Success in LGBTQ + medicine requires risk awareness


According to one of the leading experts, primary care for LGBTQ + patients should focus on early identification and management of unique health risks.

Transgender patients, for example, are nine times more likely to commit suicide than the general population (2015 US Transgender Survey (USTS). Interuniversity Consortium for Political and Social Research. May 22, 2019). doi: 10.3886 / ICPSR37229.v1), and those who are also black have an estimate HIV prevalence of 62%, demonstrating the cumulative and negative effects of intersectionality on health (

“Experiences with marginalization and stigma are directly related to some of the poor physical and mental health outcomes these patients experience,” Megan McNamara, MD, he said during a presentation at the annual meeting of internal medicine of the American College of Physicians.

McNamara, who is director of the GIVE Identity Veteran’s Experience (GIVE) clinic, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, offered a brief guide to managing LGBTQ + patients. He stressed the increase in rates of psychological distress and substance abuse, and fostered familiarity with the specific risks associated with three subgroups: men who have sex with men (MSM), women who have sex with women (WSW), and those who are transgender.

Men who have sex with men

According to McNamara, pre-exposure prophylaxis (PrEP) should be offered based on the eligibility criteria of disease control and prevention centers, which require the patient to be HIV negative, have had a male sexual partner in the last 6 months. , does not have a monogamous relationship. , and has had anal sex or a bacterial sexually transmitted infection in the last 6 months. The two PrEP options, emtricitabineTenofovir disoproxil fumarate and emtricitabine / tenofovir alafenamide are equally effective and have similar safety profiles, McNamara said, but patients with impaired renal function should receive the formulation of alafenamide.

McNamara also advised the detection of extragenital STIs in gay men, noting a 13.3% increase in risk. When asked about Papanicolau anal tests for HPV, McNamara considered the topic “highly controversial” and ultimately recommended it, citing the lack of data linking anal HPV infection and dysplasia with the later development of rectal carcinoma, as well as the inaccessible impact of a positive outcome.

“For me, the issue is … yes [a positive anal Pap test] I will not change my management, if I do not know that the anal HPV I diagnose will cause cancer, should I continue to monitor it? McNamara said.

Women who have sex with women

Beyond higher rates of psychological distress and substance abuse among lesbian and bisexual women, McNamara described an increased risk of overweight and obesity, higher smoking rates and lower Papanicolaou testing rates, which should motivate doctors to advise them accordingly cervical cancer in-line screening with guidelines. Physicians should also discuss HPV vaccination with patients, taking care to weigh the benefits and risks, as unilateral HPV vaccination is not recommended for adults over 26 years of age.

Transgender patients

Speaking of transgender patients, McNamara focused on cross-sectional hormone therapy (CSHT), first highlighting significant psychological benefits, including improvements in depression, somatization, interpersonal sensitivity, hostility, anxiety, phobic anxiety /agoraphobia, and quality of life.

According to McNamara, CSHT is relatively straightforward and can be safely administered by primary care providers. For transmasculine patients, testosterone supplementation is all that is needed, while transfeminine patients will need it spironolactone or GnRH agonists to reduce testosterone i estradiol increase feminizing hormones to pubertal levels.

CSHT is not risk-free, McNamara said, which included “very high” risks of erythrocytosis in transmasculine patients and venous thromboembolic disease in transfeminine patients; but these risks need to be considered in the context of an approximate suicide rate of 40% among transgender people.

“I can tell you in my own practice that these [suicide] the data seems true, “McNamara said.” Many, many of my patients have attempted suicide [CSHT] it’s something you really want to think about right away. “

Even when there are additional risk factors, such as pre-existing cardiovascular disease, McNamara suggested that “there are very few absolute contraindications to CSHT,” and described it as a “life-sustaining treatment.” to be seen in a similar way to any other long-term management strategy, such as diabetes therapy or hypertension.

Fostering a transgender practice

In an interview, Nicole Nisly, MD, co-director of the University of Iowa LGBTQ + Clinic Hospitals and Clinics, Iowa City, reflected on McNamara’s presentation and noted that primary care providers, with a little education, are the best candidates for care for transgender patients.

“I think [primary care providers] do a better job [caring for transgender patients] that endocrinologists, honestly, because they can provide care to the whole person, “Nisly said.” They can do a Pap test, they can screen for STIs, they can assess their mood, they can [evaluate] safety, and the whole person, unlike endocrinologists, who do hormone therapy, but someone does everything else. “

Nisly stressed the importance of personalizing care for transgender people, which depends on a welcoming practical environment, with careful attention to language.

Above all, Nisly recommended asking patients for their preferred name, sexual orientation, and gender identity.

“One of the hardest things [for transgender patients] is seeing notes with an incorrect name (the name that makes them uncomfortable) or an incorrect pronoun, “Nisly said.” This is very important for the community. “

Nisly also recommended an alternative term for cross-hormonal therapy.

“I hate the terminology of cross-sex hormone therapy, honestly,” Nisly said. “I think it’s very unwelcome and I think most of our patients don’t like the terminology, so we use ‘hormone therapy that claims gender.’

Nisly explained that the term “cross-sex” assumes a conventional definition of sex, which is inherently flawed.

When certain medical risk factors, such as pregnancy or HIV, are discussed, it is helpful to know “sex assigned at birth” for both patients and their sexual partners, Nisly said. It’s best to ask this way, rather than using terms like “boyfriend” or “girlfriend,” since “sex assigned at birth” is “terminology that the community recognizes, affirms, and is comfortable with. “.

As for the management of medical risk factors, Nisly offered some additional perspectives.

On the one hand, he recommended giving PrEP to any patient who wants to be on PrEP, noting that this desire may indicate a change in future sexual practices, which the CDC criteria do not provide. He also advised self-breakdown in the hospital of extragenital STIs, as this can increase patient comfort and grip. And, in contrast to McNamara, Nisly recommended anal Pap smear detection for any man who has sex with men and anyone with HIV of any gender. He noted that rates of anal dysplasia are “quite high” among men who have sex with men and that screening can reduce the risk of cancer.

For physicians who want to learn more about transgender patient care, Nisly recommends that they start by reading the document. Guidelines of the World Professional Association for Transgender Health.

“It’s about 300 pages,” Nisly said, “but it’s fantastic.”

McNamara and Nisly did not report any conflicts of interest.

This article originally appeared on, which is part of the Medscape professional network.

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