 12-15 (N = 221) Washington, DC area   

89% valued physician opinion about sex 99% easier to talk to a physician during visit 43% comfortable talking about STD or other problem Greater comfort noted: 

With issues of general sexual health

Adolescents with high self-esteem

MD was adolescent’s regular provider


Reaching Sexual Minority Youth in the Health Care Setting 

Ginsberg et al (2002)  

     

94 participants in focus groups/questionnaires Ages 14-23 (73# 17-21) 63% male 20% lesbian 49% gay 23% bisexual 2% transgender Explore factors sexual minority youth believe make them feel safe in a health care setting Methods: 34 statements, scored Likert scale 1-5


Reaching Sexual Minority Youth in the Health Care Setting 

LGBTQ youth value the same clinic characteristics desired by all adolescents       

Privacy Cleanliness Honesty Respect Competency Non-judgmental stance Likert scale >4.68/5.00


Reaching Sexual Minority Youth in the Health Care Setting 

Less important were: 

LGBT provider

Site that focuses on LGBT youth

Magazines for LGBTQ people in waiting rooms

Health information offered in a private place

Likert scale 3.17-3.63/5.00 

These scores still over score of 3.00 = somewhat important


Reaching Sexual Minority Youth in the Health Care Setting 

Perceived offensive actions: 

Assumption of heterosexuality

Negative reaction to revealing sexuality

Assumption of greater risk of disease 

Orientation = Behavior

Delivery of health care information from a judgmental point of view


Health Care Providers’ role in Caring for LGBT Youth


Clinicians duties 

Active listening

Non-judgmental stance

Comprehensive history (interview)

Do not be afraid to ask. . .

Do not react negatively when you get your answer


HEADS FIRST       

  

Home: Separation, support, "space to grow“ Education: Expectations, study habits, achievement Abuse: Emotional, verbal, physical, sexual Drugs: Tobacco, alcohol, marijuana, cocaine, others Safety: Hazardous activities, seatbelts, helmets Friends: Confidant, peer pressure, interaction Image: Self-esteem, looks, appearance Recreation: Exercise, relaxation, TV, media games Sexuality: Changes, feelings, experiences, identity Threats: Depressed or upset easily, harm to self or others 

Goldenring et al


Framing LGBT Health Disparities for Adolescents and Young Adults


Conceptual Framework 

The minority stress model calls attention to the chronic stress that sexual and gender minorities may experience as a result of their stigmatization;

The life course perspective looks at how events at each stage of life influence subsequent stages;

The intersectionality perspective examines an individual’s multiple identities and the ways in which they interact

The social ecology perspective emphasizes that individuals are surrounded by spheres of influence, including families, communities, and society.


Potential Psychosocial Problems of LGBT Adolescents         

Social isolation Running away Prostitution Substance abuse Compromised mental health Damaged self-esteem Depression Anxiety Suicide Remafedi, G. Clin Pediatr 1985; 24: 481-485


Family Rejection as a Predictor of Negative Health Outcomes  

Ryan et al (Dec. 2008) Retrospective survey and interviews of LGB youth about the frequency of parental/caregiver reactions to LGB experience during adolescence N = 224 48% Caucasian and 52% Latino  self-identified LGBT young adults  aged 21-25 (avg 22.82 years)  51% male, 49 % female 

 

Measured 9 negative health indicators (mental health, substance abuse, sexual risk) Rejection frequency stratified into terciles to define a “Rejection Score” Ryan et al. Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults Pediatrics 2009, 123;346-352


Family Rejection 

Higher rates of family rejection associated with poorer health outcomes 

LGBT adolescents who reported higher levels of rejection were: 

8.4 times more likely to have attempted suicide

5.9 times more likely to report high levels of depression

3.4 times more likely to use illegal drugs

3.4 times more likely to have engaged in unprotected intercourse

Ryan et al. Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults. Pediatrics 2009; 123; 346-352


LGBT Youth Health Disparities  

Please refer to appendix slides CDC Fact sheets  HIV

Growing Up Today Study  Alcohol  Tobacco

 Eating

 

Disorders

Homelessness Sexual and Reproductive Health Needs


Messaging Acceptance to Improve Health 

“As your child’s health care provider, I recognize it must be difficult for you to grapple with your child’s emerging sexuality. What we know is that youth who receive supportive messages about themselves tend to do better and have better health outcomes. I know you must care about your child, and that is why you came to see me. How can I help you offer your child a parental message of support and acceptance?”


CLOSING HEALTH CARE DISPARITIES 

Improve physician and health provider training in caring for LGBT youth and youth of color: 

Create a comfortable clinical environment

Perform inclusive sexual histories

Utilize LGBT oriented office literature

Develop and utilize LGBT inclusive forms

Utilize national/state/local LGBT health resources

Improve caregiver training to provide culturally competent care

Promote LGBT outcomes based health research, especially on LGBT Youth of Color

Engage patients to participate in LGBT focused research


Discrimination in health care is a health hazard


Questions??? Thank you for your attention! hng@metrohealth.org


LGBT Health Resources – National Organizations

www.glma.org for referrals and updated provider links

Healthy People 2010 Companion Document

LGBT health professional health campus white paper

www.pflag.org


LGBT HEALTH RESOURCES


LGBT HEALTH RESOURCES


Trans Bodies, Trans Selves 

Aka TBTS

Resource for Trans community

Written by community members and health experts

Modelled after Our Bodies, Ourselves


Health Journals


LGBT Health Resources Healthy People 2020 

– LGBT site

http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25

CDC site for LGBT Health www.cdc.gov/lgbthealth

LGBT Health Channel http://www.lgbthealthchannel.com/


LGBT Health Resources  Joint Commission

Field Guide 

http://www.jointcommiss ion.org/lgbt/

 IOM

LGBT Health Report 

http://www.iom.edu/Rep orts/2011/The-Health-ofLesbian-Gay-Bisexualand-TransgenderPeople.aspx


LGBT Health Resources – Bisexual Health  The Task 

Force: Bisexual Health Report

www.thetaskforce.org/reports_and_research/bisexual_health


LGBT Health Resources – Transgender Health TransGender Care  www.transgendercare.com World Professional Association for

Transgender Health (WPATH)  www.wpath.org

American Psychological

handout

Association

 “Answers to Your Questions About Transgender

Individuals and Gender Identity”  http://www.apa.org/topics/transgender.html


References     

  

Austin SB, Ziyadeh N, Kahn JA, Carmargo CA, Colditz GA, Field AE. Sexual Orientation, Weight Concerns, and Eating-Disordered Behaviors in Adolescent Girls and Boys. J Am Acad Child Adolesc Psychiatry. 43:9, September 2004, 1115-23 Austin SB, Ziyadeh N, Fisher LB, Kahn JA, Colditz GA, Frazier AL. Sexual Orientation and Tobacco Use in a Cohort study of IS Adolescent Girls and Boys. Arch Pediatr Adolesc Med. 2004; 158: 317322 Boekeloo B.O.; Schamus L.A.; Cheng, T. L.; Simmens, S. J. Young Adolescents' Comfort With Discussion About Sexual Problems With Their Physician .Arch Pediatr Adolesc Med. 1996;150(11):1146-1152. Corliss HL, Rosario M, Wypij D, Fisher LB, Austin SB. Sexual Orientation Disparities in Longitudinal Alcohol Use Patterns Among Adolescents Findings From the Growing Up Today Study. Arch Pediatr Adolesc Med. 2008;162(11):1146-1152 Cochran BN, Stewart AJ, Ginzler JA, Cauce AM. Challenges Faced by Homeless Sexual Minorities: Comparison of Gay, Lesbian, Bisexual, and Transgender Homeless Adolescents With Their Heterosexual Counterparts. American Journal of Public Health, May 2002, Vol. 92, No. 5, pp. 773777 Committee on Psychosocial Aspects of Child and Family Health, Coparent or Second Parent Adoption by Same-Sex Parents, Pediatrics Vol. 109 No. 2 February 2002, 339-340 Friedman et al., Homosexuality, New England Journal of Medicine. 1994, 331: 323-330 Ginsburg K, Winn R, Rudy B, Crawford J, Zhao H, Schwarz D. How to reach sexual minority youth in the health care setting: the teens offer guidance. Journal of Adolescent Health, Volume 31, Issue 5, Pages 407-416


References 

Goldenring MN, Cohen E. Getting into adolescent heads. Contemp Pediatr 1998;5:75-90.

Harrison AE. Comprehensive care of lesbian and gay patients and families. Prim Care 1996. 23(1): 31-46

Kelts EA, Allan MJ, Klein JD. Where are we on teen sex?: Delivery of reproductive health services to adolescents by family physicians. Fam Med 2001, May; 33(5): 376-381

Kruks G. Gay and Lesbian Homeless/Street Youth: Special Issues and Concerns. Journal of Adolescent Health 1991; 12:515-518

Lena SM et al., Pediatrician’s knowledge, perceptions and attitudes towards providing health care for lesbian, gay and bisexual adolescents, Ann R Coll Physicians Surg Can 2002 Oct; 35(7): 406-410

Lena SM, Wiebe T, Ingram S, Jabbour M. Pediatric Residents’ knowledge, perceptions and attitudes towards homosexually oriented youth, Ann R Coll Physicians Surg Can. 2002; 35(7): 401-405

Obedin-Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S, Wells M, Fetterman DM, Garcia G, Lunn MR. Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education. JAMA. 2011;306(9):971-977.doi:10.1001/jama.2011.1255

Pathela P et al, Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population Based Survey of New York City Men. Ann Int Med 145(6): 416-25


References   

     

Pawekski JG, Perrin EC, Foy JM, Allen CE, Crawford JE, Del Monte M, Kaufman M, Klein JD, Smith K, Springer S, Tanner, JL, Vickers, DL. The Effects of Marriage, Civil Union, and Domestic Partner Laws on Health and Well-being of Children. Pediatrics Volume 118, Number 1, July 2006. 349-64 Remafedi, G, Adolescent Homosexuality: Issues for Pediatricians, Clin Pediatr 1985; 24: 481-485 Ryan C, A Review of the Professional Literature & Research Needs for LGBT Youth of Color. Washington, DC: National Youth Advocacy Coalition, 2002. Ryan C, LGBT Youth: Health concerns, services and care. Clinical Research and Regulatory Affairs. 2003, 20(2):137-158 Ryan C, Huebner D, Diaz RM, Sanchez J. Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults. Pediatrics 2009; 123; 346352 Shuster MA, Bell RM, Petersen LP, Kanouse DE. Communication between adolescents and physicians about sexual behavior and risk prevention. Arch Pediatr Adolesc Med. 1996 Sep;150(9):906-13. Society of Adolescent Medicine, Reproductive Health Care for Adolescents J Adol Health: 1991; 649-661 Spack N. Feature: Transgenderism. Accessed 7/10/2008. http://www.imatyfa.org/permanent_files/spack-article.pdf Tesar CM, R.S., Survey of curriculum on homosexuality/bisexuality in departments of family medicine. Fam Med, 1998. 30: p. 283-7.


References 

Wallick MM, Cambre KM, Townsend MH, How the topic of homosexuality is taught at U.S. medical schools. Acad Med, 1992. 67: p. 601-04.

Ziyadeh NJ, Prokop LA, Fisher LB, Rosario M, Field AE, Carmargo CA, Austin SB. Sexual orientation, gender and alcohol use in a cohort study of U.S. adolescent girls and boys. Drug and Alcohol Dependence 87 (2007) 119-130

Diagnostic and Statistical Manual Version 5

IOM (Institute of Medicine). 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: The National Academies Press.



Lgbt health and health disparities in adolescent and pediatric health care