LGBT Health Matters: Bedside, Workforce, and Beyond

Kenneth A. Katz, MD, MSc, MSCE

Department of Dermatology, Kaiser Permanente, San Francisco, CA
Co-Chair, AAD Expert Resource Group on LGBT/Sexual and Gender Minority Health
Kenneth.Katz@gmail.com

Association of Professors of Dermatology

Chicago, IL
October 20, 2017
 Conflict of Interest Disclosure

Past 12 months (not current)

Stockholder: Prevention Health Labs
Stockholder: Arrowhead Pharmaceuticals, Inc.
 LGBT Health Matters: Bedside, Workforce, and Beyond

Clinical vignette
Framework for caring for LGBT persons
Education
Workforce
Clinical vignette
 Clinical Vignette

25-year-old man
Rash on body for two weeks

Whats next?
Questions
Tests
Management
Framework for Caring for LGBT Persons

Physician Physician
medical cultural
competence competence

Overall context of LGBT health

Overall context of LGBT life

 Overall Context of LGBT Life

Stonewall
1969
 Overall Context of LGBT Life

Stonewall DSM
1969 1973
 Overall Context of LGBT Life

Stonewall DSM AIDS

1969 1973 1981
 Overall Context of LGBT Life

Stonewall DSM AIDS Bowers

1969 1973 1981 1986
 Overall Context of LGBT Life

Stonewall DSM AIDS Bowers DADT

1969 1973 1981 1986 1994
 Overall Context of LGBT Life

DOMA
Stonewall DSM AIDS Bowers DADT HAART
1969 1973 1981 1986 1994 1996
 Overall Context of LGBT Life

DOMA
Stonewall DSM AIDS Bowers DADT HAART Lawrence Prop 8
1969 1973 1981 1986 1994 1996 2003 2008
 Overall Context of LGBT Life

DOMA
Stonewall DSM AIDS Bowers DADT HAART Lawrence Prop 8 DADT
1969 1973 1981 1986 1994 1996 2003 2008 2011
 Overall Context of LGBT Life

DOMA Windsor
Stonewall DSM AIDS Bowers DADT HAART Lawrence Prop 8 DADT DSM
1969 1973 1981 1986 1994 1996 2003 2008 2011 2013
 Overall Context of LGBT Life

DOMA Windsor Oberge

Stonewall DSM AIDS Bowers DADT HAART Lawrence Prop 8 DADT DSM -fell
1969 1973 1981 1986 1994 1996 2003 2008 2011 2013 2015
 Overall Context of LGBT Life

DOMA Windsor Oberge TG

Stonewall DSM AIDS Bowers DADT HAART Lawrence Prop 8 DADT DSM -fell military
1969 1973 1981 1986 1994 1996 2003 2008 2011 2013 2015 2016
 Overall Context of LGBT Life

Master
-piece;
DOMA Windsor Oberge TG TG
Stonewall DSM AIDS Bowers DADT HAART Lawrence Prop 8 DADT DSM -fell military military
1969 1973 1981 1986 1994 1996 2003 2008 2011 2013 2015 2016 2017
 Overall Context of LGBT Health
Healthy People 2020
Institute of Medicine report (2011)
LGBT persons knowledge and attitudes towards healthcare

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
 Healthy People 2020

Goal: Improve the health, safety, and well-being of LGBT individuals

Health disparities
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
Shortage of HCPs knowledgeable and culturally competent in LGBT health
https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
Institute of Medicine Report (2011)
LGBT persons experience unique health disparities
What is currently known about the health
status of LGBT populations?
Where do gaps in the research exist?
What are the priorities for a research agenda
to address these gaps?

http://www.nationalacademies.org/HMD/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx
Institute of Medicine Report (2011)
Recommendations
NIH research agenda to advance LGBT health
Collect sexual orientation/gender identity (SOGI)
data in federal surveys and EHRs
NIH support for developing SOGI measures
NIH support for LGBT methodological research
Training to strengthen LGBT research at NIH
NIH grant applicants should address explicitly
inclusion or exclusion of LGBT in research
http://www.nationalacademies.org/HMD/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx
NIH Sexual and Gender Minority Research Office

https://dpcpsi.nih.gov/sgmro
 Convenience survey
4916 respondents
2009

https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf
 LGB Persons Experiences with Healthcare System
I was refused health care

HCPs refused to touch me or used excessive precautions

HCPs used harsh or abusive language

HCPs blamed me for my health status

HCPs were physically rough or abusive

0 2 4 6 8 10 12 14
Percent answering yes

https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf
 LGB Persons Fears and Concerns About Accessing Healthcare

Will be refused medical service

Will be treated differently

Not enough HCPs adequately trained

0 10 20 30 40 50 60
Percent answering yes

https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf
 LGB Persons Fears and Concerns About Accessing Healthcare

Will be refused medical service

More negative responses
Will be treated differently Persons of color
Low-income respondents
Not enough HCPs adequately trained

0 10 20 30 40 50 60
Percent answering yes

https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf
 27,715 respondents
All 50 states, D.C., American Samoa, Guam, Puerto Rico, U.S. military bases
Convenience sample

http://www.transequality.org/sites/default/files/docs/usts/USTS%20Full%20Report%20-%20FINAL%201.6.17.pdf
 Negative experiences when seeing a healthcare provider in past year
Had to teach HCP about TG people to get appropriate care
Asked unnecessary or invasive questions about TG status
HCP refused to provide transition-related care
Verbally harassed in health care setting
Sexually assaulted in a health care setting

0 5 10 15 20 25 30
Percent answering yes

http://www.transequality.org/sites/default/files/docs/usts/USTS%20Full%20Report%20-%20FINAL%201.6.17.pdf
 Physician Medical Competency

Demographics
Epidemiology of dermatology-related diseases/conditions
Preventive health recommendations
LGBT Demographics in the United States

http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
LGBT Demographics in the United States

1,397,150
(0.6%)

https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf
Epidemiology of dermatology-related diseases/conditions
Gay men / men who Lesbian women / women Transgender men / FTM Transgender women / MTF
have sex with men who have sex with women
Infectious diseases Sexual health-related Testosterone-related Infectious diseases
HIV At risk for HIV and other Acne vulgaris HIV and other STDs
Other STDs (syphilis, STDs Androgenetic alopecia
gonorrhea, chlamydia Higher rates of high-risk Changes in facial & body Estrogen-related
and LGV, HSV-2, HPV) HPV infection hair, fat distribution, Melasma, changes in
Kaposi sarcoma Lower rates of HPV sweat and odor facial & body hair, fat
Invasive meningococcal vaccination initiation distribution, sweat, odor
disease and completion Surgery-related Hair loss arrest/reversal
Staphylococcus aureus Lower rates of obtaining Keloids Improvement in acne
infection Pap smears
Chest binding-related Surgery-related
Non-infectious diseases Pain, swelling, itch, skin Keloids
Skin cancer and indoor breakdown, acne,
tanning miliaria, tinea, contact Gender-affirming
Mental health among dermatitis, scarring procedures
persons with acne Hair removal
Poppers dermatitis Fillers / body contouring
https://www.ncbi.nlm.nih.gov/pubmed/?term=25487961
MSM
~ 4% of men
~80% of cases
~ 100x risk compared
with MSW
https://www.ncbi.nlm.nih.gov/pubmed/?term=25487961
Preventive Health Recommendations (CDC, USPSTF, Local)
Gay men / men who Lesbian women / women Transgender men/ Transgender women /
have sex with men who have sex with women transmen / FTM transwomen / MTF
Screening (at least yearly) Screening, vaccinations, Screening, vaccinations, Screening, vaccinations,
HIV and HIV prophylaxis and HIV prophylaxis and HIV prophylaxis
Syphilis Same as for other Determine based on Determine based on
Gonorrhea and women, including anatomy, behavioral anatomy, behavioral
chlamydia (oral, rectal, pregnant women history, and sexual history, and sexual
AND urethral) practices practices
Hepatitis B (once) Often similar to
Hepatitis C (if HIV+) recommendations for
gay men and other men
Vaccinations who have sex with men
Hepatitis A and B
HPV through age 26
Meningococcus (local)

HIV prophylaxis
Pre-exposure (PrEP)
Post-exposure (nPEP)
Preventive Health Recommendations (CDC, USPSTF, Local)
Gay men / men who Lesbian women / women Transgender men/ Transgender women /
have sex with men who have sex with women transmen / FTM transwomen / MTF
Screening (at least yearly) Screening, vaccinations, Screening, vaccinations, Screening, vaccinations,
HIV Screening tests NOT routinely
and HIV prophylaxis recommended for
and HIV prophylaxis MSM / gay men
and HIV by CDC
prophylaxis
Syphilis Same as for other
HSV-2 serology Determine based on Determine based on
Gonorrhea and women, including anatomy, behavioral anatomy, behavioral
Anal cancer,
chlamydia (oral, rectal, including anal
pregnant women Pap smears*history, and sexual history, and sexual
Hepatitis C virus
AND urethral) practices practices
Hepatitis B (once) Often similar to
CDC on
Hepatitis C (if HIV+)
screening for intra-anal warts in patients with perianal warts
recommendations for
Many persons with external anal warts also have intra-anal warts.gay Thus,
menpersons with
and other men
Vaccinations who by
external anal warts might benefit from an inspection of the anal canal have sex with men
digital
Hepatitis A and examination,
B standard anoscopy, or high-resolution anoscopy.
HPV through age 26

Meningococcus Can(local)
assess need on case-by-case basis
Consider potential harms of screening
HIV prophylaxis
* Recommended
Pre-exposure (PrEP) by HIVMA/IDSA and NY State Department of Health
Post-exposure (nPEP)
 HIV Pre-Exposure Prophylaxis (PrEP)

iPrEx trial
Enrolled HIV-negative MSM and transgender women
Daily emtricitabine-tenofovir vs. placebo
44% in HIV acquisi on in ac ve-treatment group
92% in group with detectable drug levels
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1011205
 HIV Pre-Exposure Prophylaxis (PrEP)

Kaiser Permanente Northern California

> 800 MSM
No new HIV infections since2012

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809999/pdf/civ778.pdf
 MSM Meeting CDC Indications for PrEP

Data from national population-based cross-sectional surveys

~ 25% of sexually active adult MSM met PrEP indications (492,000 men)

https://www.cdc.gov/mmwr/pdf/wk/mm6446.pdf
 Physician Cultural Competence

What is cultural competence?

Cultural competence in caring for LGBT persons
Isotretinoin, iPLEDGE, and transgender men
 What is Cultural Competence? (AAMC)

Cultural and linguistic competence: a set of congruent behaviors,

knowledge, attitudes, and policies that enables effective work in cross-
cultural situations
Culture: integrated patterns of human behavior of racial, ethnic,
social, or religious groups
Competence: having the capacity to function effectively within the
context of cultural beliefs, practices, and needs presented by patients
and their communities

https://www.aamc.org/download/54338/data/
 Cultural Competence in Caring for LGBT Persons
Concepts
Sexual attraction, behavior, orientation as distinct concepts
Gender identity along a spectrum, regardless of medical/surgical treatment
Terminology
Asking about same-sex relationships, sexual behavior, anatomy
Using pronouns and addressing persons appropriately
Documenting in medical chart
Care environment
Intake forms
Messaging around diversity and inclusion
Bathroom access
 Isotretinoin, iPLEDGE, and Transgender Men

iPLEDGE requires registering patients according to sex assigned at birth

Transgender men must be registered as females
Cultural incompetence!
FDA: Change iPLEDGE to register according to pregnancy potential,
regardless of sex or gender
https://jamanetwork.com/journals/jamadermatology/article-abstract/2481420
 Education

AAMC recommendations
Dermatology-specific educational resources
Institutional resources
http://offers.aamc.org/lgbt-dsd-health
Requirements for competency in patient care (Table 6.4)
Sensitively and effectively eliciting relevant information
Performing a complete, accurate physical exam
Describing the special health care needs and available options for quality care
Assessing unique needs and tailoring to special needs
Recognizing unique health risks and tailoring health messages and counseling
Providing effective care by utilizing screening tests and other preventive care
http://offers.aamc.org/lgbt-dsd-health
 Dermatology-Specific Educational Resources
Medical literature
Review articles and other articles
JAAD CME (submitted)
Dermatology World (forthcoming)
Textbook chapters
Dermatology in General Medicine and others (forthcoming)
Talks
AAD annual and summer meetings
World Congress of Dermatology (2019)
Grand rounds talks
Questions for ABD certifying and in-training examinations (forthcoming)
https://www.ncbi.nlm.nih.gov/pubmed/28492595; https://www.ncbi.nlm.nih.gov/pubmed/16230569
 Institutional Resources
AAD Expert Resource Group on LGBT/Sexual and Gender Minority Health
Facebook page
Contact me at Kenneth.Katz@gmail.com to be added
Gay and Lesbian Dermatology Association
www.glderm.org
Gay and Lesbian Medical Association
www.glma.org
Fenway Institute / National LGBT Health Education Center
https://www.lgbthealtheducation.org/
University-based LGBT organizations
 Workforce

Importance of diversity in the dermatology workforce

LGBT representation in the dermatology workforce
LGBT perceptions regarding dermatology as a specialty
The population is becoming increasingly diverse. Diversity includes gender, race,
ethnicity, socioeconomic status, disability, and sexual orientation. Efforts have helped
improve gender diversity in dermatology, moving our specialty toward a workforce that
reflects the patients it serves [P]ersistent disparities remain when it comes to race and
ethnicity.
Why does this matter? Diversity among the medical work force has been shown to
improve patient care.
http://www.jaad.org/article/S0190-9622(15)02474-3/pdf
Framework for Caring for LGBT Persons

Physician Physician
medical cultural
competence competence

Overall context of LGBT health

Overall context of LGBT life

LGBT representation in the dermatology workforce
LGBT representation in the dermatology workforce

No data currently available

Analysis of AAMC data in
progress
Outness
 LGBT perceptions regarding dermatology as a specialty

Dermatology Specialists (1980) Gay and Lesbian Dermatology

Association (2010)
 LGBT perceptions regarding dermatology as a specialty

Dermatology Specialists (1980) Gay and Lesbian Dermatology

Association (2010)
Medical student email, summer 2017:
I've had a couple of interesting experiences when I've shared the
[LGBT-related] research that I'm doing.... In particular, one
attending suggested that I not talk about my research at the end of
the month (we have to give a 5 minute talk) unless I wanted to be
remembered as the gay medical student
 Clinical Vignette

25-year-old man
Rash on body for two weeks

Whats next?
Questions
Tests
Management
 Clinical Vignette

25-year-old man
Rash on body
Whats for two weeks
next?
Questions: Sexual history, including gender(s) of sex partner(s)
Tests: Syphilis, HIV, other STDs
Management
Syphilis: diagnosis and management
Screening: HIV and STDs, including oral, rectal, and urethral gonorrhea and
chlamydia (negative)
Vaccination: 9-valent HPV vaccination initiated (already had hep A and hep
B; prior to meningococcal vaccination recommendation)
PrEP: met criteria. Referred for consideration
nPEP: not indicated (no high-risk exposure within past 72 hours)
Massachusetts, starting mid-1990s

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

http://www.glbthealth.org/HAPMaterials.htm#materials
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

http://www.glbthealth.org/HAPMaterials.htm#materials
 LGBT Health Matters: Bedside, Workforce, and Beyond

Clinical vignette
Framework for caring for LGBT persons
Education
Workforce
Clinical vignette
 Supplemental Materials / MSM Preventive Care

Screening for HIV and other STDs

Vaccinations
PrEP
nPEP
 HIV/STD Screening for MSM: CDC Guidelines
Test Specimen Indication Frequency
source
HIV* Blood HIV status unknown or negative and patient
or sex partner(s) with >1 sex partner since
most recent test At least annually;
Syphilis* Blood Sexually active in past year or since last test every 36 months
if risk factors
Urethral gonorrhea Urine Insertive oral or anal intercourse during past
persist or if they or
and chlamydia year, regardless of reported condom use
partners have
Rectal gonorrhea and Swab Receptive anal intercourse during past year, multiple sex
chlamydia regardless of reported condom use partners
Pharyngeal gonorrhea Swab Receptive oral intercourse during past year,
regardless of reported condom use
Hepatitis B (HBsAg) Blood No documented vaccination or infection Once
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-infection-
screening; http://www.cdc.gov/std/tg2015/specialpops.htm#MSM
 Vaccinations for MSM:
CDC and Local Public Health Guidelines
Vaccination Indication
Human papillomavirus All MSM through age 26, regardless of prior or current
(4- or 9-valent) HPV infection status
Hepatitis A No prior infection or vaccination
Hepatitis B No prior infection or vaccination
Meningococcal 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-vaccine-
recommendation-amid-growi.html
 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, HIV-
negative man

May 2014 CDC guidelines, available at: http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf

HIV Pre-Exposure Prophylaxis (PrEP) for MSM:
CDC Guidelines
All of these AND at least one of these
Adult man Any anal sex without condoms
(receptive or insertive) in past
Without acute or
6 months
established HIV infection
Any male sex partners in Any STI diagnosed or reported
past 6 months in past 6 months
In an ongoing sexual
Not in a monogamous
relationship with an HIV-
partnership with a
positive male partner
recently tested, HIV-
negative man

May 2014 CDC guidelines, available at: http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf

Non-Occupational Post-Exposure Prophylaxis for HIV (nPEP):
CDC Guidelines

https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf