Thank you, and welcome, everyone, again. We'll get started with our next session. I'd like to invite our two speakers, Dr. Christopher Vélez and Dr. Jennifer Maronke. So Dr. Vélez is a gastroenterologist in the Center for Neurointestinal Health of Massachusetts General Hospital as a part of Harvard Medical School, and he will be speaking to us today on the key considerations for digestive health in people from LGBTQIA plus communities. The format for this last session is slightly different. We'll take questions after each presentation. So please feel free to send your questions in for Dr. Vélez after his presentation, and then we'll have Dr. Maronke, and we'll take questions for her after the presentation as well. Thank you. Good afternoon, everyone. Thank you for the invitation to speak today. So I'm going to speak about the key digestive health considerations that exist in LGBTQIA communities. So these are my financial disclosures, and I think it's sometimes helpful to think about cognitive disclosures as well. So I am of LGBTQIA identity, and depending on the flow of the presentation, I may reference critical editorials that I have written related to research in LGBTQIA folks. So I'll start off with a clinical scenario. Things tend to stick in my mind more when they are a robust presentation of an issue that exists. So as a second opinion, I saw a very tearful patient with ulcerative proctosigmoiditis. He told me that my doctor said that since I have colitis, I can't have sex again. After trying to deescalate, the clinical picture and the lack of LGBTQIA cultural humility came to light. This seemed very classic for ulcerative colitis. Several months of rectal bleeding, received the proctosigmoiditis diagnosis. He preferred, quote-unquote, being the bottom or when engaging during anoreceptive intercourse. And he was matter-of-factly told by his gastroenterologist, well, you should stop having sex if you have ulcerative colitis. So I mentioned this case as a way to have a lens through which to review the information I'm about to describe in the rest of the presentation. How do we use it to understand what the LGBTQIA digestive health needs? Are they similar to other people? Are they different from other people? And offer practical advice, because I think some of you in the audience are probably struggling with how to engage with your LGBTQIA patients. So you may see different letters in the alphabet soup of LGBTQIA or sexual gender minority or SOGI that are referenced throughout different articles and that are studying and reporting outcomes in SGM folks. So LGBTQIA in general can be used interchangeably with sexual and gender minority individuals. They represent a set of communities that likely have unique needs compared to the rest of the population. There are intersecting identities, for example, sex and gender with race, morality versus being urban, socioeconomically advantaged versus disadvantaged. And to give you a sense of the numbers that we're thinking about, we're thinking they're probably on the order of 15 to 20 million people with LGBTQIA identity throughout the country, about 5%. So if some of you in the audience are thinking, well, I don't have any LGBTQ patients, or I haven't taken care of someone, likely 1 out of 20 patients, no matter where you are in the country, rural, urban, will have an LGBTQIA identity. And what does that mean for your practice? So SOGI or sexual orientation and gender identity, I think, is a very helpful thing to describe. Sexual orientation refers to an innate romantic sexual attraction to people. Gender identity, in contrast, is an innate perception of self as male, female, or other gender identity. And the way I would describe it is the vast majority of people have a gender identity that aligns with the sex that they were assigned at birth, 98%, 99% of the population. There is a small subset where that alignment does not occur. That would be someone who would be defined as transgender or gender diverse. In terms of the framework that I think of when thinking about whether or not digestive health needs exist or don't exist for people of LGBTQIA identity, I reference the biopsychosocial model in terms of thinking about how the minority identity may influence further downstream disease consideration. So if we consider LGBTQIA identity, we think of life stressors, some of which are unique to LGBTQ people, financial work, some parts of the country, people can have difficulty having jobs if they have certain identities, laws, social norms, that's very much a hot political topic in the current political climate, which may impact the way that people interact with the healthcare system, thinking about prejudice, thinking about self-stigma. And from there, you have psychosocial factors, behavioral factors, and psychological and perhaps gut-brain access factors that then may result in the end-stage manifestations of biopsychosocial stress that we may be called upon to address, such as obesity, cirrhosis, colorectal cancer, disorders of gut-brain interaction, which can then go on to affect gastrointestinal-related morbidity and mortality. And it is known in other disease conditions that disparities do exist for LGBTQIA people, but really not much has been studied in the GI space. So this is a lot of information to cram into a 15-minute talk, so this is really just a first pass for some of you in the audience, and I will reference an article that was in the Red Journal that details a lot of the specifics that I mentioned in these slides if you want to learn more about the topic. So thinking about a patient history, pronouns, procedures, it's useful at the start of a relationship to get a sense of what someone wants to be called. In reality, we do that often. Does someone want to be called doctor? Does someone want to be called miss or missus? So from a heteronormativity standpoint, we do that. This is just an extension of that courtesy that we're extending to our patients who really are at a vulnerable portion of the patient-physician relationship. So I ask at times what they have had in terms of gender-affirming surgeries. I think about who they have sex with. So even if someone identifies as a gay man or a lesbian woman, it doesn't necessarily mean that they're exclusively having sex with men or exclusively having sex with women. What type of sex, oral, vaginal, anal, anal sex is perhaps more common practice among non-LGBTQA people than is realized. And also what they're doing to protect themselves from STIs, because in some respects, we may be called upon to evaluate patients who have complaints who are actually STI-related. What they're doing to protect themselves, if they are desiring pregnancy or if there is a concern they may be pregnant, for example, a transgender man who still has his reproductive organs intact as a differential for abdominal pain would be pregnancy if he's having sex with a man. What they do for pleasure is, are GI symptoms impacting their sexual function? I think we don't do a good job for any patient about discussing if GI symptoms impact their sexual function and partner abuse, since there are increased rates of violence in the LGBTQA community. Depending on the sex practices that a member of the LGBTQA community has, minor issues like anal fissure and hemorrhoids may be much more problematic, depending on the type of sex that they have. Or if things are going well, what are they doing in order to have good bowel health, either related to sex or not related to sex? Are they using fiber? Are they engaging in some behaviors that may be detrimental, for example, laxative abuse? Is there restrictive food intake because of body dysmorphia? Anal intercourse is a more common practice than you would think. And also, how are we counseling people, for example, who have inflammatory bowel disease? How are they having sex if they have a pouch or things like that? So when it comes to infection, really this differential doesn't differ compared to LGBTQA people compared to a non-LGBTQA people, but the exposures may be different. So for example, some of these may be related to food poisoning, but given that there is some fecal-oral transmission in some practices in the LGBTQA communities, that may be a reason to ask what type of sex people are having. Giardia is a good example where they may not have gone camping recently, but that is an infection that can be transmitted fecally, orally. And there are some times where STI syndromes look like the inflammatory bowel diseases. And in general, anyone engaging in anal sex or men who have sex with men should be vaccinated against hepatitis A and B and should be screened for hepatitis C. What is not as well-known is the role of thinking about anal cancer screening. I think that in general, we would agree that for people who have HIV, that's the most important. But if people are immunocompetent or if they have an undetectable viral load, that need is unknown. Generally, if someone is of LGBTQA identity engaging in anal sex, I will withdraw more slowly the colonoscope, for example. And colon cancer generally is going to be the same thing we tell people, but we don't know if there's a difficulty in access or if some people, for example, who are transgender who have a very particular concern about the way the genitalia may be manipulated, we don't know if they're optimal strategies to improve colon cancer screening rates or frankly what those colon cancer screening rates are. So sexual violence is very prevalent in the LGBTQA communities, particularly transgender individuals, particularly transgender individuals from racial and ethnic minority communities. And I think that what we don't really know how to do well is counseling our LGBTQA patients when any of these particular conditions or practices are under consideration. In the liver, there are some LGBTQA communities that perhaps have an increased risk of mass assault, particularly lesbian women or certain transgender populations. How we manage liver disease and exogenous sex hormone administration is a very controversial topic, particularly since some of the exogenous sex hormones can be prothrombotic. So what do you do if someone has a clot? Do you tell them to stop? What would be the downstream effect of that? And hepatic adenomas fall into a similar category as well. So transgender women who have had neo-vaginas placed surgically, particularly if they're using an intestinal conduit, there may be disease of the conduit that you may be called to evaluate for. There may be fissilization. There may be inflammatory bowel disease associated with the neo-vagina. There may be diversion colitis. And a lot of the treatments would overlap. But unless you have a sense of what the anatomic inventory is, what organs they have, what organs they don't have, and what type of gender-affirming surgery they have, then you won't be able to include these in your differential diagnosis. And these are additional concerns that may happen depending on the type of surgery that someone has undergone. A lot of the use of sigmoid colon interposed to create the neo-vagina, that type of surgery has fallen out of favor. So older patients may have had these types of surgeries. In general, they tend to be avoided in younger people undergoing gender-affirming care. In terms of other conditions, we don't really know what the overall ways in which to reduce obesity, what the best practices should be in an LGBTQIA cohort. I am neuro-gastro-motility focused, so there is probably, given the biopsychosocial burden and increased risk of disorders of gut-brain interaction, we just don't know how to approach that. What I would say is, in this very brief discussion of LGBTQIA health, this is a new field or a new part of GI, and sometimes even I struggle as a gay man thinking about the best way to care for people who are of the other letters of the alphabet in the LGBTQIA mnemonic. What I would say is systematic, sustained efforts for everyone taking care of patients who have LGBTQIA identity are important. It can't just be, we did a grand rounds once, congratulations, we're now all culturally humble, culturally competent. Mistakes will be made. Normalizing good faith errors, if you make a mistake but you're trying to do well, patients know that. So just don't beat your chest and then make the patient feel awkward about apologizing, but just say, I'm sorry I called you by the wrong, you're not your preferred name. I'm sorry I assumed that you have sex with an opposite sex partner. I think you can be the most affirming clinician out there, but if a patient gets misgendered at the parking garage or by the security guard, that's enough to kind of affect the tenor of the visit. And I would say physicians, what we do is we'd like to talk and teach other physicians, but if we're not engaging our nursing colleagues or scheduling coordinator colleagues, our APP colleagues, that can contribute to a disconnect in the therapeutic alliance. And for a specialist, for example, if we're doing an open access colonoscopy, we just have less time compared to our primary care colleagues to establish those productive therapeutic alliances. So this picture was taken in D.C. outside of the Human Rights Campaign, which is an advocacy organization for LGBTQA people. And Tanya, she is stating, trans people are often mocked, humiliated, refused health care, due in part to willful ignorance. We are deserving of both human and civil rights in society. People like Tanya are why I put myself out there on a limb and emphasize the importance of LGBTQA people. We exist. We need no permission to exist. And your LGBTQA patients need to feel that you have their best interest at heart. So in terms of the clinical scenario, while the ulcerative colitis diagnosis was correct in this case, I don't think that the original gastroenterologist had considered whether or not this was an STI-related proctosigmoiditis. It turns out that that testing was negative and the UC diagnosis was correct. And stopping sex is not really a helpful advice for anyone. No one would dream of telling a patient with dyspareunia that you should just stop having sex. Sex is not optional. So what would have perhaps been a more logical advice would have been, well, when you're having a flare just because of the increased risk of pain, an STI transmission perhaps abstained from sex during a flare. But then using that as an example to say, all right, maybe you are someone that I wouldn't have necessarily considered doing biologic therapy at the get-go, but we need to get this under control as quickly as possible because it's having such an impact on your quality of life. Let's use a TNF agent. Let's do something else. So I would say in terms of final points, times are increasingly dark for LGBTQA communities in the United States. And patients are facing rollbacks to the expansion of rights that they have enjoyed over the past decade. GI as a specialty has been a bit slower compared to other specialties in terms of thinking about the unique needs that exist for the 15-plus million people of LGBTQA identity. And we have understudied this set of communities in terms of their GI needs. And I would argue the systematic assessment, implementation, education, and reinforcement of all people in healthcare, not just physicians, not just nurses, is needed. And I would say that we need to be focusing more foundational professional society and federal resources to understanding better the LGBTQA digestive health needs. Thank you. Thank you. So the first question is, could you comment or provide a suggestion on how to create a medical practice? I guess it's a two-part question. A medical practice and a fellowship that offers an inclusive curriculum. Great question. I still struggle with the best way to do it optimally because there's only so many hours in the day. I think there's some easy things that one can do in order to create an inclusive environment. Acknowledging Pride Month, which is just a couple of weeks around the corner, having at our institution, we have, you can put the Progress Pride flag, which is the rainbow flag with a representation in triangle form for racial and ethnic minority people as well as transgender people. Just having that pin can really reassure a lot of people. I would say a lot of language is gendered in a way it doesn't need to be. Like husband, wife, it can be spouse, it can be partner. And I think for fellows, I think just emphasizing that an environment is welcome and inclusive is enough. I think that some there is, it may also depend on locale. It may depend on what type of practice environment, if you're affiliated with a state institution that is trying to roll back diversity, equity, and inclusion efforts overall, that may be harder to do. But there are cheap things that you can do that will signal to patients and to trainees that they're welcome. Thank you. Then the next question has to do with guidelines as it relates to transgender patients. How do you approach gender specific guidelines for surveillance? For example, breast cancer screening in a patient with Lynch, how do you approach that conversation and how do you approach the surveillance protocol? So what I would say is basically identical to what I do of non-LGBTQIA people, but you just have to have a better sense of where they are in their journey, if you will, in expressing their gender identity. So if you're doing colon cancer screening, it's important to know where is all your colon in its native position or should we also be doing a vaginoscopy on top of a colonoscopy in order to assess for colon mucosa. I think that for breast cancer, I would say that similar mammogram guidelines, but if someone has had a mastectomy, one may need to do ultrasound or examine axillary breast tissue that may be remaining as a potential source for breast cancer. So generally the same, but then that's where the anatomic inventory is the term that is used to describe this sort of unknown or this source of physician angst, that's the reason why it's important. Thank you. And then the final question, just looking at time, you mentioned in the presentation the challenge with patients who have undergone trauma, is the approach any different when having those conversations between LGBTQIA versus non-LGBTQIA? I think the approach is similar, but you have to remember, particularly if someone has undergone gender affirming surgery, it's probably they spent the first 15, 20, 25 years of their life feeling a gender identity that did not correspond to their sex at birth. So they have a heightened concern or nervousness surrounding their genitalia. So what I may say, for example, is during a colonoscopy, the vast majority of your perineum of your anorectal area will be covered. I will let you know when we're about to do a rectal exam. I think understanding the role of trauma in terms of GI procedural endoscopic evaluation, I think is still being studied for the overall population. But I think that the lessons learned for the overall population, perhaps with just a kinder delivery is what's needed for transgender folks. Perfect. Thank you so much, Chris. Thank you.

Dr. Christopher Vélez

Dr. Jennifer Maronke

digestive health

LGBTQIA individuals

cultural humility

trauma-informed care