Rainbow Access Initiative: Training / Module 9

MODULES: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |

MODULE 9
OTHER IMPORTANT LGBT HEALTH ISSUES
Much of the material in this module is based on
The Healthy People 2010 Companion Document for LGBT Health
which was the product of a national collaborative effort that involved
nearly 200 individuals, organizations, and agencies.

"The health status of the United States is a description of the health of the total population, using information representative of most people living in this country. The ultimate measure of success in any health improvement effort is the health status of any defined population."

[from Healthy People 2010 Companion Document for LGBT Health]

A committee of the Institute of Medicine (IOM) defines access as 'the extent to which those in need of mental health and substance abuse care receive services that are appropriate to the severity of their illness and the complexity of their needs.' But too often, access only means the availability of services or their delivery and not an effective response to our needs as L, G, B, or T people.

LGBTs were identified as a national health concern by the U.S. Department of Health and Human Services in the ten-year federal plan for improving the nation's health (Healthy People 2010). That document recognized the evidence of health disparities we experience. To address our needs, we need to understand the disparities that are defined by our sexual orientation and/or gender identity. This module addresses six remaining related areas: Immunization and Infectious Diseases, Mental Health and Mental Disorders, Nutrition and Weight, Sexually Transmitted Diseases (Infections), Tobacco Use and HIV/AIDS.

Click on a link to go to a specific topic in this section:

PART ONE: Immunization and Infectious Diseases
PART TWO: Mental Health and Mental Disorders
PART THREE: Nutrition and Weight
PART FOUR: Sexually Transmitted Diseases (Infections)
PART FIVE: Tobacco Use
PART SIX: HIV/AIDS
PART SEVEN: CANCER

PART ONE: Immunization and Infectious Diseases
There are two vaccine-preventable diseases of primary concern: hepatitis A and hepatitis B.
A vaccine against the hepatitis A virus (HAV) is recommended primarily for high-risk groups. If you are a man who has sex with men (regardless of how you define your sexual orientation), you are in this category. The Centers for Disease Control and Prevention (CDC) recommends that all men who are sexually active with other men be be immunized to prevent hepatitis B (HBV). Even if you do not identify as homosexual, which is often the case of transgender persons, immunization is critical.
If you are HIV-infected it's even more important as you are then especially at risk and can suffer complications from influenza. Health and human services professional tend to overlook this critical aspect of patient care and this often results in neglect. Therefore, until such time as we have educated the professionals, it's up to you to seek the proper care. You must take the initiative. This is especially important if you are a young person who is not accustomed to seeking out health care on a timely basis as you are then putting your health at risk for hepatitis A (HAV) and and hepatitis B (HBV).

EXERCISE 24:

Now go to the Bulletin Board and

PART TWO: Mental Health and Mental Disorders

LGBT people often do not receive proper mental health care. Providers often lack the basic knowledge of the mental health needs of LGBT people; they don't understand the diversity of different populations within the LGBT communities, and they lack the ability to refer patients and clients to appropriate community resources and referrals.
For many years, homosexuality was classified as a mental disorder and studies reported high rates of suicide suicide attempts among young people who identified as homosexual. Did the classification cause gay people to be depressed or did the depression result from the classification? Since the declassification of homosexuality as a mental disorder professionals have been able to address the issue of depression directly. Nonetheless, many still do not understand the situation. And there are still diagnoses listed in the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders) that apply to transgender persons. Mental disorders may cause limitations in one's life, but they often are seen as a secondary problem. Our job, when dealing with the professionals, is to clarify the confusion and make it clear that being gay, lesbian, bisexual, or transgender is not a 'hook' on which to hang mental health issues.

EXERCISE 25:

Now go to the Bulletin Board and

PART THREE: Nutrition and Weight

If you are L,G,B, or T you may be at risk for poor nutrition, weight, and eating disorders. Lesbians, some gay and bisexual men and people living with HIV infection and LGBT or questioning adolescents tend to have a high body mass index. Lesbians are more likely to be overweight or obese than heterosexual women. A segment of gay men referred to as 'bears' (because of their larger girth) may have higher levels of compulsive eating. LGBT adolescents, particularly males, may suffer high levels of undernutrition associated with body dissatisfaction and eating disorders and this problem may extend into adulthood. Complications of HIV infection have the potential for producing malnutrition, protein depletion, and weight loss.
Furthermore, transgender persons transitioning to the opposite gender are more likely to modify their diet, their eating behaviors, or their perception of weight. This is especially true for female-to-male (FTM) transgenders who may attempt to achieve a higher BMI because it seems more masculine in appearance and male-to-female (MTF) transgenders who may be more likely to diet or have higher rates of eating disorders in an effort to attain a more feminine appearance. In addition, hormone therapy with androgens or estrogens may predispose transgenders to weight gain. Androgen therapy in FTM transgenders is known to cause a shift in lipid profiles to male patterns and this increases the risk of cardiovascular diseases. If any of these circumstances apply, you should contact a professional. You may have to 'shop around' for the help, but if these sort of disorders are left untreated, they can lead to serious illness.
There are some LGBT-competent health care and support services available which address nutrition, physical activity, and weight for lesbians with a high BMI, gay and bisexual men with weight or body image concerns, transgender individuals, persons living with HIV infection, and LGBT or questioning adolescents. Contact your local LGBT support group, association, or the resources listed as part of this module for further direction.

EXERCISE 26:

Now go to the Bulletin Board and

PART FOUR: Sexually Transmitted Diseases (Infections)
If you are L,G,B, or T you are at higher risk for STDs. And the risk increases with factors like age, economic, and racial status. In the case of STDs, the problem is not so much an ignorance on the part of providers as it is among those infected who often do not seek medical care. This is because (a) the majority of STDs do not produce any symptoms or signs, and (b) there is a stigma associated with STDs and the discomfort with discussing intimate aspects of life, especially those related to sex.
Cervical cancer caused by HPV, liver cancer caused by hepatitis B, and infertility from chlamydia or gonorrhea produce symptoms that are so mild they are disregarded, so there may be a long interval between acquisition of the STD and recognition of a symptom or health problem. Early testing, in such situations, is critical. If you have been exposed or even suspect you might have been exposed, you need to check with your physician and bes tested.
The results of not getting tested are not worth the embarassment you may feel. (And, frankly, if a professional acts in a way that causes embarassment, he or she should be reported.) An aware medical professional will take a sexual history, will properly address sexual orientation and gender identity concerns, and counsel you (or refer you to community-based organizations). We know about the risk of STDs and the methods for reducing or preventing high-risk behaviors. Your medical professional should work with you to reduce these risks.

EXERCISE 27:

Now go to the Bulletin Board and

PART FIVE: Tobacco Use

Cigarette smoking is the most important high-risk behavior associated with chronic diseases and tobacco use is higher among gay men than it is among men in the general population. Likewise, lesbians have been found to smoke more than heterosexual women. Smoking is also likely to be higher among transgender persons, especially when risk factors like poverty, low education, a higher prevalence of injection use, stressful living and work environment and sexual risk patterns are taken into account. Since people below the poverty level are more likely to smoke the implications for the prevalence of smoking among LGBT individuals and families living in poverty is profound.
These high smoking rates increase the tobacco-related health problems among LGBT people: lung cancer, chronic obstructive pulmonary disease, and an increased risk for esophageal cancer are just some of the reasons why tobacco use is a problem. If you are L, G, B, or T and a smoker, you should seek prevention and treatment services. And it is the job of those who conduct cessation and treatment programs to provide culturally competent care to LGBT smokers. If the programs in your area do not do so, why not identify the source of their funding and determine the extent to which they are obligated to do so?

EXERCISE 28:

Now go to the Bulletin Board and

PART SIX: HIV/AIDS
The Human Immunodeficiency Virus that causes AIDS attacks the CD4+ T cells and reduces the individual's ability to fight off infections. HIV is spread through unprotected anal, vaginal, oral sex; sharing needles; and mother to child during pregnancy, childbirth, or through breastfeeding. AIDS is the Acquired Immune Deficiency Syndrome, and is the result of HIV infection. AIDS is an acute form of HIV infection. A diagnosis of AIDS means that an individual is living with HIV and also has a CD4+T-cell count of 200 or less and an opportunistic infection. (More on CD4+T cells shortly.) The virus can be passed spread from one person to another during anal, vaginal, and less commonly during oral sex. HIV can also be spread by sharing needles or equipment to inject drugs, tattoo or body pierce. It can also be passed from a mother with HIV to her baby. Currently there is no vaccine to prevent HIV infection nor is there a cure.
HIV Transmission
HIV belongs to a subgroup of retroviruses known as lentiviruses, or 'slow' viruses. It attacks the immune system. People infected with HIV become vulnerable to a variety of infections and some cancers. The course of infection with these viruses is characterized by a long interval between initial infection and the onset of serious symptoms. So, when someone develops symptoms their doctor may not diagnose them as having AIDS. They may only have a few days of flu-like symptoms. But, if identified early, steps can be taken (behavior modification, support, and medical treatment) so that the individual with HIV can live longer and healthier.
CD4+ T (a type of white blood cell that helps to protect the body from infection) tells the immune system how to perform when an infection occurs. But the HIV virus targets and destroys these cells, thus weakening the immune system. A healthy, uninfected person usually has 800 to 1,200 CD4+ T cells per cubic millimeter (mm3) of blood. During untreated HIV infection, the number of these cells in a person's blood progressively declines. When the CD4+ T cell count falls below 200, the HIV infected person becomes particularly vulnerable to the opportunistic infections and cancers that typify AIDS, the end stage of HIV disease. People with AIDS often suffer infections of the lungs, intestinal tract, brain, eyes, and other organs, as well as debilitating weight loss, diarrhea, neurologic conditions, and cancers such as Kaposi's sarcoma and certain types of lymphomas.

Structure of HIV and CD4+T Cell and the Infection Process
Courtesy of the Howard Hughes Medical Institute
Most scientists think that HIV causes AIDS by directly inducing the death of CD4+ T cells or interfering with their normal function, and by triggering other events that weaken a person's immune function. For example, the network of signaling molecules that normally regulates a person's immune response is disrupted during HIV disease, impairing a person's ability to fight other infections. The HIV-mediated destruction of the lymph nodes and related immunologic organs also plays a major role in causing the immunosuppression seen in people with AIDS. Immunosuppression by HIV is confirmed by the fact that medicines, which interfere with the HIV lifecycle, preserve CD4+ T cells and immune function as well as delay clinical illness.
[For more details on the structure and process of HIV, go to the National Institute of Allergy and Infectious Diseases' Fact Sheet]

EXERCISE 29: Misinformation

There are a great many myths and misconceptions concerning the nature of AIDS. See if you can recall some you've heard, then go to the Discussion Board item titled HIV/AIDS Myths and read what others have said about the myths they've heard. If your experience is different or you'd like to add something to what others have said, post a response.

Transmission and Prevention
The HIV virus is transmitted through three primary routes:

Through unprotected vaginal, anal, or oral sex
Through shared needles (i.e. drug use, tattooing, body piercing) and Needle stick injury
From Mother to Child during pregnancy, childbirth, or breastfeeding.

The following body fluids spread HIV:

Blood
Semen
Vaginal fluid
Breast milk

HIV cannot be spread by:

Shaking hands
Dry kissing
Using the same eating or drinking utensils
Restroom facilities
Hugging
Coughing
Sneezing
Casual contact at church, in school, or in the workplace

Reducing the risk of HIV
The risk of HIV can be reduced by practicing safe sex: a latex condom for vaginal, anal, or oral sex or, if the patient has an allergy to latex, a polyurethane condom (e.g. Durex Avanti Polyurethane Condoms).
If the patient uses injection drugs, he or she can reduce risk by not sharing needles. It's important that they understand that using a needle that is not sterile not only reduces the possibility of HIV, but of hepatitis B and other blood-borne pathogens. (Most people are aware of the risk involved in sharing needles when injecting drugs. What many do not realize is that the "tie off" also, if shared, may pick up blood from one user and transfer it to another.)
The same holds true for those who share needles for tattooing, body piercing, or medicinal purposes (i.e. diabetes). The potential risk of infection is just as high for these 'legal' uses as it is for those that are illegal.
Modifying behavior will also reduce the risk. Drug and alcohol use are a prime example. When people are high or inebriated they may participate in sexual activities that put them at risk.
One more way to reduce risk is for health and childcare workers who come into contact with blood or bodily fluids containing blood, to follow universal precautions that prevent HIV, hepatitis B, and other blood-borne pathogen infections. These precautions include:

Wearing latex gloves whenever contact with blood, skin and mucous membrane cuts or lesion might occur.
Discarding gloves before working with another patient.
Washing hands.
Properly disposing of materials exposed to blood (e.g. needles).

EXERCISE 30: Are you Concerned About HIV Transmission?

Have you ever been in a situation where you were concerned about the possibility of contracting the AIDS virus? Write an e-mail to your coach and describe the situation.

PART SEVEN: CANCER

[Most of the information in this section was provided by the National LGBT Cancer Network]

Click on a link to go to a specific topic in this section:

CANCER IN THE LGBT COMMUNITIES

Lesbians and Cancer

Gay Men and Cancer

Transgender Cancer Risks

HIV and Cancer
SURVIVORSHIP ISSUES

CANCER SCREENING

Lesbians and Cancer Screening

Gay Men and Cancer Screening

Transgender People and Cancer Screening
WHAT MUST WE DO?

Lesbian, gay, bisexual and transgender (LGBT) people are disproportionately affected by cancer. Our increased risk is due to a number of factors. We aren't as likely to get screenings so cancers are detected at a later stage when treatment is more complicated and the prognosis is worse. Once we are diagnosed with cancer, we are likely to experience the added challenge of being 'out' to our provider. Added to this is the fact that there is little information about how cancer may affect our unique sexuality and relationships

Cancer research on our population is scarce; there are no national surveys or cancer registries that collect information about sexual identity or sexual orientation, so the actual LGBT cancer prevalence is concealed. The National LGBT Cancer Network estimates that there are currently one million LGBT cancer survivors in the country today.

CANCER IN THE LGBT COMMUNITIES

Lesbians and Cancer
Because the large national cancer registries and surveys have not collected data about sexual orientation, lesbians are embedded and invisible within the vast wealth of information. But there is a growing body of evidence suggesting that lesbians have the richest cluster of cancer risk factors of any group of women. Lesbians have a 2-3 times greater risk of developing breast cancer as well as several other types of cancer.

The increased risks are not due to any physiological or genetic differences between lesbians and heterosexual women. They are the result of the stress and stigma of living with homophobia and discrimination. This results in behaviors that carry an increased risk. Taken together, as a cluster, they more than double a lesbian's risk of developing cancer.

For lesbians, the four cancer risk factors are:

Cigarette smoking: Data suggests that lesbians smoke cigarettes at nearly double the rate of heterosexual women.

Alcohol Use: Research reports higher rates of heavy drinking among lesbians than heterosexual women

Obesity: Studies report that lesbians are more likely to be overweight or have a BMI over 25.

Pregnancy: Lesbians are less likely to have biological children before age 30, which would offer some protection against cancer.

Gay Men and Cancer
Gay men also have increased risks for several types of cancer. Tobacco use is nearly double that of the general population and this dramatically increases the risk for lung cancer, as well as colon cancer, esophageal cancer, anal cancer and others.

The same high-risk strains of HPV (human papillomavirus) that cause most cervical cancers in women are also responsible for causing anal cancer. The virus, spread through receptive anal intercourse, is estimated to be present in 65% of gay men without HIV and 95% of those who are HIV positive. A simple and inexpensive anal Pap test detects the virus but, unfortunately, few physicians are performing anal screening exams and offering anal pap smears to gay men, resulting in anal cancer rates as high as those of cervical cancer BEFORE the use of routine Pap smears in women.

Transgender Cancer Risks
Many transgender people use hormones as part of their transition. Hormones are implicated in the development of many types of cancer, but there has been very little research on their effects on the transgendered. The results of even the limited research that is available may be questionable, though, as many transgender people obtain their hormones without a prescription and use varying and sometimes excessive dosages.

Transgender people have extremely high rates of smoking, drinking and HIV; these all increase the risks for developing an array of cancers, including lung cancer, anal cancer and liver cancer.

HIV and Cancer
HIV-positive LGBT people have a 30-40% chance of developing cancer in their lifetime. The risks for the "AIDS-defining" cancers, e.g., Kaposi's Sarcoma, Non-Hodgkin's Lymphoma and invasive cervical cancer have decreased since the advent of Highly Active Anti-Retroviral Therapy (HAART), a combination of several (typically three or four) anti-retroviral drugs in the mid-1990's; however, HIV still dramatically increases the risk for these other types of cancers:

Hodgkin's Disease (10x)

Anal Cancer (50x)

Lung Cancer (7x)

Testicular Germ Cell Tumors (6x)

Regardless of the type of cancer, the course of the disease tends to be different for HIV positive people. Patients are younger when diagnosed, their cancer tends to be found at a more advanced stage and treatment is often complicated because of potential drug interactions.

CANCER SCREENING
People with increased cancer risks need to be extra diligent about screening. Unfortunately, the opposite is true in the LGBT community, where increased risks are coupled with lower screenings rates. Insensitive, unsafe and unwelcoming experiences with the health care system keep many LGBT people, even with adequate insurance coverage, from seeking non-emergency medical care.

Lesbians and Cancer Screening
In a large Harris Interactive Poll conducted in January 2005, 75% of lesbians reported that they delayed obtaining health care. This was true across ages, races and education levels. The two most commonly cited reasons in the Harris Poll for delaying health care visits were the cost of services and inadequate health insurance coverage. Very few companies offer same-sex partner benefits, meaning that LGBT people are limited to the insurance that their employer offers, if any. Not surprisingly, then, a smaller proportion of lesbians are covered by health insurance than women overall.

The third and fourth most cited reasons the lesbians in the Harris Interactive Poll gave for delaying health care were previous negative experiences and feared discrimination. Three quarters of the lesbians who experienced discrimination believed it was because of their sexual orientation.

Statistics obtained by the NYC Department of Health confirm this.

Only 73% of lesbians over 40 years old have ever had a mammogram vs. 87 % of heterosexual women

Only 57% of lesbians over 40 have had mammogram within the last 2 yrs vs. 77% of all women

Only 62% of lesbians have had a pap smear within the last 3 yrs vs. 80% of all women

Only 44% of lesbians over 50 have ever had a colonoscopy vs. 52% of all women over 50

Gay Men and Cancer Screening
Research suggests that the majority of gay men have not disclosed their sexual orientation to their primary physician, and they are less likely to do so than lesbians. The most cited reasons for non-disclosure were concerns about a negative response from their provider and confidentiality. A significant number of gay men thought their sexual orientation was irrelevant, even when they were HIV positive. Without knowledge of their sexual orientation, providers may not be able to offer appropriate information about health risks, cancer screening guidelines and treatment.

Transgender People and Cancer Screening
Uninsured rates are highest among transgender people. A December 1999 survey by the NYC Dept of Health found that 21% of transgender respondents reported having no health insurance of any kind. Even those with health insurance can face difficulties in obtaining appropriate cancer screenings. A transgender woman, listed on her insurance as female, but still having an intact prostate gland, would not be covered for prostate cancer screening. The same is true for a transgender man with an intact cervix.

Transgender people have additional barriers to receiving regular cancer screening, besides those of discrimination and cost. We may not see ourselves at risk for cancers related to body parts that do not match our gender. For example, a transwoman is likely to avoid prostate screening because she does not identify with that body part anymore. A transman who binds his breasts may be unlikely to have a mammogram, as it requires ownership and concern about the health of one's breasts. Unfortunately, there is no statistical information for our population.

EXERCISE 30: Screening Protocols

Choose two of the following body parts and find out what the recommended cancer screening protocols are (including age), when you should begin screening, and how frequently you should be screened.

skin
prostate
cervix
anus
breast
colon

SURVIVORSHIP ISSUES
Once diagnosed with cancer, LGBT people face some unique challenges. First, we have to decide whether it is safe to come out to our oncologist and treatment team. Even those of us who are generally comfortable revealing our sexual orientation or gender identity may be more guarded and fearful of alienating a provider when we have a life-threatening illness such as cancer. This is regrettable, as the latest research supports the idea that an empathic oncologist can help survivors understand their diagnosis, endure difficult treatments and perhaps even fare better medically.

Family support is critical for cancer survivors. But LGBT people create families in ways that are often invisible or unwelcome in a health care setting. Intake forms ask only about legal marital status, obscuring or rejecting same-sex non-legal partnerships. Providers may not then know who to invite into their office for important meetings about diagnosis and treatment decisions. Many LGBT cancer survivors report that their partners were not permitted in the emergency room with them, leaving them alone and frightened.

Almost all cancer treatments affect sexual functioning; however, oncologists and social workers rarely address the impact on LGBT sexuality adequately. For example, after treatment for prostate cancer, the most common cancer diagnosed in men, the experts say that most men can still have an erection 'good enough for intercourse.' This is not a meaningful measure for a gay man who requires a stronger erection for anal sex or needs to know if he can safely have receptive anal sex. Even when the patient is brave enough to ask, the oncologist is often ill-equipped to answer.

Support groups for cancer survivors and caregivers also pose extra challenges for LGBT people. The partner of the lesbian breast cancer survivor will probably be the only woman in her caregiver group. Similarly, the gay male partner of the prostate cancer survivor will, most likely, be the sole man in his caregiver group. This greatly diminishes the likelihood of receiving knowledgeable support for the some of the stresses and sexual difficulties they have.

WHAT MUST WE DO?
Health care providers and facilities needs to become more sensitive to the language, sexuality and family structures of the LGBT community and more knowledgeable about our cancer risks, screening needs and survivorship issues. To a large extent, the responsibility for educating our providers falls on us. Organizations like Rainbow Access Initiative and the National LGBT Cancer Network are working to educate health care professionals, but nothing has the impact or effect of one-on-one, face-to-face "teaching." Here are some specific steps you can take:

Get Screened
Early detection is crucial to successful treatment
Come out to your provider.
He or she must be aware of all aspects of your health
Educate Your provider
The odds are likely that he or she is ignorant of most LGBT health issues. Send him or her to this web site, print materials we have made available and give them to him or her.
Be open to discussing your unique sexuality and relationship(s)
As a medical professional, your provider is obliged to treat the entire person; many of them avoid the subject of sexual relationships entirely, but it's an area that is critical to treating us
Quit Smoking
Of course we know it's easy to say this and it can't be done without help. But now there are many resources available to help. Here's a link to the CDC's Resource Page.
Curb Alcohol Use
Again, this is easy to say, but it can be difficult, especially if you enjoy the club scene. Here's a link to the CDC's Resource Page.
Take Care of Weight Problems
Check your BMI and weight; if you have a problem, make sure your doctor is aware of it. Here's a link to the CDC's Resource Page on obesity.
Get an Anal Pap Test
It's simple and easy. Your doctor may not have heard of it, but can find out about it and provide it. And it's worth any embarassment you might feel.
Prostate Screening, Mammogram and Pap Smear
The fact that you are transgender and are now the right gender does not mean you should disregard the aspects of the invalid gender that still might put you at risk.

This concludes the RAI LGBT Health and Human Services program. We hope you have found it informative and useful and we would appreciate your feedback. If you have completed all eight modules and all exercises, contact your Trainer for information about how you can receive a certificate indicating you have taken this course. And PLEASE take a minute to complete our Program Survey. Your responses are strictly confidential and will help others in the LGBT community reach our goal of equality health care for all.

MODULES
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |

Rainbow Access Initiative is a 501(c)3 tax-exempt organization.
These materials were produced through a grant from the New York State Department of Health.
You may not use them without the written permission of Rainbow Access Initiative, Inc.
Permission may be obtained by contacting the Director.