Hilary Daniel, BS; Renee Butkus, BA; for the Health and Public Policy Committee of the American College of Physicians (*)
Note Added in Proof: On 12 May 2015, the U.S. Food and Drug Administration released the document "Revised Recommendations for Reducing the Risk of Human Immunodeficiency Virus Transmission by Blood and Blood Products: Draft Guidance for Industry." The proposed recommendations would replace the lifetime ban on blood donation by men who have sex with men with a 12-month deferral period from most recent sexual contact.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Acknowledgment: Additional contributions provided by Jorge Ramallo, MD.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Dr. Moyer is the elected Chair of the ACP Board of Governors. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2482.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Hilary Daniel, BS, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 2001; e-mail, HDaniel@mail.acponline.org.
Current Author Addresses: Ms. Daniel and Ms. Butkus: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 2001.
Author Contributions: Conception and design: S.S. Bornstein, R. Butkus, H. Daniel, D. DeLong, A.A. Minaei.
Analysis and interpretation of the data: J.F. Bush, H. Daniel, T.L. Henry, A.A. Minaei.
Drafting of the article: M. Beachy, R. Butkus, H. Daniel, D. DeLong.
Critical revision for important intellectual content: R. Butkus, H. Daniel, D. DeLong, R.H. Lohr, A.A. Minaei, S.U. Rehman, T.G. Tape.
Final approval of the article: M. Beachy, R. Butkus, D. DeLong, G.A. Hood, R.H. Lohr, A.A. Minaei, D.V. Moyer, S.U. Rehman, T.G. Tape.
Administrative, technical, or logistic support: T.L. Henry, G.A. Hood.
Collection and assembly of data: H. Daniel.
In this position paper, the American College of Physicians examines the health disparities experienced by the lesbian, gay, bisexual, and transgender (LGBT) community and makes a series of recommendations to achieve equity for LGBT individuals in the health care system. These recommendations include enhancing physician understanding of how to provide culturally and clinically competent care for LGBT individuals, addressing environmental and social factors that can affect their mental and physical well-being, and supporting further research into understanding their unique health needs.
Family means any person(s) who plays a significant role in an individual's life. This may include a person(s) not legally related to the individual. Members of "family" include spouses, domestic partners, and both different-sex and same-sex significant others. "Family" includes a minor patient's parents, regardless of the gender of either parent. (37)
[G]uidelines for clinical practice can be very simple: ask the appropriate questions and be open and nonjudgmental about the answers. Few patients expect their providers to be experts on all aspects of gay and lesbian life. But it is important that providers inquire about life situations, be concerned about family and other important relationships, understand support systems, and make appropriate referrals for counseling and support when necessary. (55)
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American College of Physicians
May 12, 2015
FDA Releases Draft Guidance on Blood Donation by MSM
On Tuesday May 12, 2015 the Food and Drug Administration released the document "Revised Recommendations for Reducing the Risk of Human Immunodeficiency Virus Transmission by Blood and Blood Products: Draft Guidance for Industry." The proposed recommendations would replace the lifetime deferral period on blood donation by men who have sex with men (MSM) with a 12-month deferral period from most recent sexual contact. The FDA is accepting public comment on the guidance for 60 days.
Rex Moss, MD
May 26, 2015
To the Editor: "ACP Takes a Stand against Health Disparities Affecting LGBT Individuals New policy paper aims to ensure high-quality health care for all" This is very disappointing. I love the Annals and very much enjoyed and learned a great deal at several ACP conferences. But I left the AMA as it stood up for abortion rights and I resign from ACP, now as you stand up for a number of foolish policies, more oriented to political ideology than medical care or logic. Your new policy states: For instance, health data related to marital status show a benefit for married heterosexual couples, but the committee found that the fact that LGBT partners and families live without the same protections and recognition appears to increase their risk for depression and other poor health outcomes. Does it really follow that societys protections and encouragement of heterosexual marriage has the power to prevent depression and poor health outcomes? Is it possible that heterosexual marriage is our natural state and that our minds and bodies work best when used in the appropriate way? ACP's Health and Public Policy Committee recommends: Including comprehensive transgender heath care services in public and private health benefit plans. You recommend public and private insurance pay for sexual reassignment surgery. Is there data of benefit? Perhaps a reduction in mortality, disability or morbidity? Do those who have sexual reassignment surgery live longer or commit suicide less often? Why should anyone outside the person determined to change their body pay for it? Expanding the definition of "family" to include all who maintain an emotional connection to the patient, regardless of legal or biological relationship. Do you have data that children raised in families other than with their biological parents do better or as well? In absence of data, would it not be logical to encourage keeping biological parents together or at least permit states to make the judgment for themselves how to regulate/ encourage marriage? (as opposed to having courts take over as the "determiners of all things not established by study or fact") Opposing the use of "conversion," "reorientation" or "reparative" therapies in the treatment of LGBT individuals. Do you have data that such therapies are harmful? If a deeply disturbed person is confused about his/ her sexual identity and wants to focus attention on the opposite sex and seeks counseling to do so, is that wrong or harmful? LGBT individuals have a high incidence of depression and suicide. Do you wish to oppose possible therapy that may help if you have no alternative therapy that will help? Political trends come and go. Slavery, inter-racial marriage, cocaine, smoking, breast self-exam, and epinephrine have been normal, encouraged, discouraged and tossed away. Allowing a popular political idea to lead to policy changes not supported by data, that costs a great deal of money and is very disruptive to a current healthy institution: heterosexual marriage is a poor plan. ACP think before you act. When you act wrongly think again and change. Good-bye, Rex Moss MD
Henry Ng, MD, MPH, FAAP, FACP
MetroHealth Medical Center, Case Western Reserve University School of Medicine
May 30, 2015
Conflict of Interest:
I am the President of GLMA: Health Professionals Advancing LGBT Equality
In support of the American College of Physician’s Policy Position Paper on Lesbian, Gay, Bisexual and Transgender Health Disparities
As an internist-pediatrician who has worked in LGBT health care for the last decade, I am invigorated that the American College of Physicians (ACP), one of my professional homes, has developed a set of LGBT health focused policy statements. From my perspective as an LGBT health advocate and clinical director of a hospital-based LGBT health service line, these policy statements were sorely needed to assist internists around the US and internationally to improve the health experiences and outcomes, and ultimately eliminate health disparities of LGBT patients. I am proud to see the American College of Physicians join a growing group of professional organizations with LGBT-inclusive policies or mission statements including the American Academy of Family Physicians, the American Medical Association, the American Academy of Pediatrics, the American Academy of Physician Assistants, the American Academy of Nursing , the American College of Obstetrics and Gynecology, the American Psychological Association, the American Psychiatric Association, GLMA: Health Professionals Advancing LGBT Equality and others. The nine policy statements developed by Daniel et al which compose the ACP’s policy position paper are both bold and broad in their recommendations. Many of the recommendations are timely and remind internists to keep in-step with guidelines set forth by accrediting bodies such as the Joint Commission and the Centers for Medicare & Medicaid Services. This is especially important as more and more LGBT Americans enroll in health insurance through the Affordable Care Act and begin to routinely access the US health care system. However, the ACP’s policy statements will only be as useful as they are complete and current and must be considered a living document with the capacity to grow and change based on the best available data and knowledge regarding LGBT health. I encourage the members of the ACP Health and Public Policy Committee to revisit the policy statement on regular intervals for updates to fill the many gaps in our knowledge about LGBT health.Future revisions of the policy statement should pay careful attention to details not necessarily called out in the current policy’s executive summary. For example, policy statement 2 calls for the ACP to “recommend that all public and private health benefit plans include comprehensive transgender care services and provide all covered services to transgender persons as they would all other beneficiaries.”1 The authors continue to describe the impact of arbitrary or blanket exclusions for transgender health services in their example of hysterectomy coverage for a cisgender patient, but exclusion for a transgender patient. Yet in the policy statement, the ACP falls short of stating that such hormonal and/or surgical care is medically necessary. Moreover, the term “comprehensive” is an unclear term in this context. For optimal health outcomes, comprehensive care would need to be inclusive of all medically necessary care including primary care, mental health care, transgender hormonal care, transgender-related and non-transgender-related surgical care, and HIV care. The policy authors write in policy statement 6 that the ACP supports data collection and research into the understanding the demographics of the LGBT population, potential causes of LGBT health disparities, and best practices in reducing these disparities. This statement particularly important as there exist few nationally representative datasets describing LGBT population health. In fact, Healthy People 2020 still prioritizes collecting data on LGB and Transgender populations in their four objectives.2 To date, only the 2013 National Health Interview Survey has collected nationally representative data on lesbian, gay and bisexual people.3 Federal nationally representative surveys continue to exclude transgender respondents by not collecting gender identity/expression as part of the respondents’ demographic variables. Unfortunately, the majority of electronic health records also fail to provide fields for collection of sexual orientation and gender identity (SOGI) data. Cahill et al found that integrating SOGI data collection into the meaningful use requirements was both acceptable to diverse samples of patients, including heterosexuals, and feasible.4 The ACP should consider supporting inclusion of SOGI data collection in Meaningful Use as another strategy to improve LGBT health data collection.Daniel et al write in position statement 7 that “Medical Schools, residency programs, and continue medical education programs should incorporate LGBT health issues into their curriculum. The College supports programs that would help recruit LGBT persons into the practice of medicine and programs that offer support to other LGBT medical students, residents, and practicing physicians.”1 Creating the next generation of culturally and clinically competent health professionals and internists is central to improving LGBT health. Nationally, few health organizations and hospitals have actively implemented comprehensive programs to create LGBT affirming environments, educate health professionals and staff on LGBT health, or create sustainable supportive infrastructure. There continues to be a great need for LGBT safe space programs, LGBT 101 cultural competency education, and inclusion of LGBT topics in academic discourse and mentorship. Homophobia, transphobia, few visible LGBT health professional mentors and lack of institutional support for LGBT health scholarship serve as barriers to growing a cadre of academic internists adequately prepared to care for LGBT populations.5 The College can continue to champion LGBT health by supporting inclusion of LGBT health content in internal medicine certification examination questions, internal medicine in-training examination questions and promotion of additional LGBT health education resources like Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health.6Finally, the ACP should consider adding an additional statement which addresses and acknowledges the intersectionality of our patients’ identities as noted by IOM report.7 Sexual orientation and gender identity/expression do not exist within a vacuum and are part of the multidimensionality of our identities as people. References:1. Daniel H, Butkus R; Health and Public Policy Committee of the American College of Physicians. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med. 2015 May 12. doi: 10.7326/M14-2482. [Epub ahead of print] PMID:259615982. Healthy People 2020 LGBT Health Objectives. http://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health/objectives. Accessed 5/29/153. Ward BW, Dahlhamer JM, Galinsky AM, Joestl SS. Sexual orientation and health among U.S. adults: National Health Interview Survey, 2013. National health statistics reports; no 77. Hyattsville, MD: National Center for Health Statistics. 2014.4. Cahill S, Singal R, Grasso C, King D, Mayer K, Baker K, Makadon H.Do ask, do tell: high levels of acceptability by patients of routine collection of sexual orientation and gender identity data in four diverse American community health centers.PLoS One. 2014 Sep 8;9(9):e107104. doi: 10.1371/journal.pone.0107104. eCollection 2014. PMID: 251985775. Sánchez, N; Rankin, S; Callahan, E; Ng, H.; Holaday, L; McIntosh, K; Poll-Hunter, N; John Paul Sánchez, JP LGBT Health Professional Perspectives on Academic Careers – Facilitators and Challenges. LGBT Health. Forthcoming. 2015.6. Makadon H., Mayer K.,Potter, J., Goldhammer, H. (Eds.). (2015). Fenway Guide to Lesbian, Gay. Bisexual and Transgender Health. 2nd edition. American College of Physicians. 7. IOM (Institute of Medicine). 2011.The Health of Lesbian, Gay, Bisexual and Transgender People: Build a Foundation for Better Understanding. Washington, DC: The National Academies Press.
Mark D Lacy
June 2, 2015
Access for All but losing our way in the Process
To advocate for the elimination of health care disparities among Lesbian, Gay, Bisexual, and Transgender (LGBT) persons is a worthy objective not just for these populations but all patients facing obstacles to quality care. Sadly, the American College of Physicians Position Paper published May 12, 2015 addressing LGBT Health Disparities goes beyond advocating health care access by promoting a damaging sociopolitical ideology. The Paper re-defines the meaning of family, marriage, and calls for denying LGBT persons choices in behavioral health services.
While alleging the Position Paper was the product following review of “numerous studies, reports, and surveys on LGBT health care and related health policy” many cited references are based on research neither well executed nor widely corroborated. Further, it appears the reviewers fail to account for sound, copious evidence contradicting the cited sources.
To redefine family as “those who maintain an ongoing emotional relationship with a person, regardless of their legal or biological relationship” is to deny the reality of paternity and maternity, both integral to the most wholesome child-rearing environments. Dads contribute to the growth and development of children much differently than moms do. Asserting family as whatever one wants it to be is to succumb to the solipsistic notion that the self is the final arbiter of reality, to substitute the real and immutable childhood need for mothers and fathers with the sexual-romantic mutable desires of adults. Will the next Position Paper call for endorsing the aims of the North American Man Boy Love Association or Peter Singer’s call for granting civil rights to primates? Marriage is, and for millennia has been, rooted in the male-female complementarity that makes sexual reproduction possible and child-rearing wholistic. What is at play in this Statement are very imprudent mental maneuvres, “The moment you step into the world of facts, you step into a world of limits. You can free things from alien or accidental laws, but not from the laws of their own nature. You may, if you like, free a tiger from his bars, but not free him from his stripes. Do not free a camel from his hump; you may be freeing him from being a camel”. In "re-inventing" family and the meaning of marriage is to engage in the same sort of casuistry.
With regard to the American Psychological Association (APA) being invoked as the authority to repudiate psychotherapy for unwanted sexual behaviours recall the APA Task Force unequivocally posits “Same-sex sexual attractions, behavior, and orientations per se are normal and positive variants of human sexuality.” If that is the a priori assertion, can objective assessment of “sexual orientation change efforts” (SOCE) be realistically expected? Probably not. To satisfactorily debunk SOCE entails more than citing the APA. In the meantime, persons who opt for SOCE should be given the prerogative in the same way, for example, the transgender person is offered high- dose estrogens in spite of the increased risk of thrombosis.
The LGBT Position Papers unfortunately makes the Annals a mouthpiece for the post-modern notion that we can write our own narrative and call it true, regardless of the facts. Once the Annals becomes a purveyor of ideology and asserts a world view which doesn’t comport with facts, it is no longer a reliable source of guidance for physicians.
Mark D Lacy, MD, MA, FACP
Paul J Hudson, MD, MPH, FACP
June 22, 2015
The policy on LGBT reaches beyond evidence
Dear friends at ACP,I too am disappointed at the lack of evidence for this very broad set of policy changes, which not only goes beyond the evidence but becomes an agent for changing institutions that have stood the test of millenia. For example, defining a family as something other than biological is a step in the wrong direction. The evidence shows that children need a father and they need a mother; this has something to do with biology, and cannot be socially constructed. Please reconsider your over-reach and return to medical evidence.Thank you,Paul Hudson, MD, FACP, MPH
Hilary Daniel, BS, Renee Butkus, BA
September 10, 2015
Response to Comments Made by Drs. Lacy and Ng
The two comments submitted by Drs. Lacy and Ng speak to the diversity of ACP’s 143,000 internal medicine physicians and student members. ACP advocates on a wide variety of topics and the College recognizes that not all ACP members will agree with our positions. The need to address the unique needs of the LGBT persons and their families is a based on ACP’s long standing commitment to advocate for those being negatively affected by health care disparities. Ignoring or glossing over some topics that affect health because they are controversial would be inconsistent with ACP’s mission “To enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine” including “to advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public, our patients, the medical profession, and our members.”We appreciate Dr. Ng’s support for our paper. As the paper was being developed, policies concerning same sex marriage, blood donation by men who have sex with men, and coverage for transgender health care services were undergoing change. The College recognizes the need for continued review of issues relating to LGBT health. Dr. Lacy takes issue with our call for a more inclusive definition of family. As our paper points out, it’s estimated that only 22% of U.S. families consist of married heterosexual parents with their own biological children. A modern definition of family that is inclusive of all types of families, including the LGBT population, is fundamental to reducing the disparities and inequalities that exist within the health care system and to equal treatment of LGBT patients and their visitors in the hospital setting. Our opposition to “therapy” to change the sexual orientation of an individual is based on the science that shows that sexual and gender orientation are not disability or disorder in need of treatment or cure, and that such “therapies” may be harmful to patients receiving them. Hilary Daniel, BSRenee Butkus, BA 1. Movement Advancement Project, Family Equality Council, Center for American Progress. All children matter: how legal and social inequalities hurt LGBT families: condensed version. Denver: Movement Advancement Project; 2011. Accessed at www.lgbtmap.org/file/all-children-matter-condensed-report.pdf on 11 February 20152. American Psychological Association Task Force. Report of the American Psychological Association Task Force on appropriate therapeutic responses to sexual orientation. Washington, DC: American Psychological Association; 2009. Accessed atwww.apa.org/pi/lgbt/resources/therapeutic-response.pdf on 11 February 2015.
Daniel H, Butkus R, for the Health and Public Policy Committee of the American College of Physicians. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med. 2015;163:135–137. doi: 10.7326/M14-2482
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