Know your patients who identify as LGBT to improve care

People identifying as LGBT face important and unique health issues. Dermatologists can — and should — play an important role in mitigating these issues. In his Friday morning session, “Caring for LGBT Patients: What Dermatologists Need to Know” (S007), Kaiser Permanente dermatologist Kenneth A. Katz, MD, MSc, MSCE, says a better understanding of the disparities involved is essential to working effectively with LGBT patients. 

Kenneth A. Katz, MD, MSc, MSCE

What are the health disparities, including dermatology, facing people who identify as LGBT?

Dr. Katz: According to the federal guide, “Healthy People 2020,” patients who identify as LGBT face several health disparities, including suicide, homelessness, HIV and other sexually transmitted diseases (STD), obesity, mental health issues, victimization, isolation, and tobacco and substance use. The LGBT population is less likely to follow preventive cancer screenings and lacks access to social services and culturally competent providers.

Dermatology-related disparities overlap, to some extent, with the overall health disparities above, including:

Gay men and other men who have sex with men experience higher rates of HIV and other STDs, including syphilis, Kaposi sarcoma, outbreaks of invasive meningococcal disease and methicillin-resistant staphylococcus aureus infections, skin cancer (from sun exposure and indoor tanning), and high rates of mental health concerns among people with acne.

Lesbian women and women who have sex with women experience lower rates of HPV vaccination initiation, however, and are at increased risk for HIV and other STDs.

Female-to-male (FTM)/transgender men experience adverse effects of testosterone therapy, including acne and androgenetic alopecia, keloids after gender-affirming surgery, skin infections, and inflammatory disorders related to chest binding.

Male-to-female (MTF)/ transgender women experience higher rates of HIV and other STDs, adverse effects of estrogen therapy, including melasma and keloids after gender-affirming surgery.

What are the best practices for eliciting a history related to sexual orientation
and gender identity from patients?

Eliciting these types of history from a patient is not a task that many dermatologists and other physicians are comfortable with. How we should do it — and why we should do it — hasn’t been emphasized or taught in dermatology training programs. 

When eliciting a sexual history from my patients, I try to normalize the discussion, because many patients might not be expecting to be asked about these potentially sensitive topics in dermatology settings. I tell a patient with a rash that I ask every patient with a rash about their sexual history. And then I’ll ask for permission, “Is that ok?” Once the patient has consented, I’ll ask about any aspects of sexual history I think are important to making a differential diagnosis. Then I let the patient know my thoughts about diagnosis and management, including discussing aspects of the history I’ve just taken that are relevant to my considerations.

With gender identity, I often just ask which pronoun I should use with a patient. Then I ask about aspects of gender identity — including gender-affirming medical and surgical treatments — that are relevant to the visit.

What CDC and public health agency recommendations exist regarding health promotion and disease prevention among people who identify as LGBT?

The CDC has specific recommendations for screening for HIV and other STDs for men who have sex with men and some people who are transgender. Appropriate cancer screenings are important.

Also, the CDC has specific recommendations for vaccinations, including hepatitis A and B and HPV vaccination for men who have sex with men. In some areas, meningococcal vaccination is recommended. Those recommendations apply to some people who are transgender. 

The CDC has recommendations for HIV pre-exposure prophylaxis (PrEP) for men who have sex with men and for some people who are transgender. The CDC has recommendations regarding HIV post-exposure (PEP) that pertain to LGBT persons. 

The American Academy of Dermatology has an Expert Resource Group (ERG) on LGBTQ/Sexual and Gender Minority (SGM) Health, which is open to all, regardless of sexual orientation or gender identity.