LGBT-Health


 * Lesbian, Gay, Bisexual, and Transgender. **

**FACILITATORS: April Daley, Jessica Coburn, Cheryl Glodoski**


 * **Contents** * Learner Objectives
 * Required Readings and Websites
 * Healthy People 2020 Objective
 * Related Epidemiological Data
 * Screening Guidelines and Assessment Parameters
 * Behavioral Intervention Recommendations
 * Discussion of Intervention Efficacy ||

Learner Objectives »

 * Describe how LGBT status impacts Healthy People 2020 goals through moderated discussion.
 * Compare and contrast approaches to screening, counseling, and immunization across the lifespan for the LGBT patient population.
 * Use appropriated USPSTF screening and immunization recommendations for people at risk due to LGBT health disparities.
 * Analyze different resources available for LGBT populations in order to be able to address concerns with these patients when working as an advanced practice nurse.

Required Readings and Websites
> <span style="font-family: Arial,Helvetica,sans-serif;">media type="youtube" key="R-UrQCQNaZg" height="315" width="420"
 * Centers for Disease Control and Prevention (2012)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Birkett, M., Espelage, D. L., & Koenig, B. (2009). LGB and questioning students in schools: The moderating effects of homophobic bullying and school climate on negative outcomes. Journal of Youth & Adolescence, 38(7), 989-1000.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Mc Daniel et. al., (2005) Chap 13. Family oriented care of Adolescents.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">AMA Guidelines for Adolescent preventive health and Guidelines for Adolescent preventive services
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">WEBSITE: AMA Promoting Adolescent Health
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">WEBSITE: Healthy People 2020, LBGT
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">WEBSITE: USPSTF website use to identify appropriate prevention interventions
 * <span class="wiki_link_ext" style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">USPSTF website to identify appropriate prevention interventions
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">[|It Gets Better]The It Gets Better Project was created to show young LGBT people the levels of happiness, potential, and positivity their lives will reach – if they can just get through their teen years. The It Gets Better Project wants to remind teenagers in the LGBT community that they are not alone — and it WILL get better.

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 * ==<span style="font-family: 'Arial Black',Gadget,sans-serif; font-size: 110%;">**Recommended Reading and Websites** ==
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">GLBT National Help Center Provides free and confidential telephone and internet peer, information, and local resources for callers throughout the United States. 1-888-843-4564
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Milwaukee LGBT Community Center Has many programs and groups available, including HIV services and a LGBT breast health program.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The Gay and Lesbian Medical Association
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">GLSEN, Inc. Anti-bullying resource website (2011).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Suicide Prevention Resource Center. (2008). Suicide risk and prevention for LGBT youth
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the LGBT Community: A Field Guide (The Joint Commission)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Guidelines for the Care of LGBT Patients (GLMA)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">LGBT-Related Content in Undergraduate Medical Education (JAMA)

<span style="color: #000099; font-family: Arial,Helvetica,sans-serif;">Healthy People 2020 Objective »
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 120%;">Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals.

<span style="color: #000099; font-family: Arial,Helvetica,sans-serif;">Related Epidemiological Data »
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The lesbian, gay, bisexual, and transgender (LGBT) community suffers disproportionately from many health issues. Some of these health issues are related to lifestyle differences, but many are influenced by social injustices. Social inequality is directly tied with poorer health statuses. Members of the LGBT community specifically are at an increased risk for many health issues as sexual orientation has been found to influence disparities in health (CDC, 2011). These disparities deserve attention from public health programs and prevention services that are specifically designed meet the needs of the LGBT population.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Reliable demographical information on the LGBT population has proven difficult for researchers to collect given that most studies involve probability sampling and self-reporting. The IOM (2011) makes note of this need for future research in their report: <span class="wiki_link_ext">The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. The report does however highlight a few of the more credible studies that have investigated sexual orientation identification. A study conducted by the Center for Disease Control and Prevention’s National Center for Health Statistics in 2002 found that 90.2 percent of men ages 18-44 identified themselves as heterosexual, 2.3 percent as homosexual, 1.8 percent as bisexual, and 3.9 percent as something else; 1.8 percent did not report their orientation. Findings for women ages 18-44 were similar. 90.3 percent of woman identified as heterosexual, 1.3 percent as homosexual, 2.8 percent as bisexual, and 3.8 percent as something else. 1.8 percent of women did not report their orientation (The Division of Vital Statistics, 2005).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">It should be noted that the LGBT population includes an extremely diverse collection of individuals from all age groups, races, ethnicities and socioeconomic groups. The term “LGBT” refers to a compilation of groups that each have their own specific health concerns, yet still experience common social inequities such as stigmatization, marginalization and discrimination (IOM, 2011). Major health concerns for the LGBT population include HIV, tobacco use, and mental health.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**__HIV__**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Gay and bisexual men are affected by HIV infection at a disproportionate rate and are considered the population most at risk in the United States. Men having sex with men (MSM) account for almost 2% of the United States population yet in the years 2006-2009 they accounted for over 50% of all new HIV cases (CDC, 2011). While overall incidence rates for HIV remained stable in the years 2006-2009, both young and Black MSM experienced significant increases in HIV incidence. Young MSM ages 13-29 experienced a 34% increase during these three years, while Black MSM experienced an increase of 48%. Lesbian and bisexual women are also at risk for HIV infection, especially when the following risk factors are present: injection drug use, sex with men who are infected or who have risk factors for infection, or, receipt of blood or blood products (CDC, 2011).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**__Tobacco Use__**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">According to the American Lung Association (ALA) smoking is approximately twice as prevalent in the LGBT community as a whole. This puts the LGBT population at risk for smoking related health threats such as lung cancer, heart attack, COPD, HTN, and stroke (AHA, 2010). LBGT youth are thought to be a group of particular concern. The CDC analyzed data collected from Youth Risk Behavior Surveys from years 2001-2009 and found that prevalence rates of cigarette use differed greatly based on sexual orientation. Heterosexual students reported prevalence rates of 8%-19% while gay and lesbian students reported rates of 20-48% (CDC, 2011).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**__Mental Health__**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Data from the National Longitudinal Study of Adolescent Health revealed higher suicidal ideation and suicide attempt incidence in LGBT youth than in heterosexual youth. In non-LGBT youth the risk for suicide was strengthened by the presence of depression and problem drug-use (Silenzio et al., 2011). These findings were echoed by a Nationally Representative study that found that lesbian, gay, and bisexual youth were at twice the risk for attempting suicide than their heterosexual counterparts (CDC, 2011). Aside from LGBT youth, mental health issues also affect LGBT adults at a disproportionate rate. Data from a nationally representative sample of midlife adults suggests that lesbians, gay men, and bisexual individuals are at increased risk for some mental health disorders. Findings demonstrated higher prevalence of depression, panic attacks, and psychological distress in gay and bisexual men when compared with heterosexual men. Additionally, prevalence for generalized anxiety disorder was found to be higher in lesbian and bisexual women than in heterosexual women (Cochran, Mays, and Sullivan, 2003).

<span style="color: #000099; font-family: Arial,Helvetica,sans-serif;">Screening Guidelines and Assessment Parameters »
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The American Medical Association (AMA) recommends that clinicians screen all adolescents for:


 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Eating Disorders
 * 2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Sexual Activity
 * 3) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Alcohol and Other Drug Use
 * 4) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Tobacco Use
 * 5) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">School Performance
 * 6) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Depression
 * 7) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Risk for Suicide

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Healthy People 2020 Goals: <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">1. Reduce cases of HIV <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">2. Implement antibullying policies in school <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">3. Reduce suicide and homelessness in LGBT youth <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">4. Increase patient-provider interactions <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">5. Better training for healthcare providers about LGBT patients

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">LGBT youth have a four times higher risk of self-harm and suicide (American Journal of Preventative Medicine). Suicide risk factors to assess include: <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">*Family acceptance and social support is a protective factor against suicide in LGBT youth (AJPM, 2012).
 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Hopelessness
 * 2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">LGBT Victimization
 * 3) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Gender Nonconformity
 * 4) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Suicide Attempt History
 * 5) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Impulsivity
 * 6) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Sensation-seeking

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">USPSFT Screening recommendations for a male, age 18 who is sexually active include the following:

<span style="font-family: Arial,Helvetica,sans-serif;"> <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">I<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">mmunization guidelines (CDC, 2012) for male adolescents who are sexually active include the following:


 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). (Minimum age: 10 years for Boostrix® and 11 years for Adacel®)
 * 2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Human papillomavirus vaccine (HPV). (Minimum age: 9 years).
 * 3) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Meningococcal Conjugate vaccine 1 dose (usually at age 11 or 12) and a booster (age 16).
 * 4) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Varicella 2 doses (for persons who lack immunity, **contraindicated** if immuno-compromising condition).
 * 5) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Measles, mumps, rubella (MMR) 1 or 2 doses (for persons who lack immunity, **contraindicated** if immuno-compromising condition)
 * 6) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Polio (IPV) if not caught up.
 * 7) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Influenza 1 dose annually. (Recommended for all children and adolescents)
 * 8) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Pneumococcal, Hepatitis A, Hepatitis B (recommended if some other risk factor is present).

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">In order to meet the Healthy People 2020 Objective of improving the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals, there are certain behavioral interventions that are recommended for this population. Members of the LGBT community are at increased risk for a number of health threats when compared to their heterosexual peers. Differences in sexual behavior account for some of these disparities, but others are associated with social and structural inequities, such as the stigma and discrimination that LGBT populations experience. Because of these differences, the CDC has certain recommendations for members of this community when it comes to sexual health (CDC, 2012).


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">** Remember the ABCs: Abstain, Be faithful, and use Condoms. **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;"> VIDEO: Correct Condom Use


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">** Know your status. Make an appointment to get tested, and encourage your sexual partners to get tested. **

<span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">MTV and other sponsors put together a campaign every April called <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Get Yourself Tested


 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 16px;">**Pay attention to your body. If you notice a discharge, sore, or other problems, make an appointment to get checked. Note, however, that not all STDs have symptoms.**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**CDC's STD Prevention Strategy** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The prevention and control of STDs is based on the following five major concepts:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Education and counseling of persons at risk on ways to adopt safer sexual behavior
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Identification of infected persons--with or without symptoms--unlikely to seek diagnostic and treatment services
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Effective diagnosis and treatment of infected persons
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Evaluation, treatment, and counseling of sex partners of persons who are infected with an STD
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Pre-exposure vaccination of persons at risk for vaccine-preventable STDs

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Recommended vaccinations are Hepatitis A/B and the Human Papilloma Virus (HPV) vaccines. The HPV vaccines can protect individuals from diseases caused by HPV types 16 and 18; HPV 16 and 18 cause most cervical cancers, as well as other HPV associated cancers. The CDC recommends that girls age 9 – 26 get the 3 dose series of Cervarix or Gardisil (which also protects from some strains of the virus that cause genital warts). Gardisil is also recommended for boys age 9 – 26, especially for men who have sex with men or who have compromised immune systems (including HIV).

<span style="font-family: Arial,Helvetica,sans-serif;">** Mental Health ** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Research suggests that LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide. Experiences of violence and victimization are frequent for LGBT individuals, and have long-lasting effects on the individual and the community. Personal, family, and social acceptance of sexual orientation and gender identity affects the mental health and personal safety of LGBT individuals. The negative effects of social marginalization can be found in adolescent and adult homosexuals, for example, research has shown that members of the LGBT community are at increased risk for a number of mental health problems (Healthy People 2020, 2012). Research also has found that, compared to their heterosexual counterparts, LGBT individuals are at increased risk of:
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Major depression during adolescence and adulthood;
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Bipolar disorder; and
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Generalized anxiety disorder during adolescence and adulthood.
 * <span style="color: black; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Co-morbidities of mental health problems including illegal drug use and a greater risk of suicide.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">LBGT individuals should be encouraged to access resources if they are struggling with mental health issues, and health care providers should be familiar with resources in order to provide the best care. The It Gets Better Project aims at reminding LBGT individuals that they are not alone and there are resources available.

<span style="font-family: Arial,Helvetica,sans-serif;">** CDC (2011) recommends the following interventions for prevent HIV-AIDS, **
 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Behavioral interventions, which have proven effective in reducing the risk of acquiring or transmitting HIV like access to condoms and clean needles (see Community Interventions below). Ensuring people have the information, motivation, and skills necessary to reduce their risk continues to be important.
 * 2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">HIV testing is critical in preventing the spread of HIV. Most people change behaviors to protect their partners if they know they are infected with HIV.
 * 3) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Linkage to treatment and care, which enables individuals with HIV to live longer, healthier lives and reduce their risk of transmitting HIV. It is imperative that individuals with HIV know their HIV status and are linked to ongoing care and prevention services. Substance abuse treatment if applicable.

<span class="aaglmasubtitle11" style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Ten Things Transgender Persons Should discuss with Their Healthcare Care Provider** <span class="aaglmasubtitle11" style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//(Gay and Lesbian Medical Association, 2012).// <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**1. //Access to Health Care//**: Transgender persons are often reluctant to seek medical care through a traditional provider-patient relationship. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**2.** **Health History**//: Transpersons may hide important details of their health history from their doctors, patients should see their provider as an equal partner in their health care, not as a gatekeeper or an obstacle to be overcome. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**//3. Hormones//**: Cross-gender hormone therapy gives desirable feminizing (or masculinizing) effects, but carries its own unique risks. Hormone use should be appropriately monitored by the patient and provider. Taking hormones without supervision can result in doses too high or too low, with undesired results. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**4. Cardiovascular Health:**// Transpersons may be at increased risk for heart attack or stroke, not only from hormone use but from cigarette smoking, obesity, hypertension, and failure to monitor cardiovascular risks. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**5. Cancer:**// Hormone-related cancer (breast in trans women, liver in women or men) is very rare but should be included in health screening. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**6. STDs and Safe Sex:**// Transpeople, especially youth, may be rejected by their families and find themselves homeless. Other trans people may practice unsafe sex when they are beginning to experience sexuality in their desired gender. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**7. Alcohol and Tobacco**//: Alcohol abuse is common in transgender people who experience family and social rejection, and the depression which accompanies such rejection. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**8. Depression/Anxiety**//: One of the most important aspects of the transgender therapy relationship is management of depression and/or anxiety. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**9. Injectable Silicone**//: Some trans-women want physical feminization without having to wait for the effects of estrogen. The silicone, often administered at “pumping parties” by non-medical persons, may migrate in the tissues and cause disfigurement years later. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">//**10. Fitness (Diet & Exercise):**// Exercise prior to sex reassignment surgery will reduce a person’s operative risk and promote faster recovery.

<span style="font-family: 'Arial Black',Gadget,sans-serif; font-size: 110%;">BULLYING

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">**Key Points of Birkett, Espelage, and Koenig Article (2009)** **LGB and Questioning Students in Schools: The Moderating Effects of Homophobic Bullying and School Climate on Negative Outcomes**
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Contextual factors encountered in the school setting affect a child's mental health, achievement, self-concept, and a child’s ability to form social relationships (Baker et al. 2001; Ringeisen et al. 2003).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">A lack of support from schools, teachers and administrators contributes to negative outcomes for lesbian, gay and bisexual (LGB) students (Lipkin, 2002)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The transition from elementary to middle school is a difficult time for many children. Middle school also marks the time period when many students discover their sexual identity (Dube ́ & Savin-Williams, 1999).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">School peer-support groups, counseling programs and the establishment of anti-bullying policies within schools have been associated with less peer victimization and lower rates of suicide attempts (Goodenow et al., 2006),
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">All children report the lowest levels of drug use, truancy and depression/suicidality when in a positive school climate (Birkett, Espelage & Koenig, 2009).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Both lesbian, gay, and bisexual students and children questioning their sexuality report higher levels of bullying, homophobic victimization, and negative outcomes than heterosexual youth (Birkett, Espelage & Koenig, 2009).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Youth who question their sexuality are at the greatest risk for negative outcomes such as truancy, depression/suicidality, and alcohol/marijuana use when compared with both heterosexual students and LGB students (Birkett, Espelage & Koenig, 2009).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Study results suggest that questioning youth are equally or even more important to consider than LGB youth considering their higher prevalence rates of negative outcomes (Birkett, Espelage & Koenig, 2009).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Study results confirm the previous research that has indicated that LGB students score higher than heterosexuals on various negative outcomes such as truancy,depression/suicidality and alcohol/drug use (Birkett, Espelage & Koenig, 2009).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Study results also support the previous research that indicates that school environment affects negative outcomes (Birkett, Espelage & Koenig, 2009).
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Promoting schools with low levels of homophobic teasing and a positive school climate may alleviate negative outcomes in LGB youth and youth questioning their sexuality (Birkett, Espelage & Koenig, 2009).

<span style="color: #000099; font-family: Arial,Helvetica,sans-serif;">Discussion of Intervention Efficacy »
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The United States Preventive Services Task Force (USPSTF) has updated its definitions of the grades it assigns to recommendations and now includes "suggestions for practice" associated with each grade. The USPSTF has also defined levels of certainty regarding net benefit.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">An intervention suggested by the U.S. Preventive Services Task Force (USPSTF) is to screen all adolescents for sexually transmitted disease (STD) risk, and screen for STDs appropriately. Due to the increased risk factors some members of the LGBT community have to develop STDs based on sexual behavior, this intervention is especially important for this population.The USPSTF recommends high-intensity behavioral counseling to prevent STDs for all sexually active adolescents and for adults at increased risk for STDs, and this recommendation is given a B grade, meaning service is recommended and there is high certainty that the net benefit is moderate to substantial. There is convincing evidence that high-intensity behavioral counseling interventions targeted to sexually active adolescents at increased risk for STDs reduce the incidence of STDs. These results were found 6 and 12 months after counseling took place. Reviewed studies identified that successful high-intensity interventions were delivered through multiple sessions, most often in groups, with total durations from 3 to 9 hours. Little evidence suggests that single-session interventions or interventions lasting less than 30 minutes were effective in reducing STDs. High-intensity behavioral counseling may be delivered in primary care settings or in other sectors of the health system after referral from the primary care clinician or system. In addition, risk-reduction counseling may be offered by community organizations. Strong linkages between the primary care setting and the community may greatly improve the delivery of this service.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">The USPSTF also has recommendations about screening for human immunodeficiency virus (HIV). They strongly recommend that clinicians screen for HIV in all adolescents at increased risk for HIV infection. This recommendation is given an A grade, meaning that it is strongly recommended and there is good evidence that such screening improves important health outcomes and concludes that benefits substantially outweigh harms. A person is considered to be at increased risk for HIV infection if they report 1 or more risk factor at a clinical setting, including such things as men who have had sex with men after 1975, men and women having unprotected sex with multiple partners, past or present injection drug users, men or women who exchange sex for money or drugs, individuals whose past or present sex partners are HIV-infection, bisexual individuals, persons being treated for STDs, and persons with a history of blood transfusions between 1978-1985. Persons who request an HIV test despite reporting no individual risk factors may also be considered at increased risk, since this group is likely to include individuals not willing to disclose high risk behaviors.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">There is good evidence of increased yield from routine HIV screening of persons who report no individual risk factors but are seen in high-risk or high-prevalence clinical settings. High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. To update its 1996 recommendations on HIV screening, the USPSTF examined the evidence from 1983 through June 2004 on the benefits and harms of screening and of currently available interventions for HIV infection in adults, adolescents, and pregnant women. Relevant studies on risk factor assessment and the accuracy and acceptability of testing were also reviewed. A large, good-quality U.S. study found that risk factor assessment can identify individuals at substantially higher risk for HIV, but still misses a significant proportion (20% to 26%) of HIV-positive clients who report no risk factors. There is fair evidence to indicate that a broader strategy targeted to individuals who report risk factors, combined with routine (voluntary) testing of those being seen in high-prevalence clinical settings, would result in substantially fewer missed diagnoses. In 2 good-quality studies, HIV screening of populations with a 1-percent prevalence rate was found to be cost-effective (in terms of acceptable cost per quality-adjusted life-year) compared with no screening.

<span style="color: #000099; font-family: Arial,Helvetica,sans-serif;">D2L Discussion Prompt »
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">I am Brian Jones. I am 14 yrs. old, Black, and live with my parents Joe and Toni. My parents are evangelical Baptist and believe homosexuality is a sin. My mom came with me because I need a sports physical for school. I am very nervous that people at school will find out my secret. I find boys more attractive than girls. People at school are always harassing and beating up gay students, last week a woman who was a gay activist was murdered in Milwaukee. My parents don’t know my secret.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">In one paragraph summarize,

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(a) possible effects of school climate and bullying on Brian,

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(b) Identify 2-3 strategies advanced practice nurses can use to address sexual orientation with Brian, and what routine screenings should be used with Brian?* Review the family levels of care (e.g., minimal, information & collaboration, feeling & support, primary care family assessment & counseling, and medical family therapy) in McDaniel, et al. (2005) Chapter 1.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(c) Select one of the family levels of care you will use to guide your interventions with Brain and his family, and

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">(d) identify 2 corresponding interventions based on the level of care you selected.