sexual minorities has not been prioritized because of other health concerns such as HIV/AIDS and substance use. In 2018, there were 37,968 new diagnoses of HIV in the US and its territories, with 69% being among gay and bisexual men. 51 A 2019 systematic review found 14% of transgender women have HIV, with 44% of these individuals identifying as African American, 26% as Hispanic/Latino, and 7% as White transgender women. 52 Sixty-four percent of new cases of HIV are among men who have sex with men (MSM), ages 13 to 34, with higher representation in African American and Hispanic/Latino groups. Use of pre- exposure prophylaxis is lower among these two racial/ ethnic groups than among White MSM. 51 Sexually transmitted infections (STIs) are also more prevalent among MSM, with more than 8 in 10 new cases of gonorrhea and primary and secondary syphilis, 10% of
new hepatitis A, and 20% of new hepatitis B cases are found in this group. 2 Lesbian and bisexual women are less likely to obtain routine care, are more likely to be overweight or obese, and less likely to receive screening mammography. 6,53,54 Lack of insurance or lack of knowledge about cervical cancer risk may contribute to the fact that only 74.6% of lesbian women obtain cervical screening compared to 83.3% of heterosexual and 77.9% of bisexual women. 54 As a group, lesbian and bisexual women have breast cancer risks from a higher BMI, higher frequency of nulliparity, socioeconomic disparity, delay in care, and potential lack of provider relationship, which should spur a conversation about screening mammogram before age 50. 56 When considering screening for cancer, clinicians should remember the maxim “screen what you have” in addition to considering surgical history and use of hormones to ensure thorough screening. 6
CARING FOR LBGTQ YOUTH
In the 1960s, Kohlberg hypothesized that gender- related development begins in infancy and continues progressively throughout childhood following three key concepts: gender constancy, gender consistency, and gender identity. On average, children develop gender constancy – stability across time in the identification of their gender – between ages 3 to 4 and gender consistency – recognition that gender remains the same across situations – between ages 4 to 7. 57,58 The development of gender identity appears to be the result of a complex interplay between biological, environmental, and psychological factors. 5,59 The period during which gender identity is clarified and
solidified is unclear. There is no single trajectory of gender identity development for gender minority children. Some gender non-conforming children experience significant distress, currently termed gender dysphoria. Signs of gender dysphoria may emerge as early as the preschool years. One study found that nearly all transgender men and women experienced gender dysphoria by age 7. Furthermore, most participants continued to experience gender dysphoria without treatment until their adult years. 60 However, gender incongruence in early childhood is variable whereas adolescents experience a more constant identity. 61
HEALTH CONCERNS OF LGBTQ YOUTH
Given the caveat that this group is under-studied, especially through prospective longitudinal studies, it appears that gender diverse children who come to clinical attention, on average, have poorer relationships with parents and peers, experience high rates of mistreatment from peers, and are at increased risk of physical and sexual abuse in childhood, as compared to their gender conforming peers. 31,62,63 Compared with the general population, LGBTQ youth are at a higher risk for a wide variety of health concerns: substance use, STIs, cancers, CVD, obesity,
bullying, isolation, rejection, anxiety, depression, and suicide. 1 It is difficult to tease out cause and effect in these associations. They also often receive lower quality of care because of stigma, lack of awareness among healthcare providers, and insensitivity to their unique needs. Twenty-nine percent of LGBTQ youth reported they had attempted suicide at least once in the previous year vs. 6% of heterosexual youth. In 2014, young gay and bisexual men accounted for 8 out of 10 HIV diagnoses among youth. 1
CHANGING MINDSETS
Healthcare providers must be caring and open in a non-biased way to provide an equal level of care for all patients. Sensing negativity may cause patients to withhold important information about sexual identity or avoid returning for follow-up care. It is important that personal belief systems are mutually exclusive of the healthcare relationships with all patients, including LGBTQ patients, to avoid influencing the interaction and quality of the healthcare provided. Although research and public advocacy groups cluster LGBTQ patients into categories, variances exist among each group, as do potential ethnic and familial risk factors.
These factors compound the serious nature of LGBTQ health risks. Healthcare professionals traditionally receive minimal education about the LGBTQ population’s needs. The National LGBTQIA+ Health Education Center 33 has published resources and maintains a website with webinars and learning modules. Knowledge of basic terms and definitions will assist in establishing a mutual understanding and increasing communication with LGBTQ people. 64-66 Previous studies have demonstrated that healthcare providers felt their medical education was inadequate in regards to issues
Book Code: CT24CME
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