Last week, the Human Rights Campaign Foundation – the educational arm of the country’s largest lesbian, gay, bisexual and transgender (LGBT) civil rights organization – published its annual “Leaders in LGBT Healthcare Equality Index” list. The Hospital of the University of Pennsylvania, Pennsylvania Hospital, Penn Presbyterian Medical Center, and Chester County Hospital, along with Penn’s Student Health Service, and the Penn Medicine Program for LGBT Health were all commended for offering equitable and inclusive care for LGBT patients. Our news site has more on the announcement.
Following the announcement of the recognition, on Friday, Judd D. Flesch, MD, an assistant professor of clinical medicine in the division of Pulmonary, Allergy, and Critical Care, moderated a discussion by some of Penn’s physician LGBT Health leaders about some of the biggest advancements in medical care and the critical next steps needed to improve care for this population.
The audience spanned a diverse group of medical students, nurses, trainees, residents/fellows, and other medical professionals, joined together by the common goal of improving care for this population. The panelists tackled preventive care, education, and family planning in depth, offered insight about surprising shortcomings and disparities in LGBT health, and mapped out crucial next steps to advance LGBT health in the United States.
Giang T. Nguyen, MD, MPH, a clinical associate professor of Family Medicine and Community Health, started the panel with a focus on preventive care, outlining both the current state of options, as well as goals for future research. For example, citing PrEP – one pill taken daily to prevent HIV infection – Nguyen explained that research in preventive care for men who have sex with men has far outpaced research on preventive care for women who have sex with women.
“It’s amazing how many providers in the community are not familiar with PrEP, and even among those who know about it, there a lot of folks that are not quite comfortable with prescribing it,” said Nguyen, who is also the executive director of Student Health Service at Penn. (Penn’s Student Health Service is one of only three freestanding college student health centers nationwide to be named an “LGBT Healthcare Equality Leader” by the HRC.) “The CDC recommendations are very clear. We still recommend condom use for folks who are taking PrEP to prevent other STDs, but we do a lot of PrEP prescribing at Penn Family Care and at Student Health as well.”
Nguyen also noted the importance of screening for conditions like syphilis (rates have increased in Philadelphia during the last couple years), as well as screening for sexually transmitted infections that may or may not be present. Additionally, vaccination against HPV and hepatitis A and B should also be done in primary care settings.
For women who have sex with women, screening for sexually transmitted infections, as well as screening for breast and cervical cancer can be valuable. The HPV vaccine is recommended by the CDC for adolescents and adults up to age 26.
“As we think about the diversity of gender identities out there, we need to consider what else we can do,” said Nguyen. “For example, are there better uses of anatomy inventories that health records can apply to determine the types of screenings to recommend? We really have to be vigilant.”
Every relationship is different, but we all do not have the same opportunities.
Allison Myers, MD, MPH, a clinical assistant professor of Family Medicine and Community Health, followed Nguyen’s prevention talk with an outline of current state and future goals of family planning for this population.
“Regardless of your gender and the type of relationship you’re in, if it’s a relationship where pregnancy is a concern, we offer contraception (at Penn Family Care),” said Myers, including hormonal contraception, and long acting reversible contraception like an intra-uterine device (IUD).
For trans men with a uterus, for example, they offer an (IUD), progesterone implant or shot, and condoms.
There are also ways to save preserve sperm and eggs before beginning hormone therapy.
Saving sperm is easier—once a patient gives a couple samples, they are cryopreserved at a clinic. The procedure costs about $350-$1000 plus annual storage fees. This may seem like a lot, but preserving eggs costs about $20,000 plus a yearly storage fee, making this cost-prohibitive for many people. (Patients have to take hormones to hyper stimulate the ovaries, then they have to go under sedation as a clinician harvests the eggs and then the eggs undergo a hyper rapid freezing process, then they ultimately have to form an embryo and implant that embryo in a uterus, all of which have their own associated costs.
More inclusive insurance coverage and cost lowering would of course help this disparity.
Once someone gets pregnant, they need pre-natal care. The patient can go to a midwife or Ob-Gyn. Another option is a family medicine doctor, who can take care of hormones, pregnancy care, and take care of the baby’s needs, allowing the patient to see one doctor through the entire pregnancy and postpartum period, receive lactation options, etc., offering a full continuum of care. Myers affirmed the importance of more research on the long-term impact of hormone therapy on sperm and eggs, increasing insurance coverage and affordability of egg cryopreservation, more trans-inclusive labor and postpartum care at hospitals, and more education on lactation options for LGBT patients.
Katherine Margo, MD, an associate professor of Family Medicine and Community Health, discussed the current state and future goals of patient care for LGBT patients, including how education and insurance shape the future availability of inclusive equitable care.
Every student in his/her first semester at the Perelman School of Medicine has a communications skills event with a transgender standardized patient who is experiencing something pretty benign – say knee pain or a sore throat – to instill that all people can experience common issues regardless of gender. They also learn about mental and physical health issues that are common among LGBT patients.
“They’re normal patients like everyone else,” Margo said. “When they have knee pain, it’s like when anyone else has knee pain. At Penn Family Care, the majority of our residents treat transgender patients thus greatly enriching their training.”
Margo promoted the idea of a national standardized LGBTQ curriculum for medical education with defined competencies that can be assessed. She said training in LGBT care should also be embedded in initial onboarding of staff, and finally, that a fellowship in LGBT medicine would be helpful to advance research in the field.
“Research is so important, both with health outcomes and epidemiology – there are lots of unanswered questions. Defining risk factors, collecting good epidemiological data on sex assigned at birth vs. gender identity, and appropriate screening all need to be studied more – there are a lot of opportunities,” Margo said.
Sexual orientation and gender identity
A common theme in promoting inclusive care for all patients, particularly with transgender patients, is making sure they are called by the name, gender, and pronouns that they identify with. Sometimes that information isn’t clearly displayed in electronic health records, but improvements are being made.
At Penn, for example, there is a spot in the EHR for “preferred name.” Margo notes that putting preferred pronoun near the header by the preferred name would make it easier for front line staff to properly identify patients more consistently.
Insurance is improving
Penn’s insurance coverage includes gender affirming care and some surgeries. PA Medicaid covers transgender care, and Veterans Administration insurance covers transgender care.
At the same time, many procedures are still denied coverage, such as electrolysis and tracheal shaving that are ruled as “cosmetic.” (Penn’s Student Health Insurance Plan is now one of few plans that includes coverage for electrolysis and tracheal shave).
More work is needed
The panel event closed Penn Medicine’s inaugural LGBT Health Awareness Week, but served as the most recent of many valuable conversations and actions to improve LGBT Health both within and beyond clinical walls at Penn.
“No matter what field you’re in, be the champion,” Myers said. “LGBT care is still relatively new and you can be the champion within your realm for patients. Be an advocate and when you see an unmet need, try to make it happen.”
For those interested in learning more, there is a monthly transgender health discussion group hosted by Penn Family Care, as well as a Philadelphia Trans Wellness conference (hosted by the Mazzoni Center) in August. Both events are free of charge and open to the public.