Published in the September 2014 issue of Today’s Hospitalist
YOUR ELDERLY GENTLEMAN PATIENT is being tended to in the hospital by his long-term male partner. Your other patient in the next bed complains that he doesn’t want to “see two homosexuals touching each other while his family is visiting.” How do you react?
Or what should you do when discharging a transgender patient who is unable to go home? Do you investigate whether the nursing home is friendly to lesbian, gay, bisexual or transgender (LGBT) patients?
“Competent care” is not just knowing “what drugs to give someone for a specific condition,” said Barbara E. Warren, PsyD, director for LGBT programs and policies at Mount Sinai Health System in New York. For many members of the LGBT community, being hospitalized “can be very scary. You are depending on the kindness of strangers who may have issues with your sexual orientation or gender identity.” Patients who feel they may be given suboptimal care because they are LGBT, even if that’s not the case, will not “have as good health outcomes as somebody who doesn’t feel unsafe.”
Dr. Warren and a panel of experts presented an update on LGBT health care at this spring’s Society of Hospital Medicine conference. According to panel members, hospitalists have a responsibility to improve their competence in this area, from understanding the increased cardiovascular, DVT and PE risks that transgender women taking hormones face to the side effects of some pre- and post-HIV exposure drug regimens.
“The reason we are talking about LGBT health is due to the issue of health disparities,” explained Anita Radix, MD, MPH, senior director of research and education and an infectious disease specialist at New York’s Callen-Lorde Community Health Center, which specializes in LGBT health care. “We know that people who identify as LGBT experience bias in health care, and that economic, social and environmental factors can affect health outcomes.”
Fear of discrimination
A 2010 study by Lambda Legal on barriers to health care access found that one-third of all LGB respondents nationally said they had been treated by health care providers who were “unaware” of their specific needs. The same survey found that almost 8% of LGB people, 19% of people living with HIV, and 27% of transgender or gender-nonconforming people reported having been refused needed care at some point in their lives.
A 2011 report from the Institute of Medicine (IOM) indicated that studies of LGBT aging find that “discrimination and fear of discrimination are common.” One survey found, for instance, that 33% of gay and lesbian respondents thought they would have to hide their sexual identity if they moved to a retirement home.
“This still resonates for a lot of older gay men,” Dr. Warren said “and it could be something that many hospitalists, who may be younger and more accepting of LGBT patients, are unaware of or discount. The most discriminated-against group today are transgender people, she added, “who feel they may be objects of medical curiosity for practitioners or that they will be refused care or given substandard care because they are transgender.”
And Dr. Radix reminded hospitalists to “remember that identity and behavior aren’t always the same,” which is important when taking patient histories. A study published in the Sept. 19, 2006, Annals of Internal Medicine, for instance, found that about 10% of men who described themselves as “straight” were having sex with other men.
Outcomes and access to care
Data on gender identity and orientation are rarely collected in medical research. The result is little evidence about the health disparities that LGBT people face and a lack of data on effective interventions to address those disparities.
What is documented are higher rates of smoking and substance use, obesity, mood and anxiety disorders, depression, violence, and victimization among various LGBT subgroups. According to the 2011 IOM report, for instance, studies of both older gay men and older lesbians have found elevated levels of depression compared to seniors in general. Other research finds that almost one in four LGBT adults age 50 and older reports being in poor general health.
According to Dr. Warren, many same-sex partners and the children of partners who live in states that do not recognize same-sex couples as legal parents have not had access to family health insurance. Many studies have linked adverse health care consequences to that lack of access.
Lesbian and bisexual women have higher rates of breast cancer and are less likely than heterosexual woman to have had recent Pap tests or mammograms. The Women’s Health Initiative from the National Institutes of Health has reported that lesbians have a slightly lower prevalence of stroke and hypertension than other groups (bisexual, heterosexual, nonsexual), but the highest rates of myocardial infarction.
And one 2010 study cited in the IOM report examined risk factors for reproductive cancers by looking at sisters. Compared with their straight sisters, older lesbians were found to be at greater risk for major reproductive cancers (breast, ovarian and endometrial) because they had higher rates of nulliparity, resulting in less breastfeeding and a greater trend toward obesity. On the other hand, older lesbians had less risk for cervical cancer than their heterosexual sisters, who were more likely to have used birth control pills and to have had more pregnancies.
Among gay men, HIV/AIDS remains a significant problem. The CDC reports that about 29% of people living with AIDS in the U.S. are age 50 and over. But 70% of those with HIV are over age 40, suggesting that aging with the disease will be a significant issue in years to come.
As for transgender patients, Medicaid in most states does not cover transition-related care. Moreover, most commercial insurers have onerous restrictions on coverage for that care. This includes hormone treatments, which are considered an essential treatment for many transgender patients.
Among transgender individuals, there is some evidence of an association between poor hormonal therapies and negative health outcomes in later life including osteoporosis, cardiovascular disease and poor oral health. And many transgender elders may be at greater risk for impaired health than those who are younger because of the longer duration of hormone use, which can exacerbate the effects of aging and include cardiac or pulmonary problems.
Several cases the panel presented during the update addressed the medical needs of transgender patients in the hospital. For instance, when a 45-year-old transwoman is admitted after experiencing chest pain, what should a hospitalist recommend about her hormone therapy “particularly when she is HIV-positive, a smoker, overweight and on a hormone regimen for medical transition?
“We don’t have good clinical trials in transgender people “men or women “but transdermal estrogens appear to be safer” than older regimens that used ethinyl estradiol, Dr. Radix said. “We don’t know at what age “if any “patients should reduce or stop taking hormones, and we don’t have prevention guidelines that take into account patients’ experience of being on cross-sex hormones.”
She noted, for instance, that guideline recommendations on preventive aspirin vary depending on gender, an obvious complication when dealing with a transgender person.
“What we do know,” said Dr. Radix, “is that we can mitigate a lot of the cardiovascular risks of hormone use by emphasizing tobacco cessation and doing close monitoring of traditional risk factors like hyperlipidemia.”
PrEP and nPEP
Hospitalists might also encounter patients who have taken drugs for either pre-HIV exposure prophylaxis (PrEP) or nonoccupational post-exposure prophylaxis (nPEP). The CDC first published its recommendations for PrEP in 2011 for men having sex with men; guidelines were since updated for heterosexually active adults and IV drug users. When patients consistently take the PrEP medications of tenofovir and emtricitabine (Truvada), the risk of HIV infection in people at high risk drops 92%.
Physicians also may be asked for medications given post-exposure to prevent infection. But unlike PrEP, the use of nPEP is not backed by good randomized controlled trials, and it should be used only for people who have engaged in infrequent high-risk behavior, panelists said. It also must be started less than 72 hours after exposure. For advice on how to prescribe nPEP, panelists recommended contacting the University of California, San Francisco’s PEPline.
Recent political developments, meanwhile, are making it more likely that hospitalists across all communities will need this knowledge and these resources. There are neither enough LGBT health care specialists nor LGBT-specialized clinics to deal with the population’s needs, said Dr. Warren, particularly as access to insurance grows and stigma decreases.
The Supreme Court last June overturned the law denying federal benefits to same-sex couples. And the Affordable Care Act prevents insurers from denying coverage to patients who are LGBT, have a preexisting condition like HIV/AIDS, or otherwise discriminating against individuals on the basis of sexual orientation or gender identity. That includes same-sex spouses when it comes to spousal coverage.
In 2010, the Centers for Medicare and Medicaid Services began requiring all hospitals participating in Medicare and Medicaid to respect the right of patients to choose who may visit them when hospitalized. And in 2011, the government clarified that same-sex couples have the same rights as other couples in terms of naming a representative to make medical decisions on a patient’s behalf. Most recently this May, the department of Health and Human Services removed the exclusions for gender-reassignment surgeries under Medicare, opening the door for transgender patients to receive coverage for surgery related to gender transition.
In addition, the Joint Commission in 2011 issued a field guide Section1557 with strategies for hospitals to “provide care that is more welcoming, safe and inclusive of LGBT patients and families.” While that guidance does not represent accreditation standards, Dr. Warren said the Joint Commission during its accreditation review can cite hospitals that don’t have an LGBT antidiscrimination policy in place.
“More LGBT people are going to seek care in our institutions,” said Dr. Warren. “It is critical that mainstream health care institutions be able to offer them care that is both welcoming and culturally and clinically competent.”
Deborah Gesensway is a freelance writer covering U.S. health care from Toronto.