Background
Assuming the most recent data are 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 notes that up to 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 identifies as transgender. These numbers suggest that, regardless of a physician’s geographic location, or the ethnic, religious, socioeconomic, or gender demographics of their practice, and perhaps without the physician’s awareness, he or she will provide care for lesbian, gay, bisexual, or transgender (LGBT) patients on a routine basis.
- The first step in providing high quality health care 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” includes options for domestic partner.
- Comprehensive information about behavior is necessary as a foundation for optimal education and health screening.
The first and most important step in providing superior care for lesbian, gay, bisexual, and transgender (LGBT) patients, as well as for patients who do not self-identify in any of these categories but engage in same-sex sexual encounters, is knowing who they are. This can be accomplished by taking a thorough and sensitive sexual history with all new patients and at any time when sexual behavior may be relevant to diagnosis and management.
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 health care provider; in addition, many health care providers may avoid discussing these intimate details with their patients. By providing literature in the office that reaches out to LGBT patients and by displaying symbols such as a rainbow flag, physicians can help their patients feel more at ease. History forms completed by patients should be phrased to include the full range of patient responses and not have wording that ignores LGBT patients’ lives; such forms may also facilitate conversation about sensitive topics. Physicians can overcome their own discomfort by routinely taking sexual histories. Both inside and outside the examination room, physicians can also help fight entrenched prejudice by modeling tolerance and speaking out against bias with colleagues, students, and staff.
The goal of 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 that he or she must endure such probing, personal questions is so 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 often have 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. The assumptions that health care providers make based on superficial traits can be challenged through compassionate, thorough discussion of their patients’ behaviors.
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?” The utility of asking this is that behaviors are emphasized over labels, and no assumption is made about sexual orientation; also, 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 or not barrier protection was used during them, 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 made based on potentially incorrect assumptions.
In addition, it may be useful to identify the number of current and past partners, whether or not those relationships were monogamous, whether or not barrier protection is always used (keeping in mind that condoms are often not used properly), and whether or not the patient 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 merit attention.
In many settings it is also helpful to understand how a patient’s sexual or gender identity affects their 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 if they are interested in birth control. All LGBT patients should be screened for experiences with domestic violence or hate crime. Due to 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, intravenous drugs, cocaine, methylenedioxymethamphetamine (MDMA or ecstasy), methamphetamines (crystal meth), prescriptions (including opiates and benzodiazepines), hormones, hallucinogens, and marijuana.
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, and human behavior does not always clearly align with gender- and sexual-identity labels.
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.
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 or 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 diseases (STDs) compared with men who have sex with women only. Women who have sex with men and women (WSMW) may have an increased risk for STDs 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 lesbian, gay, bisexual, and transgender (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 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 her or his 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% had observed colleagues providing substandard care to patients because of sexual orientation. In another study, 37% of young gay men reported antigay 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 that resulted from perceived social stigma were a significant contributor to depression. And a study of 912 Latino men found that experiences of social discrimination were strong predictors of suicidal ideation, anxiety, and depressed mood.
Overcoming entrenched prejudices and eliminating discriminatory practices are fundamental to health care 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 help communicate acceptance and support via posters including diverse same-sex couples, stickers depicting a rainbow flag or pink triangle, and a visible nondiscrimination statement stating that equal care will be provided to all patients, regardless of age, race, ethnicity, physical ability or attributes, religion, sexual identity, and gender identity. Modeling tolerance and speaking out against bias are also ways in which physicians can help combat antihomosexual prejudice.
The willingness of LGBT patients to disclose sexual orientation and details of their personal lives is strongly influenced by the perceived tolerance (or intolerance) of their physician. Because a patient’s sexual practices will modify risk for various diseases and can thus influence disease screening and the diagnostic evaluation, honest discussion of the patient’s sexual and social life is vital to promote optimal health. Failure to identify an LGBT patient may cause the treating physician to fail in counseling a patient and in considering a diagnosis, thus risking the patient’s life and the physician’s reputation. Incorrect assumptions about patients can have similar adverse outcomes (Table 62-1). Using simple conversational techniques, and mastering a very manageable amount of medical information, will allow family physicians to provide superior care to LGBT patients.
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 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. |
HIV/AIDS
- Not all gay men are at risk for HIV, but testing for HIV is recommended for all patients aged 13-64 years seen in health care settings after the patient is notified that testing will be performed unless the patient declines.
- Periodic screening (HIV blood tests) is recommended for all persons who are sexually active outside a mutually monogamous relationship.
- Blood tests for HIV antibodies have sensitivity and specificity greater than 99%. HIV viral load tests (eg, HIV polymerase chain reaction) should not be used for HIV screening due to the high false-positive rate.
Any publication on LGBT health that omitted mention of HIV would be incomplete, but thorough coverage of the topic is beyond the scope of this chapter. References included at the end of this discussion can assist physicians in the management of HIV-infected individuals.
Gay men comprise 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 in part be due 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 Latino men are disproportionately affected. Increased stigma associated with homosexuality in ethnic minority communities may drive individuals at risk to hide, complicating efforts at diagnosis and treatment.
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 (unprotected intercourse, multiple partners, concurrent sex and substance use, injection drug use, etc) and should intervene to reduce risk and test for HIV in patients with a positive risk history, repeating testing periodically if risk behaviors continue. A “harm reduction” strategy should be pursued 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, etc). Because patients engaging in risky behaviors often will not volunteer information about their risk, physicians must proactively assess each patient’s risk and intervene when needed.
HIV-negative individuals exposed to HIV may benefit from postexposure prophylaxis (PEP); however, the data supporting antiretroviral treatment following either occupational exposure or sexual exposure are limited. Many experts recommend a four-week regimen of PEP initiated as soon as possible after a significant exposure to HIV; the benefit of treatment started more than 72 hours after exposure is limited. Combinations of antiretroviral agents similar to those used in treating HIV may be employed, with similar adverse effects. PEP is not 100% effective in preventing HIV seroconversion.
Physicians should consider and test for HIV in individuals at risk 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, polymerase chain reaction) 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 be essentially asymptomatic for years. Generalized lymphadenopathy may persist for years; its disappearance may herald 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.
