American 

College of Physicians 
Internal Medicine Meeting 2021: Virtual Experience

LGBTQ Health: A Practical Approach

Faculty and Disclosure Information
Professor:
Megan C. McNamara, MD, MS, Member
Nothing to Disclose.

Clinical questions to be addressed:
1. What are the current recommended screening guidelines for sexually transmitted disease risk, 
malignancy, and other preventative health measures for LGBTQ patients?
2. What are practical management tips for hormonal therapy in transgender patients (e.g., selection 
of agent, risks of use)?
3. What are specific health concerns that internists should be aware of in the LGBTQ population?
4. What resources and guidelines regarding LGBTQ health are available to internists?

Posted Date: March 29, 2021

©2021 American College of Physicians. All rights reserved. Reproduction of Internal Medicine Meeting 2021: Virtual Experience presentations, or 
print or electronic material associated with presentations, is prohibited without written permission from the ACP.

Any use of program content, the name of a speaker and/or program title, or the name of ACP without the written consent of ACP is prohibited. For 
purposes of the preceding sentence, “program content” includes, but is not limited to, oral presentations, audiovisual materials used by speakers, 
program handouts, and/or summaries of the same. This rule applies before, after, and during the meeting.
 PRIMARY CARE FOR
LGBTQ PATIENTS
C

Megan McNamara, MD, MS

Professor of Medicine, CWRU School of Medicine
Director, GIVE Clinic, VA Northeast Ohio Healtthcare System

Disclosure
•I have nothing to disclose

© 2021 American College of Physicians. All rights reserved.

1
 Learning Objectives

1 2 3
Identify List Describe
•Identify important health •List screening guidelines for •Describe strategies for
care issues for LGBTQ LGBTQ patients managing cross-sex
patients hormonal therapy in high-
risk patients

BACKGROUND C

© 2021 American College of Physicians. All rights reserved.

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 • 25-year-old DFAB presenting to establish care
• Identifies as gender fluid
• Uses they/their pronouns A.G.
• Has multiple sexual partners, describes
themselves as pansexual

Definitions

GENDER IDENTITY GENDER EXPRESSION SEXUAL ORIENTATION

© 2021 American College of Physicians. All rights reserved.

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 Definitions

Definitions

https://www.shoutout.ie/blog/shoutout-to-our-lgbtq-role-models-pansexual-people

© 2021 American College of Physicians. All rights reserved.

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 Definitions

Identity
•LGBTQ

Practices
•MSM
•WSW

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016).
The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

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© 2021 American College of Physicians. All rights reserved.

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 Roadmap
• Case-based discussion
• For each case:
• Preventive care
• Guidelines and resources
• Clinical pearl

11

PRIMARY CARE FOR

MEN WHO HAVE SEX C

WITH MEN

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© 2021 American College of Physicians. All rights reserved.

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 • 54-year-old cis-gender male presenting to
establish care
• Past medical history notable for hypertension,
diabetes (last a1c 7.2%), allergic rhinitis, and
CKD (estimated creatinine clearance

P.R.
54ml/min)
• Identifies as gay
• Sexually active with 2 male partners, engages
in oral and anal receptive intercourse
• Intermittently uses condoms

13

Health care issues that should

immediately come to mind…
Identity Practices

• Mental health • HIV

• Tobacco abuse • Gonorrhea
• Excessive EtOH consumption • Chlamydia
• Syphilis
• Anogenital warts

JAMA Intern Med 2016;176(9):1344-1351

MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137.

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© 2021 American College of Physicians. All rights reserved.

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 JAMA Intern Med 2016;176(9):1344-1351

Health Risk Factors According to Sexual Orientation

40.1
Percent reporting

25.9

16.9

10.9
9.3
5.7 6 6.2
5.1

PSYCHOLOGICAL DISTRESS HEAVY DRINKING HEAVY SMOKERS

Risk factor

Heterosexual Gay Bisexual

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© 2021 American College of Physicians. All rights reserved.

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•.
MMWR Morb Mort Wkly Rep 2019; Apr 12; 68(14):321-325

Extragenital Chlamydia and Gonorrhea among MSM

13.3%

7.3%

4.5% 4.6%

1.4%

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PrEP
Emtricitabine
200mg/tenofovir disoproxil
fumarate 300mg
Emtricitabine
200mg/tenofovir
alafenamide 25mg

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© 2021 American College of Physicians. All rights reserved.

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 PrEP Eligibility Criteria MSM
HIV negative

Male sex partners

in the past 6
months

Not in a
monogamous
relationship

Anal sex in the

last six months or
bacterial STI in
the last 6 months
https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-
prep-guidelines-2017.pdf

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Which should I
choose?
• Similarly effective in reducing
the risk of HIV infection
• Similar side effect profile
• Emtricitabine 200mg/tenofovir
alafenamide 25mg safe for
patients with estimated
creatinine clearance greater
than 30ml/min

https://www.cdc.gov/hiv/clinicians/prevention/prep.
html

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© 2021 American College of Physicians. All rights reserved.

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 Back to our patient…

Assess Screen Confirm Prescribe

Assess mental Screen for Confirm eligibility Prescribe

health and chlamydia and for PrEP emtricitabine
substance use gonorrhea at 200mg/tenofovir
genital and alafenamide
extragenital sites 25mg

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Clinical pearls
• Screen extragenital sites for
chlamydia and gonorrhea
• Consider emtricitabine
200mg/tenofovir alafenamide 25mg
for PrEP if estimated creatinine
clearance is less than 60ml/min

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© 2021 American College of Physicians. All rights reserved.

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 PRIMARY CARE FOR
WOMEN WHO HAVE C

SEX WITH WOMEN

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• 40-year-old cisgender female presenting to

establish care
• Hasn’t seen a physician in more than 20 years
• Medical history is notable for tobacco abuse,
obesity, depression, and GERD
• Identifies as bisexual
• Sexually active with one cisgender female
D.S. partner for the last 3 months, uses sex toys and
engages in oral sex, does not use barrier
protection
• Reports 15 lifetime sexual partners, both men
and women

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© 2021 American College of Physicians. All rights reserved.

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 Health care issues that should
immediately come to mind…
Identity Practices

• Mental health • HPV

• Tobacco abuse • HSV-2
• Alcohol use • Bacterial vaginosis
• Overweight and obesity

JAMA Intern Med 2016;176(9):1344-1351

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JAMA Intern Med 2016;176(9):1344-1351

Health Risk Factors Among Women According to Sexual

Orientation

46.4
Percent reporting

28.4

21.9

11.7
8.9
4.8 3.4 5.2 4.2

PSYCHOLOGICAL DISTRESS HEAVY ALCOHOL CONSUMPTION HEAVY SMOKING

Health factor

Heterosexual women Lesbian women Bisexual women

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© 2021 American College of Physicians. All rights reserved.

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 Am J Public Health. 2007 June; 97(6): 1134–1140

Odds of Overweight and Obese Among Sexual Minority

3
Women
Odds as compared to heterosexual women

2.5 2.69
2.47

1.5
1.38
1
0.92

0.5

0
Overweight Obese

Lesbian Bisexual

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HPV and Sexual

minority women
• Cervical cancer screening
• Bisexual and lesbian women less likely to receive Pap
testing in the last 3 years

• HPV vaccination
• Lesbian women less likely to complete vaccination series
• Bisexual women more likely to initiate and complete series

Cancer Causes Control. 2016; 27(10):1187-1196

Prev Med 2017; 95:74-81

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© 2021 American College of Physicians. All rights reserved.

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 HPV vaccination
guidelines
• Adults aged >26 years. Catch-up HPV
vaccination is not recommended for
all adults aged >26 years. Instead,
shared clinical decision-making
regarding HPV vaccination is
recommended for some adults aged
27 through 45 years who are not
adequately vaccinated. HPV
vaccines are not licensed for use in
adults aged >45 years

MMWR Morb Mortal Wkly Rep 2019;68:698–702.

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Back to Our Patient

1 2 3 4
1. Assess 2. Encourage 3. Offer cervical 4. Discuss
cardiovascular smoking cancer screening risks/benefits of
risk factors cessation and according to HPV vaccination
weight loss current guidelines

Always discuss risk for unintended pregnancy

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© 2021 American College of Physicians. All rights reserved.

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 Clinical pearls
• Assess cardiovascular risk in sexual
minority women
• Perform cervical cancer screening
according to nationally published
guidelines
• Consider risks/benefits of HPV
vaccination in patients who are
unvaccinated and between the ages
of 26 and 45

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CROSS-SEX
HORMONE THERAPY
C

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© 2021 American College of Physicians. All rights reserved.

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 • 68-year-old transfeminine patient referred for
continuation of cross-sex hormone therapy
• Began hormonal transition 2 years ago with
spironolactone and estradiol
• Very pleased with the physical and emotional
changes that she has experienced
• Past medical history notable for hypertension,
hyperlipidemia, obesity, diabetes (most recent
P.G. a1c 9.0%)
• Not sexually active
• Does not smoke or drink EtOH, retired and lives
alone
• No history of gender affirmation surgery
• Exam notable for bp of 150/80, BMI 32

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Health care issues that should

immediately come to mind…
Identity Practices

• Mental health • HIV

• Suicidality • Gonorrhea
• Chlamydia
• Syphilis
• Anogenital warts

https://www.cdc.gov/hiv/group/gender/transgender/index.html
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016).
The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

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© 2021 American College of Physicians. All rights reserved.

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 Mental health conditions: US
transgender survey

Psychological
• 39% - 5x higher than general population
Distress
Attempted
• 40% - 9x higher than general population
suicide

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for T

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HIV
• A 2019 systematic review and meta- • In 2017 the number of transgender
analysis found that an estimated 14%of people who received a new HIV
transgender women have HIV. By diagnosis was 3x the national average
race/ethnicity, an estimated 44% of
black/African American transgender
women, 26% of
Hispanic/Latina transgender women,
and 7% of white transgender women
have HIV.

https://www.cdc.gov/hiv/group/gender/transgender/index.html

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© 2021 American College of Physicians. All rights reserved.

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 GENERAL
PRINCIPLES OF CSHT
C

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Benefits of CSHT
Reduction in depression, somatization, interpersonal
sensitivity, anxiety, hostility, and phobic
anxiety/agoraphobia
• Transgender Health 2016

Improvement in quality of life, anxiety, and depression

• JBI Database System Rev Implement Rep 2019

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© 2021 American College of Physicians. All rights reserved.

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 Principles of CSHT

•Reduce endogenous
Reduce hormones

•Replace with hormones

Replace of the affirmed gender

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CSHT: It’s all about the T!

MtF FtM

Uses two hormones: Uses testosterone

only
One decreases
testosterone
The other increases
feminizing hormones to
pubertal levels

Courtesy of Travis Scott, GIVE Clinic

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© 2021 American College of Physicians. All rights reserved.

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 Transmasculine
CSHT Risk Outcome

• Before starting: Very high Erythrocytosis (hct

>50%)
• Assess for contraindications
• Pregnancy
• Unstable cardiovascular disease
Moderate Severe liver
• Polycythemia (hct> 55%)
dysfunction
• Address medical conditions that can be Hypertension
exacerbated by hormonal depletion/therapy
Cerebrovascular
disease
Coronary artery
disease
Breast or uterine
cancer
Hembree WC. et al J Clin Endocrinol Metab. 2017; 102:3869-3903.

Coleman E. et al. International Journal of Transgenderism, 13:165–232, 2011

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Transfeminine
CSHT Risk Outcome
Very high Venous
thromboembolic
• Before starting: disease
• Assess for contraindications
• Estrogen-sensitive cancer
• End-stage liver disease Moderate Macroprolactinoma
• ? VTE related to hypercoag state
Hypertriglyceridemia
• Address medical conditions that can be Breast cancer
exacerbated by hormonal
depletion/therapy Coronary artery
disease
Cholelithiasis
Severe migraine
headaches
Coleman E. et al. International Journal of Transgenderism, 13:165–232, 2011

Hembree WC. et al J Clin Endocrinol Metab. 2017; 102:3869-3903.

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© 2021 American College of Physicians. All rights reserved.

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 CSHT Practice Points

CSHT is medically Abrupt

There are very few
necessary treatment discontinuation of
absolute Informed consent is
for many CSHT can result in
contraindications to essential
transgender significant emotional
CSHT
individuals and mental distress

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© 2021 American College of Physicians. All rights reserved.

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 Multiple Products Available

45

Recent evidence
• Large cohort studies in the US and the
Netherlands show an increased risk for VTE
and CVA among transfeminine patients
treated with CSHT

• Risk increased as compared to both cis-

gender women and cis-gender men

Circulation. 2019;139:1461–1462
Ann Intern Med. 2018;169:205-213. doi:10.7326/M17-2785

46

© 2021 American College of Physicians. All rights reserved.

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 Transfeminine CSHT

•Decrease testosterone using spironolactone or

GnRH agonists

•Choose transdermal estradiol for patients at high

risk for VTE or CVA

•Aim for testosterone levels < 50ng/dl and estradiol

levels < than 200 pg/ml

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Back to our patient…

Assess Screen Optimize Continue

Assess risk for Screen for HIV Optimize control Continue

suicidality of CV and VTE hormone therapy
risk factors as medically
necessary
treatment

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© 2021 American College of Physicians. All rights reserved.

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 Clinical pearls
• Continue CSHT unless the patient
develops an acute life-threatening
medical condition (ie active VTE, MI,
CVA) or development of a hormone-
dependent malignancy
• Monitor hemoglobin/hematocrit in
transmasculine patients treated with
testosterone
• Choose transdermal estradiol in
patients at higher risk for VTE or CVA

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Take home points

• Patients who identify as LGBTQ face unique
health care disparities
• Mental health and substance abuse issues
are more prevalent among LGBTQ, as
compared to heterosexual, individuals
• Cross-sex hormone therapy is life-sustaining
treatment for many transgender individuals

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© 2021 American College of Physicians. All rights reserved.

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© 2021 American College of Physicians. All rights reserved.

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