LGBT Health: Providing Culturally Competent Care to Patients Who are Sexual and Gender Minorities (U078)

LGBT Health: Providing Culturally Competent Care to Patients Who are Sexual and Gender Minorities (U078) Ken Katz, MD, MSc, MSCE Kaiser Permanente, San Francisco, CA Brian Ginsberg, MD Mount Sinai Hospital and Chelsea Skin & Laser, New York, NY Patrick McCleskey, MD Kaiser Permanente, Oakland, CA AAD Annual Meeting Orlando, FL March 5, 2017

LGBT Health 101 Dr. Katz Background, nomenclature and demographics Dermatology-related health concerns of women who have sex with women and men who have sex with men Preventive health recommendations for MSM Case Dr. Ginsberg Transgender persons Dr. McCleskey Taking a sexual history and a gender identity history

Conflict of Interest Disclosure Prevention Health Labs, Inc.: Co-Founder Arrowhead Pharmaceuticals Corp.: Shareholder Synta Pharmaceuticals, Inc.: Shareholder Madrigal Pharmaceuticals, Inc.: Shareholder

LGBT Health: Background

Massachusetts, starting mid-1990s http://www.glbthealth.org/hapmaterials.htm#materials

Massachusetts, starting mid-1990s same quality of care same quality of care same quality of care Important differences for LGBT patients Health disparities Dermatology-related health concerns Public health recommendations for disease prevention http://www.glbthealth.org/hapmaterials.htm#materials

Health disparities among LGBT persons LGBT youth: more likely to attempt suicide Lesbians: less likely to get preventive services for cancer Gay men: higher risk of HIV/STDs, especially among communities of color Transgender persons : high prevalence of HIV/STDs, mental health issues, suicide Lack of providers knowledgeable and culturally competent in LGBT health http://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

Research needed to understand and mitigate LGBT health disparities Collect sexual orientation and gender identity data in surveys and EHRs Strengthen NIH and other research on LGBT health https://iom.nationalacademies.org/~/media/files/report%20files/2011/the-health-of-lesbian-gay-bisexual-and-transgender- People/LGBT%20report%20release%20presentation.pdf; https://iom.nationalacademies.org/reports/2011/the-health-of-lesbian-gay-bisexual-and-transgender-people.aspx

The Joint Commission, 2014 Association of American Medical Colleges, 2014 http://www.jointcommission.org/assets/1/18/lgbtfieldguide.pdf http://offers.aamc.org/lgbt-dsd-health

Taking a Sexual History EHRs certified for meaningful use must enable collection of data on sexual orientation/gender identity Where the patient chooses to disclose this information, [it] can help the patient s care team in identifying interventions and treatments most helpful to the particular patient. A crucial step forward to improving care for LGBT communities https://www.gpo.gov/fdsys/pkg/fr-2015-10-16/pdf/2015-25595.pdf

FDA, 1988 FDA, 2017 http://www.gettyimages.com/photos/act-up?excludenudity=true&family=editorial&mediatype=photography&phrase=act%20up&sort=mostpopular; http://www.disruptivewomen.net/2015/07/27/health-politics-learning-from-history-in-art-from-the-reaganaids-era/

LGBT Health: Nomenclature

Sex, gender, and transgender Term Definition Sex Biologic construct Male / female / intersex Typically assigned at birth Gender identity Social construct Sense of being boy/man, girl/woman, or other gender Might or might not align with sex assigned at birth Transgender Gender identity does not align with sex assigned at birth Male-to-female/transgender woman/trans woman Female-to-male/transgender man/trans man Adjective, not noun: Transgender, not transgendered Adadpted from: https://iom.nationalacademies.org/reports/2011/the-health-of-lesbian-gay-bisexual-and-transgender-people.aspx; https://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf

Sexual orientation and sexual behavior Term Definition Sexual orientation Describes sex of those to whom a person is attracted Gay/lesbian Heterosexual/straight Bisexual Sexual behavior Describes biologic sex of sex partners Men: Men who have sex with men (MSM), MSW, MSMW Women: Women who have sex with women (WSW), WSM, WSMW Adadpted from: https://iom.nationalacademies.org/reports/2011/the-health-of-lesbian-gay-bisexual-and-transgender-people.aspx; https://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf

Sexual orientation and sexual behavior Term Definition Sexual orientation Describes sex of those to whom a person is attracted Gay/lesbian Heterosexual/straight Bisexual Sexual behavior Describes biologic sex of sex partners Men: Men who have sex with men (MSM), MSW, MSMW Women: Women who have sex with women (WSW), WSM, WSMW Behavior is more important than orientation for health issues discussed in this presentation Adadpted from: https://iom.nationalacademies.org/reports/2011/the-health-of-lesbian-gay-bisexual-and-transgender-people.aspx; https://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf

Term Definition LGBT and SGM LGBT(Q)(I) Lesbian, gay, bisexual, and transgender, (queer), (questioning), (intersex) SGM Sexual and gender minority Umbrella phrase for LGBT persons and others whose sexual orientation, gender identity and expressions, or reproductive development varies from traditional, societal, cultural, or physiological norms Adadpted from: https://iom.nationalacademies.org/reports/2011/the-health-of-lesbian-gay-bisexual-and-transgender-people.aspx; https://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf

LGBT Health: Demographics

Adults in the United States 3.8% identify as LGBT 9 million people 3.5% LGB 0.3% transgender 8.2% ever engaged in same-sex sexual behavior 19 million people 11% report at least some same-sex sexual attraction 26 million people http://williamsinstitute.law.ucla.edu/wp-content/uploads/gates-how-many-people-lgbt-apr-2011.pdf

Dermatology-related health concerns of women who have sex with women (WSW) and men who have sex with men (MSM)

Dermatology-related health concerns of WSW and MSM WSW MSM At risk for STDs HIV Other STDs: syphilis, gonorrhea, chlamydia including LGV, HSV-2 Kaposi sarcoma Meningococcal meningitis Staphylococcus aureus infection Poppers dermatitis Skin cancer and indoor tanning Katz KA, et al. Arch Dermatol. 2005;141:1303-10. Turrion-Merino L, et al. JAMA Dermatol. 2015;151:1260-1. Mansh M, et al. JAMA Dermatol. 2015;151:1308-1316. Yeung H, et al. JAMA Dermatol. 2016;152:99-101. Schauber J, et al. Clin Exp Dermatol. 2012;37:587-8. Blashill AJ, et al. JAMA Dermatol. 2015;151:1293-4. Styperek A, et al. J Clin Aesthet Dermatol. 2013;6:22-9. Ginsberg BA, et al. J Am Acad Dermatol. 2016 Feb;74(2):303-8.

39,513 new HIV infections in 2015 https://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-surveillance-slides-msm.pdf

https://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-surveillance-genepi.pdf

23,872 primary and secondary syphilis cases in 2015 https://www.cdc.gov/std/stats15/slides/stds-survrpt-2015-all-slides.pdf

https://www.ncbi.nlm.nih.gov/pubmed/?term=25487961

https://www.ncbi.nlm.nih.gov/pubmed/?term=25487961

388 cases (0.6% of total syphilis cases) 69% MSM 51% living with HIV 28% with primary or secondary syphilis 22% had other neurosyphilis symptoms Symptoms: blurry vision (64%), vision loss (33%), eye pain or red eye (14%) https://www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6543a2.pdf

Screen syphilis patients for visual complaints Test all syphilis patients for HIV if not known to be HIV-positive Perform neuro exam including cranial nerves in all syphilis patients Refer syphilis patients with ocular complaints for ophtho exam and LP Treat ocular syphilis according to neurosyphilis recommendations Report ocular syphilis cases to health department within 24 hours https://www.cdc.gov/std/syphilis/clinicaladvisoryos2015.htm

https://www.cdph.ca.gov/programs/std/documents/neurosyphilisguide.pdf

74 cases New York City (23), Los Angeles (14), Chicago (11), other jurisdictions 59% living with HIV 32% died http://www.cdc.gov/mmwr/pdf/wk/mm6444.pdf

https://www.cdph.ca.gov/healthinfo/discond/documents/cdph-msm-mening-health-advisory-aug16-2016.pdf

Compared with heterosexuals Sexual minority men skin cancer (4.3% vs 2.7%; 6.7% vs. 3.2%), including melanoma and NMSC More likely to have tanned indoors Sexual minority women No difference in overall skin cancer history; NMSC less likely Less likely to have tanned indoors http://jamanetwork.com/journals/jamadermatology/fullarticle/2453327

Sexual minority males All (white, black, Hispanic) more likely to tan indoors than heterosexual males Sexual minority females White: less likely to tan indoors than heterosexual females Black or Hispanic: more likely to tan indoors than heterosexual females http://jamanetwork.com/journals/jamadermatology/fullarticle/2593711?resultclick=1

LGBT Health: Preventive health recommendations for MSM http://www.newyorker.com/culture/culture-desk/cover-story-obamas-gay-marriage-announcement

Test HIV/STD Screening for MSM: CDC Guidelines Specimen source Indication HIV* Blood HIV status unknown or negative and patient or sex partner(s) with >1 sex partner since most recent test Syphilis* Blood Sexually active in past year or since last test Urethral gonorrhea and chlamydia Rectal gonorrhea and chlamydia Urine Swab Insertive oral or anal intercourse during past year, regardless of reported condom use Receptive anal intercourse during past year, regardless of reported condom use Pharyngeal gonorrhea Swab Receptive oral intercourse during past year, regardless of reported condom use Hepatitis B (HBsAg) Blood No documented vaccination or infection Once Frequency At least annually; every 3 6 months if risk factors persist or if they or partners have multiple sex partners Hepatitis C Blood HIV-infected MSM only At least once *Also recommended by U.S. Preventive Services Task Force; https://www.uspreventiveservicestaskforce.org/page/document/updatesummaryfinal/syphilis-infection-in-nonpregnant-adults-and-adolescents; https://www.uspreventiveservicestaskforce.org/page/document/recommendationstatementfinal/human-immunodeficiency-virus-hiv-infectionscreening; http://www.cdc.gov/std/tg2015/specialpops.htm#msm

HIV/STD Screening for MSM: CDC Guidelines Screening tests NOT routinely recommended for MSM HSV-2 serology Anal cancer, including anal Pap smears Hepatitis C virus Screening for intra-anal warts in patients with perianal warts CDC: Many persons with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy. Can assess need on case-by-case basis Consider potential harms of screening Based on: http://www.cdc.gov/std/tg2015/specialpops.htm#msm; http://www.cdc.gov/std/tg2015/hpv-cancer.htm

Vaccinations for MSM: CDC and Local Public Health Guidelines Vaccination Human papillomavirus (4- or 9-valent) Hepatitis A Hepatitis B Meningococcal Indication All MSM through age 26, regardless of prior or current HPV infection status No prior infection or vaccination No prior infection or vaccination MSM living in Los Angeles, New York City, Chicago, or planning to have sex with men from those cities or from various European cities Based on: http://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions-shell.html and http://www.cdph.ca.gov/healthinfo/discond/documents/msm_meningococcal_vaccine_health_advisory_april15_2014.pdf; http://www.cityofchicago.org/city/en/depts/cdph/provdrs/infect_dis/news/2015/june/cdph-and-cdc-expand-meningitis-vaccinerecommendation-amid-growi.html

HIV Pre-Exposure Prophylaxis (PrEP) for MSM: CDC Guidelines All of these Adult man Without acute or established HIV infection Any male sex partners in past 6 months Not in a monogamous partnership with a recently tested, HIVnegative man AND at least one of these Any anal sex without condoms (receptive or insertive) in past 6 months Any STI diagnosed or reported in past 6 months In an ongoing sexual relationship with an HIVpositive male partner May 2014 CDC guidelines, available at: http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf

Studied HIV-negative MSM and transgender women Daily emtricitabine-tenofovir vs. placebo 44% in HIV in active-treatment group 92% in active-treatment group with detectable drug levels http://www.nejm.org/doi/pdf/10.1056/nejmoa1011205

Non-Occupational Post-Exposure Prophylaxis for HIV (npep): CDC Guidelines https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf

LGBT Health: Case http://www.villagevoice.com/news/daniel-choi-driven-crazy-by-dont-ask-dont-tell-hopes-to-rejoin-the-military-6725441

Itchy rash for two weeks New sex partner No recent STD or HIV testing 25-year-old man

Laboratory Results Test Result T. pallidum enzyme immunoassay (EIA) Reactive RPR Reactive, 1:128 Biopsy result Syphilis HIV 1 and 2 antibody and viral load Negative Urine test for gonorrhea and chlamydia Negative

Laboratory Results Test Result T. pallidum enzyme immunoassay (EIA) Reactive RPR Reactive, 1:128 Biopsy result Syphilis HIV 1 and 2 antibody and viral load Negative Urine test for gonorrhea and chlamydia Negative Neurologic and ocular review of systems and exam negative Treated appropriately for secondary syphilis Case reported to local public health jurisdiction ARE WE DONE?

Laboratory Results Test Result T. pallidum enzyme immunoassay (EIA) Reactive RPR Reactive, 1:128 Biopsy result Syphilis HIV 1 and 2 antibody and viral load Negative Urine test for gonorrhea and chlamydia Negative Neurologic and ocular review of systems and exam negative Treated appropriately for secondary syphilis Case reported to local public health jurisdiction ARE WE DONE? NO: gender of sex partners, other preventive care

Laboratory Results Test Result T. pallidum enzyme immunoassay (EIA) Reactive RPR Reactive, 1:128 Biopsy result Syphilis HIV 1 and 2 antibody and viral load Negative Urine test for gonorrhea and chlamydia Negative Rectal test for gonorrhea and chlamydia NEGATIVE Pharyngeal test for gonorrhea and chlamydia NEGATIVE

Vaccinations Vaccine Hepatitis A Hepatitis B HPV (9-valent) Meningococcal Status Already had Already had ORDERED ORDERED

HIV Pre-Exposure Prophylaxis (PrEP) Among MSM: CDC Guidelines All of these Adult man Without acute or established HIV infection Any male sex partners in past 6 months Not in a monogamous partnership with a recently tested, HIVnegative man AND at least one of these Any anal sex without condoms (receptive or insertive) in past 6 months Any STI diagnosed or reported in past 6 months In an ongoing sexual relationship with an HIVpositive male partner May 2014 CDC guidelines, available at: http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf

LGBT Health: Providing Culturally Competent Care to Patients Who are Sexual and Gender Minorities (U078) Ken Katz, MD, MSc, MSCE Kaiser Permanente San Francisco, CA AAD Annual Meeting Orlando, FL March 5, 2017