of HIV cases overall remained constant, and it likely reflects the fact that prevention efforts are not reaching men who have sex with men but do not identify as gay when asked on a survey. This is particularly true among black men between the ages of 13 and 29 who have sex with men, a population in which there has been an almost 50 percent increase in the incidence of HIV cases between 2006 and 2009.

These data highlight the fact that LGBT people are not one homogeneous group, but rather that they reflect the same cultural diversity seen throughout the general population. Understanding the cultural diversity among, in this case, men who have sex with men, is going to be key to developing ways to reach underserved populations, but that lesson applies to all LGBT people, said Makadon. That understanding cannot start without data about these underserved populations.

In terms of understanding the T in LGBT, the IOM report noted that there are significant health disparities that have been documented among transgender people. It is critical that clinicians have information on a patient’s gender identity, gender expression, birth sex, medical history, and current anatomy. The only way to get this information is by educating both clinicians and the transgender community about the importance of discussing these issues to ensure access to high-quality care. The clinician, said Makadon, has to be the point person in gathering this information, but the field needs to figure out ways to help clinicians so that they do not spend all of their time just gathering data and not having time to talk to their patients.

THE IMPACT ON QUALITY OF CARE

To illustrate the importance of all clinicians, not just the primary care physician, having information about a patient’s gender identity, Makadon discussed two case studies. The first case involved a 50-year-old woman who developed a high fever and chills after head and neck surgery. The infection source turned out to be the patient’s prostate gland, which nobody knew she had because nobody had asked about her gender identity and she had not volunteered this information. She could have received much quicker treatment for her infection had her surgeon and the hospital staff known she was a transgender woman.

The second case involved a 55-year-old man who came to his physician with pain and on X-ray appeared to have metastases from an unknown primary cancer. Evaluation ultimately showed that he had developed cancer in his residual breast tissue that remained after having “top surgery” to remove his breasts. None of his physicians were aware that he was a transgender man, so he had not been advised to have routine breast screening even though his mother and sister had also had breast cancer.



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