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 V.21 No.23 | June 7 - 13, 2012 

Miss Diagnosis

“We’re Both Dad”

Health care’s LGBT blind spot

Melanie, born during the death throes of the second Bush administration, was all of one hour old when I arrived at the newborn nursery at the busiest hospital in Dallas.

After giving Melanie her first bath, I tucked her into her bassinet and wheeled her out of the nursery back to her parents. I knocked gingerly on the door to Patient Room 302, hoping I wasn’t disturbing a sleeping new mother exhausted after the trials of labor.

Two men in plaid pajama pants and old sweatshirts opened the door. “Delivery!” I exclaimed. The men looked at each other, and then to the bassinet, and back to each other, beaming.

“Which one of you is Dad?” I asked, peering beyond them to the bed, where I expected to see a tired mom resting. But the bed was empty and neatly made, hospital corners undisturbed.

One of the men arched his eyebrow at me and laughed a little. “We’re both Dad,” he replied. They held out their wrists to me, and I saw that they wore hospital ID bracelets matching the baby’s.

“We’re adopting her,” the other man explained when I didn’t reply.

“Oh!” I exclaimed, finally orienting to reality. “Oh! Cool!”

Cool. God, I cringe when I think about that.

Like all new parents, they marveled at Melanie’s tiny feet, smelled her fuzzy baby hair, and counted her fingers and toes. Melanie yawned adorably and stretched out her arms. Then she puckered her little mouth, knit her brow and, with absolute predictability, filled her diaper with a quantity of poop large enough to call into question the first law of thermodynamics.

John and Zach looked at one another in shock. Then denial set it. “She didn’t just ... did ... no! Did she?!”

Zach and John had read every parenting book in the library. While Zach reviewed the step-by-step instructions for changing a diaper aloud, John disappeared into the giant, stuffed diaper bag that they had brought. He emerged with a pack of diapers in one hand, a fistful of wipes in the other and a tube of diaper cream between his teeth.

I always get a kick out of watching brand-new parents fumble with the first diaper change, nervous and unused to the mechanics of maneuvering a 6-pound human.

Considering all I’ve witnessed in my career—dramatic resuscitations and miraculous recoveries included—it’s a little funny that teaching a couple of dudes how to wipe a baby butt stands out in my mind as one of my proudest moments as nurse. But I met Melanie, John and Zach years before "Modern Family" would air on prime time and the president would finally evolve enough to voice his support of gay marriage.

John and Zach had struggled to adopt for more than a decade. Getting to teach them how to change a diaper felt like being at the epicenter of a seismic shift in culture.

Yet it also got me thinking about how I had greeted the couple with the assumption that only one of them could be Melanie’s dad. What happens when millions of these assumptions occur every day in almost every corner of health care across the country?

Dr. Edward Fancovic is the director of LGBT Equity and Inclusion at the University of New Mexico Health Sciences Center. He says lack of awareness and insensitivity to LGBT issues can harm patients: Many folks encountering discriminatory behavior within the health system avoid seeking care all together. Those who do make it into the doctor’s office may withhold information if the clinician comes across as judgmental or uninformed.

Fancovic says that only about half of gay men and one-third of gay women declare their sexual orientation to their doctor up front, so training clinicians to take the initiative and ask these sensitive questions helps minimize the Don’t Ask, Don’t Tell mentality in health care. “When you ask questions that are neutrally phrased, that describe behavior without any labels or judgment, you’ll get an honest answer,” he says. Over the course of his career, Fancovic has seen progress in this area. Things aren’t perfect, but newer clinicians do use the tools that are being taught, he says, and tend to show greater sensitivity.

While the climate for LGBT patients has improved considerably over the last 30 years, huge gaps in care still exist. “When I began my career, there was nothing that represented me as a gay man in the medical establishment. That needs to change,” he says. Mentoring helps open the door for others within the LGBT community to find their way in medicine: “If there are people out there who are interested in a career in medicine, they can do it, they should do it, and they’ve got the support to do it,” he says.

As visibility increases, the whole concept of LGBT health broadens. Fancovic says fixating on certain topics is overly simplistic. “You hear ‘gay’ and want to talk about HIV and suicide.”

These issues, while important, don’t fully capture the complexity of a person's health. He cites immunizations, cholesterol screening, tobacco use, weight reduction, and care of the aging and elderly as just a few examples of other major LGBT health needs.

Health care providers who make assumptions about their patients may not ask the right questions or offer needed services. For instance, lesbians may have a lower risk for developing cervical cancer and sexually transmitted infections. Yet many women identifying as lesbian have a history of heterosexual intercourse, and certain lesbian sexual practices can still transmit infections. Because of this, Fancovic says women identifying as lesbian should be offered pap testing and STI screenings.

When it comes to talking about health issues, LGBT patients need a strong voice in the conversation. To help facilitate the discussion, Fancovic points patients to glma.org. The website has lists of topics and talking points for gay, lesbian or transgender people to bring up at their doctor’s appointment. As families like John, Zach and Melanie become more common, I’m looking forward to the day that diaper changing makes it on to one of those lists.

Expert Opinion: LGBT Health

At 6-foot-4, Dr. Ed Fancovic cuts an imposing figure. Add his reputation as a respected educator, an expert in LGBT health, and a human encyclopedia of general medical know-how, and you’ve got an intimidation factor of about a billion. It’s no wonder that I barely had the guts to squeak out a “hello” when I, then a hopelessly green nurse practitioner student, first met him.

Fast-forward a couple of years to my first day on the job as a newly minted nurse practitioner. I show up to work with my sad little briefcase and a lunch that, I kid you not, my mom packed for me. The clinic director guides me to my new office and, lo and behold, who do I see hanging out at the desk next to mine? None other than Fancovic himself, mentoring a medical student through a difficult clinical case. This time I manage to deliver an audible “hello.”

Fancovic’s willingness to share his time and expertise made him an obvious target for some Alibi questioning. Here are a few extra LGBT health pointers, from the expert himself:

Immunizations

Dr. Fancovic makes sure his patients are immunized against hepatitis A, hepatitis B and human papillomavirus (HPV). These diseases can be transmitted sexually, so he says it’s especially important that folks get immunized. Patients should ask about vaccines, since some doctors or health care providers may be unaware that LGBT clients need to have them. And FYI, males can and should get the HPV vaccine, since it not only prevents cervical cancer but probably anal and penile cancers as well.

Sexually transmitted infections

In addition to immunizations, Fancovic recommends that sexually active gay men and other folks engaging in unprotected or high-risk sexual behavior get screened for sexually transmitted infections (including HIV) at least once a year.

Women’s health and general screening

One of the greatest health needs for lesbians is just getting to the doctor, he says. Heterosexual women often get seen on a yearly basis, since many women use some form of prescription birth control. Lesbians who don’t require birth control just don’t get in to be seen, which means they’re less likely to receive services like blood pressure checks, cholesterol screening, and pap testing.

Fancovic says the one area where lesbian health shines is mammogram rates—lesbians tend to get more mammograms than their heterosexual peers. And, BTW, transgender men may still need mammograms and pap tests if they still have a uterus. Some experts recommend that men who have sex with men get anal pap testing, and that both women and men living with HIV receive annual pap testing.

Transgender health:

Transgender women often take female hormones like estrogen. Estrogen is a double-edged sword, since it predisposes women to blood clots and all kinds of other junk (breast cancer, migraines, etc.). Fancovic says transgender women are a whopping 100 to 1,000 times more likely to develop a blood clot during first year of hormone use. Signs of a blood clot in the leg might include a tender, swollen red area behind the knee or calf, a low-grade fever and leg pain, or one leg that is more swollen than the other. If a clot travels to the lung, people experience difficultly breathing, chest pain, and a sensation that patients typically describe as a sense of doom. Call 911!

Likewise, females transitioning to males can run into issues with testosterone. Fancovic says transgender men need to be checked for high cholesterol, liver problems, high red blood cell count and acne. Plus, he points out that there can be major safety issues if people using these hormones on their own, through the Internet, without the supervision of a medical professional. An unsafe dose or impure product can spell health disaster, so it’s best to seek professional guidance.

Mental health

The research on anxiety, depression and substance use goes back and forth, but Fancovic says recent data suggests there probably is some increase in alcohol abuse in LGBT populations. Gay men and lesbians use tobacco at higher rates, and Fancovic says there’s fairly consistent data that gay and bisexual men under the age of 30 use all recreational drugs at higher rates than other groups. However, this tends to taper off after the age of 30. It’s always important for health care providers to ask about substance abuse (including tobacco and alcohol).

He says awareness of these issues is increasing, but identifying culturally sensitive mental health care providers is difficult. Increasing the number of LGBT providers can help meet these behavioral health needs.

HIV

Here in the United States, HIV has evolved from a death sentence for young people into a chronic disease that can be controlled into a person’s twilight years. Fancovic says here in the Land of Enchantment, HIV patients are able to get coverage through the high-risk insurance pool, and that ADAP (Aids Drugs Assistance Programs) have no waiting list. Another thing to be proud of: Rates of HIV in New Mexico are quite low compared to the rest of the country.

Unfortunately, he adds that that the Health Department’s 2010 epidemiology data shows that 48 percent of Hispanics already have AIDS at the time of diagnosis (meaning it’s a late diagnosis), and this percentage is rising. The infection rate in younger men is also climbing, and heterosexual transmission to women is creeping upwards. Why? Fancovic points to mission fatigue—a diminishing sense of urgency now that young people aren’t routinely dying of AIDS. He says that keeping HIV rates low requires regular HIV screening, persistent community outreach, and savvy public relation campaigns.

For more information, check out the New Mexico Department of Health’s 2010 report on LGBT health disparities.

Despite its brilliant name, this column is not intended to prevent, diagnose or treat awesomeness. Or any other ailments, for that matter.

Whitny Doyle is a family nurse practitioner.

The opinions expressed are solely those of the author.
 

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