Lec 4: Contemporary Ethics LGBTQ Training

Question 1

Definitions
1.) Sex
2.) Gender
3.) Gender Nonbinary

Answer 1

1.) Sex: Assigned based on external genitalia
2.) Gender: Assigned based on an internal sense of self and how one fits into society (how someone feels)
3.) Gender Nonbinary- Gender which does not fit
as male or female Spectrum

Question 2

Definitions: Sexual Minorities
1.) Lesbian
2.) Gay
3.) Bisexual
4.) Queer

Answer 2

1.) Lesbian –a woman who is emotionally, romantically, or sexually attracted to other women
2.) Gay –a person who emotionally, romantically, or sexually attracted to members of the same gender. This term often refers to homosexual men but is not limited to this use.
3.) Bisexual –a person emotionally, romantically or sexually attracted to more than one sex, gender or gender identity though not necessarily simultaneously, in the same way or to the same degree.
4.) Queer – a term people often use to express fluid identities and orientations. Often used interchangeably with ‘LGBT.’ Academic, political, and cultural adoption of this term and its addition to the LGBTQ acronym has been recent, and its historical use may hold a negative connotation for some LGBT people.

Question 3

Definitions: Gender Minorities
1.) Transgender
2.) Cisgender

Answer 3

1.) Transgender- an umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth
—- Being transgender does not imply any specific sexual orientation
—- Transgender people may identify as any sexuality including the sexual minorities
.
2.) Cisgender- people whose gender identify is the same as the sex they were assigned at birth
—- Being cisgender does not imply any specific sexual orientation
—- Cisgender people may identify as any sexuality including the sexual minorities

Question 4

Gender ≠ Sexual Orientation
Define Gender Identity

Answer 4

Question 5

Gender ≠ Sexual Orientation
Define Gender Expression

Answer 5

Question 6

Gender ≠ Sexual Orientation
Define Sexual Orientation

Answer 6

Question 7

Health Disparities in the LGBT community

Answer 7

• Higher rates of depression and anxiety
• Higher rates of suicide attempts and homelessness
• Higher rates of violence victimization
• Lower rates of mammography and Pap smear screening
• Higher rates of smoking and substance abuse
• Higher rates of HIV and other sexually transmitted diseases (4x times higher!!)
• Higher rates of unhealthy weight control/perception

Question 8

US Transgender Survey Report (2015)

Answer 8

• 1 out of 10 transgender people who come out to their family experience physical violence by a family member
• 30% of all transgender people have experienced mistreatment in the workplace
• 30% live in poverty
• 1 out of 3 transgender people have a negative experience at their medical visit
• 23% don’t engage in medical care due to fear of mistreatment
• 25-55% have problems with insurance covering their care

Question 9

Transgender people are more likely to:

Answer 9

• Be fired or denied a job
• Face harassment and bullying at school
• Become homeless or live in extreme poverty
• Be evicted or denied housing or access to a shelter
• Be denied access to critical medical care
• Be incarcerated or targeted by law enforcement
• Face abuse and violence

Question 10

Goals of LGBT Awareness/Competency

Answer 10

• Improve healthcare to the LGBT patients
• Decrease LGBT health disparities
• Improve outreach and education on health risks of
  LGBT people
• Create an LGBT affirming environment for healthcare
  professionals and patients

Question 11

Definitions: Coming out

Answer 11

the ongoing process in which one acknowledges,
accepts and appreciates one’s sexual orientation or gender identity and shares it with others

Question 12

Definitions: Heteronormative

Answer 12

the cultural belief which assumes that heterosexuality is the norm

Question 13

Definitions: Implicit and Implicit Bias

Answer 13

1.) Implicit-an individual feeling that we are unaware of and/or mistaken about their nature
— Our own personal preference
— Our own personal aversions
2.) Implicit bias-our attitude towards people and associated stereotypes with them without conscious knowledge

Question 14

Prevalence: 2016 Estimates…nationwide and NM?

Answer 14

• Nationwide: ~1,400,000 people identify as TGNB (0.58%)
• New Mexico ranked #3 with 0.75% identifying as TGNB

Question 15

Gender Pronouns…Use pronouns the patient uses

Answer 15

• Female: she/her
• Male: he/him
• Gender neutral: they/them (can be used as singular), ze/hir, it

Question 16

Gender Pronouns (general)

Answer 16

• Patients may identify as one gender but not yet ready to
  use pronouns for that gender
• Periodically ask and check to make sure the patient is still using the pronouns you are using
• Electronic Medical Records (EMR) and systems of care… Determine how to record sex assigned at birth and affirmed gender

Question 17

Informed Consent Model

Answer 17

Question 18

Treatments for Gender Dysphoria

Answer 18

-* Social transition
- Psychotherapy
- Pharmacologic therapy
- Surgery (Gender confirmation surgery)
- Voice training
- Electrolysis (hair removal tx)

Question 19

Feminizing Hormone Therapy
General approach…

Answer 19

Combine estrogen with anti-androgen

Question 20

Estradiol Formulations

Answer 20

Question 21

Anti-Androgens (2 main medications)

Answer 21

1.) Spironolactone
- MOA: Directly inhibits testosterone synthesis and androgen binding to the androgen receptor (testicles and adrenal glands)
- Dose is usually higher than cardiovascular disease (100-400mg/day)
- Oral tablet
- Inexpensive
.
2.) Gonadotropin-Releasing Hormone (GnRH) analog
- MOA: Blocks GnRH receptor, thus blocking the release of follicle stimulating hormone and luteinizing hormone at the level of the pituitary
- Monthly or every 3 month injection
- ~$3,000-$8,000 per month

Question 22

Masculinizing Hormone Therapy
Goals and general approach

Answer 22

1.) Goals
- To develop male secondary sex characteristics
- To suppress/minimize female secondary sex characteristics
2.) General approach: Testosterone monotherapy

Question 23

Testosterone Formulations

Answer 23

Question 24

Contraindications to Testosterone Therapy??

Answer 24

Pregnancy - Informed consent process for shared decision making should be used in patients with risk factors

Question 25

Ethical Case 1
A 16 yo male (DFAB, not on hormone therapy) comes
to clinic for with their parents to pursue medical
management of their diagnosed gender dysphoria. She
is feeling discouraged because her father is not
supportive of her transition.

Answer 25

• Under a pediatric ethics framework, caregivers have a responsibility to promote the best interests of the child.
• Data suggest that transgender youth who are supported in their identities and who have access to gender-affirming care have better mental health outcomes.
• That often means that the first step in cases of parental
  disagreement is supporting families in exploring their discomforts and educating them regarding the benefits of gender-affirming care for transgender adolescents. However, there are times when dualparent support is unachievable.

Question 26

Ethical Case 2
- A 67 yo female (DMAB, on estradiol 4mg since 9/2019)
comes to clinic for additional hormone therapy
management. She is feeling discouraged because her
testosterone level came back high and she is not
experiencing any effects of estrogen.
- PMH: NSTEMI 2018, DVT 2014
- Labs: testosterone 1330 (goal <50), estradiol 39 (goal 100- 200)
.
Should additional hormone therapy initiated for a patient with medical comorbidities that may be worsened by exogenous hormone therapy?

Answer 26

• Without hormone therapy, a patient may continue to
  experience an unacceptable level of gender dysphoria,
  which carries mental health burdens and risks.
• However, this concern must be balanced against the
  medical risks associated with using hormones.
• It is ethically appropriate to discuss risks, benefits, and
  alternatives with patients to ensure adequate
  understanding and informed consent, including discussing whether any risks can be mitigated with adjunctive treatments (i.e., concurrent anticoagulation therapy, forms of estrogen that carry a lower incidence of VTE, tobacco cessation, and/or psychotherapy)

Question 27

The Basics: Being an Ally

Answer 27

• TGNB cultural competency (Learn yourself, Train staff)
• Create a gender affirming setting (De-gender language, Post written nondiscrimination policy, Gender neutral bathrooms)
  .
• There is no one way to be a ‘perfect’ ally. Be respectful, do your best, and keep trying.
• You don’t have to understand someone’s identity to
  respect it.
• You can’t always tell if someone is transgender simply
  by looking at them. There is no “one right way” to be
  transgender.
• Continue to educate yourself.

Question 28

Interacting with Transgender People

Answer 28

• Use the language a transgender person uses for themselves.
  .
• If you don’t know what pronouns to use, ask.
  EX: “Hi, I’m Kelsea and I use she/her/hers as my pronouns. How about you?” If you accidentally use the wrong pronouns, apologize and move on. Making a big deal out of a pronoun mistake may be awkward and often draws unwanted attention to the transgender person.
  .
• Be careful and considerate about what other questions you ask! There are many topics—medical transition, life pre-transition, sexual activity—that you may be curious about. That doesn’t mean it’s appropriate to ask a transgender person about them, or expect a transgender person to be comfortable sharing intimate details about themselves. There are two questions you can ask yourself that may help determine if a topic is appropriate to bring up: “Do I need to know this information to treat them respectfully?”, “Would I be comfortable if this question was turned around and asked of me?”
  .
• Someone’s transgender identity is their private information to share, or not
  .
• Avoid compliments or advice based on stereotypes about transgender people, or about how men and women should look or act. People sometimes intend to be supportive but unintentionally hurt transgender people by focusing on their looks or whether they conform to gender stereotypes. Here are some examples of what to avoid, as they often feel like backhanded compliments: “You look like a real woman! I never would have known that you’re trans.”, “You would look less trans if you just got a wig/shaved better/wore more makeup/etc.”, “No real man would wear clothing like that. You should change if you don’t want people to know you’re trans!”.

Question 29

Resources

Answer 29

• World Professional Association for Transgender
  Health (WPATH.org)
• The Endocrine Society Guidelines
• Fenway National LGBTQ Health Education Center
• UCSF Center of Excellence for Transgender Health