Sept/October 2020
Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
LGBTQ+ Health & Wellness
In This Issue: • • • •
Physicians Wellness Collaborative Launches Honoring Choices COVID-19 Resource Guide Race in Medicine Webinar Luminary of Twin Cities Medicine
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Contents VOLUME 22, NO. 4 SEPTEMBER/OCTOBER 2020
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Minnesota’s Mark on Advancing LGBTQ+ Health Care
By James Pathoulas, MS3
4
President’s Message
No Judgment, Just Help
By Ryan Greiner, MD
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TCMS in Action
By Ruth Parriott, MSW, MPH, CEO
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Page 28
In this issue
Racism and Disparities in Mental Health By Diana Chapa, MD, Nakita Natala, MD and Raghu Gandhi, MD
LGBTQ+ Health
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• Gender Medicine in the Twin Cities: A Brief History
8 • Colleague Interview: A Conversation with Eli Coleman, PhD By Debra Thorp, MD
14 • Caring for Transgender and Gender Diverse Youth By Rhamy Magid, MD, FAAP 16
• SPONSORED CONTENT: Customized, Comprehensive Care for the LGBTQ+ Community
By Erik Stanley Haugland, MD 18 • LGBTQ+ Health: Looking Beyond the Language By Joshua Thompson, MD, MPH and James Smith, MD, MPH
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• The Future for LGBTQ+ Physicians is Bright
By Barrett Holen, MD
22 • Ending the Harmful Practice of Conversion “Therapy” By Jacob Thomas 24 • Transgender Hormone Therapy By Mary Sauer, PharmD, BCACP, AE-C, CDCES 25 • Special Considerations for LGBTQ+ End-of-Life Care By Beret Fitzgerald, Rachel Oldfather and Kerry Hjelmgren
Sept/October 2020
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Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
LGBTQ+ Health & Wellness
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Environmental Health — LGBTQ+ Community and Climate Change By Anna Johnson and Mike Menzel, MD
Page 5 MetroDoctors
Career Opportunities
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Luminary of twin cities medicine
Frank S. Rhame, MD
The Journal of the Twin Cities Medical Society
In This Issue: • • • •
Physicians Wellness Collaborative Launches Honoring Choices COVID-19 Resource Guide Race in Medicine Webinar Luminary of Twin Cities Medicine
The perspectives on LGBTQ+ Health and Wellness from several physicians and groups are featured and celebrated in this issue.
September/October 2020
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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.
Sept/Oct Index to Advertisers TCMS Officers
President: Ryan Greiner, MD President-Elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD TCMS Executive Staff
Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Annie Krapek, MPH, Senior Project Manager (612) 362-3715; akrapek@metrodoctors.com Amber Kerrigan, Program Coordinator (612) 362-3706; akerrigan@metrodoctors.com
COPIC..................................................................10 Crutchfield Dermatology...................................... Inside Front Cover Deaf and Hard of Hearing Services................ 2 M Health Fairview.............................................27 MedCraft..............................................................23 Minnesota Community Care.........................13 North Memorial...................Inside Back Cover Physicians Wellness Collaborative.................11 PNC Bank.......................... Outside Back Cover Red Pine Realty...................................................13 Schuster Clinic....................................................21
Kate Feuling Porter, MPH, Program Manager (612) 362-3724; kfeuling@metrodoctors.com
Do your patients have trouble using the phone due to a hearing loss, speech or physical disability? The Telephone Equipment Distribution Program offers easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Web: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.
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The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Minnesota’s Mark on Advancing LGBTQ+ Health Care Our country is referred to as the great social experiment. Consider how a scientific publication detailing this nation’s social experiment with LGBTQ+ rights would read: The introduction would recap America’s history of LGBTQ+ prejudice. The methods section would describe a power struggle marked by riots, lawsuits and a devastating AIDS epidemic. The results and conclusion would include stricken anti-sodomy laws, marriage equality and improved health outcomes. In the opinion of the Supreme Court that extended marriage equality to all Americans, Justice Kennedy wrote, “The nature of injustice is that we may not always see it in our own times.” His words, intended for LGBTQ+ persons, ring true for many movements and are particularly poignant following George Floyd’s murder. His death led to heated discourse that has caused many white Minnesotans, including myself, to realize that they failed to see the full extent of current injustice in our community. Dr. Chapa and her colleagues provide readers with a historical understanding of racism in health care and offer instructions that can be applied to actively listen and improve the healthcare experience for Black, Indigenous and people of color. Our Colleague Interview highlights the work of Dr. Eli Coleman, a pioneer who has advanced LGBTQ+ health through education and research. His interview touches on work at the Program in Human Sexuality and his well-known human sexuality course at the University of Minnesota Medical School. Gender affirming therapy is now offered by most health systems in the Metro. However, readers will understand this was not always the case after reading Dr. Debra Thorp’s article. Her piece examines how providers in our state worked together to redefine gender care and expand services for patients. While gender care has traditionally fallen under the scope of adult medicine, Dr. Rhamy Magid of Hennepin Healthcare offers a recap of gender care basics in the pediatric population. Dr. Magid’s work is an excellent example of how Twin Cities doctors are moving the needle on LGBTQ+ health care. Dr. Erik Haugland discusses his successful experience
By James Pathoulas, MS3 Member, MetroDoctors Editorial Board
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The Journal of the Twin Cities Medical Society
at North Memorial with gender care as a part of comprehensive primary care. His article features the importance and role of primary care in the lives of LGBTQ+ people. M Health primary care physicians Dr. Josh Thompson and Dr. James Smith follow with a useful guide for understanding the language needed to provide competent LGBTQ+ care. Their article offers knowledge that can be used by all readers. In a personal essay, Dr. Barret Holen shares coming to terms with his sexuality and professional identity as a physician. His thoughts are a reminder of the social navigation required of LGBTQ+ providers. Conversion therapy is a harmful practice that aims to “reverse” same-sex attraction. It remains legal in most of greater Minnesota. Jacob Thomas from OutFront discusses recent municipal bans and calls for all to take real action against conversion therapy. Pharmacist Mary Sauer provides an excellent framework for understanding medications used in gender affirming hormone care. She is followed by Beret Fitzgerald, MS4 and Rachel Oldfather, MS4, along with Kerry Hjelmgren, Executive Director, Honoring Choices MN, who have put together a guide that details special considerations on documentation at the end of life for LGBTQ+ people. Finally, Dr. Frank Rhame, our Luminary, shares how his passion for virology led to a prolific clinical and research career combating HIV/AIDS and now COVID-19. His lifetime of work has advanced the global fight against HIV/AIDS. The pages of this MetroDoctors issue contain information and stories from Minnesotans who have stepped up to make this a better world for LGBTQ+ people. Innovators for change, they have altered the course of the great American experiment. I hope that after reading this issue, our readers find themselves better able to see injustice and use new information to build a more equal Minnesota. Thanks to Marin Olson and Ryan Kenney for their comments on this Editor’s Message. September/October 2020
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President’s Message
No Judgment, Just Help Ryan Greiner, MD
T
here are many challenges facing physicians today, but one that I am most passionate about is physician wellness. We cannot serve others when we do not have balance and support for our own health. In the last year of my TCMS presidency, I am thrilled that the vision for a robust program for supporting behavioral health for physicians and their families has come to fruition. Physicians Serving Physicians (PSP) has offered confidential peer support to physicians experiencing substance use concerns for nearly 40 years and is excited to announce the launch of the Physicians Wellness Collaborative (PWC). In addition to substance use support, PWC will provide mental health and wellness support at no cost to physicians, residents, medical students — and their immediate family members — across their career lifecycle. All inquiries are confidential at (612) 362-3747, https://pwc-mn.org. Growing evidence is showing that despite higher levels of resilience than the general population, resilient physicians are still experiencing high levels of burnout (West et al., 2020). To move our impact further upstream, we are looking to partner with other organizations to promote system level interventions to address stigma towards mental health treatment, burnout, and moral distress in the physician community. The images you see on this page are the new “look” of PWC that can be shared free of charge within health systems and clinics. In addition, PWC is partnered with the Graduate Medical Education Office at the University of Minnesota. The partnership expands mental health and wellness options for Residents and Fellows across the state of Minnesota. Residents and Fellows can learn more about these resources by calling the Physicians Wellness Collaborative at (612) 362-3747 or visiting the website at https://pwc-mn.org. PWC is anchored by a new Executive Director, Timothy J. Usset MDiv, LMFT, MPH. Tim is a licensed marriage and family therapist who has worked extensively with moral injury, spiritual distress, and post-traumatic stress disorder on numerous clinical trials and clinical areas within the Veterans Health Administration. He is pursuing research on physician well-being, burnout, and moral injury as a PhD student at the University of Minnesota’s School of Public Health. Tim is available for individual or organizational consultation at tusset@ metrodoctors.com or (612) 362-3747. I encourage you to access these services and broadly share the resource with your colleagues. Let’s take care of ourselves in order to fulfill our dream of serving individuals and communities.
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TCMS IN ACTION Ruth Parriott, MSW, MPH, CEO
Public Health Advocacy Program Grows Threefold
If the number of applications for our Dr. Pete Dehnel Public Health Advocacy Fellowship are any indication, medical students are rising to the challenge of reducing health inequities rooted in racism and laid bare by the impact of COVID-19. TCMS is thrilled to welcome 30 UMN medical students to the 2020-21 cohort, tripling the size of our participants from past years. The incoming fellows have a wide variety of passions, including improving maternal health outcomes for women of color, addressing the impacts of climate change on health inequities, improving health outcomes for incarcerated individuals, and addressing high school drop out as a public health issue. This program would not be possible without our volunteer physician mentors who generously share their time and wisdom with the students. Follow TCMS on Twitter and Instagram @tcmsmn to meet the students and their mentors throughout the school year. MN CovidSitters Get a Boost from TCMS Foundation
The TCMS Foundation was honored to contribute the first major grant to MN CovidSitters, the new nonprofit founded by medical students to provide free childcare (and other supports) to essential healthcare workers. The $5,000 gift will help to provide liability insurance coverage for medical student volunteers and expand website capacity. Over 250 healthcare families have already been served. You can learn more about this
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innovative organization at https://www. mncovidsitters.org/. Honoring Choices Meets the Challenge
The novel coronavirus pandemic created an urgent demand for advance care planning for COVID-19 individuals, families and healthcare providers. Honoring Choices Minnesota has experienced a surge in requests for healthcare directive forms and guidance related to medical decisions for those who become seriously ill with a COVID-19 infection. In response, Honoring Choices created an educational guide on COVID-19 and advance care planning. The free resource is available at: bit.ly/HCMcovid-19. Advance Care Planning Information:
Advance Care Planning Knowing your voice is heard when making decisions about health care is important. Advance Care Planning is the process of preparing for a time when you may not be able to make your own medical decisions. The best time to make these decisions is when you are able to make your own choices. Health Care Agent Discussing and sharing your wishes with your loved ones, health care team and health care agent is important. A health care agent makes health care decisions based on your wishes if you are unable to communicate.
Health Care Directive By writing a Health Care Directive, you can make your voice heard so your wishes are followed. A Health Care Directive is a written plan outlining your values and priorities for your future medical treatment.
Your individual health care goals, values, and preferences matter greatly if you experience severe or life-threatening illness from COVID-19. People of any age with underlying medical conditions and people over age 65 have a higher risk of developing life-threatening illness with COVID-19. Complications from this virus could render you unable to make medical decisions for yourself. Due to your specific risk factors, you may have COVID-19-specific preferences you wish to convey. Your loved ones and health care team need to know who will make medical decisions for you and how you want to be cared for if you become critically ill. This guide is intended to help you address COVID-19 as a part of your advance care planning process. The most important predictors of survival are age and pre-existing conditions. To help you determine your risk level, visit: https://www.nhpco.org/wpcontent/uploads/COVID-19-Shared-Decision-Making-Tool.pdf.
Make or Update Your Advance Care Plan for COVID-19 1) Choose and ask a trusted adult to make medical decisions for you in the event that you become unable to communicate (this person is your health care agent). 2) Consider potential options for treatment, care, and support if you were to contract COVID-19:
Hospitalization Would you prefer to receive care in a hospital or at home? If you prefer to receive care in the hospital, do you wish to receive intensive care and CPR (cardiopulmonary resuscitation) as attempts to prolong your life? If you prefer to receive care at home, do you wish for skilled symptom management focused on comfort? Oxygen Support If recommended by your health care team, would you accept oxygen support? Oxygen treatment involves inhaling oxygen through a tube in your nose or mask over your mouth.
Mechanical Ventilation Lung failure is the main cause of death from COVID-19. If you become critically ill, a specialized team will determine if you are eligible for a ventilator, if one is available. A ventilator is a machine that pushes a mixture of air and oxygen in and out of your lungs to breathe for you. The machine connects to a tube that goes through your mouth and down your windpipe at the back of your throat. Inserting this tube down your windpipe is called intubation. When the tube is in place, you cannot talk or swallow. You will receive medicine to help stay calm while the tube is in place. Being on a ventilator requires care in the Intensive Care Unit (ICU) at the hospital. Early studies suggest that individuals placed on a ventilator for COVID-19 will likely require lengthy mechanical ventilation, and the risk of death increases the longer individuals are on a ventilator. If the ventilator does not improve your condition or your condition worsens, you will be assessed to see whether the ventilator can still help you. It may be decided that the ventilator will no longer help you, so the breathing machine may be stopped. You will be kept comfortable during this process, and the focus of your care will be managing your symptoms and providing comfort. If you have concerns about ventilator use based on your current health, contact your health care provider.
Medications Medications are used to provide sedation while on a ventilator or to provide symptom management. These symptoms may include: pain, shortness of breath, anxiety, nausea, and others. If you have concerns about specific medications used for treatment, talk with your health care provider and share with your health care agent.
Tobacco Control Policy Marches Forward
Despite the pandemic, commercial tobacco use remains the major cause of premature death in the US and in Minnesota. In May, advocates celebrated as the state legislature joined over 75 municipalities in raising the age for legal purchase of tobacco products to 21 statewide. Local policy is also advancing, especially around restricting flavored tobacco products, which are very appealing to young people. Edina recently passed an exemplary ordinance banning the sale of all flavored tobacco products, including menthol. Now is an ideal time to educate candidates for state and local office on tobacco prevention policies. If you’d like to get involved, contact Kate Feuling Porter at kfeuling@metrodoctors.com.
The Journal of the Twin Cities Medical Society
Changing the Culture of Physicians The use of race as a proxy for genetics perpetuates structural racism that contributes to health inequities. TCMS is proud to co-present with MAFP, AAPMN and MMA “Race in Medicine: A Conversation” featuring panelists Dr. Andrea Westby, Dr. Mary Owen, and Dr. Nathan Chomilo, and moderated by Dr. Zeke McKinney. This vibrant conversation was recorded on August 25 and is offered as a CME webinar linked on our website at metrodoctors.com. We strongly encourage you to watch this conversation with its predecessor “What’s RACE Got to Do With It? Race In Medicine” by Drs. Ebiere Okah and Andrea Westby, also a CME webinar linked on our website. One of the first steps in embracing anti-racism is to recognize the role institutions in the US have played in perpetuating racism, and medicine is no exception. TCMS recommends an excellent historical tutorial provided by the New York Times 1619 podcast. Episode four, entitled “How the Bad Blood Started,” details the actions of organized medicine to maintain segregation in healthcare settings. It can be found here: bit.ly/1619badblood. TCMS 10-year Celebration Still to Come!
Given the current requirements of social distancing, TCMS is (again) delaying our 2020 gathering in the hopes that 2021 will offer a more conducive environment. Stay safe, everyone! September/October 2020
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Racism and Disparities in Mental Health History
A brief internet search will reveal that psychiatry was first introduced as a medical specialty in the early 1800s and will outline how the field has advanced itself over the years with updates to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and discovery of evidence-based interventions. Harder to find is American psychiatry’s dark history of systemic racism that has harmed marginalized populations, particularly the Black community and used psychiatric diagnoses and theories to perpetuate racism. Authors of a chapter in the book Racism and Psychiatry (Gordon-Achebe et al., 2019) outline how leaders in the field publicized theories that elevated the white race and pathologized the Black race. These theories were accepted as scientific, but at their core reflected the dominant social political culture of the time. The psychiatric illness, “Drapetomania” was described by a wellknown proslavery American physician in the 1850s to identify slaves who did not conform and could be treated by whipping (Gordon-Achebe et al., 2019). In the late 1960s, a change in the DSM-II diagnosis of schizophrenia resulted in psychiatrists using the new paranoid subtype criteria to diagnose “hostile” and “aggressive” Black men connected to the civil rights movement with schizophrenia and justify institutionalizing them (Metzl, 2010). These are two of many historical examples of psychiatric disorders being used by dominant white Americans to oppress and fuel racial By Diana Chapa, MD, Nakita Natala, MD and Raghu Gandhi, MD
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Diana Chapa, MD
Nakita Natala, MD
disparities. As the world and social climate has changed in the United States, so has the field of psychiatry and how mental health diagnoses are utilized and at times weaponized against certain populations. What is still missing within mainstream current psychiatry training, research and patient care is how this history has been integral in generating the present distrust and the disparities that exist within mental health — particularly for racial and ethnic minority groups. Health Disparities
Health disparities in the US would not exist without structural racism. Centuries of racist practices has led to people from racial and ethnic minority groups being less likely to receive mental health care, evidenced-based treatment (US general surgeon 2001) and be included in research studies and more likely to use emergency rooms (Wang et al., 2000). In 2015, approximately 48% of white adults with mental illness received care, compared to 31% of Black and/or Latinx, and 22% of Asian adults (Agency for Healthcare
Raghu Gandhi, MD
Research and Quality, 2015). Racial and ethnic minority groups also have lower rates of using prescription drugs, outpatient services and higher rates of using inpatient services (SAMSA 2015). Barriers to care include: 1. Insurance/employment: 21.1% of Latinx Americans are uninsured, compared with 7.5% of white non-Hispanic Americans. Low rates of insurance coverage are likely to be a function of ethnicity, immigration status and citizen status (US census 2015). For American Indian populations, 21% lack health insurance, which is due to a higher rate of poverty, (26.6 % versus 14.7% national average). Higher unemployment and inflexible job demands affect the ability to arrange for transportation, child care and time off work. 2. Workforce: Lack of diversity among mental healthcare providers influence comfort levels when receiving care. 3. Lack of culturally competent providers: limited awareness of how culture
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The Journal of the Twin Cities Medical Society
influences perception of mental illness and idioms of distress commonly used in different cultures. 4. Implicit bias among healthcare providers: Black Americans more frequently receive a diagnosis of schizophrenia and less frequently receive a diagnosis of mood disorders (Gara et al., 2012). Physicians were 23% more verbally dominant and engaged 33% less in patient-centered communication with Black compared to white patients (Johnson R, et al., 2015). 5. Language barriers: Latinx Americans are more likely to report poor communication with healthcare providers. Studies have found bilingual patients are evaluated differently when interviewed in English versus Spanish. Limited availability of trained interpreters impacts communication. 6. Distrust in the healthcare system: Previous discriminatory experiences, unethical research practices, intergenerational trauma with forced removal from land, internment camp placement and separation from families. A Call to Action
The killing of Mr. George Floyd highlighted how systemic racism continues to have a strong hold in our society. In spite of knowledge gained, society and we in health care have allowed our institutional practices and policies to be driven and determined not by biological and social science, but by individual biases and a centuries old race classification and demarcation system that justifies white privilege. White privilege has then allowed for the ability to, without guilt, look away from the inaccurate, toxic racial ideologies that have contributed to the determinants that cause disparities. Racism and discrimination have real physical and emotional consequences that persist lifelong. Studies “point to discrimination as a clear contributor to the racial/ethnic health disparities observed for African American, Latino, and Native American populations, compared to their white counterparts” (A. D. Benner, 2018). Census Bureau data as reported
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onUS households’ emergency weekly surveys shows that since the video showing Mr. Floyd’s killing, depression and anxiety symptoms have continued to increase and especially in Black and Asian Americans (A. Fowers, 2020). Racism, microaggressions and biased thought and behavior remain a daily occurrence. Health care is no exception. As an institution it has continued to function with policies that do not promote a diverse professional climate, continues to train in a culture that perpetuates biases and continues to provide biased influenced care with consequences over which our patients have no choice but to bear. Today society finds itself at a turning point. It has become uncomfortably difficult for us to continue with the status quo of the past. The time is now for the institution and providers of health care to lead the way to an anti-racist society and to function as an institution that accepts the genuine and detrimental consequences of unaddressed racism and biases. What can each of us do to contribute toward this anti-racist movement? 1. Commit to learn about and accept how racism, an invented social construct, has impacted us. 2. Demand and support workforce diversity and inclusive work environments. 3. Implement implicit bias training and make changes to our general medical education curriculum to include topics around racism, diversity, equity and inclusion. 4. Commit to having the difficult conversations about racism and necessary change. 5. Advocate for research and allocating of resources to address the determinants that contribute to healthcare disparities. Without our commitment to action, the biases, microaggressions, white privilege and racism will continue. With the knowledge we have gained and the visual evidence we now have of needless loss of life, we can no longer justify inaction as racial inequity will easily continue with inaction. Today, we know inaction is complicit racism.
The Journal of the Twin Cities Medical Society
Diana Chapa, MD, has been working as a child and adolescent psychiatrist and consultant for the past 25 years. She has held positions as both clinical and medical director for inpatient psychiatric services. She has also enjoyed teaching in the Ethnic Studies Department at St. Cloud State University, and in the Child and Adolescent Psychiatric Departments at University of Minnesota and Medical College of Wisconsin. Nakita Natala, MD, Child and Adolescent Psychiatrist, Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Minnesota. Dr. Natala is passionate about cross-cultural psychiatry, global mental health and developmental disorders, particularly autism. Raghu Gandhi, MD, is an Assistant Professor at the University of Minnesota and is board certified in Child and Adolescent psychiatry. Dr. Gandhi is passionate about children’s mental health and neurodevelopmental disorders. References 1. Gordon-Achebe K., Hairston D.R., Miller S., Legha R., Starks S. (2019) Origins of Racism in American Medicine and Psychiatry. In: Medlock M., Shtasel D., Trinh NH.,Williams D. (eds). Racism and Psychiatry. Current Clinical Psychiatry. HumanaPress, Cham. 2. Metzl, Jonathan M. Protest Psychosis: How Schizophrenia Became a Black Disease, Beacon Press, 2010. 3. Aprile D. Benner, Y. W.-P. (2018). Racial/Ethnic Discrimination and Well-Being During Adolescence: A Meta-Analytic Review. American Psychologist, 73(7), 855-883. 4. Johnson R, et al. “Patient race/ethnicity and quality of patient-physician communication during medical visits.” Am J Public Health. 2004. 94(12), 2084-90. 5. Alyssa Fowers, W.W. (2020, June 12). Depression and Anxiety spiked among Black Americans after George Floyd’s death. Washington Post. 6. Gara MA, Vega WA, Arndt S, et al. Influence of Patient Race and Ethnicity on Clinical Assessment in Patients With Affective Disorders. Arch Gen Psychiatry. 2012;69(6):593–600. 7. Wang PS, Berglund P, Kessler RC. “Recent care of common mental disorders in the United States: Prevalence and conformance with evidence-based recommendations.” J Gen Intern Med. 2000. 15(5), 284-292. 8. Agency for Healthcare Research and Quality. 2015 National Healthcare Quality and Disparities Report. 2016. 9. US Census. Health Insurance Coverage in the United States. 2015. https://www.census.gov/ content/dam/Census/library/publications/2016/ demo/ p60-257.pdf.
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LGBTQ + Health
Colleague Interview: A Conversation with Eli Coleman, PhD
E
li Coleman, PhD, (Pronouns: he/him/his) is Professor and Director of the Program in Human Sexuality in the Department of Family Medicine and Community Health, University of Minnesota Medical School. He holds the first endowed academic chair in sexual health in the country. Dr. Coleman is the author of numerous articles and books on compulsive sexual behavior, sexual offenders, sexual orientation, gender dysphoria, chemical dependency, family intimacy, and on the psychological and pharmacological treatment of a variety of sexual dysfunctions and disorders. He is one of the founding editors of the International Journal of Transgenderism and is the founding and current editor of the International Journal of Sexual Health. He is one of the past-presidents of the Society for the Scientific Study of Sexuality, the World Professional Association for Transgender Health (WPATH), the World Association for Sexual Health, the International Academy for Sex Research and the Society for Sex Therapy and Research. He is currently the Chair of the WPATH Standards of Care Revision Committee. He has been a frequent consultant to the World Health Organization (WHO), the Pan American Health Organization (the regional office of WHO), and the Centers for Disease Control and Prevention.
How did you begin a career in sexual health? It was mostly accidental. I was training to become a psychologist and came to the University of Minnesota to finish my doctorate where I discovered the Program in Human Sexuality (PHS). I was looking for a dissertation topic and decided to study sex therapy. Keep in mind, at that time very little was known, and it was a wide-open area for research. Afterwards, the PHS was offered a faculty position. I took the position thinking I would take it for a year or two, however, I am still faculty 40 years later. The reason I stayed on as faculty was the work. My work is about a very central aspect of people’s lives and examines the essence of being human.
The University of Minnesota Program for Human Sexuality recently celebrated 50 years. How has the program changed over time? It has changed a great deal. The program was established in the 1970s, on the wings of the sexual revolution. It was really 8
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started to train medical students. At that time LGBTQ+ issues were new in public discussion and physicians didn’t have needed training. Minnesota was an early pioneer in establishing this type of program. This was made possible through new federal and foundation grant funding for medical training and research in sexuality throughout the 1970s. However, in the 1980s much of this national funding disappeared and other medical schools had to close their training programs. At Minnesota, we were able to build up our clinical services and our teaching and research efforts “survived” on clinical revenue. The 1980s was a difficult time for sex research. During the Reagan-Bush era we saw very little funding for human sexuality studies on a national level and there was less emphasis on research. However, the HIV/AIDS epidemic was a turning point and there was again recognition that research in human sexuality was an important part of improving human health. We developed funding for post-doctoral fellows and rebuilt a robust research program. MetroDoctors
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What has the program achieved? The Program for Human Sexuality is the largest sexual health institute in the United States. We have taught human sexuality to every medical student at the University of Minnesota since 1970. The program has also trained more postdoctoral fellows in human sexuality than any other institution. We also created the first two endowed academic chairs in sexual health in the United States. Our publications have advanced sexual science and have been cited more than 12,000 times.
How did Minnesota become a thought leader on the topic of human sexuality? A core group of interdisciplinary visionaries came together and set down some fundamental principles that have guided us throughout the history. It is particularly interesting that the program began with a synergy of faculty from the Medical School and local faculty from several theological seminaries.
How has research surrounding human sexuality changed since the 1970s and 1980s? Much of the recent funding for HIV/AIDS has gone toward biomedical projects; therefore, we have shifted toward research on sexual abuse and aggression and compulsive sexual behavior. There is a renewed focus on women’s sexual health issues and we have a very strong research program focusing on transgender health. We also have a new NIH funding grant to develop models of training health professionals in sexuality.
How has sex and sexuality research based at the University of Minnesota improved the lives of people both within Minnesota and globally? The early efforts of the program were focused on training medical students. Minnesota was a pioneer; we published a lot of work that had a big impact on medical education throughout the country. Through our research and training, we have had profound impact on a variety of issues: physical disability and sexuality, family sexual abuse, gay affirmative health care, sexual offending, chemical dependency and family intimacy, sexual aggression, compulsive sexual behavior, HIV prevention, women’s sexual health and transgender health. These are issues that directly or indirectly impact every individual, family and community in Minnesota and around the world. We have changed and improved lives through our research, education, clinical services and advocacy efforts. MetroDoctors
The Journal of the Twin Cities Medical Society
How has the care provided to LGBTQ+ people changed over time within the field? I would say the 1980s was a time when people, including myself, were really promoting gay-affirmative approaches to therapy. Around that same time the Program in Human Sexuality took on the Gender Program from the Department of Psychiatry and shifted the focus not only on gender affirming surgery but working to establish standards of care that were evidence based for hormone and mental health therapy and holistic aspects of care. I would say today there is an emphasis on wellness and evidence-based medicine that wasn’t present 20 years ago. I like to make an “outrageous” claim that our program has changed the climate for LGBTQ+ people in our state through the education of doctors and other healthcare providers. They were opinion leaders that contributed to the passage of marriage equality referendum.
How have conversations surrounding race and sexuality changed since the death of George Floyd? They have completely changed. We have been talking about and looking at race and sexuality before the term “intersectionality” was invented but we realize now that we were still only scratching the surface. Our programs and research need to have a diversity of races, ethnicities and sexualities. One thing we are looking at is helping people understand that implicit bias is not just about sexual orientation or gender identity but race and understanding how those interact. There is not a simple solution, however we are looking at what we are doing right currently and how we can make lasting changes within the program. It is an ongoing discussion, and we have a lot to learn. There is greater support for us to address race more directly.
What past policy/legislation changes are you most proud of? I was the senior scientist and editor of former US Surgeon General David Satcher’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior in 2001. This document is still the most comprehensive vision of sexual health promotion for our country. Since then, there is much more recognition that sexual health is fundamental to overall health and well-being. Sexual health has been legitimized as a national health issue and recognized need for research and education. (Continued on page 10)
September/October 2020
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LGBTQ + Health Colleague Interview (Continued from page 9)
What has been a difficult part of being in your position as director? We went through a very rough time in the 1980s both in terms of our education and research efforts. It was a conservative time and we faced a lot of criticism of the value of our course from our own medical students. Ultimately, we gained support from faculty who were practicing physicians, had taken the course previously, and knew the value. Research funding was challenging but we persevered and came into a better era that helped us grow and become what we are today.
What are the next steps to improving sexual health within the United States? Education. Education. Education. We also need to conduct research with public health implications, translate our research and inform leaders involved in public policy, and develop evidence-based treatments for clinical care. This is how we move forward.
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How have trainees’ and physicians’ attitudes toward LGBTQ+ people changed since you first started teaching? They have changed tremendously. Our course from the very beginning addressed diversity. It started with teaching students to have a professional attitude and helping students become comfortable talking about sexuality. Over time, the program has had a tremendous impact on physicians within our state. We could tell easily in residency programs who came from the University of Minnesota compared to other medical schools who had lost their sexuality training programs. Our research showed that students at the University of Minnesota were more comfortable bringing up topics about sexuality and being sensitive with patients. I remember when we would discuss treatment for transgender patients, students in the 1980s would give us a look as if we were doing something inconceivable. However, we provided education and powerful patient testimonials. It was about getting a real person in front of students and having that person share their story. It becomes less abstract that way. Today, students are already familiar with transgender issues and typically have a sense of activism and social justice perspective. Instead of being resistant to working with sexual and gender minorities, they want to know how they can do more and learn more. I feel students today appreciate what we do and push us to do more — it is really nice.
MetroDoctors
The Journal of the Twin Cities Medical Society
LGBTQ + Health
Gender Medicine in the Twin Cities: A Brief History
I
magine your patient has a condition with somewhere between a five and 40% mortality rate (depending on the study), and you have something that will most likely help. There is even a multinational organization that guides appropriate treatment. But most insurance policies won’t cover it because treatment is deemed to be “medically unnecessary.” So some of your patients can afford treatment, but many cannot. Those who cannot afford treatment and even some of those who can, are unable to live the lives they were meant to live, leading to increasing problems with depression, anxiety, substance abuse, PTSD and hopelessness. Because of discrimination in society, many end up turning to sex work and contracting HIV. Others succumb to the mental health dangers of being denied medically necessary care and/or the ongoing discrimination in society. How would you feel? What would you do? This is what it was like to practice what is now called “Gender Medicine” back in the early 1990s when I first started prescribing hormones and doing hysterectomies for transmen. It was hard work, both literally and emotionally. It was (and still is) a labor of love for my LGBTQ+ community. It took a little while to be able to find my fellow Gender Medicine practicing colleagues in the larger community, though I was very lucky to have been led into this work by my senior partner, Mario Petrini, MD. He was a mentor to me in so many ways that it would take a whole separate article to enumerate them. In more than just this one area, he helped me understand the principles of medical By Debra Thorp, MD
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practice; and the transgender and gender non-conforming patients I inherited from him as he gradually retired taught me much in those early days. I am forever grateful to them, as well, for opening my eyes to their everyday realities. What I and my fellow Gender Medicine colleagues across the city did in the beginning, and continue to do now, was to find all the resources that we could find to provide the best possible evidence-based care. There were a few books and journal articles then, as well as the Standards of Care from what was then the Harry Benjamin Society and is now the World Professional Association for Transgender Health (WPATH). Fast forward 30 years — now there is a Transgender Center of Excellence in San Francisco and Los Angeles and the Fenway Clinic in Boston to provide resources online and in written form. WPATH has continued to provide updated Standards of Care (Version 8 is due out soon). There are journals like Transgender Health. And many local healthcare organizations, including HealthPartners, are working to provide ALL clinicians and support staff of all types the kind of education they need to provide respectful, competent care. At Park Nicollet, we have founded a Gender Services Clinic through which we can provide much of the care that our patients need. Where we can’t provide that care ourselves, we work with partners to do so. To have the support of one’s partners and administration to provide care to people who need it so much is one reason I have been so grateful to practice where I do. I am also grateful to still be doing Gender Medicine when most insurance, including Medicare and Medicaid, cover transition care. This is
because Article 1557 of the Affordable Care Act has been interpreted to include sexual orientation and gender identity in the provision where discrimination is illegal based on sex. I understand the practice of Gender Medicine did not start in the Twin Cities with Mario Petrini. Dr. Petrini had run a Gender Identity Clinic while practicing in Detroit. When he moved to the Twin Cities to practice at what was then the St. Louis Park Medical Center (now Park Nicollet Clinic, part of HealthPartners), he began prescribing hormones and doing hysterectomies. The Program in Human Sexuality had been established here long before that, practicing Gender Medicine with hormones, gender affirming surgeries, and the provision of cutting edge mental health services. In fact, the staff at the Program in Human Sexuality, led admirably by Dr. Eli Coleman, have been integral to WPATH for decades, and continue to be extremely active in that organization. Dr. Coleman has been a leader in the development of several versions of the WPATH Standards of Care, including the soon to be released 8th version.
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The Journal of the Twin Cities Medical Society
In the intervening time, the number of Minnesota clinicians who provide mental health services, prescribe hormones, provide respectful primary care, do gender affirming surgeries, and are strong members of or allies to the transgender and gender non-conforming communities has grown exponentially. A small group of us from several clinics across the Twin Cities used to meet every other month at a local restaurant to provide each other support and co-strategize on how to get the needed care to our patients. Now, while we still have that small local group, there are huge numbers of clinicians who do provide this care across the state. Primary care and OB/ GYN residents are educated in the care of sexual and gender minority patients as a matter of course in their residencies. JustUs Health puts on the Opportunity Conference every year to bring community and care providers together. And they are about to launch a website to help community members seeking Gender Medicine care as well as clinicians looking for resources for their patients. This was unheard of in the past, but is a fabulous demonstration of how far we’ve come. For more information on the current status of care for the Trans and Gender Non-Conforming Community, please visit this website: https://www. justushealth.org/VOH for the most current Minnesota information. I wish this could just be a positive article about life being rosier now for our patients and those of us who provide their care. The reality is however, that our transgender and gender non-conforming patients continue to face discrimination in everyday life. It can be very dangerous for transwomen, especially transwomen of color, to be out in the world. At least 16 transgender people (mostly transwomen of color) have been murdered in the US so far in 2020 and reported as hate crimes based on their being transgender. Discrimination in the workplace, in housing, in education, in health care, and many other avenues of life is still too real for our patients. The recent Supreme Court Decision on June 15, 2020, stated that the 1964 Civil Rights Act protects gay, lesbian and transgender employees from discrimination in the workplace based on sex, which should help reverse some of that MetroDoctors
structural discrimination. Hopefully, that decision will also be used to reverse the recent executive ruling (effective August 1, 2020) by the Department of Health and Human Services that does allow discrimination on the basis of sexual orientation and/or gender identity, in reversal of the Obama era interpretation of article 1557 of the Affordable Care Act. I am worried that we will go back to insurance (public and/or private) not covering medically necessary treatment of Gender Dysphoria. This has been a brief overview of a short time in the history of one area of medicine in the Twin Cities. An area in which I have been grateful to be involved. I look forward to what the next 30 years will bring! Debra Thorp, MD, has worked as an OB/ GYN at Park Nicollet for over 30 years; Gender Medicine has been a large part of that practice for most of that time. She is currently the Medical Director of the Gender Services Clinic after serving in a variety of leadership roles within the Department of OB/GYN at Park Nicollet Clinic and Methodist Hospital.
The Journal of the Twin Cities Medical Society MCC_6.10.19 Ad_English_5x5_r4.indd 2
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LGBTQ + Health
Caring for Transgender and Gender Diverse Youth
R
ecent years have seen an increasing recognition of the human and medical rights of transgender and gender diverse (TGD) people in the United States. As such, there has been an effort in the medical community to increase awareness and knowledge of optimal care for TGD individuals, including young people. TGD people, and particularly TGD people of color, bear a disproportionate burden of morbidity and mortality. It behooves us to do a better job medically, as one step toward a more equitable society. This article will focus on the care of TGD youth, but the reader interested in more detailed care guidelines for both the adult and pediatric populations is encouraged to examine the Endocrine Society’s Clinical Practice Guideline (Hembree, 2017) and the website of UC San Francisco’s Center of Excellence for Transgender Health (UCSF Center of Excellence for Transgender Health, n.d.). Due to the necessarily short format of this article, an in-depth review of the diagnosis and management of gender dysphoria (GD) is not possible. The focus here will be: 1) to define GD and discuss the rationale for treatment; 2) to review the specific modalities of medical treatment for children and adolescents; and 3) to touch briefly on ethical and other considerations the practitioner should attend to when caring for this group of young people.
By Rhamy Magid, MD, FAAP
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harassment, homelessness and verbal and physical abuse, among other external stressors and stigma. In the section on treatment below, we will discuss how, even in the absence of pharmacologic interventions, we can help mitigate a significant portion of the mental health burden by simple social interventions such as using preferred names and pronouns. Modalities of Treatment
Gender Dysphoria
GD is defined as the distress experienced due to a conflict between one’s sex assigned at birth and one’s gender identity. It is important to emphasize here that it is the distress which is pathologic and treatable. TGD identity is not a pathology; it is an identity factor. But if there is associated distress (i.e. GD is present) and it goes untreated, there is significant risk for morbidity and mortality. TGD individuals experience substantially higher rates of anxiety, depression, substance use disorder, self-injury, and suicidal thinking and attempts (Olson K. e., 2015). Forty percent of transgender adults report having ever attempted suicide (James, 2016). Among TGD youth, estimates of the prevalence of suicide attempts range from 25-32%. (Olson J., 2015) These mental health comorbidities do not arise from the TGD identity itself, but rather they likely result from a combination of GD and minority stress, as these youth experience a significant amount of peer and family rejection,
Before discussing medical treatment of GD, it is critical to pause and point out that TGD identity does not presume the presence of GD. While some TGD individuals experience GD and desire treatment, a significant proportion do not desire any intervention. It is, therefore, critical for the medical provider to listen to their patients. Explicitly ask about the presence or absence of distress around gender incongruence. Ask about goals of treatment. Do not presume that an individual desires an outward appearance consistent with our society’s prevailing image of “masculinity” or “femininity.” What matters for your patient is what makes them feel whole, with an aligned body-mind existence, thereby reducing or eliminating mental health comorbidities and improving quality of life. Once it is established that the TGD pediatric patient is experiencing GD and does desire treatment, then the treatment offered will depend on their pubertal status and age. Once again, it is critical to listen to the youth and their parents regarding goals of treatment, and not to presume to know the desired outcome based solely on stated gender identity.
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The Journal of the Twin Cities Medical Society
The prepubertal youth does not require any medical intervention. Because they have not yet reached Tanner stage 2, they do not meet criteria for treatment with a puberty-blocking medication. But that does not mean we cannot, as medical providers, offer life-saving interventions. At this developmental stage, the child is in the midst of formative experiences that will shape how they perceive the world and its acceptance or rejection of them. If their parents, teachers and peers reject their gender identity, a crucial part of who they are, then they learn that they are unloved due to an inherent and immutable identity factor. If, on the other hand, we can help guide the parents to be unconditionally supportive, the child is likely to avoid the mental unhealth comorbidities described above. For example, Olson et al. described prepubescent youth who were socially supported (i.e. at home, school and in public, they used the names and pronouns that matched their gender identity — not their assigned sex). They were found to have depression measures on par with (and anxiety levels only slightly higher than) their cisgender siblings and age-matched non-sibling controls. (Olson K. e., 2015). The early pubertal child, who has reached at least Tanner stage 2, may be eligible for treatment with a puberty-blocking medication (commonly known as “blockers”). The first-line option for such treatment is a long-acting gonadotropin releasing hormone (GnRH) analogue (Hembree, 2017), the most common of which are leuprolide and histrelin. The GnRH analogues act at the level of the pituitary, desensitizing receptors and thereby halting downstream production of the sex steroids testosterone and estrogen. The result is the cessation of development of secondary sex characteristics. In natal males, virilization will stop. In natal females, breast tissue will become atrophic and menses will stop (or will not start in the premenarchal person). This results in significantly improved psychological and physical outcomes for the individual, reducing their present dysphoria and potentially minimizing or even
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precluding the need for future surgeries (de Vries, 2011) (Turban, 2020). Treatment with GnRH analogues is fully reversible, and if the patient desires to terminate treatment, they will resume their natal/ endogenous puberty (Hembree, 2017). Finally, in the older adolescent, we may begin to use hormone therapy (i.e. testosterone or estradiol) to initiate a puberty that aligns with their gender identity. Historically, the age of such initiation was 16 years, but this was a somewhat arbitrary threshold, and it certainly does not align with the timing of puberty onset in the vast majority of the population. The current guidelines acknowledge this fact and suggest that a lower limit of 13.5 years may be more appropriate. Using a gradually increasing dose of the respective sex steroids, the pubertal process yields secondary sex characteristics that align with the individual’s identified gender. Unlike with the GnRH agonists, which are fully reversible, the effects of sex steroids are considered partially reversible. For example voice deepening, clitoral enlargement, and scalp hair loss in those taking testosterone, and breast development in those taking estradiol, will not regress if the individual stops taking the medication. To the question of safety, hormone therapy has long been used in the treatment of adult transgender persons and has a track record of safety. A growing body of peer-reviewed literature is now emerging demonstrating that it is also safe in adolescents (Jarin, 2017). Ethical and Other Considerations
First and foremost, see the human being in front of you. As humans, we all desire to be heard and respected. Your TGD patients are no different. Even if you do not feel comfortable with the medical management of GnRH agonists or hormones, you can still foster a trusting and supportive relationship with your young patients. You can use their preferred names and pronouns, and ensure that all your staff do the same. You can listen to your patients’ stories and validate their experiences. You can make
The Journal of the Twin Cities Medical Society
appropriate referrals — to gender specialists, mental health providers, endocrinologists, surgeons, etc. But if you choose to ignore their experience, you risk missing the opportunity to prevent adverse medical and mental health outcomes, up to and including suicide. With respect to the healthcare team, the ideal scenario is to have a multidisciplinary team that includes medical and mental health providers. Of course, this is not possible in all settings. For the medical provider practicing without the benefit of an in-house mental health provider, it is advisable to have a list of gender-affirming therapists to whom you can refer your patients if needed. For one such list, readers may email a request to the author. Readers may also find additional resources at the website of RECLAIM, a Twin Cities mental health provider focused on queer and trans youth (RECLAIM – Resources for Queer and Trans Youth, n.d.). Conclusion
As physicians, we are privileged to help guide our patients on a path to better health. We also have the responsibility to ensure that all people have access to that path, regardless of their race, gender identity, sexual orientation, or ability to pay. By becoming more familiar with the optimal management of TGD youth in your practice environment, you will better serve your patients’ health and better fulfill your duty to health equity. Rhamy Magid, MD, FAAP, is a primary care pediatrician and the founder and Medical Director of the Pediatric Gender and Sexual Health Clinic (PGSHC) at Hennepin Healthcare. He is a graduate of the University of Minnesota Medical School, and did his postgraduate residency training in Pediatrics also at the University of Minnesota. The PGSHC is an interdisciplinary clinic focused on the health of LGBTQ+ youth. You can find more information on the PGSHC here: https://www.hennepinhealthcare.org/ specialty/pediatric-gender-sexual-health/. Emails to Dr. Magid can be sent to rhamy. magid@hcmed.org. September/October 2020
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Sponsored Content
Customized, Comprehensive Care for the LGBTQ+ Community Contributed by Erik Stanley Haugland, MD
I
n recent years the healthcare industry has done an increasingly better job of creating strong, effective experiences for diverse population segments. However, many challenges still remain when it comes to providing primary care for individuals within the LGBTQ+ population. LGBTQ+ individuals often face a host of social and economic barriers that keep them from seeking primary care and obtaining important health screenings. These barriers can range from a lack of consistent insurance coverage, to higher rates of unemployment, to less cultural competence among providers, to outright bias and discrimination. Concerning Statistics Regarding the Health of the LGBTQ+ Population
Data compiled by the US Office of Disease Prevention and Health Promotion provides some startling facts concerning the health of LGBTQ+ individuals such as: • The LGBTQ+ population has the highest rate of tobacco use in the US. • Transgender individuals are much less likely to have health insurance. • Lesbians and bisexual females are more likely to be overweight or obese. These factors and a host of others contribute to poor health outcomes for many LGBTQ+ individuals, including higher rates of heart disease, diabetes, STDs including HIV/AIDS and substance abuse. The current pandemic is also causing greater health issues for senior members of this population. Recent studies from the Human Rights Campaign Foundation 16
September/October 2020
place for comprehensive health care. So, they are required to visit separate specialty gender clinics to ensure they get all the care they need. This can make receiving quality care more problematic given their unique health needs. The Importance of Primary Care
and Sage report that older LGBTQ+ adults are particularly vulnerable to becoming seriously ill from COVID-19. To explain the reasons for this greater risk, experts have pointed to additional stressors for the LGBTQ+ population that can lead to chronic conditions later in life, including a much higher rate of tobacco use, as noted earlier. In addition to experiencing more risk in terms of their physical health, the LGBTQ+ population also faces a higher rate of mental health issues. Older LGBTQ+ individuals are often isolated and more fearful of stigma, while LGBTQ+ youths contemplate suicide at three times the rate of their peers, according to the CDC. This is particularly frightening given that suicide is often reported as the second or third leading cause of death among young people in the US. For transgender customers, health care can be even more complex. Most transgender individuals do not have one
The LGBTQ+ community tends to avoid primary care, as they often feel stigmatized and don’t want to experience uncomfortable conversations. And yet as they face higher rates of tobacco use, high blood pressure, obesity and other chronic conditions, it is arguably even more important for LGBTQ+ individuals to have access to a primary care provider for overall health assessments and to recommend routine screenings. In addition, those doctors need to understand the unique needs and additional guidelines for preventative health for the LGBTQ+ population including: • Men who have sex with men (MSM) within this population have a risk of anal cancer that is 80 times that of their heterosexual peers. As a result, they may need to have routine anal pap smears every one to three years. • Transgender women may need more routine cancer screenings and could require both a prostate check and a mammogram on a regular basis. • Testosterone treatments may cause higher levels of cholesterol, hypertension and coronary artery disease, indicating a need for more routine screenings. • Estrogen treatments increase the risk of high cholesterol and cardiovascular
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disease, so cardiovascular screenings are even more vital for transgender women. Primary care physicians are typically quite involved in screening mental as well as physical health for the LGBTQ+ population. Understanding the unique life experiences of LGBTQ+ individuals can be crucial to evaluating and treating potential and existing mental health problems. Of course, it’s important to note that hormones can also play a large role in how people are feeling, and primary care doctors need to acknowledge that as well. The National Alliance on Mental Illness (NAMI) reports that mental health conditions like post-traumatic stress disorder, anxiety and depression are almost three times as high for the LGBTQ+ population. Stigma and discrimination play a large role in this statistic. Healthcare providers need to be not only aware of that fact, but also aggressively working to improve those numbers overall. To ensure the needs of this community are being met, it’s important to have more holistic primary care programs designed specifically for LGBTQ+ individuals, from preventative care, to supportive programs that address chronic conditions. The transgender community, in particular, has complex needs that go far beyond hormone therapy programs. While gender care clinics as a specialty are still the norm within most healthcare networks, that model is considered outdated by many experts today. North Memorial Health Answers the Need for Quality Health Care for the LGBTQ+ Community
North Memorial Health is committed to creating an environment where the LGBTQ+ community can receive care from care teams who are both culturally and medically competent. Many of our North Memorial Health providers and team members are LGBTQ+ or straight allies, and experts in the different aspects of the physical, sexual and emotional health of the LGBTQ+ population. In fact, North Memorial Health Clinics in Brooklyn
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Center and Maple Grove are two of the few places in the state of Minnesota where LGBTQ+ patients, including transgender individuals, can obtain both primary and gender-related medical care, psychological support, and clinical pharmacy services all in one location. Because this type of holistic care doesn’t exist in greater Minnesota, many people come from cities as far away as International Falls and Moorhead to receive health care at these clinics. The clinic is also one of just a few in the state that can treat youth with puberty blockers, to avoid some of the defining sexual characteristics that may happen if those individuals go through puberty normally. Most young customers are seen by counselors as well as clinical pharmacists with specific skills in managing these types of programs, helping to avoid many of the emotional and physical problems experienced from too much of the “wrong” hormones. For adult transgender customers, initial visits are with the primary care physician, who identifies a care plan and refers the customer to a counselor with a specific background and training in working with transgender individuals. Clinical pharmacists can then help set the stage for potential hormone therapy, follow up on existing prescriptions and troubleshoot medication problems. All customers within the clinic have access to a full team of providers, clinical pharmacists, counselors and care coordinators focused on specific issues like diabetes. Holistic care like the kind provided at North Memorial Health Clinic is crucial to reducing many of the healthcare problems the LGBTQ+ population faces today. Although the situation is getting better, it’s not improving as quickly as it could. Many healthcare providers are still untrained when it comes to LGBTQ+ care and too many doctors and team members aren’t interacting with LGBTQ+ individuals correctly. The right standard of care is vital, from writing notes consistent with the patient’s expressed gender, to prescribing the correct routine screenings, to using the right pronouns. Long-term health management for the
The Journal of the Twin Cities Medical Society
LGBTQ+ community is a problem that is often overlooked within our healthcare system today. It’s important that LGBTQ+ individuals have a place to go where they can feel comfortable showing up as their true authentic selves, and where providers and team members are aware of, and sensitive to, their specific emotional and physical healthcare needs. That’s why at North Memorial Health Clinic we’re dedicated to improving care for LGBTQ+ individuals across the Minnesota healthcare system. Our Brooklyn Center and Maple Grove Clinic teams regularly visit other groups of providers to provide information on becoming culturally competent in terms of providing health care to LGBTQ+ individuals, and to educate doctors and team members on the latest guidelines for preventative health care for the LGBTQ+ population. North Memorial Health Clinic – Brooklyn Center is also a training site for medical students and residents to gain more exposure, and hopefully a deeper understanding, of the unique aspects of LGBTQ+ health care. Everyone experiences better health outcomes when they see a provider on a regular basis, and it’s important to have a primary care provider who can prescribe the correct routine screenings and who is educated on specialty care needs. Continuing to see the same doctor year over year means that the conversation can be carried on, not repeated with every new visit. That’s especially important for the LGBTQ+ community who are often met with enormous challenges when it comes to staying healthy, both physically and emotionally. Erik Stanley Haugland, MD is a family and transgender medicine provider at North Memorial Health Clinic – Brooklyn Park focusing on geriatric customers, customers with sexual health concerns, and lesbian, gay, bisexual, transgender and queer (LGBTQ+) customers. He consistently works to support LGBTQ+ health by partnering with clinical pharmacists to complete hormone management for transgender customers and follows World Professional Association of Transgender Health (WPATH) standards of care. September/October 2020
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LGBTQ + Health
LGBTQ+ Health: Looking Beyond the Language
A
s of 2017, UCLA’s Williams Institute estimated that 4.1% of people living in Minnesota identify as LGBTQ+ (lesbian, gay, bisexual, transgender or queer).1 This means we are all taking care of LGBTQ+ patients, whether or not they feel comfortable making us aware of their identities. When caring for patients, providers have a responsibility — ethically and professionally — to consider the social context of that care. This is especially true for our patients who belong to one or more marginalized communities. When we fail to do so, we perpetuate this marginalization and worsen health disparities. This article is intended to be a starting point to help you as a provider feel more comfortable caring for your LGBTQ+ patients, demystify some common concerns, and empower you to learn more about specific ways you can improve care for LGBTQ+ patients. We will begin with the topic of language because this is where we see many providers start and end their journey. It is easy to get hung up on and subsequently frustrated by the vast array of terms and identities applied by and to LGBTQ+ patients. To some it can feel like having to learn a new language with grammatical rules that change regularly. Some providers avoid using certain terms out of fear of offending their patients.2 We would like to get you to think about language as a way to connect with your patients. Table 1 includes some possible definitions of words commonly used to reference sexual and gender minorities. The terms we include are fluid and their usage will By Joshua Thompson, MD, MPH and James Smith, MD, MPH
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Joshua Thompson, MD, MPH
James Smith, MD, MPH
vary person to person, depending on their cultural background as well as personal preference. It is, therefore, less important for you as a provider to try and memorize definitions. Instead, it is important for you to keep an open mind and avoid making assumptions about your patients’ identity based on their behaviors or about their health needs based on those identities. This latter point is critical for providers to understand. Most of the time, it is not a patient’s identity that should drive their preventive care needs, differential diagnosis, or optimal treatment, but rather that person’s biology (organs, hormonal milieu, etc.) and behaviors. When you are in doubt about whether your expectations of these things match up with a patient’s stated identity and — importantly — if the answer would be relevant to their care, we urge you to talk to your patient about it. As long as you can explain your rationale for needing to know and ask in a kind way, most LGBTQ+ people will be just fine answering whatever questions you have if it means avoiding assumptions.3 Surveys have shown that LGBTQ+
people often do not seek care due to a perceived feeling of being unwelcome.4 To begin to work on improving health equity, providers have a responsibility to create a safe and affirming environment in which to treat this population, and this involves more than just language. In some cases, it may involve a change to the entire culture of a clinic, from the schedulers, to the front desk and support staff, to providers. Forms that are given to patients to fill out should be reviewed and revised to use language that is more inclusive. Informational or marketing brochures and posters can be chosen thoughtfully to reflect the diversity and health needs of the patients you are seeing, including your LGBTQ+ patients. Not all of these measures need to be done at once, and even small changes over time can signify to your patients that your clinic is a place they can go and receive excellent care. There are many organizations, including the Joint Commission or GLMA (formerly the Gay and Lesbian Medical Association) that have resources with concrete suggestions on additional ways to improve the climate of your clinic.5,6
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The Journal of the Twin Cities Medical Society
We recognize for many of you this is a lot of new information and for some of you it will be old news. Wherever you are in your journey, we encourage you to continue learning more. An easy place to start is with your specialty’s professional society, many of whom have issued guidelines and best practice statements or endorsed specific educational opportunities for improving the care of LGBTQ+ patients.7-9 For those wanting a deeper understanding of health disparities and evidence-based care, the National LGBTQIA+ Health Education Center (www.lgbtqiahealtheducation.org)
has a massive library of webinars that are CME accredited. At the end of the day, most LGBTQ+ people who walk into your office are looking for the same care all your other patients are there for and to be treated with the same dignity and respect afforded those patients. If you can do that for them, remain humble and open-minded, and maintain open communication, then you will already be one of the best providers that many LGBTQ+ patients have ever encountered.
Terms Related to Attraction, Orientation, or Behavior Gay
A person attracted to people of the same gender
Lesbian
A woman attracted to other women
Bisexual
A person attracted to two or more genders
Pansexual
A person attracted to all genders
Asexual
A person not sexually attracted to any gender Terms Related to Gender and Sex
Trans or Transgender
A person whose gender identity does not match the sex they were assigned at birth
Trans woman
A woman whose sex assigned at birth was not female
Trans man
A man whose sex assigned at birth was not male
Cis or Cisgender
A person whose gender identity matches the sex they were assigned at birth
Intersex
A person born with or who develops physical or physiologic traits consistent with more than one sex
Nonbinary (NB), Genderqueer
A person whose gender identity does not match the traditional male or female dichotomy Umbrella Terms
LGBTQ
Acronym for lesbian, gay, bisexual, transgender, and queer. Often used to refer to all sexual and gender minority communities. May include additional letters such as “I” (intersex), “A” (asexual, ally), etc.
Queer
Term used within sexual and gender minority communities. Definition is variable but can sometimes include anyone who does not identify as heterosexual and cisgender.
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Joshua Thompson, MD, MPH is a family physician at the M Physicians Mill City Clinic in Minneapolis and an assistant professor in the Department of Family Medicine and Community Health at UMN. He is passionate about training future and current physicians to provide high-quality care to their LGBTQ+ patients. He can be reached at jthomps@umn.edu. James Smith, MD, MPH is a third year resident at the UMN North Memorial Family Medicine Residency Program. His interests include health advocacy and policy, adolescent health, and sports medicine. He can be reached at smit8366@umn.edu. References: 1. LGBT Demographic Data Interactive 2019. The Williams Institute, UCLA School of Law. https:// williamsinstitute.law.ucla.edu/visualization/ lgbt-stats/?topic=LGBT#about-the-data. Accessed July 6, 2020. 2. Beagan B, Fredericks E, and Bryson M. Family physician perceptions of working with LGBTQ patients: physician training needs. CMEJ. 2016; 6(1): e14-e22. 3. Alpert A, CichoskiKelly EM, and Fox AD. What lesbian, gay, bisexual, transgender, queer, and intersex patients say doctors should know and do: a qualitative study. J Homosex. 2017; 64(10: 1368-1389. 4. Improving lesbian, gay, bisexual and transgender access to healthcare at New York City health and hospitals corporation facilities. New York, NY: Office of the New York City Public Advocate; 2008. https://www.sageusa. org/resource-posts/improving-lesbian-gay-bisexual-and-transgender-access-to-healthcare -at-new-york-city-health-and-hospitals-corporation-facilities-2/. Accessed July 6, 2020. 5. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL: The Joint Commission; 2011. https://www.jointcommission.org/-/media/ enterprise/tjc/imported-resource-assets/documents/lgbtfieldguide_web_linked_verpdf.pdf. Accessed July 6, 2020. 6. Guidelines for care of lesbian, gay, bisexual, and transgender patients. GLMA. http:// www.glma.org/_data/n_0001/resources/live/ Welcoming%20Environment.pdf. Accessed July 6, 2020. 7. American College of Obstetricians and Gynecologists. Health care for transgender individuals: Committee Opinion No. 512. Obstet Gynecol. 2011; 118: 1454-1458. 8. AAP Committee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013; 132(1): 198-203. 9. Lesbian, gay, bisexual, transgender (LGBT) health toolkit. American Academy of Family Physicians. https://www.aafp.org/patient-care/ public-health/lgbt-toolkit.html. Access July 6, 2020.
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LGBTQ + Health
The Future for LGBTQ+ Physicians is Bright
I
n the over 50 years since the Stonewall riots, the United States has made dramatic progress in the way LGBTQ+ people are viewed and embraced. More strikingly, in just the past five years, LGBTQ+ Americans have had these changes reinforced into legal protections. Both in the landmark 2015 marriage equality Supreme Court ruling and most recently the title VII ruling that ensured federal protection in the workplace, change has been brisk. While the country as a whole has made tremendous progress in LGBTQ+ rights and acceptance, the culture in medicine has seemed to lag. Medicine, in general, has been a straight, white, male profession. It wasn’t until 1973, the American Psychiatric Association (APA) removed the diagnosis of “homosexuality” from the second edition of its Diagnostic and Statistical Manual (DSM). These theories regarded adult homosexuality as a disease, a condition deviating from “normal,” heterosexual development. With language like that in the medical literature, it is no wonder why it took so long for the culture in medicine to change. While we have made considerable progress, I’ve seen firsthand — as a patient, student and young physician — areas where we have room to grow. I distinctly remember being a premed student and going to get a routine physical. The physician was going through sexual history and used tones and phrases to insinuate I was straight. By Barrett Holen, MD
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I didn’t correct him. It was a minor and brief encounter, but I remember that feeling of “not being normal” and the awkwardness that accompanied it. I reflected on that experience and realized if I felt that way during that simple history taking, I can’t even imagine what other folks have experienced in health care. I vowed at that time that I would do my best to ensure my future patients didn’t have similar feelings that I did, regardless of sexual orientation, race, or any other culturally sensitive topic. As I started medical school in 2012, I initially didn’t disclose my sexual orientation to my classmates or faculty. I didn’t want this part of me to potentially affect my career. I initially feared discrimination from my peers, faculty, evaluators, and even patients. I then reflected again. If I wasn’t honest and open about myself, what example am I setting for my patients? So, I slowly started to open up to my classmates. When someone would
ask if I had a girlfriend, I would correct them and say “boyfriend.” They usually apologized. I never was offended; I just didn’t want to propagate something that wasn’t true. Being able to speak casually about your personal life or loved ones may seem trivial to some, but feeling comfortable to do so is so incredibly important and it reaffirms that you matter. I was in medical school during the time when LGBTQ+ curricula started to gain traction. I could sense there was meaningful change happening. However, these changes weren’t embraced by everyone in the medical community. I remember hearing an elderly attending comment that he thought that it was a “waste of time” and “unnecessary.” Regardless, it was positive change both for the culture within medicine and the care we provide our patients. Still, I struggled with if it was possible to be “out” in medicine. I sometimes believed in the false dichotomy of having to choose between being a physician and being openly gay. As I progressed through medical school and started to think about possible specialties, I wondered to myself if certain specialties wouldn’t be possible as a gay person. There were certain specialties that further reinforced the straight, white, male stereotype. If I wanted to be a surgeon or have a career in academics (areas traditionally straight males dominated) would I have to hide who I was? Being gay was just one part (a wonderful part) of who I was, and I didn’t want it to limit my future career opportunities. In some ways I felt a way that perhaps many women or people of color feel — that a
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certain career path wouldn’t be an option simply because of who they are. There was a constant internal battle between being honest and true to myself and risking potential negative effects on my future career. I decided on Internal Medicine and moved to Washington, D.C. to start my residency. While there, I had my first interactions with openly gay faculty and administrators. While the District of Columbia in general is LGBTQ+ friendly, having the visibility of LGBTQ+ folks being open and proud about who they are was an important and refreshing sight. Having that visibility is so incredibly important, particularly to medical students. Homophobic comments among staff and co-residents were infrequent, yet there were still signs that we had progress to make. I remember one patient making a comment about a medical student who had just rounded on him, stating to me (after the student left) that he thought the student was “obviously gay” and that he “didn’t agree with that.” I didn’t know how to react. I was internally torn between my role to provide objective, impartial care to my patient and my own self-worth. Forming a human connection with your patients is critical in building a trusting doctor-patient relationship. When I’m having a conversation with a patient and they ask, sincerely, if I have a wife or girlfriend, do I correct them? I still, to this day, deny the existence of my partner if I feel that it would elicit an unwelcome interaction. It hurts. We have, however, made tremendous progress in many areas, especially in visibility. As the country as a whole has more LGBTQ+ visibility this trickles down into our patients, healthcare workers and other physicians. Health systems from a corperate level are making LGBTQ+ issues a priority, whether it is education for its employees or supporting resources for the unique health needs of LGBTQ+ patients, you can palpate the concerted effort. As I started my first job out of residency, I was happy to see openly MetroDoctors
LGBTQ+ physicians not only among staff but also in leadership roles. The rapid positive changes, even in just the past few years, has been inspiring to see. We need to continue to propel this powerful momentum of change to ensure that our future continues to look so bright. And colorful. Barrett Holen, MD grew up in rural Minnesota. He did his undergraduate training
The Journal of the Twin Cities Medical Society
in New York City prior to receiving his medical degree from the University of Minnesota. He completed an Internal Medicine residency at The George Washington University Hospital with a concentration in underserved medicine and public health. Upon completion, Dr. Holen accepted a job as a full-time Hospitalist at North Memorial. He enjoys travel and adventurous foods.
est. 1978
September/October 2020
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LGBTQ + Health
Ending the Harmful Practice of Conversion “Therapy”
T
he medical profession overwhelmingly understands that conversion “therapy” is anything but therapy and actively causes harm to those subjected to such an unethical malpractice. Some politicians are proving harder to convince. “Conversion therapy,” often referred to as “reparative therapy,” “ex-gay therapy,” or “sexual orientation change efforts,” includes a range of dangerous and discredited practices aimed at changing a person’s sexual orientation, or efforts to change a person’s gender identity or expression. These harmful practices are based on the a priori assumption that being Lesbian, Gay, Bisexual, Transgender, or Queer (LGBTQ+) is a mental illness that should be cured — that being LGBTQ+ is wrong or “less than.” Over the past decade every major, reputable medical association has come out against the practice of conversion “therapy” either by denouncing it outright or by actively campaigning for policies that ban the practice. That list includes the American Psychiatric Association, Minnesota Chapter of the National Alliance on Mental Illness, American Medical Association, American Academy of Pediatrics, American Psychological Association and so many more. The United Nations in a 2015 report to the General Assembly, High Commissioner and Secretary-General established conversion “therapy” as torture (Report: A/HRC/29/23). Unfortunately, LGBTQ+ people across the country are still being coerced and subjected to these harmful practices, which put LGBTQ+ youth at particular risk for serious harms such as depression, By Jacob Thomas
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September/October 2020
substance abuse and suicide. As of June 2020, only 20 states and fewer than100 municipalities in the United States have banned the discredited practice on minors. No bans exist within the United States with regard to adults. According to a 2019 study by the Williams Institute at UCLA, 700,000 people in the United States have been subjected to conversion “therapy” and an estimated 16,000 LGBTQ+ youth living in states without protections will undergo the practice from a licensed medical professional by the time they turn 18 years of age. At the time of that research only 18 states and far fewer municipalities protected LGBTQ+ youth and still 10,000 youth were estimated to have been saved from conversion “therapy” because of these pieces of legislation. An important point of clarification here is that all the laws implemented or proposed only affect licensed medical professionals. The Williams Institute estimated that 57,000 LGBTQ+ youth across the country will receive conversion “therapy” from a religious or spiritual advisor. Notably, many of the national organizations dedicated to this type of extramedical “treatment” have disbanded and/or issued apologies for the harm they caused. While the laws put forward do not inhibit religious or spiritual advisors from continuing to cause harm to LGBTQ+ youth, they do help educate parents and the public that being LGBTQ+ is not something that can nor should be cured. The hope is that no child is made to feel less than or hurt simply because of who they are. Particularly, for medical providers, it is also to ensure that “Primum non nocere” remains an essential part of the Hippocratic Oath.
In Minnesota, efforts to ban conversion “therapy” have been ongoing since 2013. OutFront Minnesota, the state’s largest LGBTQ+ civil rights organization ultimately became the main organization advocating for a ban in the state in 2016. OutFront Minnesota was established in 1987 primarily as a crisis/help line for LGBTQ+ Minnesotans experiencing domestic violence, sexual violence and hate crime and bias issues because law enforcement could not be trusted to keep our communities safe. That helpline is still operating to this day serving more than 1,000 people annually. OutFront quickly expanded to help secure legislative wins and community education initiatives as well. The first major win arrived with the Human Rights Act of 1993. This legislation made Minnesota the first state to protect not just LGB people but also extended first in the nation protections to transgender people. Another major point in Minnesota’s
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queer history and in OutFront’s own story is the Vote No campaign and marriage equality. In 2011/2012 a ballot initiative was proposed that would have barred same-sex couples from marrying at the constitutional level in Minnesota. It was already illegal by state statute. OutFront Minnesota and Project 515 cofounded Minnesotans United For All Families which went on to defeat the anti-LGBTQ+ ballot measure in 2012. The Vote No campaign brought with it a new way of organizing and engaging with voters. Storytelling, sharing and what is known as “deep canvassing” were transformative models that led to Minnesota becoming the first state to defeat a marriage ballot initiative. Minnesota then went on to extend the right to marry to LGBTQ+ Minnesotans the following year. So why am I telling you all of this and how is it relevant to the medical malpractice known as conversion “therapy?” Well, the lessons learned over the years directly apply to how we can, together, stop this archaic notion that LGBTQ+ people need to be cured or even can be. The medical profession and science are constantly moving forward and improving on current knowledges and practices. It is past time to relegate conversion “therapy” to the dustbins of things we know better not to do. As Minnesotans from all walks of life come forward to share our horrors and experiences with conversion “therapy” we need medical professionals to join the chorus calling for its end. You are uniquely suited for this task and your predecessors have, in fact, already started
this work. In 1972, the now infamous, Dr. Henry Anonymous (later revealed to be John Fryer, MD) sat on a panel regarding homosexuality and its pathology in the Diagnostic and Statistical Manual (DSM). By the next year, the American Psychiatric Association removed homosexuality as a mental illness in the DSM. Minnesota has long been a state that pushes progress forward. From being the first state to protect LGBTQ+ people from discrimination to securing the right to marry for same-sex couples and providing gender neutral markers on licenses, Minnesota is known for leading the way. However, every day the harmful and discredited practice of conversion “therapy” is allowed to continue, our legacy is further tarnished and LGBTQ+ youth suffer. Last year, after the Minnesota Senate failed to pass these life-saving protections, Minneapolis and Duluth stepped up and implemented bans on conversion “therapy” within their jurisdictions. Saint Paul and Red Wing joined them this year. The momentum to protect LGBTQ+ youth is on our side. The time to get this done is now. Minnesotans know that we all deserve a state that treats us equally, affords us the best chances to live and thrive and protects us — especially our children and the most vulnerable — from harm. Jacob Thomas is the Communications and Brand Manager at OutFront Minnesota, the state’s largest LGBTQ+ civil rights organization. He has written locally and internationally on coming out, LGBTQ+ and human rights issues, veteran issues and other topics.
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September/October 2020
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LGBTQ + Health
Transgender Hormone Therapy
W
hen caring for a transgender or gender diverse individual, it is important to understand resources available to practitioners. There are three major guidelines available for the care of transgender individuals. The World Professional Association for Transgender Health (WPATH) has created a 120-page document called the “Standards of Care” available in 18 different languages. The Endocrine Society has created clinical practice guidelines and the University of California San Francisco (UCSF) created a document called “Caring for Gender-Affirming and Gender Nonbinary People” to help care for transgender individuals. Estrogen and testosterone cause permanent changes. WPATH and UCSF recommend a risk vs benefit discussion, as well as documented informed consent. Many clinics have created consent forms to start or continue hormonal therapy. Of note, the WPATH does recommend having a therapist who specializes in transgender care as part of the care team for additional support. For an individual who is transitioning from female to male, testosterone is the primary medication prescribed. There are many testosterone products available on the market. Therefore, it is important to talk with the individual about cost and method of delivery to determine which testosterone product will be most successful. Testosterone injections may be given subcutaneously in the abdomen or intramuscularly in the thigh weekly. There is also a new oral capsule testosterone product available. Regardless of the testosterone product used, dosing is based on total testosterone levels and patient satisfaction with secondary sexual characteristics. By Mary Sauer, PharmD, BCACP, AE-C, CDCES
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Transgender males cannot take testosterone if they are pregnant. Individuals with a history of estrogen or testosterone related cancers and uncontrolled coronary artery disease should not take testosterone. Permanent changes from testosterone include a larger clitoris, lower voice, and increased body and facial hair. Additional side effects include increased muscle mass, amenorrhea, increase libido and fat redistribution. Risks include acne, thrombophlebitis, emotional changes, increased red blood cell count, infertility, male pattern hair loss, liver problems and weight gain. For an individual who is transitioning from male to female, androgen antagonist, estrogen, and progesterone may be used. The most commonly used androgen antagonist is spironolactone. This works by desensitizing endogenous testosterone allowing for lower doses of estrogen to be prescribed, which lowers the overall risks associated with estrogen use. Bicalutamide is also an androgen antagonist, but is not recommended due to concerns with fulminant hepatitis. Estrogen is dosed based on estradiol levels and patient satisfaction with secondary sexual characteristics. It is important to note there are many estrogen products available. The cheapest option is estradiol tablets. However, these undergo extensive first past metabolism and have the highest risk associated with venous thromboembolisms (VTEs) and diabetes. If oral estrogen tablets are used, it is recommended to take these tablets sublingually to try and bypass first pass metabolism. Many transgender females report estrogen feels sandy or chalky and has a sweet taste when taken sublingually. Progesterone is currently a controversial topic in transgender medicine. There are two studies suggesting it improves breast
development and libido; other studies have not found similar results. Many transgender clinics may not prescribe progesterone due to lack of support for its use in the literature, increased pill burden and cost. Transgender females should not take estrogen if they have a history of estrogen-dependent cancers, VTEs, or a history of macroprolactinoma. Permanent changes include breast development and larger areolae and nipples. Additional side effects include decreased body hair, fat redistribution, increased high-density lipoprotein (HDL) cholesterol, smaller prostate gland and penile size. Risks include thrombosis, chronic problem veins in the legs, liver problems, weight gain and infertility. Mary Sauer, PharmD, BCACP, AE-C, CDCES, Medication Therapy Management, Asthma Educator, Certified Diabetes Educator. Dr. Sauer focuses on caring for customers through shared decision making. She received her Doctorate Degree from the University of Minnesota College of Pharmacy and completed her Family Medicine Residency at Park Nicollet. References: 1. World Professional Association for Transgender Health (WPATH) Standards of Care. https://wpath.org/publications/soc. Accessed 06/29/2020. 2. Deutsch,M. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. UCSF Transgender Care. June 17, 2016 https://transcare.ucsf.edu/ guidelines. Accessed 06/29/2020. 3. Hembree, WC, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. JCEM September 2017. https://www. endocrine.org/clinical-practice-guidelines/gender-dysphoria-gender-incongruence. Accessed 06/29/2020.
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Special Considerations for LGBTQ+ End-of-Life Care As a population, LGBTQ+ older adults are more likely than their heterosexual peers to have poorer health status and be more hesitant to seek care.1,2 This has important implications for aging and how aging LGBTQ+ adults make decisions about end-of-life (EOL) care. We aim to highlight some key considerations for providers when having EOL discussions with their aging LGBTQ+ patients. Additionally, it is important for providers to recognize these aging LGBTQ+ considerations are in addition to, rather than instead of, common concerns and considerations of their heterosexual counterparts. Next of Kin
While the nationwide legalization of same sex marriage in 2015 allows many couples to enjoy the benefits of legal marriage, many same sex couples are still not married.1,3 Compared to their heterosexual peers, aging LGBTQ+ adults are more likely to be single, live alone, and not have children.1 This phenomenon can lead to isolation as they age or dependence on informal social networks. This becomes particularly important during EOL care planning and legal defaults to next of kin in healthcare decisions. In Minnesota, there is no next of kin law for medical decision-making, so it is crucial for adults to appoint a healthcare agent in their healthcare directive. When planning for EOL care, these social and legal dynamics have an impact on patients’ ability to agein-place as well as EOL decision-making. Whereas heterosexual elderly adults often rely on spouses and children for medical decision-making, aging LGBTQ+ By Beret Fitzgerald, Rachel Oldfather and Kerry Hjelmgren
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adults often rely on their “family of choice” which is comprised of friends and neighbors.4 While a person’s chosen family may provide support for things like groceries and errands, many LGBTQ+ elderly adults cite diffiBeret Fitzgerald culty in asking for the level of support they need in aging or in making EOL care decisions.2 Furthermore, the reliance on a patient’s chosen family can lead to conflict with biological family as well as difficulty in decision-making if there is not legal recognition of a patient’s partner or friends.4 This makes early and clear discussions about health care directives and proxy decision makers especially important for aging LGBTQ+ people. Many older adults fear placement in a nursing home, however, having a family caregiver is a key predictor of ability to age-in-place.5 Brennan-Ing et al. found that nearly two-thirds of elderly LGBTQ+ adults lived alone (63%) and many LGBTQ+ aging adults describe difficulty creating friendships where they could ask someone to take on the role of caregiving making it less likely that they have someone to help them age-in-place. 2,4 Those that do have a caregiver may encounter difficulty in getting financial support for them. While the National Family Caregiver Support Act protects caregivers regardless of their relationship to the patient, policies like the Family Medical Leave Act, bereavement leave, and Social Security benefits are reserved for those who are legally related to the patient.5 It is important to keep in mind the differences in these relationships and financial barriers
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Rachel Oldfather
Kerry Hjelmgren
for LGBTQ+ people when discussing transitions to higher levels of care. Grief in the LGBTQ+ Community
Part of providing holistic care to patients during EOL planning and palliative care is attending to their grief. LGBTQ+ patients and their loved ones may go through bereavement in ways that are different than their heterosexual counterparts. This may include survivor guilt, disenfranchised grief, and the influence of traumas specific to the LGBTQ+ community. Disenfranchised grief occurs when a person’s “bereavement experience is not acknowledged or perceived as legitimate by healthcare providers or others.”3 This experience is made worse when either family or healthcare providers do not recognize and consider input from significant others during EOL planning.6 This becomes apparent when paired with the idea of chosen families. The community that shows up and supports LGBTQ+ people during EOL care and decision-making may not have legal or familial ties to a patient. Having legalized documentation such as a healthcare directive can help with both decision-making and recognition, but providers should keep in mind that there are additional barriers to this for the (Continued on page 26)
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LGBTQ + Health Special Considerations for LGBTQ+ End-of-Life Care (Continued from page 25)
LGBTQ+ community discussed below. While most LGBTQ+ people’s EOL care does not specifically relate to HIV/ AIDS, it is important to acknowledge for many patients.6 The experience and trauma of living through the peak of the HIV/AIDS crisis has resulted in fear and denial for some aging LGBTQ+ people and influences their perceptions of EOL planning. Provider Sensitivity and Supportive Environments
While many of the concerns surrounding EOL discussions in the LGBTQ+ community are not specific to sexual orientation, the role of sexuality in EOL planning should not be overlooked. As providers, we have the opportunity to create a supportive environment that allows patients to feel comfortable and confident in sharing their values during EOL planning, including their sexual orientation. One key practice providers should adopt is minimizing heterosexual assumptions, such as spousal gender, marriage status, and familial support networks, within assessment and care, and thus strengthen open communication.7 Physical intimacy and sexuality remain important for many people even as they face terminal illnesses or age. Greibling et al. found that many LGBTQ+ adults with terminal illnesses still considered sexuality an important aspect of their wellbeing.3 In the context of palliative care and EOL discussions, supporting patients successfully requires providers to be open and proactive in bringing up such topics. These issues are not unique to the aging LGBTQ+ community, but due to frequent discrimination
many people choose to withhold information such as sexual orientation and HIV status during care.3 Another key aspect of supporting aging LGBTQ+ adults in EOL care planning is helping them navigate surrogate decision-makers. People are often familiar with healthcare decision-makers and healthcare directives, however, Cartwright et al. found that roughly half of LGBTQ+ adults had completed the documents.6 Reasons for not completing forms, such as feeling like it wasn’t necessary or uncertainty about who to appoint as an agent, were similar to their heterosexual peers. However, factors such as fear of family usurping EOL care decisions and gender or sexual orientation not being recognized after death are of particular concern to LGBTQ+ people.6 A durable power of attorney for health care, a crucial element of a healthcare directive, is a key document to improve the likelihood of non-family significant others making EOL decisions. Providers should be comfortable bringing up the importance of legal documentation and options with patients.5 Conclusion/Practice Considerations
Elderly LGBTQ+ people experience higher rates of discrimination, poorer health and isolation as they age compared to their heterosexual peers. When patients have experienced discrimination from the healthcare system, good intentions are not sufficient. This is increasingly important with the recent decision to roll back discrimination protections for LGBTQ+ patients in health care. Providers need to be proactive in their approach to EOL care planning with their LGBTQ+ patients. By opening the conversation early and often to the
Documents Assigning Healthcare Agents Legally binding
Non-legally binding
•
Healthcare directive (IF notarized or • signed by two adult witnesses who are not their healthcare agents)
•
Living will IF healthcare agent is specified
•
5 Wishes
•
Unsigned/not-witnessed healthcare directive Living will without Power of Attorney for Healthcare designation
*The POLST form is a legal medical order but does not allow for assigning a healthcare agent.
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unique considerations of aging LGBTQ+ people we can proactively help them age according to their values. Beret Fitzgerald is a fourth year medical student at the University of Minnesota. After studying Philosophy as an undergraduate at Carleton College, she became interested in the ethics of healthcare decision making and patient autonomy. Rachel Oldfather is a fourth year medical student at the University of Minnesota Medical School. She earned her bachelor’s degree in geography with minors in chemistry and biology at Macalester College in St. Paul, MN. Rachel is interested in both Internal Medicine and combined Med/Peds and is applying to residency programs that will allow for opportunities to train as both a learner and as an educator. Kerry Gervais Hjelmgren is the Executive Director of Honoring Choices Minnesota, and is working on a Master’s degree in Palliative Care from the University of Maryland. She earned her bachelor’s degree in Philosophy and English from St. Olaf College, and a graduate certificate in Aging and Applied Thanatology from the University of Maryland. References: 1. Wallace SP, Cochran SD, Durazo EM, Ford CL. The health of aging lesbian, gay and bisexual adults in California. Policy Brief (UCLA Center for Health Policy Research). 2011 Mar; 1. 2. de Vries B, Gutman G, Humble Á, et al. Endof-Life Preparations Among LGBT Older Canadian Adults: The Missing Conversations. Int J Aging Hum Dev. 2019;88(4):358-379. doi:10.1177/0091415019836738. 3. Griebling TL. Sexuality and aging: a focus on lesbian, gay, bisexual, and transgender (LGBT) needs in palliative and end-of-life care. Curr Opin Support Palliat Care. 2016;10(1):95-101. doi:10.1097/SPC.0000000000000196. 4. Brennan-Ing M, Seidel L, Larson B, Karpiak SE. Social care networks and older LGBT adults: challenges for the future. J Homosex. 2014;61(1):21-52. doi:10.1080/00918369.2013. 835235. 5. Croghan CF, Moone RP, Olson AM. Friends, family, and caregiving among midlife and older lesbian, gay, bisexual, and transgender adults. J Homosex. 2014;61(1):79-102. doi:10. 1080/00918369.2013.835238. 6. Cartwright C, Hughes M, Lienert T. End-of-life care for gay, lesbian, bisexual and transgender people. Cult Health Sex. 2012;14(5):537-548. doi:10.1080/13691058.2012.673639. 7. Harding R, Epiphaniou E, Chidgey-Clark J. Needs, experiences, and preferences of sexual minorities for end-of-life care and palliative care: a systematic review. J Palliat Med. 2012;15(5):602-611. doi:10.1089/ jpm.2011.0279.
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Environmental Health —
LGBTQ+ Community and Climate Change Everyone’s lives will be impacted by climate change. But what about the people and communities already disproportionately experiencing the effects of inequitable systems? Those who contribute the least to climate change are suffering its greatest impacts. Both nationally and globally people of Black, Indigenous, people of color (BIPOC) and the poor, will experience an unduly high level of some of the most damaging and dramatic effects of climate change.1 Less discussed when assessing the impact of the climate crisis, however, is the LGBTQ+ community. They are disproportionately more vulnerable to the harmful impacts of a warming planet. They are more likely to be living on lower incomes, to experience homelessness, and have limited access to health care.2 BIPOC members of the LBGTQ+ community face multiple overlapping structure disadvantages. People on lower incomes have fewer financial alternatives with less access to capital. They face increased risk under the same set of circumstances as those with more privilege. The LGBTQ+ community in particular tends to face financial challenges that stem from discrimination and intolerance. Unemployment puts LGBTQ+ populations at greater risk of poverty and homelessness, making them more vulnerable to the effects of climate change. Trans folks also can face barriers and discrimination in the healthcare system: one in four transgender people report
having avoided medical care out of fear of being disrespected or mistreated. Their socioeconomic status increases exposure to the effects of climate change because they tend to live in areas with higher levels of air pollution and aren’t able to seek medical care for the secondary health impacts. Forty percent of homeless youth identify as LGBTQ+. Those who are without a safe place to live are more exposed to extreme weather events that are more common due to climate change. As we adapt to
By Anna Johnson and Mike Menzel, MD MetroDoctors
The Journal of the Twin Cities Medical Society
a changing climate, we need to address equitable solutions to those more affected by climate change. References: 1. IPCC, Climate Change: Impacts, Adaptation and Vulnerability, Chapter 14, p841, March 2014. 2. UCLA School of Law, Homelessness Among LGBTQ Adults in the US, May 2020.
Anna Johnson, Policy and Public Affairs, Fresh Energy, and Mike Menzel, MD, TCMS Environmental Health Task Force.
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LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD
FRANK S. RHAME, MD It is indeed rare for one of our Luminaries to be featured at the pinnacle of their profound professional activity, but that seems to be the case here. Let’s follow along his career and determine whether that’s a true statement. Dr. Frank Rhame, though born in Pennsylvania, had many early life home travels — finally and thankfully ending up in the Twin Cities in 1979 with a U of M medical faculty position. His BS degree was from Cal Tech and his MD was earned at Columbia in New York City. There followed internal medicine and infectious disease (ID) post graduate specialty and fellowship certifications at Columbia, the University of Michigan and Stanford University. The discipline of ID incorporates the study of disorders caused by organisms such as bacteria, fungi and parasites — the relevance of viral diseases perhaps taking on a less important clinical prominence until the emergence of the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Frank’s senior college year interest in “phase genetics” stoked his later involvement with the pathogenic activity of viruses — those submicroscopic particles of genetic material that invade host cells and therein perform their replicating “dirty work.” Dr. Rhame’s initial clinical and epidemiological activity was in the area of nosocomial infection prevention. That interest subtly evolved into clinical virology involvement when, in the early ’80s, he — and medicine in general — was challenged by a baffling and virulent condition of very sick young patients with pancytopenia and multisystemic disease who succumbed to their illness in frightening numbers. When asked how those early AIDS patients were initially diagnosed and treated, his response honestly stated, “We hadn’t a clue!” As he and other dedicated physicians empathetically plodded forward with few therapeutic tools to help those patients, valuable strides were being taken to better understand the disease’s public health and sexual medicine implications and the eventual antiviral agents that would prolong and save their lives. Frank, and “the wonderful circle of like-minded scientists with whom I had the honor of working,” played pivotal roles through the years in each of those meaningful advancements with AIDS via clinical research, education and direct patient engagement. Those preceding experiences stood him in good stead for what was to come about much later — thusly preparing him for the more current virus induced pandemic of COVID-19. 28
September/October 2020
Along the way, Dr. Frank participated in >200 clinical studies for pharma, NIH and the CDC, authored >100 journal articles and essays, advanced to professorships in epidemiology and ID at our U of M, held numerous editorial positions in peer reviewed publications, and became a local expert in travel advice and international medicine. His numerous commendations and honors include “Clinician of the Year” from the ID Society of America and “First a Physician” from our own TCMS. The good doctor Rhame is presently “as busy as I’ve ever been” with research and advisory capacities related to COVID-19. His work with Remdesivir and convalescent serum plasma administration has attracted international attention and is certain to result in more well-deserved plaudits. Expressions of his current concerns and optimistic thoughts are easily extracted from some of his recent quotations: “This virus has exposed and exploited weaknesses in our public health approach;” “Other countries were better prepared in their approach to this viral pandemic and we should and will learn and modify from them;” “Eventual immunization will be of huge help to our populations and old people in particular.” So . . . early on we asked if Dr. Rhame — our modest Luminary, proud father, grandfather and husband of his professionally accomplished wife — was now at the height of his splendid career? Answer: A resounding YES! — and he has been “right-up-there” for decades, and, has every intention of continuing along that same successfully productive path. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
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