Medical Treatments
Though psychiatrists are not primary medical providers, there are some medical topics with which they should be familiar to have a complete picture of the health of LGBTQ populations.
Discussions of health-related topics in men who have sex with men (MSM) and transgender women typically emphasize the prevention and treatment of sexually transmitted infections (STIs) such as HIV and Hepatitis B. While MSMs face a number of other health issues, including increased mental health symptoms and unique patterns of substance abuse, STIs do play a large role in primary health care for this population, and psychiatrists should be aware of advances in this field. In addition, STIs can affect cancer risk, and MSM are at increased risk of penile and anal cancers caused by the human papilloma virus (HPV) (Van Aar et al., 2013).
Health providers have typically learned about post-exposure prophylaxis (PEP) as it pertains to needle sticks, sexual assaults, or unprotected sex, but may be less familiar with pre-exposure prophylaxis (PrEP). A once daily pill (brand name: Truvada, generic name: tenofovir/emtricitabine) is now being used as HIV prevention in at-risk populations. Truvada is well tolerated and highly effective in preventing HIV seroconversion (Spinner et al., 2016). In one study of targeted PrEP introduction into a population of 3700 high risk MSM, the incidence rate of new HIV infection in the year following PrEP use was lowered by 25% compared to the year prior to PrEP introduction (Grulich, 2018).
HIV itself can have neuropsychiatric effects. The term used to describe these is HIV-Associated neurocognitive disorder (HAND). While access to anti-retroviral medications can prevent AIDS dementia and AIDS mania, even those with decreased viral loads and higher CD4 counts may, over time, experience neurocognitive impairment, likely due to the inability of current HIV medications to successfully protect the nervous system from the effects of the virus (Clifford & Ances, 2013).
Psychiatrists treating people on HIV medications should research the side effects and possible drug interactions. Some HIV medications have psychiatric side effects (Treisman & Soudry, 2016) and some are well-known to interact with other medications, including psychotropic medications. Ritonavir, for example, is specifically used for the purpose of boosting the efficacy of other HIV treatments through inhibition of CYP3A4 (Larson et al., 2014). However, psychiatric medications such as benzodiazepines, sertraline, venlafaxine, mirtazapine, and haloperidol are also broken down by CYP3A4, and concurrent use with ritonavir should be monitored closely (English et al., 2012).
The health concerns of self-identified lesbians, bisexual women, and queer women (also sometimes called sexual minority women) are often overlooked. However, sexual minority women experience unique health challenges. They are more likely than heterosexual women to be overweight or obese, which can lead to other health problems (GLMA, 2001). They also drink more heavily than other women and engage less with the health care system, undergoing fewer routine physical exams, pap smears for cervical cancer, and mammograms for breast cancer (Roberts et al., 2004). Discrimination in health care settings contributes to these disparities in health care utilization, suggesting that improved health provider competency in LGBTQ care could improve outcomes (Johnson et al., 2016).
Trans people may interact with the health care system as part of the physical transition process. Not all trans people desire physical transition (hormones, surgeries), although many do. Interventions can be expensive, and even those who are interested in physical transition may not be able to afford it. Nonbinary or genderqueer people may be interested in interventions that create a more androgynous look. Many health insurance companies explicitly exclude transition-related care. Some even make it difficult for trans people to obtain routine care. Trans men, for example, may not be covered for pap smears despite retaining a cervix.
In terms of private insurance, on a federal level, the Patient Protection and Affordable Care Act, often called the Affordable Care Act (ACA) or “Obamacare” prohibits discrimination based on gender identity by health plans receiving federal funding or that are part of exchanges. Some private insurance companies can continue to discriminate, but many cannot (NCTE, Healthcare). On a state level, 19 states and the District of Columbia outlaw the exclusion of transition-related care by private insurance companies, but this leaves 31 states that do permit exclusion (MAP, Healthcare laws and policies).
Government-sponsored health care programs differ somewhat from private insurance. As of 2014, Medicare now covers both hormone therapy and some surgeries for transgender people (NCTE, Medicare). However, many surgeons do not accept Medicare because it does not pay well. Medicaid, which generally pays even less, has separate rules because it is a state/federal partnership. Thirteen states and the District of Columbia have Medicaid programs that cover at least some transition-related care, 22 states have no specific policy, and 15 explicitly exclude transition-related care (MAP, Healthcare laws and policies). A Federal Lawsuit has been lodged against a managed care company accusing it of not following Federal parity guidelines. (https://www.nytimes.com/2019/03/05/health/unitedhealth-mental-health-parity.html)
Hormone treatment for transgender people is generally very straightforward and can be done by primary care providers without the assistance of endocrinology unless there are complicating medical issues. The Endocrine Society publishes guidelines for hormone therapy in trans people, and these are freely available online (Hembree et al., 2017).
Trans men typically take testosterone, usually injected approximately every two weeks. Many transgender men, within 2 years or so of starting testosterone, are read as male in social settings. Testosterone increases muscle mass, as well as body and facial hair, deepens the voice, leads to cessation of menses, and causes the clitoris/phallus to grow. Many of these changes are irreversible. There are also often unwanted side effects of testosterone, such as acne and male pattern baldness. Additionally, the vaginal lining can atrophy, causing pain if the man chooses to use this body part for sex. (Of note: It can be helpful to ask trans people how they would like you to refer to their body parts, as some prefer other terms to traditional anatomical terms. For example, some trans men call the vagina their “front hole.”) Lab monitoring while on testosterone is relatively basic, and includes hemoglobin/hemtocrit (for polycythemia), liver function tests (for transaminitis), and testosterone level (can be helpful to ensure it is within normal range if a client is not experiencing desired effects). There are very few absolute contraindications to testosterone use, and few drug interactions (Gorton & Erickson-Schroth, 2017).
Trans women typically take estrogen (injected, patch, or pill), often alongside an androgen-blocker such as spironolactone. Physical changes from estrogen and spironolactone include skin softening, female-typical fat distribution, and loss of muscle mass. Unlike testosterone, feminizing regimens do not typically, by themselves, allow a person to be read as their desired gender in social situations. An already deep voice does not change, and masculine features such as the adam’s apple and facial hair remain. Lab monitoring of feminizing hormones includes estrogen level, liver function tests (for transaminitis from estrogen), and potassium (for hyperkalemia from spironolactone). Estrogen should be used with caution in those who are at increased risk for blood clots. However, a history of a DVT or PE does not necessarily preclude the possibility of taking estrogen as long as the person is engaged in regular medical care (Wesp & Deutsch, 2017). Two important drug interactions for psychiatrists to be aware of in their patients taking feminizing hormones are between lithium and spironolactone (spironolactone can cause an increase in lithium levels, leading to toxicity) and between lamotrigine and estrogen (estrogen can decrease lamotrigine levels, so lamotrigine dose may need to be increased).
Psychiatrists are often interested in the mental health effects of hormones. Outpatient practitioners may wonder whether estrogen is causing a client to be more depressed or tearful, or inpatient/ER practitioners may wonder if testosterone is contributing to mania or psychosis. There is no evidence that hormones, when taken in prescribed doses, lead to depression, mania, or psychosis. There are some people who use “street hormones” (obtained outside of prescriptions) who may experience side effects. They may use street hormones because they cannot afford to see health providers, or because they have had bad experiences in the health care setting. Clients on prescribed hormone regimens prior to entering an inpatient unit should be continued on these medications, as it can affect both emotional and physical health to stop them abruptly, and can damage the therapeutic alliance.
One well-known effect of testosterone is an increase in libido. Not all trans men experience this change, but many do (Gorton & Erickson-Schroth, 2017). Feminizing hormones have more complicated effects on libido and sexuality. Some trans women report a decrease in libido when starting these medications, while others say that beginning their transition makes them more comfortable with themselves and more interested in sexual relationships (Schulman & Erickson-Schroth, 2017).
Most importantly, research from multiple studies shows that hormone treatment increases quality of life and decreases depression and anxiety (White Hughto & Reisner, 2016).
The details of surgeries for transgender clients are beyond the scope of this review, but important to note is that surgery is a very individual choice, and is often based on expected outcome and financial access. The most common surgery for transgender men is “top surgery” (mastectomy). Many trans men do not have genital surgery (options include the very expensive, multi-step phalloplasty, as well as metoidioplasty, which is an extension of the clitoris/phallus by cutting the suspensory ligament). Feminizing surgeries include breast augmentations, bottom surgery (vaginoplasty), and facial feminization surgeries.
Psychiatrists are more likely to be involved in the surgery process than the hormone therapy process, as hormones are now commonly prescribed by primary care through an informed consent model, while surgeons generally require at least one letter from a mental health provider and sometimes two. This can put psychiatrists in the role of “gatekeepers” and disrupt the therapeutic relationship. Psychiatrists working with trans clients who desire surgeries may want to do further reading about how to balance their conflicting roles and support their clients. In general, an evaluation for surgery closely approximates any other informed consent process, and psychiatrists should focus on determining decision-making capacity.
There are numerous other interventions trans people may undergo as part of the physical transition process aside from hormones and surgeries. For example, trans women may have electrolysis to remove facial hair. This process is expensive and not covered by insurance but can be extremely helpful in allowing a person to be read as their desired gender. Some trans people, most commonly trans women without access to surgeries, may also use silicone injections (“pumping”), often performed by unlicensed providers, to shape their bodies. Silicone injection carries with it serious risks such as cellulitis, necrosis, migration of silicone, and pulmonary embolus (Murariu et al., 2015).
As part of the informed consent process when starting hormones or having surgeries, medical providers should also discuss with trans clients the effects these interventions may have on their fertility. The effects of surgeries on fertility depends on the anatomy. Hormones can be more complicated. Although not guaranteed, trans men may be able to stop testosterone and restart ovulation. There are numerous cases of trans men who have previously been on testosterone giving birth (Light, A., 2014). Testosterone is known to cause birth defects, so trans men engaging in sex where they have the possibility of becoming pregnant should be advised to use effective birth control (Gorton & Erickson-Schroth, 2017). Trans women starting feminizing hormones are generally advised to bank sperm first if they have any desire to have biological children. This is because feminizing hormones can lead to irreversible infertility.
CME Question:
Which of the following is true about the physical health of LGBTQ people?
Sexual minority women are more likely than heterosexual women to engage in routine primary health care.
Hormones prescribed to transgender people for transition can lead to psychosis and mania.
Pre-exposure prophylaxis (PrEP) is well tolerated and highly effective in preventing HIV seroconversion
Insurance companies typically cover all transition-related health care as long as the patient has a diagnosis of gender dysphoria.
Answer: 3