Harvey J. Makadon

Sexual and Gender Minority Health: What We Know and What Needs to Be Done

We describe the emergence of lesbian, gay, bisexual, and transgender (LGBT) health as a key area of study and practice for clinicians and public health professionals. We discuss the specific needs of LGBT populations on the basis of the most recent epidemiological and clinical investigations, methods for defining and measuring LGBT populations, and the barriers they face in obtaining appropriate care and services. We then discuss how clinicians and public health professionals can improve research methods, clinical outcomes, and service delivery for lesbian, gay, bisexual, and transgender people.

Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients.

The medical community’s efforts to address intimate partner violence (IPV) have often neglected members of the lesbian, gay, bisexual, and transgender (LGBT) population. Heterosexual women are primarily targeted for IPV screening and intervention despite the similar prevalence of IPV in LGBT individuals and its detrimental health effects. Here, we highlight the burden of IPV in LGBT relationships, discuss how LGBT and heterosexual IPV differ, and outline steps clinicians can take to address IPV in their LGBT patients.

Bisexuality, sexual risk taking, and HIV prevalence among men who have sex with men accessing voluntary counseling and testing services in Mumbai, India.

Objectives:To describe sociodemographics, sexual risk behavior, and estimate HIV and sexually transmitted infection (STI) prevalence among men who have sex with men (MSM) in Mumbai, India. Methods:Eight hundred thirty-one MSM attending voluntary counseling and testing (VCT) services at the Humsafar Trust, answered a behavioral questionnaire and consented for Venereal Disease Research Laboratory and HIV testing from January 2003 through December 2004. Multivariate logistic regression was performed for sociodemographics, sexual risk behavior, and STIs with HIV result as an outcome. Results:HIV prevalence among MSM was 12.5%. MSM who were illiterate [adjusted odds ratio (AOR) 2.28; 95% confidence interval (CI): 1.08 to 4.84], married (AOR 2.70; 95% CI: 1,56 to 4.76), preferred male partners (AOR 4.68; 95% CI: 1.90 to 11.51), had partners of both genders (AOR 2.73; 95% CI: 1.03 to 7.23), presented with an STI (AOR 3.31; 95% CI: 1.96 to 5.61); or presented with a reactive venereal disease research laboratory test (AOR 4.92; 95% CI: 2.55 to 9.53) at their VCT visit were more likely to be HIV infected. Conclusions:MSM accessing VCT services in Mumbai have a high risk of STI and HIV acquisition. Culturally appropriate interventions that focus on sexual risk behavior and promote condom use among MSM, particularly the bridge population of bisexual men, are needed to slow the urban Indian AIDS epidemic.

Promoting the Successful Development of Sexual and Gender Minority Youths

Because of societal discomfort with atypical expressions of sexual orientation and gender identity, lesbian, gay, bisexual and transgender (LGBT) youths have experienced enhanced developmental challenges compared with their heterosexual peers. A recent special issue of the American Journal of Public Health delineated how social stigma affecting LGBT youths has resulted in a wide range of health disparities, ranging from increased prevalence of depression and substance use to downstream effects, such as an increased risk for cancer and cardiovascular disease when older. We review the clinical significance of these findings for health care professionals, who need to become informed about these associations to provide better care for their sexual and gender minority youth patients, and to be able to educate their parents and other caregivers.

Nurses and Physicians: Prospects for Collaboration

Excerpt Relations between professional groups reflect their histories as well as the politics, economics, and culture of the times. Those between physicians and nurses are no exception. The current...

Transgender men and pregnancy

Transgender people have experienced significant advances in societal acceptance despite experiencing continued stigma and discrimination. While it can still be difficult to access quality health care, and there is a great deal to be done to create affirming health care organizations, there is growing interest around the United States in advancing transgender health. The focus of this commentary is to provide guidance to clinicians caring for transgender men or other gender nonconforming people who are contemplating, carrying, or have completed a pregnancy. Terms transgender and gender nonconforming specifically refer to those whose gender identity (e.g., being a man) differs from their female sex assigned at birth. Many, if not most transgender men retain their female reproductive organs and retain the capacity to have children. Review of their experience demonstrates the need for preconception counseling that includes discussion of stopping testosterone while trying to conceive and during pregnancy, and anticipating increasing experiences of gender dysphoria during and after pregnancy. The clinical aspects of delivery itself fall within the realm of routine obstetrical care, although further research is needed into how mode and environment of delivery may affect gender dysphoria. Postpartum considerations include discussion of options for chest (breast) feeding, and how and when to reinitiate testosterone. A positive perinatal experience begins from the moment transgender men first present for care and depends on comprehensive affirmation of gender diversity.

Caring for people with AIDS and HIV infection in hospital-based primary care practice

ConclusionThe future health care needs of individuals with HIV infection are uncertain but clearly growing. Through close teamwork and the integration of patients infected with HIV into mainstream care, the practice we describe has attempted to establish a framework for care that can be adapted and expanded to meet future needs. This capacity is becoming even more important as care for those in the early stages of HIV infection is extended, requiring regular follow-up. As the AIDS epidemic continues, it is important to monitor this and similar efforts closely. Ultimately, we may need to build programs on the strengths of existing and interested institutions without regard to whether they are AIDS-specific or decentralized. Our goal should be to insure that each, regardless of structure, be evaluated with respect to the quality of care provided. Given the growing primary care needs of people with HIV infection, national leaders in primary care must consider how to incorporate the capacity to meet these needs into their programs.

Intensity of in-hospital care for persons with AIDS.

Summary:We evaluated the intensity of medical care for 30 consecutive AIDS patients at one hospital, using methodology based on the Delay Tool of Selker et al. Of 25 AIDS patients who survived hospitalization, 15 had at least one delay day in the hospital. Major factors associated with care that could have been provided at an alternative site included difficulty with skilled nursing facility placement in 20% of the patients, difficulty coordinating out-of-hospital care in 28%, and scheduling of outpatient surgical procedures in 12%. For the 15 patients who could have received some of their care at a lower intensity setting, a median of 7 hospital days could have been potentially saved with better coordination of outpatient care and increased availability of skilled nursing facilities. The five patients who died in hospital also used large amounts of resources and had long lengths of stay. Prior studies of non-AIDS patients revealed similar results, suggesting that, for reasons of quality of care, quality of life, and economics, policy-makers must develop managed care programs, skilled nursing facilities that accept AIDS patients, inpatient psychiatry facilities, and increased hospice availability.

Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments

Lesbian, gay, bisexual and transgender (LGBT) people face pervasive health disparities and barriers to high-quality care. Adequate LGBT sexual health education for emerging health professionals is currently lacking. Clinical training programs and healthcare organisations are well poised to start addressing these disparities and affirming LGBT patients through curricula designed to cultivate core competencies in LBGT health as well as health care environments that welcome, include and protect LGBT patients, students and staff. Health education programs can emphasise mastery of basic LGBT concepts and terminology, as well as openness towards and acceptance of LGBT people. Core concepts, language and positive attitudes can be instilled alongside clinical skill in delivering inclusive sexual health care, through novel educational strategies and paradigms for clinical implementation. Caring for the health needs of LGBT patients also involves the creation of health care settings that affirm LGBT communities in a manner that is responsive to culturally specific needs, sensitivities and challenges that vary across the globe.

Value management: optimizing quality, service, and cost.

&NA; Hospitals have wrestled with balancing quality, service, and cost for years—and the visibility and urgency around measuring and communicating real metrics has grown exponentially in the last decade. However, even today, most hospital leaders cannot articulate or demonstrate the “value” they provide to patients and payers. Instead of developing a strategic direction that is based around a core value proposition, they focus their strategic efforts on tactical decisions like physician recruitment, facility expansion, and physician alignment. In the healthcare paradigm of the next decade, alignment of various tactical initiatives will require a more coherent understanding of the hospitals core value positioning. The authors draw on their experience in a variety of healthcare settings to suggest that for most hospitals, quality (i.e., clinical outcomes and patient safety) will become the most visible indicator of value, and introduce a framework to help healthcare providers influence their value positioning based on this variable.