Jaime Lewis (Host): According to recent studies, LGBTQ+ individuals face significant health disparities compared to their heterosexual and cisgender peers, including higher rates of mental health challenges, substance use and barriers to care. But there is hope. With inclusive healthcare practices and increased awareness, these gaps can be narrowed.

Here for a panel discussion on LGBTQ+ health are Von Biggs, Community Outreach and Engagement Coordinator, and HIV and Healthcare Advocate. And Dr. Jason Ceavers, a primary care physician specializing in LGBTQ+ health, both from Holy Cross Health in Fort Lauderdale. They'll discuss the current landscape of LGBTQ+ health, best practices for medical teams, and the role of preventative care.

 This is Thrive with Holy Cross Health, a production of Holy Cross Health. I'm Jaime Lewis. Von Biggs and Dr. Ceavers. Thank you for being here.

Von Biggs: Thank you for having us.

Jason Ceavers, MD: Thank you.

Host: Of course. Well, Mr. Biggs, let's start with you. What are some common health disparities facing LGBTQ individuals and how can healthcare providers address these disparities in their practice?

Von Biggs: Right. A lot of disparities that we engage, especially as LGBTQ individuals, it's not just us. There are also disparities in everybody in some way, shape, or form. But really the disparities we seem to face are mental health challenges, as our LGBTQ+ individuals face more depression, suicide ideation due to stress, stigma, discrimination and social isolation.

All those are both, I would say, a community problem as well as an at home problem. We have higher rates of substance abuse using coping mechanisms like smoking and drugs, just to deal with stress, and marginalization in the community. Barriers to preventive care because of past experiences of LGBTQ+ discrimination, negative experiences, you know, within medical providers that don't understand them of who they are, or don't see them, I should say. Increased risk of chronic conditions due to stress, especially for like our transgender siblings due to access to affirming care, and limited access to affirming care and therapies which result patients seeking other alternatives like the black market, which as we've seen, just through history, has provided some horrible outcomes for some individuals that have done that. And I don't know if Dr. Ceavers, if you had anything to add to that.

Jason Ceavers, MD: I don't think there's much to add except from my perspective, it's really about being there for the patient and being that safe place for them to be to kind of help with these stigmas and ideas behind the medical field, and that's really what we strive to do here, is to really dig into, okay, what is it that's stopping people from getting care and causing all these high rates of mental health disorders and low rates of cancer screenings, and how can we provide that in a, in an open area so that people know that they can come here and they can be treated just like anybody else.

Host: You mentioned mental health challenges and Dr. Ceavers, I'm curious, how has the recent research improved our understanding of those mental health challenges that are unique to the LGBTQ+ community?

Jason Ceavers, MD: Sure, and I will echo what Von was saying. A lot of it's not unique to our community and the research shows that we are in our committee where you have higher rates of substance abuse, depression, anxiety, suicide, but those are all because of the limited trust and access to care. So if you're not willing to come to see your physician, then you're not going to be treated. The trans community is especially vulnerable population with higher rates than any other community for mental health disorders because of the massive mistrust they have and the idea that they're going to be judged and not treated for who they are.

So not going to get care is part of the reason why we have such high mental health issues or mental health disorders in our community and it's on us, on all of us. Vonn and I work together in the community. It's on all of us to get out there and meet them where they are and say, no, that's not what's going to happen in our clinic, that's not going to happen in most of the younger physicians at county clinics because of the way we were trained is a little bit different than the trainings 50 years ago.

Host: I'm sure that makes a huge difference. Mr. Biggs, in your experience, what are some of the best practices for general practitioners to create a more inclusive and welcoming environment for these kinds of patients?

Von Biggs: You know, I've been here in South Florida for six years, so I'm one of those patients that encourage if your practice isn't working well for you, fire them. I look at it as, it goes without saying. We've got a proven model that's now worked very well with us.

We are embedded in an LGBTQ community. One of the third largest in the country, and our clinic is in the heart of that community. Dr. Ceavers and I being out embedded into that community and other members of Holy Cross there, and especially with doctors being in that community without a white coat. It allows that compassion and that empathy and it just shows them as a human, just like the rest of us.

Jason Ceavers, MD: So it's a good thing I took off my white coat?.

Von Biggs: Right. Thank you. Yeah. But you know, when patients are, feel like they're being treated, and not herded as cattle, they're not a number. They're actually a human being and they're actually, they have that compassion and that feeling coming from the doctor who really wants to understand and get to the root of the issues, not just check a box and get them out the door. And onto the next patient. I think that makes huge strides. Advertising for a community that specialize in LGBTQ+ health is crucial. The LGBTQ+ community, we are the best for complaining. So if you think about it, if there's something not going well, we're going to make it vocal.

It's going to go on social media, it's going to go everywhere. And if people aren't paying attention, then clinics are not paying attention to that. They're missing the boat because they've got to be able to show that inclusivity, all around. And that's just as simple as putting a flag in the window, letting people know that they're safe, letting them know that they can talk to the provider about their sexual health and sexual issues, which so many providers don't do, in communities. I know we'll get to some of those topics later, but, they just have to be able to be represented. They have to see people like them too embedded in these places, and once they do, it's a safe environment for them.

Jaime Lewis (Host): Dr. Ceavers, this is a huge question and a very big topic, but how do hormone replacement therapies differ for transgender individuals, and what should patients and doctors be aware of when it comes to these treatments?

Jason Ceavers, MD: So Von and I were actually talking about this previously. We were thinking about what are the kind of differences between hormone therapies. In general, the difference really comes down to how the diagnosis is made. When we look at cisgender people either getting on testosterone or estrogen, it's really, well, let's check at estrogen level.

Let's check a testosterone level and see if we can treat it. When we're talking about the transgender community, that's not what determines that. That's a conversation between the provider and the patient to really get to the bottom of things. Gender incongruence is a hundred percent a real diagnosis and something that we should be treating.

But it also can be clouded by a lot of the mental health issues that we've talked about previously, on this podcast. And so it's really a longer conversation and a longer time period between starting the therapy and diagnosis because we really want to make sure, okay, yes, we have a gender incongruence here, but is there an underlying depression that might be leading towards it. And so it's a, it takes up many visits to really get comfortable. I've had a patient, who I said, okay, let's do it. I'd like to talk to you a little bit more about it. Let's spend the whole next visit talking about it. And between that visit, and when I saw her again, she was admitted to the hospital because she tried to kill herself.

I, as a provider, I didn't feel comfortable at that time doing it because there's something else underlying that might be driving decisions that, we really don't want to happen. Because when we do gender affirming care, we're starting with the androgen, sure. But the next step after that is reconstructive, kind of gender affirming surgeries.

We want to make sure that we're all on the same page in what we're doing. It's not necessarily the levels of the testosterone or checking the testosterone levels, all of that kind of plays out to be the same. It's really how do we determine when to do it and when not to do it is vastly different.

And it really takes a lot of time and discussion between the patient and provider to get that done. But once you get past that point, it really, the treatment's the same. You know, we're going to get testosterone, we're going to measure it, we're going to see how the levels are because, we want them to be in the same levels as a cis male, because we don't want to overdo it. You know, it really doesn't change that much when it comes to the actual treatment is how do we determine it that is a major difference.

Host: Mr. Biggs what role do you think preventative care plays in managing the long-term health of LGBTQ+ individuals? And what kind of specific screenings should be emphasized?

Von Biggs: This is a huge topic in itself because I'm involved at some national levels and this is a topic we talk about all the time. I know Dr. Ceavers and I have talked about a lot of these issues as well. So I'm sure he'll have something to add to that. But you know, when you look at general health screenings in general, including cancer screenings, based on the anatomy, if you are sexually active; you need to be tested at least quarterly for your STIs and HIV. It should be almost a normal procedure, just like getting your blood pressure checked, your temperature checked. If you're sexually active, get the test done because if you can catch it and you know your status, it's a great empowerment tool for yourself.

And so many people just don't get them. We're in a county that we're number one in the country for HIV and STI transmissions, knowing that everybody should, if they're sexually active or using any type of injection drug, if they're any type of substance abuse, sharing of needles or anything, they should all be tested.

It just shouldn't even be a question. It should happen. And a lot of providers are hesitant at doing that because it does take time. It's going to take questions asking them about their sexual health. Those to me, are screening tools that every physician should talk about with patients.

We see too many cases of late diagnosis of HIV where they've had HIV for a long time and they were never diagnosed or late stages of syphilis or gonorrhea, or chlamydia. So it's very important to have those. In my opinion, I feel like if anybody comes in, I know Dr. Ceavers and I have talked about this, so this may start a debate, I don't know.

But if anybody walked in and got received, non-reactive HIV tests, they should walk out the door with a bottle of PrEP that day. They really should and they should be started on PrEP at that moment because anything we can do to stop the transmission of HIV is what we need to do, as well as their negative screen for their STIs.

They should walk out with a bottle of doxy as well and be told how to use it effectively. But doctors today, and I'm not saying Dr. Ceavers because I know it's different with him, and a lot of our doctors here, they're not comfortable having those conversations.

They don't have the time. I know Dr. Ceavers says, we hear that from the community all the time, that our doctors do spend the time, gathering the information. But we do need a way that we can now start giving people empowerment to walk out the door, taking care of their health from the moment they're screened.

And that's not even to go into immunizations and all those other things that it should do as well. So I don't know if Dr. Ceavers you want to add to that.

Jason Ceavers, MD: I actually do. Because it is a very loaded question. One of the things that we would talk about are cancer screenings and from a provider standpoint, I don't think there's enough education for providers on the appropriate cancer screenings for certain patients. And it is a very uncomfortable conversation, on where do we learn the base sex of our patient, because that's where all of our screenings happen.

If you have a double mastectomy, you don't do breast cancer screening once a year. You do chest wall screenings where you're just doing physical exams. If you are going from male to female and you're on estrogen, then when you're over 50, you're going to start doing breast cancer screenings.

You know, and that kind of stuff isn't exactly taught to providers. And so that, there's a lot of work to be done on both sides, and it really, it stems from the providers realizing we don't know everything. And we just want to help patients. So let's have an honest, open conversation. Let's spend a little time on the important things. I can look at your blood pressure and see that it's fine, but how are you doing overall? How do you feel about everything that's going on? You know, a lot of my conversations in this day and age or surrounded about the political environment and how everybody feels, and it's a lot of just let's talk it out because it, so much more than just the numbers is how the patient actually feels.

And those, immunizations are another big hitter topic, and is just takes a longer conversation.

Von Biggs: It's also our aging community too. I mean, we are trending more and more, especially down in South Florida. We have more concentration of aging individuals than anywhere else in the USA. You can't circumvent the idea that once, especially in LGBTQ, the older, or as I refer to elders, because I know I'm considered an elder. But the same reason a lot of them go into isolation. They don't feel connected anymore to a community. They've lost their friends, they've lost their family in a lot of cases. And once they're like maybe in a home or something, they don't get out in the community.

They don't feel seen. And unfortunately they die alone. Those type of things are where we need to have those screenings with the physicians when they're coming in to see the doctors as well, making sure that they are taking care of themselves.

Host: Mr. Biggs mentioned PrEP earlier, and Dr. Ceavers, I'm kind of wondering if you could discuss the significance of what PrEP is, talk about the difference between it and PEP in the prevention of HIV and how they're being used within the LGBTQ+ community.

Jason Ceavers, MD: PrEP and PEP, so PrEP is the pre-exposure, prophylactic prophylactics, and PEP is the post-exposure. They're different regimens. So PrEP is actually not the full treatment for HIV and PEP is, and to be honest with you, I have maybe prescribed one prescription for PEP, which is a post-exposure and that was a needle stick because the majority of our community really understands the importance of being protected both from HIV and STDs.

As Von also mentioned, doxy PEP that we prescribe as well now to prevent against STIs, but it really shapes the community and for a while, there was a lot of stigma behind these kind of medications, and there wasn't a lot of people taking them. But the more we're out there, the more patients that are doing it, the more that we're open about our sexual health and what it is that we do, or if we're positive, if we're negative, what are we taking?

The more we have the ability to end this, the HIV pandemic, because it's the patients who, well, I'm not sure. All right. Well, let's talk about why you're not sure. Again, it goes back to these longer conversations that we have to have because they're very important conversations, especially in our community, and PrEP is, thank goodness, the most prescribed medication, I think beyond blood pressure medications in my clinic because my patients understand that. Even patients that come in that aren't on these medications, it's a very simple question.

So why aren't you on PrEP? And it just evolves from there either you're right, you're not the candidate for it, or let's think about it and let's, you know, talk to your partner, talk to your friends and just let me know what you decide if you have any more questions.

And let's figure out, because that is our biggest tool to eradicate HIV and our community, at in understands that. You know, we still have very high HIV infection rate, and we're working on that. We're expanding further and further out into the community so we can get to the more underserved populations.

But there's a strong there push for it now that I don't think was there before. And now with newer kind of injectable medications that you don't have to take a pill every day. That a 19 or a 20-year-old wouldn't want to do, they can just get an injection every other month. There's even more research going into that to doing it less than every other month.

So it's really exciting time in the PrEP world, that I only have to prescribe one PEP and that was for a needle stick in the hospital. It's is a really positive look on it now, and I think we all need to embrace that and really push that onto the rest of the community.

Jaime Lewis (Host): Mr. Biggs, I'm thinking of course not only of people who are considered the patient, but the families of the patients, and the support communities around them. I'm wondering how you would suggest that families and friends of LGBTQ+ members of the community can support their own health, both physical healthcare and mental healthcare?

Von Biggs: Right. It's a challenge. I think about our LGBTQ youth who is the largest population to try suicide. And a lot of that comes from non-support of their families. So we hear that a lot. Political climates play a very important role in LGBTQ youth as well. The Trevor Project saw a 700% increase in suicide hotline calls once the new administration took over.

And it's an incredibly impactful to our youth. But as far as families themselves, they've got to provide that unconditional emotional support, help them navigate their healthcare. A lot of them don't know how to navigate healthcare. A lot of them, unfortunately, get kicked out of the homes when they tell their parents they're gay. And that's so unfortunate. But finding the right provider, advocating for respectful and inclusive care is so important. Being by their side to take them through that process until they are empowered enough to speak up for themselves. Because that's the thing.

Normalize conversations around mental therapy. I mean, we've got to have just normalize. It's okay to be, I've seen a therapist. Creating that safe and affirming home environment, that's the biggest key.

It's, they've got to feel safe at home. And that, as far as the youth, we hear that that's not what's happening. For the elders, I'm 61 now. I came out at 50, so, I got to navigate being out and gay and queer, completely different than someone that's my age that did it back in maybe the seventies and eighties.

Luckily I've got people's shoulders to stand on that navigated that path for me, so I can thank them for that. But, people my age, a lot of our families are gone. So it's not like they're not there for that support now, where they, they might not have been either when I was younger.

So, that comes to your friends, that comes with finding a chosen family, which so many of the people in the gay community have is identifying who their chosen family is, that they feel safe and comfortable around.

Host: Just on a last note, is there anything that either of you would like to add to leave the audience with?

Jason Ceavers, MD: I think I was going to piggyback off of what Von said, and it's not about blood family all the time. It's about chosen family and the support can come from anywhere. It could be least the expected person. And you find yourself like in a different position. And I've seen it. So it's never, well, my parents don't do this, or my brother doesn't do this.

It's like, okay, but let's find a group that you fit into that you can find that person that you want to emulate, you want to have a mentor who can teach you things about PrEP and mental health and hormone therapy and all the things that we've talked about, is the kind of the people that need to be out in the community.

We harp on it a lot, Vonn and I, because that's what we believe is to be the most important thing, is to be out there and to help people by just white coat off, shorts on, sitting at a fair just like everybody else. Let's talk about it. These are not white coat on in the room conversations.

This is a very open, honest conversation that just can happen anywhere. The more comfortable people are, the more you're going to learn. As a physician, all we care about is everything that we need to know and everything you want to tell us about you so that we can do the best recommendations for you and your healthcare.

Von Biggs: I'll end with this and that is, you know, I've worked here for Holy Cross, going on three years now, and it's just been an amazing thing being a queer individual working for a Catholic institution, which we are questioned all the time about that being working for Catholics and it's not about the religion. You know, we believe healthcare should be a place of healing, not fear. Affirming care is lifesaving, and we need to focus on that part of it, and it's essential to saving lives and improving outcomes, not only for the LGBTQ community, but for everyone. I believe strongly, just as Dr. Ceavers says, our outreach efforts. We know that stigma and discrimination have kept too many people from getting the care they deserve and need. And our mission has been to break down those barriers. And I feel like we're doing that every day of the week. So with that, it's a great organization and I love being part of it in the middle of one of the largest gay communities in the country.

Host: Fantastic. Thank you both so much for joining us, for giving us all your insight and uh, and expertise.

Jason Ceavers, MD: Thank you very much for having us.

Von Biggs: Thank you.

Host: That was Von Biggs, Community Outreach and Engagement Coordinator, and HIV and Healthcare Advocate. And Dr. Jason Ceavers, a primary care physician specializing in LGBTQ+ health, both from Holy Cross Health in Fort Lauderdale. To learn more or to schedule an appointment, visit holycross.com/lgbtq and thank you for listening to Thrive with Holy Cross Health.