LGBTQ HEALTH: WHO, WHAT, WHERE

AND WHY WE SHOULD CARE

ROQUELYN RAMIREZ-BENZON
 OBJECTIVES

• Introduce you to LGBTQ terminology

• Discuss historical and contemporary health concerns
of the LGBTQ community
• Present current legal and regulatory standards
related to LGBTQ health
DEFINITIONS LGBTIQ

• Gay, Lesbian
• Exclusive physical and emotional attraction to members of one’s own
sex

• Bisexual
• Physical and emotional attraction to members of both sexes

• Transgender (gender identity)

• A person who feels his or her body is not the sex it should be,
regardless of transformational hormone or surgical status

• Cis-Gender
• A person whose gender identity matches their sex at birth
Transgender
(gender identity) LGBTIQ

• MtF = Male-to-Female (she) transwoman

• Born with male anatomy, female gender

• FtM = Female-to-Male (he) transman

• Born with female anatomy, male gender
Definitions LGBTIQ

• Intersex
• The vogue term for hermaphrodite. People born with the
sexual characteristics of both sexes

• Questioning
• People who suspect they might be LGBT, but are not yet
certain

• Queer
• Inclusive term of the LGBTIQ community
• Unique paradigm
GENDER NON-CONFORMITY OR GENDER
DYSPHORIA

GENDER NON- GENDER DYSPHORIA

CONFORMITY

• the extent to which a person’s • discomfort or distress that is

gender identity, role, or caused by a discrepancy between
expression differs from the a person’s gender identity and
cultural norms prescribed for that person’s sex assigned at birth
people of a particular sex (IOM, (and the associated gender role
2011 definition) and/or primary and secondary sex
characteristics) (WPATH, 2011)
 EARLY SOCIAL TRANSITION

• Child lives as gender that matches their identity

• Trial run - name, attire, social roles at school, in community
• Reversible
• Family decision whether to disclose to others or not

• Approx. 25% of children who were assessed for gender

dysphoria grew up to be cis-gender gay vs. transgender.
 CHILDREN AND YOUTH

• EARLY medical and mental health services

• Family support is critical to positive health outcomes
• Puberty experienced congruent with gender (delay until
sure)
• Reduces need for later medical interventions
• Prevents unwanted sex characteristics (i.e. breasts)
• Decreases stress, anxiety, depression
A report published in 2021 by UCLA School of Law’s
Williams Institute ranked the Philippines at 36th
out of 175 nations in terms of accepting the
lesbian, gay, bisexual, transgender, queer, questioning,
intersex, and asexual (LBTQIA+) community.

But even with the Philippines being more socially

accepting of the LBTQIA+ community, some of
its members still regularly experience
discrimination and harassment.
OVERREPRESENTED HEALTH
PROBLEMS

• HIV/ AIDS
• Trauma/ Victimization
• Mental Health Concerns
• Addictions

• Is this because they’re LGBT? –or- because of the

context within which LGBT people must exist?
 HIV (HUMAN IMMUNODEFICIENCY VIRUS) AND AIDS
(ACQUIRED IMMUNODEFICIENCY SYNDROME)

It can affect individuals of any sexual orientation or gender

identity. However, certain populations, including some
within the LGBTQ+ community, may be at a higher risk
due to various factors. It's crucial to recognize that being a
member of the LGBTQ+ community does not inherently
increase the risk of HIV or AIDS. Instead, specific
behaviors and risk factors may contribute to varying rates
within different subgroups.
1. Behavioral Risk Factors
2. Prevalence Rates
3. Prevention and Education
4. Cultural Competency in Healthcare
TRAUMA/ VICTIMIZATION

• Parental abuse
• Increased prevalence of verbal and physical abuse and
heightened suicidal ideation among those who disclosed their
s.o. to their families

• Hate crimes
• Hate crimes are criminal acts committed against individuals or
groups because of their real or perceived membership in a
particular social group.
MENTAL HEALTH –
DEPRESSION & ANXIETY

• LGBT children often grow up in a society

that says that they should not exist and/or
should not act on their feelings.
• These societal mores can be internalized = internalized
homophobia
 INTERNALIZED HOMOPHOBIA
It involves the acceptance and internalization of negative societal
attitudes and stereotypes about being LGBTQ+, leading
individuals to harbor negative feelings or shame about their own
sexual orientation.

KEY ASPECTS OF INTERNALIZED

HOMOPHOBIA INCLUDE:
1. Self-stigmatization
2. Fear of Rejection
3. Negative Self Image
4. Avoidance of LGBTQ+ Spaces
5. Strained Relationships
6. Mental Health Impact
 DEPRESSION

• Prevalence of depression 17.2% higher than in U.S.

adult men in general
• Distress & depression associated w/:
• lack of a partner;
• not identifying as gay, queer, or homosexual;
• experiencing multiple episodes of antigay violence
in the previous 5 years; and
• very high levels of community alienation

Mills 2004
 LGBT VICTIMIZATION
• At least 50 transgender or gender nonbinary individuals have been
murdered across the archipelago since 2010 — but the real death toll is
likely much higher.

‘Justice for Jennifer’

Members of the Philippines’ LGBTQ and
women’s rights communities say that Laude’s
death gave rise to an anger that first crackled like
fire and soon started to spread. In crowds, they
turned out to protest in front of the US Embassy
and a courthouse in Olongapo, calling for ‘Justice
for Jennifer” as they waved rainbow banners and
burned an American flag. In December 2015,
when a court found Pemberton guilty of homicide
and sentenced him to six to ten years of
imprisonment
 LGBT VICTIMIZATION

The children found her first. Playing along

the riverbanks in Caloocan City, to the north
of Manila, they ran across piles of stones and
discarded rubbish to where the woman
floated in the muddy shallows. Her long
black hair was a watery crown, her face
tilted towards the sky. Later that afternoon,
the police came and dragged her body onto
dry land and marked it as evidence. Her
name was Madonna—or Donna—Nierra, her ‘I’m scared every damn day’
sister announced through her tears. She was
23 years old, and she was found less than
two miles away from home.
 MENTAL HEALTH - SUICIDE

• LGB youth = 30% attempted

suicide (double the hetero
rate)
• School bullying increased the
risk of suicide (Bouris et al, 2016)

‘I’m scared every damn day’

ADDICTIONS
• Stressors and Discrimination:
Ecstacy: MDMA
• LGBTQ+ individuals may face unique stressors, including
discrimination, social stigma, and family rejection, which can
contribute to mental health challenges and substance abuse.
• Mental Health and Addiction
Higher rates of mental health issues, such as depression, anxiety,
and suicidality, among LGBTQ+ individuals may contribute to a
higher risk of substance abuse as a form of coping
• Barriers to Treatment
Inclusive and culturally competent healthcare is crucial for
addressing substance abuse within the community.
 WHAT ABOUT SCHOOL?
• What is DepEd Order No. 32 s. 2017 or Gender-
Responsive Basic Education Policy?
• Signed in 2017, DepEd’s Gender-Responsive Basic
Education Policy integrates “the principles of gender
equality, gender equity, gender sensitivity, non-
discrimination, and human rights” in elementary and
high schools across the country.
• The 2017 DepEd order hopes to ensure students are
protected from gender-related violence, abuse,
exploitation, discrimination, and bullying, as well as
to promote gender equality and non-discrimination
across levels.
Encourage individual well-being:
• Normalize mental health conversations: Openly discuss
mental health within the LGBTQ+ community and encourage
individuals to seek help when needed.
• Promote healthy coping mechanisms: Encourage stress-
management techniques like mindfulness, exercise, and
creative expression.
• Connect individuals to resources: Share information about
LGBTQ+-friendly therapists, support groups, and crisis
hotlines.
Remember:

Every individual is unique: Avoid generalizations and

respect the diverse experiences within the LGBTQ+
community.

Focus on empowerment: Promote self-acceptance,

resilience, and the power of community.

Celebrate progress: Acknowledge the strides made

towards LGBTQ+ mental health equity and continue
working for further advancements.
THANK YOU!
CASE 1

• A 15yo questioning female student presents to the school nurse asking

him to sponsor a Gay Straight Alliance (GSA) at their school. The best
school nurse answer:
A. “yes, of course I’ll sponsor a GSA”
B. “I’d like to but I’ll need to talk to the principal first”
C. “I think I’d like to talk to your parents first – we’ll be back in touch”
D. “You really need to talk to our school psychologist about this”
SC CODE 59-32-30A(5)
LOCAL SCHOOL BOARDS TO IMPLEMENT
COMPREHENSIVE HEALTH EDUCATION PROGRAM;
GUIDELINES AND RESTRICTIONS

• (5) The program of instruction provided for in this

section may not include a discussion of alternate
sexual lifestyles from heterosexual relationships
including, but not limited to, homosexual
relationships except in the context of instruction
concerning sexually transmitted diseases.
CASE 2
• 30yo transman who initiated social gender affirmation 5 years ago,
chest construction at 25yo, testosterone from 25-28yo. He grew a beard
and stopped taking T. Beard growth persisted. No menstruation for 5
years. He would like the option to become pregnant in the future
because he wants children but has legal concerns related to adoption.
As the NP you first:
A. Conduct an exam and draw labs
B. Conduct an exam, draw labs and refer to endocrinology
C. Conduct an exam, draw labs and refer to GYN
YOUR PATIENT WANTS TO
TRANSITION – NOW WHAT? The pdf is free

1. Google “WPATH
Guidelines”
2. Refer to a Psych NP or
other mental health
provider
3. Start hormone therapy

[Link]
RESEARCH ON HORMONES – IS IT
SAFE?

FTM MTF

• No increase in CAD found in 876 • Increased risk of CAD at

FTM pts (Gooren, 200) high doses.
• Increased risk of CA at low
doses
• If prior MI – PO estradiol
does not incr. or decr. risk for
further emboli
WPATH Standards of Care

The criteria for hormone therapy are as follows:

• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and
to consent for treatment;
• Age of majority in a given country (if younger,
follow the Standards of Care outlined in section
VI);
• If significant medical or mental health concerns
are present, they must be reasonably well
controlled
 Rx information taken from
Cavanaugh 2016
HORMONES FTM - OPTIONS

• Injectable Testosterone
• Testosterone Enanthate or Cypionate 100-200 mg IM q 2 wks (20 -22g x 1 ½” needles)

• Transdermal Testosterone
• Androderm TTS 2-8mg daily
• Topical testosterone gels in packets and pumps, multiple formulations (Testim, Androgel)
5 to 10 gm (50 to 100 mg of testosterone) applied topically daily
• Axiron 2% pump gel for axillary application 1 pump to each axilla daily

• Testosterone Pellet
• Testopel- implant 6-10 pellets q 3 to 6 months

• Buccal Testosterone
• Striant 30 mg buccal system q 12 hours
TESTOSTERONE

RISKS MONITORING

• Baseline CBC, CMP, lipids,

•  HDL  triglycerites
renal panel, fasting glucose
•  insulin resistance
• 3 month, then Q 6-12 mo
•  sleep apnea • CBC, liver enzymes,
• Infertility serum testosterone
• Q 6-12 mo
• Mental health changes
• Lipid profile, HbA1c
HORMONES MTF OPTIONS
• Oral Estrogen
• Estradiol (estrace) 2-6mg PO or SL daily(can be divided into BID dosing)
• Premarin (conjugated estrogens) 1.25-10mg PO daily (can be divided into BID dosing)

• Transdermal estrogen (preferred for 40yo)

• Estradiol patch 0.1-0.4mg twice weekly

• Injectable Estrogens [NOTE – shortage right now]

• Estradiol valerate5-20mg IM q2 weeks
• Estradiol cypionate2-10mg IM weekly

• Antiandrogens
• Spironolactone (aldactone) 50-400mg PO daily (can be divided into BID dosing)
• Finasteride (Proscar) 2.5-5mg PO daily

• Progestins – increase breast development, but CV risk, weight gain & depression
MTF – ESTROGEN

RISKS MONITORING
• CAD weight triglycerides • Baseline – CBC, CMP, lipids,
• libido glucose tolerance renal, fasting glucose,
• Gallbladder ds
testosterone, prolactin

• Infertility • 6mo. – serum testosterone &

estradiol
• Mental health changes
• Spronolactone carries risks of
• If on spironolactone
hypotension, hyperkalemia and • 1 mo. then 3mo. – lipids, lytes,
creatinine, glucose
renal insufficiency
 MTF SURGICAL OPTIONS (~30%)

• Removal of scrotum & penis

• Creation of vagina, labia, clitoris &
mons
• Breast augmentation
• Tracheal shave
• Facial feminization
• Brow
• nose

Taken from Schechter 2017 p.37

FTM SURGICAL OPTIONS (~30%)

• Phalloplasty with urethral • Chest reconstruction

reconstruction & creation
of scrotum (uncommon)
STAGED SURGERIES

• Genital FtM • Chest Contouring FtM

• Tissue removal from donor • Mastectomy
site • Revision of prior surgery to
• Urethral reconstruction decrease scarring and
• Implant prosthesis remove arm flaps
YOU’RE AN ORG LEADER/ MANAGER
WHAT CAN YOU DO?

• Know the law and standards related to LGBTQ

patients
• Train your staff – receptionist to CNO
• Work on the culture of your organization to make it
safe.
Joint Commission Standards (2011)

• The patient-centered communication standards for

Hospitals (CAMH).
• Elements of performance 28 and 29 under
RI.01.01.01, require access to a support person and
non-discrimination of care.

The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and FamilyCentered Care
for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL, Oct. 2011.
[Link].
RI.01.01.01 ELEMENT 29

“No longer considered to be simply a patient’s

right, effective communication is now accepted
as an essential component of quality care and
patient safety.”
HOSPITAL VISITATION

• January 2010 Centers for Medicare and Medicaid

Services (CMS) regulation required hospitals to
permit patients to designate visitors & prohibits
discrimination in visitation based on so/gi. 42
C.F.R. § 482.13
• Compliance with requirements for Medicare Conditions of
Participation (CoPs)
HOSPITAL VISITATION

• July 2011 Joint Commission standard – prohibition on

discrimination based on orientation or gender identity.
• “Prohibit discrimination based on age, race, ethnicity,
religion, culture, language, physical or mental
disability, socioeconomic status, sex, sexual
orientation, and gender identity or expression.”
RI.01.01.01 EP29 (p.48 of Joint Commission LGBT
doc).
CMS – EQUAL COVERAGE TO CARE IN
THE SAME NURSING HOME AS A SPOUSE

• Aug. 29, 2013 - CMS announced the guarantee of

Medicare coverage applies to ALL spouses regardless
of sexual orientation.
• Prior to this same-sex spouses with Medicare Advantage plans were not
eligible to live in the same nursing home as their spouse.
FMLA
• All spouses are now covered under FMLA if the employer is FMLA
covered. (3/15 injunction against same sex spouses dissolved by SCOTUS
Obergefell ruling)

FMLA may be used for

• The birth of a child, adoption or foster parent;
• To care for a spouse, son, daughter, or parent who has a serious health
condition;
• For a serious health condition that makes the employee unable to perform
the essential functions of his or her job; or
• For any qualifying exigency arising out of the fact that a spouse, son,
daughter, or parent is a military member on covered active duty or call to
covered active duty status.

[Link]
AFFORDABLE CARE ACT

• Section 1557 – Civil Rights provisions of

the Act.
• Applies civil rights protections to the Health
Insurance Marketplace created by the ACA – and
includes LGBT people
ACA & PREVENTIVE CARE

May 2015 DOL Guidance on the ACA confirms

• Plans cannot limit sex-specific preventive
services by gender identity. If a provider
orders the service it is considered appropriate.

[Link]
THE LAW

SC ANTI- TRANSGENDER
BILL
• S.1203 defeated May 4, 2016
TITLE IX -
EDUCATION
• Grimm v. Glouchester
(2015)
TITLE VII - EEOC • Appealed to SCOTUS

• Macy v. Holder (EEOC, 2012) – • Administrative guidance

gender non-conformity = gender.
 HOW DO I FIND AN
AFFIRMING PROVIDER?

[Link]
• Then click on: Resources – For Patients – Find a Provider
• A searchable provider directory (location, specialty,
transition care etc.).

Provider Directory at the Harriet Hancock LGBT

Center
RESOURCES

Locally
• Harriet Hancock LGBT Center
• IRIS = LGBT group on campus

Nationally
• The Trevor Project – suicide hotline for LGBT youth [Link] 1-866-
488-7386
• Trans Lifeline [Link] 1-877-565-8860

Providers [Link]
[Link]
HOW CAN AN LGBT PERSON KNOW
IF SOMEONE IS SAFE TO TALK TO?

• Go with your instincts

• If you get a bad vibe from someone – trust your instincts and get out of
there.

• Look for these symbols

WHAT WE CAN DO AS NURSES

• Be Authentic
• Encourage Authenticity in others
• Share
• Be flexible, scootch over a little, share the bench ≈ share the power
LAURA C. HEIN PHD, RN, FAAN
HEIN@[Link]