Soins de santé LGBTQ+ : Construire une fondation pour une meilleure compréhensionBulletin WHEC pratique et de directives cliniques de gestion pour les fournisseurs de soins de santé. Subvention à l'éducation fournie par la santé des femmes et de l'Education Center (WHEC). LGBTQ, is an abbreviation for lesbian, gay, bisexual, transgender, and queer. There is no single LGBTQ+ community, rather a very diverse population that comes from all racial, ethnic, cultural, socio-economic, and geographic backgrounds. It is very difficult to know the percentage of people who identify themselves, as LGBTQ+. Stigma and the fear of biases contribute to an under-reporting of actual sexual orientation. Some people may also self-identify one way, even if their internal desires or sexual behavior, imply a different orientation. Some LGBTQ+ teens cope with these thoughts and feelings in harmful ways. They may try to hurt themselves. Medical association of LGBTQ+ healthcare practitioners, provides a directory of LGBTQ+ friendly healthcare practitioners. Understanding sexual orientation, gender identity, and sex assigned at birth among the LGBTQ+ community, is imperative in today's healthcare industry and climate. Children may be born to, adopted by, or cared for temporarily by married couples, non-married couples, single parents, grandparents, or legal guardians, and any of these may be heterosexual, gay or lesbian, or of another orientation. Children need secure and enduring relationships, with committed and nurturing adults, to enhance their life experiences for optimal social-emotional and cognitive development. Scientific evidence affirms that children have similar developmental and emotional needs, and receive similar parenting, whether they are raised by parents of same or different genders. The purpose of this document is to describe acceptable terms for gender and sexual identity in lesbian, gay, bisexual, transgender, or queer (LGBTQ+) patients. It summarizes challenges in the care of the LGBTQ+ population and outlines communication strategies, to provide culturally correct evaluation and treatment of this segment of patients. And explain the cultural competence in the care of LGBTQ+ people. Women's Health and Education Center (WHEC) promotes optimal health and wellbeing of all children and all adults. In the United States, public policy related to marriage and family is largely a state function. Consequently, the laws across the country that regulate marriage, adoption, and foster parenting by gay men and lesbians are an inconsistent patchwork. Even civil marriage in a state that permits, it does not ensure access to federal benefits. A core mission of WHEC is, to support the best interests of all children and all adults, regardless of their home or family structure, on the basis of the common principles of justice. INTRODUCTIONAll children need support and nurturing from stable, health and well-functioning adults to become resilient and effective adults. Understanding the history of LGBTQ+ community both in American society and within the profession of psychiatry is essential, in bringing context to the treatment. Some major milestones have contributed to the civil rights of LGBTQ+ people to greater acceptance. First, the Stonewall riots of 1969 have become the historic launching point for gay rights. In 2003, the Supreme Court struck down sodomy laws across the United States (U.S.) with their decision in Lawrence vs. Texas. In 2013, the Supreme Court decision on United States vs. Windsor led to the same sex couple being allowed, to share the same federal benefits as opposite sex couples being allowed to share, ending the Defense of Marriage Act. And in June 2015, the Supreme Court's decision on Obergefell vs. Hodges led to same-sex marriage becoming legal in all 50 states. In the context of Psychiatry, the American Psychiatric Association (APA) removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), in 1973 based on the new scientific studies, opening the way for new understanding and management of LGBTQ+ patients.  Table 1. Table 1. Homosexuality (now known as LGBTQ+); Abbreviations; DSM - Diagnostic and Statistical Manual of Mental Disorders; LGBTQ - lesbian, gay, bisexual, transgender and queer. Members of the LGBTQ+ community have unfortunately experienced a challenging history, but health professionals can learn to provide compassionate, comprehensive, and high-quality care with education. Learning to take care of members of this community involves understanding and being open to multiple special considerations and avoiding unconscious and perceived biases. Size of the LGBTQ+ PopulationData on the proportion of LGBTQ+ people in the U.S. population are sorely lacking. Rough estimates are available, based on the parental reports for children and the number of adults, seeking hormone therapy or surgery at specialty clinics, for the treatment of gender dysphoria. Based on rating on the Child Behavior Check List, 1% of boys and 3.5% of girls reported "wishes to be of opposite sex." With respect to adults, based on the number of transsexual adults at specialty clinics around the world for treatment of gender dysphoria, the estimated size of the population ranges from 1:2,900 (in Singapore) to 1:100,000 (in United States) for transsexual women; and 1:8,300 (in Singapore) to 1:400,000 (in United States) for transsexual men. However, the number of adults seeking treatment appears to be increasing, and ratio of transgender women to transgender men appears to be decreasing. HOMOSEXUALITY CONDUCT AS A CRIME,Long before Freud articulated his theory of sexuality, theological doctrine and secular law sought to regulate sexual behaviors and attachment punishments to a variety of sex acts, that were non-procreative or occurred outside of marriage. Proscribed sexual behaviors were often referred to collectively as sodomy, a term that was not clearly defined in most religious and legal texts but included homosexual behavior as well as other non-procreative and extramarital sexual acts. U.S. sodomy laws, which existed in all of the states until 1961, when Illinois eliminated its statute, were the legacy of these prohibitions. Sodomy laws were regularly used to justify differential treatment of sexual-minorities in a variety of arenas, including employment, child custody, and immigration. The expansion of disclosure about sexuality from the domains of law and theology into medicine, psychiatry, and psychology was considered a sign of progress, by many at that time, because it offered the hope of treatment and cure (rather than punishment), for phenomena that society generally regarded as problematic. After Freud, the division of people into "heterosexuals" and "homosexuals" involved stigmatization of the latter. Many early physicians and sexologists regarded homosexuality as a pathology, in contrast to "normal" heterosexuality, although this view was not unanimous. Freud himself believed that homosexuality represented a less than optimal outcome for psychosexual development, but did not believe it should be classified as an illness. In the 1940s, however, American psychoanalysts broke with Freud, and the view that homosexuality was an illness, soon became the dominant position in American psychoanalysis and psychiatry. Thus, during World War II same-sex behavior, previously had been classified as a criminal offence under military regulations, prohibiting sodomy, the armed services now sought to bar homosexual persons from their ranks. However, many lesbians and gay men served successfully in the military, often with the knowledge of their heterosexual comrades. At the national level, a U.S. Senate committee issued a 1950 report, concluding that homosexuals were not qualified for federal employment, and they represented a security risk because they could be blackmailed about their sexuality. In 1952, the newly created DSM listed homosexuality as a sociopathic personality disturbance, along with substance abuse and sexual disorders. This classification of homosexuality was used as the basis for laws and regulations, that denied homosexuals employment or prohibited them, from being licensed in many occupations. Many states also passed sexual psychopath laws to criminalize homosexuals as well as rapists, pedophiles, and sadomasochists, in 1987. Many psychiatrists during this time, attempted various "cures" (i.e., attempts to change homosexuals into heterosexuals), including psychotherapy, hormone treatments, aversive conditioning with nausea-inducing drugs, lobotomy, electroshock, and castration. Meanwhile, some scientific research challenged the illness model. In a landmark study funded by the National Institute of Mental Health, directly tested the assumption underlying homosexuality's inclusion in the DSM, namely, that homosexuality was inherently lined with psychopathology (1991). The conclusion that received extensive support in subsequent empirical research by the National Institutes of Health (NIH), in USA was, homosexuality is not inherently associated with psychopathology, and it is not a clinical entity. This became the consensus view of mainstream mental health professionals in the United States. Although the AIDS epidemic continues to ravage sexual-minority communities today, some of its long-term consequences are already apparent. Many HIV-positive gay and bisexual men are surviving and thriving today thanks to the development of new HIV treatments. While the AIDS epidemic had considerable impact on individual lives, it also changed the LGBTQ+ community, creating an infrastructure of organizations, dedicated to meeting the health and social needs of LGBTQ+ individuals. DEFINITIONSPATIENT vs. PROVIDER USE OF SLANG TERMSMembers of the LGBTQ+ community, in describing their sexual orientation or partners, may use terms such as fag, dyke, gay, homo, or queer. While patients may use these terms, they are considered derogatory when describing a patient by a healthcare providers. The provider and staff should listen to the LGBTQ+ patient and follow their lead, and when in doubt, ask the patient, how they or their partner should be described? Once the terms are established, a note should be made in the record to follow the pattern of description for future visits. Electronic Medical Records (EMRs) may require modification to provide appropriate terminology. STIGMA AND RISK FACTORSFAST FACTS
Despite advances in LGBTQ+ rights and acceptance, stigma, both internal and external, continues to be the greatest problem facing sexual and gender minorities. Internally, many LGBTQ+ people develop, and internalized homophobia that can contribute to problems with self-acceptance, anxiety, depression, difficulty forming intimate relationships, and being open about what sexual orientation or gender identity, one actually has. Externally, stigma may be exhibited by the surrounding society and even from withing the LGBTQ+ community. For example, some gay and lesbian people have a difficult time accepting bisexuals. Transgender people have been excluded from some gay organizations, and are only recently received more notice and acceptance throughout the country. Additionally, most LGBTQ+ people are not raised by people who identify as LGBTQ+. Accordingly, they might not have the ability to seek support from parents or peers who may understand these struggles. LGBTQ+ persons who struggle with higher rates of anxiety, affective disorder related conditions, and substance use disorders most likely have struggled with stigma and the coping with and self-acceptance process. Alarmingly, LGBTQ+ people also have a nearly 3 times higher risk of suicide or suicidal behavior. LGBTQ+ people also face disparities in the physical medical context, including increased tobacco use, HIV and AIDS, and weight-related problems. LGBTQ+ people are also at greater risk for discrimination, verbal abuse, physical assaults and violence, and perhaps even childhood sexual abuse. Though legal protections have been increasing dramatically, many places do not protect sexual or gender minorities in the workplace, housing, or access to healthcare. Fears of potential discrimination contribute to some LGBTQ+ people not seeking the help they need - medically or psychiatrically - in a timely manner if at all. Studies have shown that many are afraid to be open about their sexual orientation or feelings with their mental health providers. GENDER AWARENESS, HUMILITY, AND SENSITIVITYThe ways people express their gender can vary. Just like everyone else, transgender people can express their gender through their choice of clothing and style of hair or makeup. Some may choose a name and pronouns that reflect their gender identity. They may openly have their chosen name, and ask others to respect their pronouns (he, she, they, etc.). Some choose to take hormones or have surgeries so that their bodies more closely match their gender identity. Others do not. There is no "right" way to be a transgender person. Many communities accept LGBTQ+ people without bias. But some communities do not. For adults and teens, hate crimes, job discrimination, and housing discrimination can be serious problems. For teens, bullying in school, talk with your parents or another trusted adults, a teacher, or your principal. Teens who do not feel supported by adults are more likely to be depressed. Some LGBTQ+ teens cope with these thoughts and feelings in harmful ways. They may try to hurt themselves. They may turn to drugs and alcohol. Some skip school or drop out. some run away from home. Lesbian or bisexual girls may be more likely to smoke or have eating disorders. Telling your parents can be big decision. Help and support in educating parents, family members, and friends about LGBTQ+. If you do not want to talk with your parents, you can talk with a teacher, counselor, doctor, or other healthcare professionals. It is a good idea to ask about what can be kept private, before you talk to a professional. There are also websites, hotlines and resources, at the end of this chapter, where you can be anonymous if you need information. All teens and adults who are sexually active are at risk of getting a sexually transmitted infection (STI). Many STIs can be passed from one partner to another through oral sex. These STIs include: human immunodeficiency virus (HIV), human papilloma virus (HPV), genital herpes, syphilis, gonorrhea, chlamydia. Some STIs (HPV and genital herpes) can be transmitted through skin-to-skin contact. HPV also may be spread by contact between genitals and fingers. Factors That Put LGBTQ+ Patients At Risk For Mental Health Violence against the LGBTQ+ community has increased over recent years. LGBTQ+ hate crimes are still rising 86% from 2016 to 2021. LGBTQ+ people of color - particularly transgender people - are disproportionately affected by these hate crimes. Challenges abound on the legislative front as well. The White House Administration had made repeated attempts to ban transgender soldiers from serving in the miliary. While these bans have not held up in court, they add to the contentious climate of LGBTQ+ Americans.
ASSESSMENT AND SCREENINGUnderstand and Promote Understanding. Healthcare providers should be aware effects of stigma such as prejudice, harassment, discrimination, and violence in lives of LGBTQ+ individuals. Healthcare providers can help reduce stigma by educating the public about LGBTQ+ health issues, policies and by advocating for equal care and equal rights.
 Figure 1. Four realms of assessment and consolidated sexuality and gender identity. Create an Inclusive Environment. Providers should ensure an inclusive environment by collaborating with LGBTQ+ patients and clients in program design, individual service planning, and the creation of policies and procedures. Policies, procedures, forms, and regulations should be inclusive of LGBTQ+ patients while minimizing re-traumatization. Anti-discrimination and hiring policies as well as well as policies concerning client services should include sexual orientation and gender identity. Employee and client forms should allow LGBTQ+ individuals to answer honestly and thoroughly. Plan for Continuity of Care. Given the high risk of HIV, suicide attempts, drug and alcohol abuse, and tobacco use among LGBTQ+ people, healthcare providers must determine appropriate levels of care. Providers should consider treatment within their scope of practice; make necessary referrals to integrated clinics; provide a continuum of care referrals for services; and offer services the patient will receive after discharge such as follow-up and monitoring activities, outreach, recruitment, and retention. Provide Trauma-Informed Care. LGBTQ+ people often experience trauma as gender minorities. Common clinical concerns specific to LGBTQ+ individuals can be addressed by implementing the following principles:
 Figure 2. Gender and sexuality Assessment tool. Despite barriers to work and success, the LGBTQ+ community continues to thrive, and many serve as leaders in the workforce. BEST PRACTICES & RECOMMENDATIONSBridging the divide and creating respectful dialogue, is the way forward. We live in a very divisive world. So much of what we see and hear as part of the socio-political narrative is filled with argument, and contention that polarizes discussion, ideas, and sometimes even people. There are two core principles, "Do No Harm" and "Facilitate Self-Determination" are the foundation. The guidelines that provide context and a rationale for each principle, are listed below. These standards help clinicians promote safety and respect for any client, who might be feeling their way through a complex journey between sexual orientation, gender identity and help de-escalate the divisive discourse around legislative issues. The Women's Health and Education Center (WHEC) recommends the following best practices for your work with LGBTQ+ patients:
GUIDING PRINCIPLESIn addition to incorporating best practices and recommendations, be aware of seven guiding principles for understanding gender and sexuality.
HEALTHCARE FOR TRANSGENDER TEENSThe term transgender has come to be widely used to refer to a diverse group of individuals who cross or transcend culturally defined categories of gender. Most people are told they are a boy, or a girl (male or female) based on the genitals they were born with. This is the sex you are assigned at birth. For some people, that male or female label may not feel right. Someone born female may feel that they are really a male, and someone born male may feel that they are really a female. People who feel this way are called transgender. Others may feel that they belong to neither gender or to both genders. People who feel this way sometimes identify as "gender non-binary," "gender fluid," or "gender-queer," gender-neutral, or agender or gender non-conforming. Gender Transition Care. It is a process patient can go through to express gender. The way of transitioning include:
Healthcare professionals can help transition safely. Taking treatment from anyone without a medical license can be dangerous. In most places like United States, permission from parent or guardian to do a hormonal or surgical transition is needed, before the patient is 18 years old. Consultation with mental health professionals and get a letter of support, before starting treatment is highly recommended. This may involve multiple counseling sessions. How do puberty blockers work? Puberty blockers (also called suppressors) are medications that delay the changes that come with sexual maturity. These medications can stop menstrual periods and the growth of breasts, or stop the deepening of the voice and the growth of facial hair. Most effects of puberty blockers are reversible. Puberty blockers are given as in hormonal-implant or as a shot. Sometimes it is started when the early stages of puberty are started this include - budding breasts, growing testicles, and light pubic hair. How does hormone treatment work? Hormone treatment is medication that helps you look or sound more masculine or feminine. This also may be called cross-sex hormone treatment or gender-affirming hormone therapy. Depending on the treatment, these medications can help you develop sex characteristics, such as:
Most of these changes cannot be reversed. Depending on the hormone, treatment comes in several forms, including as a shot, pill, patch, gel, cream, or implant. Suggested earliest age to wait before the treatment is started is 16 years old, but sometimes puberty blockers can be started in the meantime, if your healthcare professionals recommend it. Benefits and risks of puberty blockers and hormonal treatment. Risks of puberty blockers and hormones treatments are:
Benefits of puberty blockers and hormone treatment are: Puberty blockers may help the emotional and social development. They may make patients more comfortable in their own bodies. Many studies have shown that hormone treatment is shown to help transgender people with depression and boost self-esteem. These treatments prevent changes in the body that patients are not comfortable with. They also may prevent the need for future surgery, such as removal of breasts (mastectomy). Both transgender males and females may need to see an obstetrician and gynecologist and other healthcare professionals, such as urologist and psychiatrist during medical transition care and after the transition. Make sure to see an obstetrician and gynecologist if patient has reproductive organs (like a uterus or a vagina), and are taking feminizing hormones (like estrogen). Gender Affirmation (Confirmation) or Sex Reassignment Surgery Gender affirmation surgery refers to procedures that help people transition to their self-identified gender. Gender-affirmation options may include facial surgery, top surgery or bottom surgery. Most people who choose gender affirmation surgeries report improved mental health and quality of life. The notion of changing one's sex through surgery or other means existed well before the term transsexual became commonly used. In the early 20th century, European scientists began to experiment with "sex transformation" with animals and then with humans. In Germany, doctors at Magnus Hirschfield's Institute for Sexual Science stated performing sex-change operations in 1920s and 1930s. Over time, understanding and acceptance of transgender sex reassignment surgery has grown confirming by a body of research. In 1966, the Johns Hopkins University (U.S.A.) announced its program to perform and evaluate the efficacy of sex reassignment surgery, thus providing professional legitimacy for sex reassignment as a treatment for transsexualism. This was soon followed by similar programs at the University of Minnesota (U.S.A.) and other universities and medical centers in the U.S.A. Common transgender surgery options include: Facial reconstruction to make facial features more masculine or feminine; Chest or "Top" surgery to remove breast tissue for a more masculine appearance or enhance breast size and shape for a more feminine appearance; and Genital or "Bottom" surgery to transform and reconstruct the genitalia. Surgical management is usually only an option for people over the age of 18 years. One surgery that may be available for teens is mastectomy (removal of breasts). Surveys report that around 1 in 4 transgender and non-binary people choose gender affirmation surgery. Many insurance companies require patients and or physicians to submit specific documentation before they will cover a gender-affirmation surgery. These documentation includes:
DEVELOP HEALTHY RELATIONSHIPS REGARDLESS OF SEXUALITYAround the puberty and teens years, relationships outside your family become more important. Teens have relationships with their family and friends and will probably interested in romantic or sexual relationship. But healthy relationships do not have to include sex, and or only to the heterosexual sex. Many boys and girls are attracted to members of their own sex during puberty. Some discover that they are gay, lesbian, or bisexual during these years. When deciding whether to have sex, what are some things to consider? Ask yourself what your feelings are about sex? Are you really ready for sex? DO NOT have sex just because: everyone else is; sex will make you more popular; talked into it; afraid the other person will break up with you if you do not; and feel that it will make you a 'real' man or woman. A healthy relationship include: Respect; Good communication; Honesty; Independence; and Equality. You feel physically safe in a healthy relationship, and you are comfortable just being yourself. You have other friends and hobbies or interests, and you can enjoy being together and spending some time apart. You and the other person both enjoy the relationship. Consent is an important part of a healthy relationship because it shows respect. Unhealthy relationships may include the following: Control, such as making all the decisions or keeping you asway from other people, physical abuse, such as pushing or grabbing, hurting, punching or teasing that is mean or makes you feel bad, dramatic statements, and pressure to do things you do not want to do, including sex. The lack of recognition of marriage between partners of the same-sex has health implications as well. A large body of research has shown that positive health outcomes are associated with marriage. These positive effects are derived in part from the increased social support and relative stability associated with a legally recognized commitment. Denial of legal recognition of marriage between same-sex couples also has a direct impact on LGBTQ+ individuals' interactions with the healthcare system. In many cases, employer-sponsored health insurance is not extended to same-sex partners, affecting their access to affordable healthcare. PROTECT TRANSGENDER PATIENTS AND THEIR REPRODUCTIVE HEALTHIn 2010, the U.S. Department of Labor expanded the scope of Family and Medical Leave Act to ensure that employees would be allowed unpaid leave to care for the children of unmarried same-sex partners; however, the act still does not extend this leave to care for unmarried same-sex partners themselves. Some states in U.S. have extended this leave to unmarried same-sex partners, but most have not. In 2010, President Obama issued a memorandum directing the U.S. Department of Health and Human Services to adopt regulations requiring all hospitals receiving Medicaid or Medicare dollars to permit visitation by a designated visitor with regard to sexual orientation or gender identity and requiring those hospitals to respect all patient's advance directives. PARENTING AND CHILDRENBefore the emergence of visible gay communities in the U.S.A., many lesbian, gay men, and bisexual people married heterosexually for a variety of reasons, including social and family pressures, a desire to avoid stigma, and a perception that such marriages were the only available route to having children. Sometimes individuals have recognized their homosexuality or bisexuality only after marrying a person of the other sex. Many lesbian, gay and bisexual individuals became parents through such marriages. In more recent times, many lesbian, gay and bisexual adults have conceived and reared children while in a same-sex relationship. Other same-sex couples and sexual-minority individuals have adopted children. Data from the 2002 National Survey of Family Growth indicate that more than 35% of lesbians aged 18 - 44 years had given birth and that 16% of gay men in that age group had a biological or adopted child. Fewer sexual minority than heterosexual individuals are parents, but there are many lesbian mothers and gay fathers in the U.S.A. today. Thus, many children are currently being reared by one or more sexual-minority parents. The legal status of those parents and of their children varies from state to state. For example, states differ on whether they consider a parent's sexual orientation to be relevant to custody or visitation in divorce proceedings. In recent years, some states have enacted laws and policies forbidding gay and lesbian individuals or couples from foster-parenting or adopting children; other states have considered laws banning same-sex couples, or all unmarried couples, from foster-parenting or adopting children. A long-standing ban on adoptions by lesbian and gay parents in Florida was overturned in 2010. |