some point (Herman et al., 2019). In addition to risk factors common to the non-transgender public, elevated risks of suicidal thoughts and attempts were more likely among transgender people who report heavy substance use, poor general health, have a disability, or experienced recent homelessness or an arrest (Herman et al., 2019). Stress and mental health issues can increase the use of tobacco, alcohol, and other substances to relieve stress. In 2016, the Centers for Disease Control and Prevention (CDC) reported that 20.5% of LGB adults smoked compared to 15.3% of heterosexual adults (CDC, n.d.). This means that about one in five LGB adults is a smoker. Limited information exists on transgender tobacco use; however, it is reported to be higher than among the general population (CDC, n.d.). Although actual substance abuse rates are unknown, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports rates of 20% to 30% vs. 9% for the general population (Redding, 2014). In 2019, 7.6 million LGB adults > 18 had a mental health or substance use disorder. That is a 20.5% increase from 2018 (SAMHSA, 2020). Although cardiovascular deaths have declined since 2010, in the US there remains significant differences based on race, sex, and income (American Heart Association, 2020; Caceres et al., 2020). Caceres and colleagues (2017) found that sexual minority persons experienced a higher prevalence of elevated cardiovascular (CVD) risk because of largely modifiable conditions than their heterosexual peers. For women these included tobacco, alcohol, and illicit drug use, mental health issues, and elevated body mass index. For men the risks were because of tobacco use, illicit drug use, and poor mental health (Caceres et al., 2017). Repeat exposure to interpersonal stress (discrimination, family rejection, expectation of stigma), general stress (financial, life adversity, childhood trauma) and the potential for additional physical stress from hormone or antiretroviral treatments combined with risks of tobacco, illicit drugs, excess alcohol, and elevated BMI are believed to increase CVD risk.
These findings were based on subjective data rather than physical markers and show the need for further research. According to Caceres and colleagues (2020), cardiovascular health research in 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 (CDC, 2020b). A 2019 systematic review found 14% of transgender women have HIV; racial and ethnic breakdown is 44% African American, 26% Hispanic/Latino, and 7% of White transgender women (CDC, 2019). Sixty-four percent of new cases 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 (CDC, 2020b). Sexually transmitted infections (STI) are also more prevalent among MSM, in particular 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 (Kates et al., 2018). Lesbian and bisexual women are less likely to obtain routine care and are more likely to be overweight or obese (Blosnich et al., 2014; McElroy et al., 2016). 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 (White et al., 2017). 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 (Boehmer, 2018). 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.
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. Healthcare professionals traditionally receive minimal education about the LGBTQ population’s needs. The National LGBTQQIA+ Health Education Center (2016) 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 (Berkeley University of California, n.d.; New Jersey Institute of Technology, n.d.; University of California Davis, n.d.).
Healthcare Professional Consideration: Healthcare professionals should ensure that they keep up to date with the concerns and needs of the LGBTQ population through continuing education opportunities. Continuing education with a focus on human sexuality, sexual minorities, and specific aspects of LGBTQ healthcare can increase knowledge and provider/staff comfort, as well as decrease bias. identifying specialty providers familiar with LGBTQ concerns and risks and knowledge of local LGBTQ-friendly resources. Displaying sensitivity to the healthcare needs of all patients is an important step in decreasing healthcare disparity in the United States. In addition to self-education and national guidelines, healthcare providers and their patients benefit from
HEALTHCARE PREFERENCES
Martos and colleagues (2018) examined qualitative data from Lifestyle Interviews of LGB persons in three age cohorts from the Generations Study, looking for influences on healthcare preferences in the population. Findings centered around themes of stigma, expertise, identity, service type, and access. Stigma was the factor that most influenced participants’ preferences and communication with providers. Martos and colleagues (2018) defined stigma
as “real or perceived negative social attitudes directed toward participants about one or more of their identities” (p. 6). Findings showed that stigma influenced participants’ communication with their providers and varied from concern over one’s own comfort to comfort of both provider and participant. Although avoiding stigma was a high priority, there were many different ideas on how to achieve this in the healthcare experience.
Book Code: SWTX1525
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