Meeting the Health Care Needs of the LGBTQ Community (podcast)

Dr. Kim: Some of the every day issues are pretty similar to the general population, but there are definitely some unique needs. STD (sexually transmitted disease) prevention is very important as are HIV prevention and HIV treatment.

With the evolvement of newer anti-retrovirals, we’re really not seeing the death sentence that we used to see in the past with HIV. It’s become more of a chronic disease, very manageable. A lot of our patients have very normal lives. There are still some challenges with HIV. It’s seen more as a chronic inflammatory disease. There is increased risk of cardiovascular disease, and more premature aging with HIV, but besides that, it’s come a long way.

Other LGBTQ issues include hepatitis. We’re more proactive about screening and preventing hepatitis A and hepatitis B in the gay population. In addition, we vaccinate for meningitis because there have been some outbreaks in the gay community.

Cancer screening is a little bit different. For the gay population, we have discussions about anal cancer screening. This is very controversial right now. There are some proponents in the LGBTQ community that do anal pap smears or just plain anoscopy during physicals for example, almost like when women get a Pap smear.

Dr. Champaneria: Transgender patients have unique needs. They need a multi-disciplinary approach to their healthcare. Sometimes access can be a problem. But once they find the right physicians and the right practitioners — who can help prescribe their hormones, can help them with their mental health and finding the right surgeons — that will provide them the best care possible. It is a very big team approach, definitely.

Dr. Kim: As these medical teams start forming spontaneously over time, we start getting to know who we are. I started to get to know Dr. Champaneria as a surgeon. Now we work together a lot. We share a lot of the same patients. There are a lot of mental health providers that refer to me for hormone therapy, and I refer back to them, and we all start knowing who we are. We start becoming our own community in that way as well.

Dr. Kim: As frequently as necessary. The guideline for gay men says STD testing should be done at least annually. A lot of our gay patients take PrEP. PrEP is Pre-exposure Prophylaxis. It’s a daily medication that is taken to prevent HIV.

We have some patients who are higher at risk for an STD, who can just call us and ask if they can get tested.

Dr. Kim: Condoms are very effective for some but not all STDs. Condoms are very effective at preventing STDs that are spread mostly through body fluid, such as gonorrhea, chlamydia and HIV.

But there are some STDs that are spread through skin-to-skin contact. Herpes and genital warts may not necessarily be prevented through condom use because the condom won’t completely cover the skin and provide a barrier in terms of skin-to-skin transmission.

Dr. Champaneria: Definitely, there is a rise in the number of STIs (sexually trasmitted infections) within our community because patients either by choice or through other various reasons don’t use a condom. Because of that, they don’t have that skin barrier. Patients sometimes will just say, they’re on PrEP, and so they don’t have that skin barrier.

Dr. Kim: PrEP is very effective, but it’s not 100 percent effective. Sometimes mistakes can happen just like they can happen with birth control. Someone may forget their pill, and then they end up getting pregnant. It’s always a good idea to try to be completely safe when you’re talking about a chronic condition that is lifelong.

Dr. Champaneria: And PrEP doesn’t treat herpes, or gonorrhea, or syphilis. It’s mainly geared toward HIV.

Dr. Kim: There is a potentially higher rate of throat cancer in gay men. There might be more HPV acquisition that occurs during their lifetime. But for now, there is no screening done for either in the general community, or specifically the LGBT community.

For anal cancer screening, that’s very controversial. Some options are to do anal Pap smears, or just a plain examination during the physical. A more specific exam is called an anoscopy, where we’re able to look at the lining to see if there are any concerns of any pre-cancer or cancer.

Dr. Kim: There is believed to be a slightly increased risk of obesity as well as some breast cancer and possibly ovarian cancer. Obesity, we feel is multi-factorial. There might not be as many pressures to attain a certain appearance in the community. In addition, there might be more increased risk of estrogen-dependent type cancers because obesity and increased body fat can increase estrogen levels. The screening is the same for breast cancer.

For ovarian cancer, there is less use of birth control pills, so there is a little bit more risk because birth control pills can be preventive. The lesbian community in general tends not to use oral contraceptive as much unless it’s for treating a non-contraception type condition.

Dr. Kim: For the bisexual community, I tailor the care toward where they are on the spectrum. There are some people who are more toward the heterosexual side. Some people are more toward the gay side, or the lesbian side.

The other thing that is also important is to just recognize and try to validate their perspective because a lot of times in the LGBT community they’re not recognized. They’re recognized as being in transition toward one orientation or the other. Sometimes they might just default to just being, and saying, “Well, I’m just going to be what people want to perceive me as.” Sometimes I find out that some of my patients are bisexual when I never even knew, and I thought they were straight.

Dr. Champaneria: The transgender community has a specialized set of issues that they have to deal with. One of them is gender dysphoria. Gender dysphoria is feeling depressed or anxious about the gender that they were born into. They identify with another gender. These patients can feel lonely. They can feel anxious. They can feel depressed. It’s important for them to seek the correct care for that, meaning seeking a mental health professional, a social worker, a psychiatrist, even a family medicine doctor.

Dr. Champaneria: My specialty is transgender classic surgery, and that means helping the patient reach their physical ideal in their gender transition. For certain patients, that involves top surgery. Top surgery basically means a mastectomy for my female-to-male patients, as well as breast surgery for my male-to-female patients. It’s either creating a masculine chest appearance or a feminine chest appearance. Another aspect of gender confirmation surgery is facial feminization. That basically involves restructuring different parts of the face to make it look more feminine.

Most of the patients who are undergoing the transition are candidates for transgender plastic surgery. There are certain guidelines that are given by the World Society for Transgender Health. Typically those patients have to be living in their gender of choice for one year, and also have a letter of approval from a mental health professional, letting surgeons, insurance and others know that they are ready for surgery and are good candidates for surgery.

The major risks for this surgery include the typical surgical complications that could happen, such as bleeding and infection. Sometimes there are asymmetries. Sometimes if we do nipple grafts for our transgender top surgery for female-to-male patients, those can have issues as well. The basic surgical complications could potentially occur, but they are rare.

Dr. Champaneria: Some of my patients actually don’t take hormones. Some of them undergo this transition process without the hormonal therapy. But often times they’re seeking counsel with an endocrinologist who prescribes hormones. For me as a plastic surgeon, I don’t have them come off of their hormones. I have them continue throughout their process.

Dr. Kim: The increased risks are mostly theoretical because when we’re treating with hormones we’re really just aiming for the physiologic levels of the goal gender that the patient has. Some people if they go on too much testosterone, they can get a rise in their blood count, which can actually predispose them for getting blood clots or any kind of thromboembolic phenomenon. For estrogen, there is a risk of getting blood cots as well. But again, the doses that we use are very physiologic. So, we don’t tend to see problems too much.

There is a theoretical risk for heart attack, stroke and cancer. But it’s hard to say if it’s increased. We definitely don’t sub-therapeutically dose or do something that’s different for what is age appropriate for that gender. When people are getting of age, these risks might go up, as they do in the general population.

Dr. Champaneria: As for injectable silicone for instant curves, I think in theory that sounds amazing to get an instant result, but I think that it is actually quite dangerous. There are other body contouring procedures that we offer that are more safe than injecting silicone. One is fat grafting, where we take fat from other parts of the body, process it, and then inject it again. You’re basically using your own body fat to give you those gentle curves.

Dr. Kim: There are a lot of words for for gender queer. The more general term is gender non-binary or people who do not completely identify with a male gender identity or a female gender identity, but are somewhere in between. People can be all over the spectrum. With hormone treatment for this population, we see where they want to go, and keep their treatment appropriate. But if they want to fully try to transition toward the opposite of their assigned gender, we take them kind of where they want to.

Dr. Kim: Members of the LGBTQ community can have children just like anyone else. There are different ways that this is pursued. For gay couples, it can be simple adoption, or doing a surrogacy type pregnancy where they get a donor egg. For lesbian couples, intrauterine insemination is an option. For transgender, it’s a little bit more tricky. Depending on where patients are with their transition, it can make pregnancy difficult.

A lot of times, for trans men, they need to consider whether or not they need to preserve oocytes, or preserve their eggs, before they go through hormonal transition because fertility might decrease. If they decide to do bottom surgery, or to have a hysterectomy, then that will make pregnancy impossible. For our trans female patients, again they might want to preserve sperm before they go through hormonal transition because hormones will suppress their ability to make sperm.

Dr. Kim: It’s unfortunate that despite all the progress that we’ve made and how welcoming people are, there is still a lot of discrimination. A lot of people still live in the closet, especially while they’re still young. There is increased depression and anxiety in the community. So, it’s something that we definitely pay attention to when we see our patients. We check in with them. People who are actually the happiest are the people who have completed their process of coming out, and are able to live the lives that they wanted to live. We actually see more of the issues with people who have not been able to come out because of fear of discrimination or rejection.

Dr. Champaneria: For members of the transgender community, surgery is kind of at the end stage. It’s not the first stage. The physical manifestation of plastic surgery should happen after they are getting treated for their loneliness, depression, anxiety. Transgender patients definitely need access to mental health professionals.

Dr. Champaneria: Age can vary, There is no exact number that we can pinpoint as practitioners. As early as possible, but the patient has to be comfortable themselves with their own sexuality.

Dr. Kim: There is a difference between gender identity versus sexual orientation as well. A lot of our transgender patients, they feel it when they’re as young as they can remember. There is a lot of discussion nowadays with parents, especially in pediatrics, to kind of sense and check in with their children about that, and if that’s the case, treatments are done before puberty as well.

Dr. Kim: It’s helpful. I think that patients definitely feel more comfortable, but I think what’s important is just knowing that your doctor is open minded, and open to learn if they don’t know.

Dr. Champaneria: I definitely agree with that. I think you should find a physician, a doctor who you trust and that you can openly and honestly discuss your issues and concerns with. It would be great if they are a part of the LGBT community, but that’s not a mandatory requirement. Just make sure that you’re comfortable with whoever you seek care with.