Bill Klaproth: So, what makes primary care different for LGBT people? What are some myths in regard to LGBT medicine? And what is the future of LGBT medicine? Well, let's find out with Eric Centerville, a physician assistant at SolutionHealth. This is the SolutionHealth podcast. I'm Bill Klaproth. Eric, thank you so much for your time. First off, I'm just kind of curious: what got you into LGBT primary care?

Eric Centerville: Yeah. So, that's actually a pretty great question. It's never something that I really set out to do. I didn't start my PA kind of saying I want to do LGBT primary care. I felt like it kind of fell into my lap a little bit with my first transgender patient that I had. I felt very ill-prepared to work with them, so, I ended up going to a conference by Fenway Health in Boston on transgender medicine. I learned a lot of really interesting things, and I started to get more and more involved with working with LGBT patients and seeing the need for a primary care provider that gives them specific care.

Host: That's interesting. You said that you felt like you were ill-prepared to treat your first transgender patient. So, what type of training do you have in working with LGBT patients?

Eric: I've been doing a lot of conferences, so, there are no great educational programs for health care providers. In fact, you know, when you're looking at different medical schools, PA schools, nurse practitioners, school programs, they don't contain any LGBT education, so, you pretty much have to go out on your own and look. So, I've been doing trainings through Fenway Health, and I've also been working with some endocrinologists shadowing them to kind of see what they do, especially when it comes to hormones, and it's a lot of self-education. Currently, I'm in my doctorate program working on solutions to find better programs for people to teach them about LGBT health care.

Host: So, then, what makes primary care different for LGBT people?

Eric: So, when it comes to primary care, a lot of people have gotten criticism saying that we should treat everyone equally, and I totally agree, but, quite frankly, the health care risks for LGBT people are different than your cisgender or heterosexual people. So, when it comes to specifically LGBT care where our goal is to create an affirming environment, making sure that people know that we're giving them a safe place we're using pronouns and language that's comfortable for them. We also do cancer screenings that a lot of health care providers don't know need to be done, different vaccines that need to be given for patient populations, and also prescribe hormone therapy for our transgender patients and set them up with any sort of surgical consults. 

Host: Alright, got it. So, this is really interesting. Can you describe to us what a typical visit kind of looks like and what age ranges do you see?

Eric: Yeah. So, I work with all age ranges. I work in a pediatrics and internal medicine clinic. So, typically, 90% of my day is seeing just general pediatrics and general internal medicine, and about 10% is working with LGBT-specific populations. So, I see patients from the first day they're born to the last day they're on earth, and a typical visit with me really ranges on the age and also, with the goals of a patient. The first time I meet an adult patient, you know, it's really about getting to know kind of where they're at in their health care, how can I help them on their gender journey or coming out with a different sexual orientation with their family.
Talking about mental health care, making sure that we're using the right pronouns, using the right names for them. So, it's just really setting the standard for what the patient wants to do. We're really letting them kind of be the pilot, and I'm the navigator. I help them out.

Host: Hmm. I like how you said that. That's really good. What are some of the myths regarding LGBT medicine?

Eric: Yeah. So, there are a lot of myths that I see with patients and with other health care providers. One of the biggest ones I see comes with HPV vaccination. So, with HPV vaccination, you know, there's a lot of at-risk categories that health care providers just weren't trained in, especially men who have sex with men or trans men, trans women also have higher rates of HPV, and they're less likely to be vaccinated because originally people thought it was only, you know, Something that you need if you have a risk for cervical cancer. Now we're finding that actually is something that you can get many different types of cancers, like in the throat, the rectum. So, we are making sure that all of our patients are vaccinated now. The other thing is that transgender men don't need pap smears, and that's simply not true either. They actually have some of the highest risks of any patient population. Now, we don't always do pap smears in our clinic for trans men because that can be really dysphoric where they lose their sense of themselves when they have that experience. So, we talked to them about utilizing other techniques like self-collection, where we actually allow them to be controlled in a situation and collect a sample with just a regular cotton Q-tip to see if there is any concern for HPV. So, that's just a few of the myths we try to tackle in medicine. especially when it comes to LGBT medicine and how we're trying to promote better health for our patients.

Host: Well, it's easy to see how providing a supportive environment is such a benefit. Speaking of a supportive environment, let me ask you this: how do you address sensitive topics for trans men, such as pregnancy, monthly bleeding, and pap smears?

Eric: Yeah. So, this is obviously a very sensitive topic for a lot of trans men. You know, we want to make sure that the environment is affirming for them and that they feel comfortable. A lot of times, we don't address these things on our first visit. If that's something that they're not willing to discuss or, you know, to talk about further, but when it comes to trans men, they still have the ability to become pregnant, to hold a child. It's important to have these conversations about fertility options. So, we help them along that journey, and we can talk to them about how we can maintain fertility. The other thing is monthly bleeding. I think that can be really distressing for a lot of trans men, and we do use things like progesterone-only medications, which are not feminizing, to stop monthly bleeding, and then the pap smears, we talked a little bit about, the HPV only testing, but you know, So, sometimes trans men do need paps, and if that's the case, we can set up an affirming environment. We can make sure it's a longer visit So, they're okay. We're comfortable with the whole process.

Host: There have been a lot of ads on TV recently about a drug that can prevent HIV. Do you prescribe these drugs?

Eric: Yes. And yes, we do, actually. So, there are two drugs currently on the market for this right now. They both contain a medication called tenofovir essentially, and these medications, when taken regularly, can actually prevent people from getting HIV if they are exposed to it, which is pretty amazing, in my opinion.
So, it's kind of an exciting time in LGBT health care because now we can prevent people from getting HIV altogether, for your really simple medications to use, they do require follow-ups every three months, just to make sure that we're doing any sort of STD screening and to also, make sure that we're doing HIV screening on these patients. But they work really well, and they're very well tolerated by patients. So, we definitely offer that service at our clinic.

Host: So, I’m happy we're doing topics like this. It seems like for a long time, LGBT people have been all lumped together when it comes to medicine. So, I'm very happy that we're specifically talking about this. Do you think this will increase? What do you believe is the future of LGBT medicine?

Eric: Yeah. So, I would say that, you know, my vision of the future of LGBT medicine, one, we're seeing a huge explosion of research right now in this population, which has been really great. If you look just five years ago in research for transgender people or LGBT people in general, it was very much lacking and now we're seeing new articles every month about it.

So, there's been a lot of exposure in the medical community. The other thing you're seeing, too is medical school accreditation bodies are actually now requiring LGBT medicine to be taught to these health care providers. So, we want to make sure that these people that are graduating from PA programs and PE programs and med schools are competent in this.

It's not a complex medicine that we're providing for these people. These are medications that we're using pretty much every day, but just in a different way. So, getting that comfort and that knowledge creating confidence in the future of health care is really important. That's what we're going to see with LGBT medicine.

Host: You mentioned comfort and knowledge. Are those, some of the reasons why members of the LGBT community avoid seeing their primary care provider?

Eric: Yeah. So, this one actually is a very personal question to myself because as a gay man, I had this experience where I was out to everyone in the world and everyone on Facebook and Instagram, but I didn't tell my own health care provider. So, that was something that for me was really difficult, even as a health care provider working in LGBT medicine. So, what makes it so difficult, I think is that as an LGBT person, we don't always know if we're going to have a good experience or if our health care provider is knowledgeable of our health care needs or, if it's going to be a safe space for us.

So, really part of my clinic is we're trying to make visibility. We're putting rainbow flag stickers all over our clinic. We're making sure that we're using the proper pronouns and names for patients So, they can feel affirmed. They can feel like it's a safe place for them. Because I gave a lot of talks about LGBT medicine, and I tell people I've saved more lives with a rainbow sticker than I have ever with my CPR training, and so, it's a cheap thing that we can do to buy some rainbow stickers, but it really makes a huge impact the LGBT community.

Host: Well, first off, thank you for sharing your story. That's very powerful and can help a lot of people. So, it sounds like your message is if you are a member of the LGBT community, don't be afraid to share that with your physician. Is that right?

Eric: Yeah, I think that that is a really good message. I think that when I'm talking to my colleagues, a lot of them are very affirming. You actually see in national statistics that the vast majority, over 90% of health care providers, are very affirming and very accepting of LGBT people.
But sometimes they just don't know how to outwardly say that to a patient. So, talking to your health care provider is very important because, you know, if we don't know the risk factors that you have, if we don't know about your gender journey or your sexual orientation, that could potentially negatively impact your health care.

If we're not screening for the proper things from vaccinating for things like HPV or hepatitis A, it's really important as a health care provider for me to know that type of information.

Host: And then it sounds like the message to other physicians is make sure you provide and work to create that supportive environment for LGBT patients.

Eric: Absolutely. And you know, it's one of those things that you can be affirming. You can be supportive, and you don't need to know anything about LGBT medicine. And you can tell that to your patient. That's okay to say, I'm so glad you shared that information with me. I'm really thankful for it. But let me give you some resources of places that we can go or some other people that can help you.

And that's essentially what I do with my practice is I work throughout Elliot Health system, kind of as a consultant for other primary care providers to help them understand hormones for a patient or to see the patient separately. Just talk about their mental health, talk about cancer restraints, talk about their journey for affirming their gender.

Host: Yeah. I could see how useful and helpful that is. Eric, this has really been informative and interesting. Thank you so much for your time. We appreciate it.

Eric: Great. Thank you so much for having me.

Host: That's Eric Centerville, and this is the SolutionHealth podcast from SolutionHealth. I'm Bill Klaproth. Thanks for listening.