Ismael is a 29 year-old male with history of HIV infection, depression, posttraumatic stress disorder and methamphetamine addiction who is presenting for a follow-up visit at an academic-based HIV specialty clinic, where internal medicine residents rotate in their second year. The resident who previously cared for Ismael wrote in her off-service note that the team had decided to hold off on prescribing antiretroviral therapy to Ismael because “he’s currently noncompliant with meds, goes on meth binges periodically that include unprotected sex with anonymous partners, and may become homeless and lose the only social support he has if his partner kicks him out of the house.” Three years ago while adherent to his regimen, which included ritonavir 100 mg daily, atazanavir 300 mg daily, and daily Narcotics Anonymous (NA) meetings, Ismael’s viral load was <40 copies/mL and his CD4 count was above 500 cells/μL.
A month ago, a new resident asked Ismael, “When was the last time you used meth?” To which Ismael responded, “Last weekend.” The resident referred Ismael to the clinic’s addiction physician. After greeting him today, the first thing the resident asks Ismael is, “So…when was the last time you used meth?” When Ismael replies, “A month ago, right after I saw you,” the resident appears stunned, and starts to read the note written by the addiction physician without saying a word.
Born in Mexico, Ismael grew up on both sides of the US-Mexico border and lived for periods of time in both countries. He never met his biological father but his mother began to live with a man he considers his stepfather when he was two or three years old. Ismael loved his stepfather, a truck driver who would sit Ismael on his lap while pretending to be teaching him to drive. This game eventually led to overt fondling when Ismael was about 6 years old, an experience that filled Ismael with dread, shame and confusion. His mother struggled with alcoholism, and, as far as he can remember, she abused him and his four siblings emotionally and physically. After his mother and stepfather separated and his mother abandoned the children, Ismael and his siblings lived in an orphanage where Ismael was bullied by other boys. He woke up many times in the night when some of the older boys were touching him sexually and attempting penetration. While at the orphanage, Ismael met an American couple who visited him periodically. That couple eventually adopted him legally.
Although Ismael’s material circumstances changed drastically when he moved in with his adoptive parents at the age of 14, he withdrew socially and his academic performance progressively worsened. A few credits short of graduating from high school, Ismael joined the military at age 18, and for a while was sexually active with both men and women. When he was 20 years old, he came out as a gay man, left the military and moved in with a partner. Older and more experienced, this man introduced Ismael to methamphetamine. Ismael left him after a few years, tired of being controlled and subjected to bouts of domestic violence. He met his current partner more than two years ago through NA friends.
The resident stops reading and looks at Ismael, feeling unsure how this information may contribute to Ismael’s HIV treatment. Ismael interrupts the resident’s pondering and says, “I brought my NA sponsor, and he wants to meet you. Can he come in?”
Optimizing addiction treatment has important parallels to optimizing the care of patients who are or may be lesbian, gay, bisexual, transgender (LGBT), gender nonconforming, and/or born with a difference of sex development (DSD). Addiction topics, similar to concerns related to sexual orientation, gender identity, gender expression, and sex development, are frequently marginalized. Medical education and subsequently mainstream medicine therefore all too frequently foster ongoing ignorance, stigma and discrimination. Information exchange regarding addiction treatment, education, and improving the health of patients who are or may be LGBT, gender nonconforming and/or born with DSD may be mutually beneficial.
In November 2014 the Association for American Medical Colleges (AAMC) published recommendations for achieving competence for people who are LGBT, gender nonconforming and/or born with DSD and opportunities for their integration into medical education. A professional competency can be defined as “an observable ability of a health professional, integrating multiple components such as knowledge, skills, values, and attitudes.” Professional competencies therefore extend beyond a prescribed set of didactic knowledge or specific skills by integrating these together into higher order professional abilities.
To illustrate, two examples of competence in caring for the aforementioned populations are:
- Sensitively and effectively eliciting relevant information about sex anatomy, sex development, sexual behavior, sexual history, sexual orientation, sexual identity and gender identity from all patients in a developmentally appropriate manner.
- Developing rapport with all individuals (patient, families, and/or members of the health care team) regardless of others’ gender identities, gender expressions, body types, sexual identities, or sexual orientations, to promote respectful and affirming interpersonal exchanges, including staying current with evolving terminology.
This article is the first of a three part article series designed to introduce sexual orientation, gender identity, gender expression and sex development topics to addiction physicians. The relevance of this series to addiction medicine is twofold: first, LGBT populations have been shown to have a higher risk of addiction than non-LGBT populations.,, While the literature does not well articulate the prevalence of addiction among those who are gender nonconforming and/or born with DSD, the underlying processes of stigma and discrimination suggest that these communities are too at risk. Understanding and utilizing the terminology that individuals use to describe themselves across these four domains is the foundation of respectful patient care. Applying the AAMC competencies to addiction medicine will support quality, personalized care to patients with diverse sexual orientations, gender identities, gender expressions and sex developments.
Secondly, the AAMC’s professional competencies, recommendations for integration and assessment, and current initiatives to improve the health of individuals in the aforementioned populations can serve as a resource for addiction clinicians who may find inspiration in employing similar strategies to teach addiction topics within medicine. Given an essential component of ASAM’s mission is to educate physicians about the disease of addiction, the AAMC has demonstrated a powerful approach to address the health needs of highly stigmatized patient populations through medical education.
The AAMC Guide includes an extensive glossary of terms, but several terms are worth defining here in order to illustrate the key topics mentioned above: sexual orientation, gender identity, gender expression, and biological sex development.
Sexual orientation “is an individual’s inclination to feel sexual attraction or arousal to a particular body type or identity. Relatively common forms of sexual orientation include heterosexuality (opposite-sex or opposite-gender attraction), homosexuality (same-sex or same-gender attraction) or bisexuality (attraction to people who are the opposite sex or gender along with attraction to people who are the same sex or gender).” Sexual orientation identity terms include lesbian, gay, bisexual and straight; “homosexual” and “heterosexual” may be used to describe behaviors, but not an identity.
Sexual orientation is distinct from gender identity, which is “an individual’s personal and subjective inner sense of self as belonging to a particular gender (e.g. boy/man, girl/woman, genderqueer, transmasculine spectrum, transfeminine spectrum).” Transgender refers to an individual “who has a gender identity that does not align with the gender labels assigned at birth.”
Gender expression is “the mannerisms, personal traits, clothing choices, etc., that serve to communicate a person’s identity as they relate to a particular societal gender role.” Gender expression may align with gender identity. In contrast, gender nonconformity refers to “a person who does not conform to prevailing gendered behaviors or roles within a specific society.”
Sex is distinct from sexual orientation and gender identity or expression, and refers to “the aggregate of an individual’s biological traits (genotypical and phenotypical) as those traits map to male/female differentiation and the male-female anatomical and physiological spectrum.” Differences of Sex Development, or DSD, is “an umbrella term for a wide variety of congenital conditions in which the development of chromosomal, gonadal, and/or anatomical sex is atypical.” Atypical sex development does not uniformly require medical attention, although there are some differences of sex development that may require medical treatment to prevent the risk of malignancy, support urological function or even maintain life.
All addiction physicians will work with patients who both have addiction and who also are lesbian, gay, bisexual, transgender (LGBT), gender nonconforming, and/or born with a difference of sex development (DSD). These patients face increased stigmatization related both to their addiction and their sexual orientation, gender identity, gender expression and/or sex development. Our patients are therefore best served by addiction physicians competent in each of the ways articulated in the AAMC Guide. Subsequent articles in this series will highlight case examples that demonstrate the practical applicability of these concepts in real-world cases.
For those interested in learning more, be sure to attend the ASAM Annual Conference this coming April 2015 in Austin, TX, which will feature a workshop session entitled, “Sexual Orientation, Gender Identity, and Sex Development Competencies & Addiction Medicine” the morning of Friday April 24, 2015.
The AAMC’s Implementation Guide can be downloaded via http://www.aamc.org/lgbtdsd, and is a key resource for all addiction physicians. An accompanying video series available via http://www.aamc.org/axis is available to support institutional advocates and other supporters of physician education in LGBT Health topics. There are also a number of organizations that offer CME coursework in sexual orientation, gender identity, gender expression, and sex development topics, including GLMA: Health Professionals Advancing LGBT Equality, www.glma.org.
Brian Hurley, MD, MBA, is an addiction physician and Quality Scholar in the VA Greater Los Angeles Healthcare System, affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA) and will become a UCLA Robert Wood Johnson Clinical Scholar in July 2015. He completed addiction psychiatry fellowship training at NYU and general psychiatry training at Massachusetts General Hospital and McLean Hospital. Brian is currently the co-chair of ASAM’s Membership Committee and will become ASAM’s Treasurer at the April 2015 ASAM Annual Conference. Brian has previously served as National President of the American Medical Student Association.
Carey Roth Bayer, EdD, RN, CSE, is an associate professor in the Departments of Community Health and Preventive Medicine/Medical Education at Morehouse School of Medicine. She is also the associate director of educational leadership in the Satcher Health Leadership Institute. She primarily teaches human sexuality with medical students, residents, and health policy fellows. Dr. Bayer serves on the Association of American Medical Colleges’ Committee on Sexual Orientation, Gender Identity, and Sex Development. Her work focuses on the intersections of medical education and sexuality education.
Alice Dreger, PhD, is a professor of clinical medical humanities and bioethics at Northwestern University’s Feinberg School of Medicine and one of the editors of the AAMC resource guide. She is by training and vocation a historian of science and medicine and has worked for almost 20 years on improving the care of individuals born with DSD. She is the former chair of the Intersex Society of North America and writes for the mainstream. Her latest book is Galileo’s Middle Finger: Heretics, Activists, and the Search for Justice in Science (Penguin Press, 2015).
Andres D Sciolla, MD, is an Associate Professor at the Department of Psychiatry & Behavioral Sciences at the University of California, Davis the Medical Director for Northgate Point Regional Support Team, a community mental health clinic. In addition, Dr Sciolla is Co-Director of the Doctoring 2 course at the School of Medicine. Prior to UC Davis, Dr Sciolla was at UC San Diego, where he was an Associate Training Director for the general psychiatry residency training program. Dr Sciolla is a member of the Dean’s LGBTQI Advisory Council at UC Davis, and was a member of the Chancellor’s Advisory Committee on Lesbian, Gay, Bisexual and Transgender Issues at UC San Diego.
Jennifer Potter, MD, is associate professor of medicine at Harvard Medical School (HMS) and director of women’s health programs at two HMS teaching affiliates. Jennifer Potter has more than 24 years of experience caring for members of the LGBT community and is widely recognized as a leader in curriculum development to enhance care for underserved women, sexual and gender minorities, people with disabilities, and cancer survivors. Dr. Potter is associate editor for AAMC’s MedEdPORTAL LGBT collection and co-editor of the Fenway Guide to LGBT Health, a seminal textbook for health professions trainees.
Kristen L. Eckstrand, PhD, holds her PhD in Neuroscience and is an MD candidate at Vanderbilt University, chair of the Association of American Medical Colleges’ Sexual Orientation, Gender Identity and Sexual Development Patient Care Advisory Panel and co-editor of the AAMC's publication. She is the co-director of the Vanderbilt Program for LGBTI Health, vice president of Education of the GLMA: Health Professionals Advancing LGBT Equality, and a member of the AMA Advisory Committee on Lesbian, Gay, Bisexual and Transgender Issues.
 This case has been previously published, which has been slightly edited for this magazine article: Sciolla, A. Scenario 6, HIV Risk Behaviors in an Adult Man in Hollenbach A, Eckstrand K, & Dreger A (Eds). Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, and Born with DSD: A Resource for Medical Educators, Association of American Medical Colleges (2014).
 Hollenbach A, Eckstrand K, & Dreger A (Eds). Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, and Born with DSD: A Resource for Medical Educators, Association of American Medical Colleges (2014).
 Frank, Jason R., et al. "Competency-based medical education: theory to practice." Medical teacher 32.8 (2010): 638-645.
 Center for Substance Abuse Treatment. A provider’s introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2001. HHS Publication No. (SMA) 01-3498.
 Green, Kelly E., and Brian A. Feinstein. "Substance use in lesbian, gay, and bisexual populations: An update on empirical research and implications for treatment." Psychology of Addictive Behaviors 26.2 (2012): 265.
 Flentje, Annesa, Cristina L. Bacca, and Bryan N. Cochran. "Missing data in substance abuse research? Researchers’ reporting practices of sexual orientation and gender identity." Drug and alcohol dependence 147 (2015): 280-284.