Section 5. Workforce development to encourage delivery of high-quality services for SGM patients

Many SGM people presenting for primary care may have had uncomfortable or even traumatic experiences in medical settings in the past. They may not have benefited from screening and treatment services centered on their particular health needs. For this reason, it is not only critical to train providers and staff in basic SGM healthcare competency and use of supportive language (see Section 4) but also to encourage them to become knowledgeable about identifying and addressing health considerations that might be relevant to this population.

SGM people’s routine primary care does not typically require specialized medical knowledge, but awareness of clinical issues that are common among this population is key to effective care. These common issues are highlighted in Table 9.4. Table 9.5 showcases online training opportunities related to each issue.

Providers and staff involved in routine primary care also require competency in collecting comprehensive health histories (including social and sexual health histories) and conducting physical exams (including breast, pelvic/urogenital, rectal, and prostate exams) in ways that are supportive of SGM patients:

Patient Histories: All employees who take patient histories or work one-on-one with patients to complete history forms must understand the questions being asked, be able to respond to patient concerns about these questions, and also understand the clinical significance of the answers that patients provide.

Physical Exams: Providers should employ organ inventories and be aware of bodily areas that may be sensitive to SGM patients and how to address their concerns, such as explaining why a physical exam is necessary and asking patients to suggest ways to make the experience safe and comfortable.

Table 9.4

Common Health Conditions among SGM Patients

Mental health

Anxiety, depression, and trauma-associated symptoms are common among SGM people, and suicidal ideation and behavior are concerning symptoms impacted by stressful social factors (e.g., isolation from other SGM people, experiences of rejection, stigma, discrimination, violence, and homelessness). Providers should pay close attention to each patient’s history to determine what recommendations, screening, and referrals are required.

Diet and exercise

Under- and over-eating and lack of, or excessive, exercise can affect SGM people in many ways and predispose patients to other health conditions (e.g., diabetes, metabolic syndrome, bulimia, and anorexia).

Intimate Partner Violence (IPV)

SGM people experience IPV at alarming rates, but negative stigma (e.g., the belief that IPV cannot occur or is less harmful when occurring between same-sex partners) may contribute to underreporting. Providers should explore possible historical and current abuse and understand the possible connection of abuse to mental health and substance use.

Tobacco, Alcohol and Drug Misuse

Substance misuse is common in SGM populations, often related to social stressors, mental health, and “bar culture.” Providers should be prepared to explore such issues with patients and offer support and referrals to affirming treatment.

Cancer

Standard screenings for cancer occur at lower rates among SGM patients compared with non-SGM patients. Providers should offer such screenings based on the patient’s history and the organs present. When referring out for anoscopy, mammograms, or other imaging, they must understand the importance of sending patients to SGM-affirming facilities.

Cardio-vascular health

All patients should receive counseling and screening for cardiovascular disease based on personal/family history. Providers must be aware of how hormone therapy affects standard test results and risks for transgender patients.

Family Planning

Providers should engage SGM patients in conversations about having families. All patients who can be impregnated should also be offered contraception. Options for parenting should be discussed with patients considering puberty blockers, hormones, and surgery for gender affirmation.

Table 9.5

Online Training Opportunities by Treatment Area

Webinars hosted by the National LGBT Health Education Center: https://www.lgbthealtheducation.org/resources/type/webinar/

Mental Health

Behavioral Health Care for Transgender Adults
Behavioral Health Care for Lesbian, Gay, and Bisexual People
Behavioral Health Assessments and Referral for Gender-Affirming Surgery
Mental Health Care and Assessment of Transgender Adults
Supporting LGBTQ Youth: Providing Affirmative and Inclusive Care across the Spectrum of Gender and Sexual Identity
Obesity, Feeding and Eating Disorders, and Body Dysmorphic Disorder among LGBTQ Youth
Best Practices in Behavioral Health for Sexual Minority Women
Providing Mental Health Assessments for Gender Affirming Surgery Referral Letters
Importance of Behavioral Health Integration for LGBT Patients

Diet and Exercise

Obesity, Feeding and Eating Disorders, and Body Dysmorphic Disorder among LGBTQ Youth

Intimate Partner Violence

Implementing Routine Intimate Partner Violence Screening in a Primary Care Setting
Same-Sex Domestic Violence: Considerations, Suggestions, and Resources

Tobacco, Alcohol, Drug Misuse

Addressing Opioid Use Disorders among LGBT People through Trauma-informed Care and Behavioral Health Integration
Providing Care for Addictions in the LGBT Community
SBIRT [Screening, Brief Intervention, and Referral to Treatment] with LGBT Patients: Identifying and Addressing Unhealthy Substance Use in Primary Care Settings
Reducing Tobacco Use in LGBT Communities: How Can We Do Better?

Cancer

Anal Dysplasia and Cancer in At-Risk Groups: What Providers Need to Know
Breast Cancer Risk and Prevention in Lesbian and Bisexual Women
If You Have It, Check It: Overcoming Barriers to Cervical Cancer Screening with Patients on the Female-to-Male Transgender Spectrum

Cardiovascular Health	LGBT Health Disparities & Hypertension Control Opportunities with the American Heart Association Considerations for Heart Health of LGBT Identified Patients
Family Planning	Building Your Family: LGBTQ Reproductive Options Pathways to LGBT Parenthood: Assisted Reproduction and Adoption LGBT Families: Improving Access to Better Health Care

Gender-Affirming Care

Providers should be mindful that transgender or gender-diverse patients may be uncomfortable with parts of their bodies or may anticipate that caregivers will be uncomfortable with their bodies. Providers also require a basic understanding of social, medical/pharmaceutical, and surgical options for gender affirmation; should ask about experiences with such options when collecting histories; and make referrals as needed. Of note, gender-affirming hormone therapy is in the scope of primary care. Providers at your clinic are likely to be quite familiar with appropriate medications due to their use in managing menopause, contraception, hirsutism, male pattern baldness, prostatism, or abnormal uterine bleeding.⁴ Complex cases may warrant input from an endocrinologist or other specialist.

Providers should be prepared to support families of children and teens exploring their gender and sexuality and be aware of resources both in and outside the clinic to support this exploration. When working with youth, it is best to use a multi-disciplinary team approach that includes a professional trained to conduct assessments to determine the appropriateness of treatments, such as puberty blockers and hormone therapy. If such a professional is not available locally, arrangements to collaborate with someone in another location should be put in place. Providers who do not offer this care should be sufficiently familiar with guidelines to have an initial conversation with a patient and then make suitable recommendations and referrals for additional care.

Table 9.6 identifies online training opportunities for facilitating the delivery of gender-affirming care among providers and staff at your clinic. Table 9.7 highlights easily accessible professional development publications to supplement the online training opportunities. Appendix G provides additional resources for caring for transgender and gender-diverse patients, including administering hormones.

Table 9.6

Medical Gender-Affirming Care: Online Training Opportunities

Center for Excellence for Transgender Health at the University of California, San Francisco

https://prevention.ucsf.edu/transhealth/education/trans101

1. Trans 101: Transgender People in Everyday Work and Life!

Center for Excellence for Transgender Health at the University of California, San Francisco

https://prevention.ucsf.edu/transhealth/education/acknowledging-gender-sex

2. Acknowledging Gender and Sex: Supporting Health Care Providers in Serving Transgender Patients and Clients

National LGBT Health Education Center

https://www.lgbtqiahealtheducation.org/resources/in/transgender-health/type/webinar/

3. Optimizing Transgender Health: A Core Course for Healthcare Providers

National LGBT Health Education Center

https://www.lgbtqiahealtheducation.org/courses/sexual-health-for-transgender-and-gender-diverse-people-2020/

4. Sexual Health for Transgender and Gender-Diverse People (2020)

Endocrine Society

https://education.endocrine.org/content/gender-affirming-hormone-therapy-transgender-individuals

5. Gender-Affirming Hormone Therapy for Transgender Individuals

National LGBT Health Education Center

https://www.lgbtqiahealtheducation.org/courses/gender-affirming-hormone-therapy-estrogen-anti-androgens-and-progesterone/

https://www.lgbtqiahealtheducation.org/courses/gender-affirming-hormone-therapy-testosterone/

6. Gender-Affirming Hormone Therapy: Estrogen, Anti-Androgens, and Progesterone

7. Gender-Affirming Hormone Therapy: Testosterone

World Professional Association for Transgender Health Global Education Initiative

https://www.wpath.org/gei

8. Best Practices in Transgender Medical and Mental Health Care

Table 9.7

Medical Gender-Affirming Care: Professional Development Publications

National LGBT Health Education Center

https://www.lgbthealtheducation.org/wp-content/uploads/2016/12/Affirmative-Care-for-Transgender-and-Gender-Non-conforming-People-Best-Practices-for-Front-line-Health-Care-Staff.pdf

1. Best Practices for Front-line Staff

National LGBT Health Education Center

https://www.lgbthealtheducation.org/wp-content/uploads/2017/02/Providing-Affirmative-Care-for-People-with-Non-Binary-Gender-Identities.pdf

2. Providing Affirmative Care for Patients with Non-Binary Gender Identities

InterACT Advocates for Intersex Youth

https://interactadvocates.org/wp-content/uploads/2015/12/BROCHURE-interACT-Doctors-final-web.pdf

3. What We Wish Our Doctors Knew

Substance Abuse and Mental Health Services Administration	https://store.samhsa.gov/sites/default/files/d7/priv/pep14-lgbtkids.pdf
4. A Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children
SAGE: Advocacy & Services for LGBT Elders	https://www.sageusa.org/resource-posts/age-friendly-inclusive-services-a-practical-guide-to-creating-welcoming-lgbt-organizations/
5. Age-Friendly Inclusive Services: A Practical Guide to Creating Welcoming LGBT Organizations
Nurses (HEALE)	http://www.nursesheale.org/
6. Nurses’ health education about LGBTQ elders (HEALE) cultural competency curriculum

Human Rights Campaign	https://www.thehrcfoundation.org/professional-resources/transgender-affirming-hospital-policies
7. Transgender-Affirming Hospital Policies
More Inclusive Healthcare	https://moreinclusivehealthcare.com/
8. More Inclusive Healthcare: First steps toward health equity
SAGE: Advocacy & Services for LGBT Elders	https://sageusa.care/our-services/coaching-training/on-demand-courses/
9. SAGE CARE: On-Demand Courses

SGM-relevant treatment

Several treatments may be relevant for some SGM patients. These include Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) for HIV, as well as puberty blockers and gender-affirming hormone therapy (see Table 9.8). Providers interested in implementing clinical guidelines related to these treatments may require training and support, such as in-person or virtual consultation with other prescribers. Project ECHO® LGBT and Transgender Health ECHO®may offer web-based videoconferencing with experts in the field for participating FQHCs. They provide consultation on challenging cases and build knowledge on SGM-relevant treatment topics.

Not all providers will be familiar with SGM-relevant treatments or comfortable administering them. Yet, a clinic needs a strategy to make them available. For example, one or more providers can lead and be the “go-to” people for patients requiring such treatments, coaching their colleagues in administering them or caring for patients themselves. When this model is used, all providers should still be prepared to provide basic care to SGM patients when the “go-to” people are unavailable. When no providers are available to offer these treatments, patients should be referred to qualified clinicians in the community.

Table 9.8

PrEP and PEP	Puberty Blockers	Hormone Therapy
PrEP helps prevent an HIV-negative person from getting HIV from a sexual or injection-drug-using partner who is positive. PEP is a short-term antiretroviral treatment that reduces the likelihood of HIV infection after potential exposure.	Medicines that inhibit puberty by blocking the production of hormones (testosterone and estrogen) that lead to changes in the body (e.g., periods and breast growth, or voice-deepening and facial hair growth). Stops processes like periods and breast or facial hair growth and voice-deepening.	Exogenous testosterone is used in transgender men to induce virilization and suppress feminizing characteristics. In transgender women, exogenous estrogen may help feminize patients. Anti-androgens are used as adjuncts to help suppress masculinizing features.

Potential steps to include in action plans to support workforce development in delivering high-quality services to SGM patients

As part of the clinic’s organizational assessment, determine the level of SGM-specific expertise in the clinic, identifying both strengths and gaps to be addressed through professional development for providers and staff.
Create an inventory of well-established guidelines for caring for SGM patients that can be readily accessed through the Internet.
Determine availability of professional development options.
Identify local in-person training opportunities (e.g., clinical experts from a nearby academic medical center or state/county public health offices or local SGM advocacy organizations).
Identify online training opportunities. Table 9.9 provides a list of relevant webinars.
Conduct online searches of professional development publications. Table 9.10 provides examples of professional development publications that may be useful.
Inform providers and staff about professional development options via staff email blasts, staff meetings, and during professional evaluations.
Explore the possibility of creating and implementing a mentorship program or “go-to” model by engaging experts in the clinic or outside agencies.
Arrange for providers and staff to be given access and time to participate in professional development, including mentorship programs.
Incentivize and reward providers and staff who take part in professional development, including mentorship programs.
Recruit new providers and staff with SGM-specific expertise.

Table 9.9

Understanding Prep, Pep, And STIs: Online Training Opportunities

National LGBT Health Education Center

https://www.lgbtqiahealtheducation.org/courses/pre-exposure-prophylaxis-prep-for-hiv-the-basics-and-beyond/

1. Pre-Exposure Prophylaxis (PrEP) for HIV: The Basics and Beyond

National LGBT Health Education Center

https://www.lgbthealtheducation.org/wp-content/uploads/2019/06/Whats-New-Webinar-6-2019-PDF.pdf

2. Webinar slides: What’s new in PrEP and STIs? Cases from a Sexual Health Clinic

AIDS Education & Training Center Program

https://aidsetc.org/resource-type/online-and-self-paced-learning

3. Online and Self-Paced Learning Resources

Table 9.10

Understanding Prep, Pep, And STIs: Professional Development Publications