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Driving Compassionate Care for LGBTQIA+ Patients with Virtual Insights

Published on June 27, 2023  |  By: RubiconMD

More than 11 million LGBTQIA+ individuals today face significant healthcare access issues due, coexisting chronic conditions, stigmatization, prejudice, and socioeconomic disparities. Making more inclusive and gender-affirming healthcare available is a public healthcare imperative. In this blog post, we share how virtual healthcare specialists at RubiconMD play a crucial role in supporting and educating PCPs so that they can deliver higher quality, more compassionate care to LGBTQIA+ patients.

In the not-so-distant past, only a few hours of medical school training were spent covering issues relating to LGBTQIA+ health. So, it’s not surprising that this community experiences significant health disparities and access-to-care barriers. LGBTQIA+ people experience nuanced health issues that intersect with a number of social health determinant variables, which can make accessing quality, compassionate, and gender-affirming care even more difficult to come by. 

Despite progress and awareness around LGBTQIA+ issues, those in this community still experience poorer health outcomes than non-LGBTQIA+ individuals. LGBTQIA+ patients have higher rates of pulmonary and heart diseases caused by higher-than-average incidence of tobacco use, as well as higher rates of alcoholism, suicide, mental health issues, breast, and gynecologic cancers. Many are also managing chronic conditions or living with disabilities that impact work, school, and daily life.

On top of differing health nuances, LGBTQIA+ patients often have no choice but to receive care from healthcare providers that may not have received specific and/or current educational training on LGBTQIA-related health issues. Research shows that medical students with exposure to gay, lesbian, bisexual, and transgender patients are more likely to take more comprehensive patient histories, have more tolerant and inclusive attitudes toward LGBTQIA+ patients, and have overall greater knowledge of the health issues affecting this community.2 Without this understanding, patients are left without the supportive, tailored insights and care plans required to close gaps in care and produce better health outcomes. 

Beyond difficulties accessing informed care, the current social climate and institutional biases present more complex and discouraging hurdles. One survey from the Center for American Progress found that almost one in 10 LGBTQIA+ individuals reported that a healthcare professional refused to see them in the prior year — discrimination that those individuals attributed to their actual or perceived sexual orientation. In the same survey, one-third of transgender people reported negative experiences in a healthcare setting, which included being denied treatment because of their gender identity.2 Such discrimination and stigma create an understandable mistrust of the healthcare system that may lead those in the LGBTQIA+ community to avoid seeking necessary care altogether, contributing to poorer health outcomes.

With RubiconMD, primary care teams can access the leading virtual Specialist Network, creating an access point to the top-tier specialists in infectious diseases, psychiatry, gynecology, and transgender health to more effectively care for the nuanced needs of the LGBTQIA+ community. Virtual specialty consults are a powerful tool for primary care teams in delivering higher quality, tailored care — a tool that creates more needed allies. By prioritizing accessibility to supportive, culturally appropriate care, we can reduce care inequities and provide the necessary support to ensure the health and well-being of all individuals, regardless of their sexual orientation or gender identity.  At a time when the transgender community and trans health is under attack, RubiconMD is proud to support primary care clinicians with trans patients by connecting them with knowledgeable trans health specialists who understand their unique care needs.

Below is a case example of how a PCP used the support of a transgender health specialist to guide care for a transgender patient. The specialist provided thorough recommendations on how to provide the optimal dose of testosterone for this transgender male patient and how to monitor his hormone levels via blood work.

Primary Care Clinician Submission:

20 y/o transgender male – currently on Depotesterone 50mg q week from Planned Parenthood but wants to transition this to my care. No concerns from state law as the testosterone was started after age 18.

I do not know the dosages – if ramped up or followed with labs, how often, what levels are monitored and how frequently? Also, can you speak more to state laws? Looking for more info as far as continuing his med here. 

Trans Health Specialist eConsult:

Hi, thanks for the consult and for caring for this patient! I start my transmasculine patients on testosterone cypionate at the dose that your patient is currently using – 50 mg IM weekly. Transmasculine patients can also use Testosterone biweekly (at double the weekly dose). I prefer weekly dosing because the patient will have more stable levels, and he will have a smoother transition emotionally because there will be less variation between peak and trough serum testosterone levels. One of the main goals of providing hormone care is to ensure that the patient on an optimal dose of Testosterone. After a patient has received four injections on any given dose, you should check the CBC and SMA-20 to rule out toxicity. You should also check a Total Testosterone level in the middle of the injection cycle. The goal is for the level to be approximately in the middle of normal male range (around 500-550 ng/dL). Depending on the result you get, you can adjust the patient’s dose up or down. Since you inherited the patient on a stable dose, I suggest checking labs mid-cycle now. Assuming everything is normal and that your patient has an appropriate Testosterone level, you should monitor CBC, SMA-20, Lipids and Total Testosterone level quarterly. You can expect that his H/H will gradually enter normal male range (if it’s not already there). You should be sure that he never exceeds the upper limit of normal male range (I use HCT of 51 as the cutoff, and at that point I’ll reduce the dose). AST/ALT will sometimes be a little above normal in early transition, but they should normalize by six months into treatment. I watch lipids because LDLs will typically worsen over time and may enter the abnormal range. And finally, I watch the testosterone level because it can drift up or down gradually over time. If you need to adjust the Testosterone dose because the level is too high or low, you should change it by 10 mg at a time, and as noted above, repeat the level after four injections on the new dose. One other comment: I noticed in the clinical summary that you shared, the ICD10 code attached to the patient’s Transgender care was Z78.9. At our practice, we use F64.9 when treating a patient for Gender Dysphoria. Please let me know if you have additional questions about this patient.

By empowering PCPs to provide these specialist insights and care to their LGBTQIA+ patients through virtual specialty care, more patients can receive personalized, essential, and affirming care. eConsults offer an enhanced primary care experience, not only to improve patients’ health outcomes, but to ensure that they feel heard, seen, and cared for in every way possible.

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