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Channa Amarasekera: Hi, everyone, thanks for the opportunity to present here. My name's Channa Amarasekera. I'm the director of the Gay and Bisexual Men's Urology Program at Northwestern Hospital, which is a few blocks from here.

All right. It's important to talk about the LGBT rights movement in the US if we're going to talk about LGBT healthcare. You're here in Illinois, so I wanted to give a shout-out to Illinois as being the state where there was the first gay rights organization in 1924, but there was a lot of discrimination back then until very recently.

In 1952, the American Psychiatric Association considered homosexuality a sociopathic personality disturbance, and this was later removed in 1973. In 1962, Illinois was the first state to decriminalize homosexual acts between consenting adults in private. In 1969, the modern gay rights movement really began with patrons at Stonewall, in a gay bar, in New York, revolting against the police. Then, the LGBT community plunged into the AIDS crisis of the '80s. Discovered first in '81 or reported first in '81, I should say, but it took about four years for President Reagan to acknowledge that AIDS was a problem in public address.

Once the community recovered from that, there was then some steady advances with gay rights with a 2003 US Supreme Court case, Lawrence vs. Texas, that ruled that sodomy laws in the US were unconstitutional. Then things quickly progressed. In 2015, there was gay marriage, which was the law of the land. In 2020, there were two cases that extended federal protection from workplace discrimination for LGBT people. And then, very recently, or two days ago, we had the first openly lesbian governor elected in Massachusetts, so things have been moving pretty quickly. Just to highlight how quickly things have changed, this is a real headline from an article in 1969, which is quite sensational, but this would never fly anymore, so things have changed significantly.

In terms of health and wellness disparities, LGBT youth are two to three times more likely to attempt suicide. They're more likely to be homeless. MSM or men who have sex with men are at higher risk for HIV, STDs, especially among communities of color. LGBTQ+ populations have the highest rates of tobacco, alcohol, and other drug use. Lesbians in particular are less likely to access cancer-screening services. And then, LGBTQ+ adults are more likely to live in households with food and economic insecurity with 13.1%, reporting sometimes or often not having enough to eat in the past seven days, compared to 7.2 non-LGBT adults, and this was in 2021.

These disparities in access to care and economic privilege can lead to health disparities. There are some chronic conditions where LGBT people fare less well than their straight counterparts, including hypertension and heart disease, mental health areas, access to insurance, and then substance use behavior. So, in terms of why they have these disparities in care, there's marginalization in healthcare, a history of mistrust and discrimination at the community level, which is particularly pronounced during the AIDS epidemic in the 1980s. There's often heteronormative attitudes in clinic where physicians or providers may assume that a patient is heterosexual, and a combination of this can lead to direct impact of stigma and chronic stress on health outcomes for this population.

In terms of creating an inclusive clinic environment, there are three things that might be helpful with this. There's a structural environment where you can provide cues to patients that you're open and welcoming of all types of people, including LGBT people. This can be in the form of posters or brochures that target this population in general. You can also have things like gender-neutral bathrooms, which can signal a willingness or acceptance of this community. Then there's the systemic environment, which are things like policies in the clinic or trainings that you can have for our providers and staff to be LGBTQ inclusive and tolerant. And then, there's the interpersonal environment where physicians are trained to be not just competent in LGBT healthcare, but allies in health and advocate for these patients.

It's often difficult to talk about sexuality in clinic. It's frequently not discussed in clinical settings, and often that's because there are gaps in provider knowledge and comfort. There's a significant rate of nondisclosure among LGBTQ patients in GU oncology clinics with the burden often falling upon the patient. Providers can be trained to provide a safe environment for disclosure and respond with affirmations to foster patient-physician trust. An easy way to do this is to add a sexuality and gender information section in the EMR, and this is found to be acceptable both to patients who are LGBT and otherwise who visit clinics.

Sexuality can often be an important domain for patients to be able to disclose that to their physicians, but also, it's effective to know this when physicians are making decisions on behalf of the patient. In terms of LGBT inclusive language in clinic, it's important not to assume the patient's heterosexual or cisgender, and asking open-ended questions to give the patient the space to disclose their sexual identity is important. Using pronouns, sexual orientation, and gender identity information in the EMR or intake forms and in your conversations with the patient is also often helpful, and then, using gender-neutral terms such as partner instead of husband or wife to document patient's social history.

With urologic healthcare and LGBT specific issues, there's the issue of PSA screening, which can often be elevated with receptive intercourse where there's vigorous stimulation of the prostate and release of PSA leading to potentially unwarranted biopsies. Then there's always the opportunity to detect anal cancer, which there's a higher prevalence of in gay and bisexual men during the DRE, so it's important to pay attention to that.

And then, when treating for things like prostate cancer, it's important to recognize that LGBT patients may prioritize their sexual health and specific aspects of sexual health differently, than their non-LGBT counterparts. In particular, erectile function in general may need to be more firm for patients who are the penetrative partners, compared to men who have sex with women for vaginal penetration. And then, for men who don't engage in penetrative anal intercourse, they may not care so much about erectile functioning at all, so it's important to figure out how this plays into their life overall. In terms of rectal health for men who engage in receptive anal intercourse, rectal health is of particularly importance, particularly with radiation where there could be fibrosis and bleeding and pain. So, if you're steering a prostate cancer patient towards one type of treatment or another, it might be important to figure out what role they play in sex.

This is also of importance when talking about brachytherapy because there's radioactive seeds in the prostate. You may be placing his partner at risk if you choose an isotope with a long half-life, so they should be counseled about that too. Loss of ejaculatory function has been of particularly importance to gay and bisexual men compared to their straight counterparts, so counseling these patients that this is a likely outcome is important to manage expectations. And post-prostate cancer treatment, often there's a lot of experimentation within this community because they've lost in many cases the ability to have an erection. So, they might experiment with other roles in sex, which may put them at higher risk. There's about a 6% higher risk of getting an STD in the first year after prostate cancer treatment, so counseling these patients about this risk and potentially discussing things like pre-exposure prophylaxis can be helpful and may prevent them from getting a lifelong condition that needs to be managed with medications.

And then, urinary incontinence is important because gay and bisexual men often have different sexual repertoires where it may not just be about penetrative sex, and there's a higher incidence of oral sex or other types of sex where there's visible incontinence, which may be problematic for these patients. Other things you might see patients for are things like STI screening. If patients present to you with proctitis and pelvic pain, often rectal screening for gonorrhea chlamydia is important. And then, looking for other areas where you might want to screen are pharyngeal screens, where you often think about just screening urine for straight men.

There are higher rates of syphilis, so if you have an ulcer that presents to your clinic, it's important to keep in mind that testing for syphilis might be helpful. And then, more recently, there's been an outbreak of monkeypox, so keeping that in mind is helpful in protecting both yourself and your staff as you do this. Awareness of LGBT-specific aspects of urologic conditions, it increases trust, it aids in decision-making, and improves health outcomes both physically and mentally for the patients. This is just a five-minute primer I realize, but if you have time, here are some resources to learn more about caring for LGBT patients.