Prevention

Abstract

Busy health care providers of sexual and gender minority patients may feel lost when trying to identify long-term priorities for the patient’s care. The motivated clinician seeking guidance on treating special populations may feel discouraged by the limited quality and clarity of currently available evidence. This chapter discusses the challenges of applying mainstream clinical prevention guidelines to sexual and gender minorities. Where major guidelines and interventions can be plausibly adapted, those recommendations are stated. Prevention practices across domains of violence, mental health, substance use, cancer, infectious disease, and bone density are discussed.

Appendices

Boards-Style Application Questions

Question 1.

A 22-year-old male named Greg presents to clinic for a wellness exam. As part of a thorough history, you ask about sexual history, sexual orientation, gender identity, partners, and exposures. He initially identifies as a straight cisgender male. Upon further questioning, he has a history of exclusively male sexual partners and says that he’s “probably bisexual.” He is in a non-monogamous relationship with a cisgender male and uses condoms infrequently. How would you classify this patient’s sexual behavior ?

• A. MSM

• B. MSF

• C. Bisexual

• D. Gay

• E. Straight

Question 2.

How would you classify Greg’s sexual identity ?

• A. MSM

• B. MSF

• C. Bisexual

• D. Gay

• E. Straight

Question 3.

Which of the following questions would be most appropriate to screen for intimate partner violence (IPV) ?

• A. Do you feel safe at home?

• B. Have you ever been hurt by someone close to you?

• C. Have you lost interest in things you usually enjoy?

• D. All of the above

• E. B & C only

Question 4.

A 35-year-old female-to-male (FtM) patient named Erick presents to your office to establish care with you. During introductions, you ascertain by asking that this patient uses the pronouns he, him, and his. He has been on testosterone for about five years and is happy with his physical changes, but has not yet been able to afford hysterectomy or chest reconstruction. He has never had a Pap smear since “that kind of checkup freaks me out.” He smokes about a half pack of cigarettes per day but has smoked as much as two packs per day at some point in his life. He identifies as pansexual and has had multiple sexual partners in the past year which include transmen, cis women, and cis men. What screening tests should he be offered?

• A. Cervical cancer screening (Pap smear)

• B. Lung cancer screening

• C. Mammogram

• D. STI testing

• E. All of the above

• F. A and D only

Question 5.

After some discussion, Erick agrees to have a cervical cancer screen. What are some techniques that you can use to make this exam more comfortable for your patient?

• A. Asking him if there are certain words he prefer that you use or avoid

• B. Scheduling the exam on a different day when he can bring a support person

• C. Using the smallest speculum available

• D. All of the above

Question 6.

Your next patient is a 50-year-old transgender woman who is coming in for her routine complete physical. She had gender affirmation surgery many years ago and has been on stable doses of estrogen for over a decade. Her only medical issue is obesity, with a BMI of 41. She is in a long-term monogamous relationship with her cisgender female partner of many years. What routine screening tests should you offer this patient?

• A. Colon cancer screening

• B. Mammogram

• C. Pap smear of the neovagina

• D. STI screening

• E. All of the above

• F. A and B only

• G. A, B, and C only

Boards-Style Application Questions Answer Key

Question 1.

The correct answer is A. Sexual orientation (options C, D, and E) does not indicate sexual behavior , or vice versa. It can only be said regarding sexual behavior that Greg is man who has sex with men. MSF (option B) is not used to refer to any sexual behavior.

Question 2.

The correct answer is C. Bisexual is his self-identification. His sexual history lacking contact with women is irrelevant, so it would be inappropriate to call him gay both because the word does not describe sexual behaviors and because it is not the identification he used for himself (option D). A person’s current sexual identity or sexual orientation could be straight even without history of romantic or attraction to women (E). MSF (B) is not used to refer to any sexual behavior.

Question 3.

The correct answer is E. Despite its continuing popularity, (A) has been demonstrated to have very low sensitivity. Option B would be correct on its. It is a good question because it is objective and is on the HITS screening, which has been validated in men and women. Option C is a question about anhedonia, which is a common depression symptom in abused persons that is reasonable to ask about, but it is non-specific to intimate partner violence.

Question 4.

The correct answer is F. STI testing is indicated based on his recent sexual history (option D). Erick does not require mammograms at his age (C) unless less there is breast cancer in a first degree relative occurring at a young age. If he gets total chest reconstruction, he will never need mammograms, but they are still indicated after breast reduction. Low-dose computed tomography (B) for lung cancer screening applies only to those who have accumulated enough pack-years of smoking and who are between 55 and 88 years old. Everyone with a cervix between ages 21 and 65 needs Pap smears, though the frequency may vary.

Question 5.

The correct answer is D. In the long term, it is best to prevent adverse experiences that will dissuade Erick from future screenings. It is clear that (A) and (B) demonstrate personal respect by not using invalidating vocabulary and minimizing anxiety, respectively. It is particularly important to use small specula in trans men using hormones due to vaginal changes from testosterone therapy (C).

Question 6.

The correct answer is F. Colon cancer screening (option A) is indicated in all persons starting at 50, or younger depending on family history. Mammograms (B) are recommended in transgender women if they are at least 50 and have had at least five years estrogen and progesterone use. High-risk clinical factors like family history suggest considering younger starting age. Surgically constructed neovaginas do not require Paps (C). Her sexual history is very low risk, obviating the need for STI screening (D).