Health Disparities in the LGBT Elderly Ethnogeriatrics Course

Health Disparities in the LGBT Elderly Ethnogeriatrics Course Feb 2011 Katherine Breitenbach, APN Charles Rhee, MD Erika Sullivan, MS 4 Megan Huisingh-Scheetz, MD, MPH

Case ¡ ¡ ¡ 71 yo F presented to clinic to establish care. PMH - Type 2 DM, HTN, HL, OA Soc Hx – l l ¡ 40 pyh tobacco, Remote etoh abuse? , No illicits Lives alone in 3 flat bldg, paranoid about break-in’s She is a “big spender” and has a “poor credit score, ” No children Fxnl Hx – l l Missed paying bills, Completed HS, Transfers and mobility limited by knee and shoulder OA GDS – 3/15, MMSE – 29/30

Case MD referred to SW for counseling for “anxiety” symptoms ¡ Pt revealed to SW that she had female sexual partners, denied being lesbian. ¡ Led to significant stress b/c of the lack of community acceptance. ¡ To date, MD and pt have never discussed pt’s sexuality. ¡

How might this issue affect her health? ¡ ¡ ¡ Risk factors Lack of social support networks POA and Living Will l ¡ ¡ Social Isolation and loneliness Psychological consequences l ¡ ¡ State variation Depression, Anxiety, Mistrust/Confidentiality/Fear of Judgment Government recognition of partner l Medicare benefit

Defining Gender and Sexual Orientation ¡ ¡ ¡ What is Gender: “A construct of biological psychosocial, and cultural factors generaly used to classify individuals as male or female. : What is Transgender: “An inclusive term to describe people who have gender identities, expressions, or behaviors not traditionally associated with their birth sex. ” What is sexual orientation: “Sexual orientation encompasses more than sexual behavior, because individuals may identify with a specific sexual minority group without expressing those behaviors. ” In contrast, they may practice sexual behaviors consistent with definitions of homosexuality but not define themselves within the terms gay, lesbian, or bisexual. Mayer et al. (2008). Sexual identity and gender minority health: what we know and what needs to be done. American Journal of Public Health 98(6).

Decreased Access/Utilization of Health Care services in the GLBT population ¡ ¡ ¡ Lack of utilization of services out of fear of judgement or discrimination Uninsured “Heterosexism” ¡ ¡ ¡ Less preventative measures, decreased risk reduction for illness Decreased screening Lack of population based research

Leading Health Indicators among Sex and Gender Minorities: Healthy People 2010 Leading Health Indicators in the General US Population ¡ ¡ ¡ ¡ ¡ Physical Activity Overweight and Obesity Tobacco Use Substance Abuse Responsible Sexual Behavior Mental Health Injury and Violence Environmental quality Immunizations Access to Care Areas of Increased Concern for Sexual and Gender Minorities

Caring for Lesbian and Bisexual Women: Considerations for Clinicians ¡ Tobacco Abuse l l ¡ ¡ ¡ Only demographic whose smoking increases with age LBT women smoke 200% more than other women** Overweight and Obesity Lower rates of Childbirth Increased rates of Breast Cancer l Screening for other CA is imperative, pap, mammogram, colonoscopy all at appropriate intervals **Bye, L. , Gruskin, E. , Greenwood, G. , Albright, V. , and Krotki, K. The 2003 California Lesbian, Gays, Bisexuals, and Transgender (LGBT) Tobacco Survey, Field Research Corporation, San Francisco, CA. 2004

Caring for Gay and Bisexual Men: Considerations for Clinicians ¡ HIV/AIDS l l l ¡ STD/STI l l ¡ Increased rates and recurrence of Syphilis CDC reccomends annual screening Hepatitis immunization HPV increased risk for anal CA Substance Abuse l ¡ 42% of new HIV infections/year s/e of drugs HART therapy increases lipids AIDS Dementia Increased risk for unsafe sex behaviors Eating and body image disorders

Caring for Transgender patients: MALE to FEMALE (MTF) ¡ FEMALE to MALE (FTM) ¡ l l Prostate/Breast/Cervical CA screenings still important aspect of care Long term effects of hormone therapy ¡ l Increased cardiovascular risk Violence/Stigma

LGBT Demographics http: //www. communitymarketinginc. com/documents/temp/CMIIndex 2011. pdf

LGBT Communities In US Cities

Heteronormative Behavior ¡ ¡ Attitude, language and behavior which stipulates that heterosexuality is “normal” and that all other gender pairings are “abnormal” Assumptions about sexual practice and orientation can be discriminatory and prevent individuals from accessing proper health care Interpersonal interactions ¡ Intended or unintended persecution and prejudice Legislated nationally ¡ Local, state and federal laws prohibiting same sex unions ¡ Power of attorney and next of kin Health care ¡ Intake questionnaire forms ¡ Sexual histories

Support and Resources for the Patient and Provider Healthcare provider Religious/spiritual Patient Legal Social

LGBT Healthcare Resources Gay & Lesbian Medical Association (GLMA) http: //www. glma. org Comprehensive listing of healthcare resources for LGBT patients, as well as for physicians seeking additional information on the care of LGBT patients Howard Brown Health Center - http: //www. howardbrown. org Chicago based LGBT health organization offering health care services to the LGBT community as well as information regarding services available throughout the Chicago area

LGBT Healthcare Resources (cont) The Body - The Complete HIV/AIDS Resources http: //www. thebody. com Extensive database on HIV/AIDS treatment, research, and educational material for both patients and providers The Ruth M. Rothstein Core Center http: //www. corecenter. org Integrated HIV/AIDS center in Chicago (Cook County Hospital/Rush Hospital) offering medical treatment as well as social services Illinois Dept. of Public Health AIDS Drug Assistance Program (ADAP) - http: //www. idph. state. il. us/health/aids/adap. htm

LGBT Social Resources Center on Halsted - http: //www. centeronhalsted. org Large Chicago-based LGBT community center offering a wide variety of social activities, as well as multiple support group meetings. Notably, http: //www. centeronhalsted. org/cohsage. html which focuses on LGBT activities for individuals 55 or older. National Resource Center on LGBT Aging http: //www. lgbtagingcenter. org/ Relatively new website still in progress which will address issues specific to geriatric LGBT populations

LGBT Social Resources (cont) Chicago House - http: //www. chicagohouse. org Organization devoted to providing housing and support to HIV positive patients who may be also impacted by poverty, homelessness, mental illness, or substance abuse Parents, Families, and Friends of Lesbians and Gays (PFLAG) - http: //www. pflagillinois. org/ National organization formed by LGBT allies with multiple resources regarding issues such as coming out or accepting a newly out family member

LGBT Religious Resources Gaychurch. org - http: //www. gaychurch. org/Find_a_Church/united_states/ us_illinois. htm Comprehensive listing of gay friendly churches (Christian/Catholic) in the Chicago land area, organized by location and denomination Hebrew Union College / Institute for Judaism and Sexual Orientation http: //huc. edu/ijso/Syn. Org/LGBT/list/ National listing of gay friendly synagogues

LGBT Legal Resources Lambda Legal - http: //www. lambdalegal. org National organization with numerous resources including information regarding LGBT specific medical-legal issues such as visitation rights, POA, and discrimination AIDS Legal Council of Chicago - http: //www. aidslegal. com/ Provides legal assistance and advocacy for people living with HIV/AIDS on issues such as access to care

Interventions ¡ Provider / Staff Education l l l Core competency and exposure during training Get to know local resources Understand the unique risks and challenges ¡ ¡ Clinical Encounter l l ¡ Social support, legal support services Neutralize discussion and language Routine Confidentiality Use patient preferred pronouns Welcoming Environment l l Unisex bathrooms Non-discrimination statement http: //www. qahc. org. au/files/shared/docs/GLMA_guide. pdf