LGBTQ+ Care

Everyone deserves to feel comfortable with the medical care that they receive regardless of an individual’s age, gender, or sexual orientation.

At Boston Direct Health we pride ourselves on providing medical care to all without judgment. Dr. Zivich and staff provide a safe environment for our LGBTQ+ patients. Our staff is comfortable and competent with the fundamentals of interacting with our LGBTQ+ patients. This includes the knowledge to appropriately use LGBTQ+ related language, initiate open discussions of health and sexual health behaviors with patients, and supportively acknowledge the romantic partners and families of our LGBTQ+ patients.

Everyone deserves the opportunity to be open and honest with their doctor without feeling less than. Opening up to your physician can be cathartic and healing. We firmly believe that no patient should ever feel judged or uncomfortable when talking about their medical concerns. We believe primary care is an ideal place to start improving the health of our LGBTQ+ community due to our person/patient-centered approach. The access we offer to our patients of varied social backgrounds, and the prevention, screening, and treatment services, we strive to provide to our patients across their lifespan.

We at BDH foster relationships with and engage our LGBTQ+ patients in vital prevention, assessment, and treatment services.

Why Choose Boston Direct Health for LGBTQ+ Care?

At Boston Direct Health, we advocate for three fundamental tenets to improve care for LGBTQ+ patients:

• Patients can safely seek and receive healthcare services, be treated with dignity and respect, and be confident that their care is tailored to who they are as a person. Inclusive of their unique needs as an LGBTQ+ person.
• Several intersecting factors shape diversity in LGBTQ+ communities, including gender identity and expression, sexual orientation, race and ethnicity, ability, place of geographical residence, socioeconomic status, country of origin, housing situation, and age. All of these factors are key considerations in our patient care.
• The reported history of adversity faced by LGBTQ+ patients when accessing and receiving services is acknowledged and addressed using trauma-informed approaches to ensure that all patients feel respected, cared for, and safe when coming to our practice.

At BDH, we take every opportunity to solicit input from LGBTQ+ patients, and their advocates, regarding additional changes to improve accessibility and quality of care. We believe it is also important to tap into a variety of perspectives because there is so much diversity among LGBTQ+ patients.

The LGBTQ+ care offered at BDH

We offer the following LGBTQ+ health services to those in Boston and surrounding areas:

Sexual Health

LGBTQ+ individuals have unique medical needs when it comes to their sexual health. Sexual health is more than just screening for STIs and STDs. We do provide access to HIV screening and STI screening, and our patients are able to get into the office for screening, often on the same day as requested, and treated when appropriate.

Gay men, men who have sex with men, and other individuals who have penetrative anal intercourse benefit from a provider that can discuss proper anal health, discussing lubrication, the risks and benefits of douching, and how to medically manage anal fissures, hemorrhoids, screening for anal cancer and other rectal maladies. Some individuals engage in more anonymous sex with finding partners via apps, group sex, and utilizing substances to enhance sexual pleasure like amyl nitrites (poppers) and illicit drugs. At Boston Direct Health, the goal is to create an environment for honesty with your doctor without judgment. The focus is on your health and mitigating risks when possible.

There are now many options available for reducing the risk of individuals who are at higher risk of exposure to HIV. At BDH we want patients to feel comfortable talking about their sexual preferences and confident that their medical doctors are up to date with the latest information on HIV prevention and HIV treatment. There are multiple options for PrEP now – Truvada, Descovy, Tenofovir-Emtricitabine, Cabotegravir, and in the future, there may be even more. For patients with HIV, Dr. Zivich previously completed the certification through the American Academy of HIV Medicine (AAHIVM) and is up to date with the latest treatment options.

Considerations for individuals who do not have penetrative intercourse include discussions on safe sex practices with oral sex, discussions about libido and enjoyment of sex as well as ensuring appropriate cancer screenings. Lesbians, women who have sex with women, and individuals with a cervix that do not have penetrative sex are still at risk of cervical cancer and HPV need appropriate screening and having a medical provider able to have these discussions is important.

Mental health & substance use

Unfortunately, LGBTQ+ individuals are more inclined to have mental health issues and increase substance use. We screen all patients for anxiety, depression, and other mental health concerns. When appropriate we provide the necessary medications. We do not have mental health therapists or psychiatrists on staff.

We want our patients to be honest with us, there is enough shame with substance use and addiction already. Patients should not feel judged for their habits, whether that includes taking GHB, Ketamine, Methamphetamine, or other substances. We encourage the cessation of drug use and are here to assist patients when they are ready to seek help. Our providers have an understanding of the side effects of overuse, long-term use, and withdrawal. However, we do not provide medication-assisted therapies such as suboxone and methadone. When needing additional assistance, we help guide patients through rehab centers. Ultimately our goal is to provide and mitigate risks whenever possible and be here when our patients are ready for medical help.

Gender affirming care

At Boston Direct Health, we provide an environment where an individual can safely and openly talk to their doctor about gender exploration. We encourage but do not require patients to work with a therapist while they pursue their gender-affirming treatments. There’s no predetermined journey or specific order needed to transition, other than requirements for behavioral health evaluation and preparation for gender-affirming surgery and presenting full time in one’s chosen gender identity for 1 year prior to genital procedures.

What are your goals?

• Are you wanting to pursue the maximum degree of medically appropriate feminizing/masculinizing effects?
• Are you non-binary and only want partial effects of the hormones?
• Do you know your reproductive plans for the future?
• Are you unsure about what you want and looking to explore with your doctor?

Having an idea of your goals prior to the appointment helps initiate the conversation. As stated before there is no one correct path for transitioning. For the medical therapies, multiple factors play a role in how someone feminizes or masculinizes on hormones that cannot be controlled, such as genetics, age, and how the body responds to the medications and hormones. Because everyone is different, LGBTQ+ individuals may be put on different medications at different doses. There is no one size fits with gender-affirming care.

Consider hormone therapy as going through second puberty. Like puberty, there are a lot of physical, mental, and emotional changes that your body will go through. BDH provides hormone replacement therapy in Boston for gender exploration and transition.  For individuals who have not gone through puberty yet, we refer to Boston Children’s GeMS program:

Feminizing Gender-Affirming Treatment

Feminizing gender-affirming treatment generally involves a combination of estrogen, testosterone-blockers such as spironolactone and/or finasteride, and sometimes progesterone.

The treatment generally has the following effects:

• Pores become smaller, less oil production, sweat less
• Nipple tenderness and appearance of small “buds” under the nipples. The rate of breast growth, size, and shape vary from person to person. Breasts can take a couple of years on hormones before fully developed.
• Fat redistributes on the face for a more feminine appearance and body fat depositing more in the hips and thighs as opposed to the abdomen.
• Hair thickness will decrease on the face and body, but will not fully go away unless pursuing laser hair and/or electrolysis treatments. Any balding spots on the scalp will likely remain.
• No change to vocal cords.
• As testosterone levels drop, desire for sex may decrease, and obtaining an erection for penetrative sex can be more challenging. Depending on an individual’s desired sexual function there is a role for maintaining a higher testosterone level or initiating medications such as Sildenafil or Tadalafil (Viagra and Cialis).
• Testicles will decrease in size.
• The impact of feminizing hormones on long-term fertility is unclear. There is a decrease in sperm production, but it doesn’t always stop completely. If sexually active with someone who can become pregnant then using a form of birth control is important. Some individuals, when trying to reproduce, will stop feminizing hormones for about 3-6 months with good success. Lastly, sperm banking prior to initiating hormones can be helpful to ensure fewer difficulties with fertility in the future. A great referral place we send patients is at the Boston IVF: https://www.bostonivf.com/
• Risks: blood clots – including heart attack and stroke risk is higher in tobacco smokers, increase risk of breast cancer, possible increase in migraine headaches, gallbladder disease

Masculinizing Gender-Affirming Treatment

Masculinizing gender affirming treatment generally involves utilizing testosterone. The effects of this can include:

• Skin becomes thicker, with larger pores, more oily skin, a change in body odor and an increase risk of acne
• Body fat will redistribute with less fat around the hips and thighs, gain body fat around the abdomen. Generally, there is no change to the chest wall due to the hormones and would need surgery to make any changes.
• Muscle mass will increase, more so if exercising, which is recommended.
• Thickening of the vocal cords will result in lowering of the voice. This is a permanent change.
• Increase thickness and amount of body hair and facial hair. Potential for hair thinning on the scalp. Hair growth and hair loss are largely genetic.
• Increase in libido, the desire for sex.
• Enlargement of the clitoris, this effect is permanent.
• Individuals notice that their periods become light, arrive later, and are shorter in duration. After a few cycles, they stop altogether.
• Testosterone decreases the chances of becoming pregnant but does not eliminate the odds. It is important to use a form of birth control if sexually active with an individual who may result in a pregnancy.
• Testosterone may make it difficult for eggs to be released from the ovaries and depending on the length of hormone therapy, may make reproduction very challenging. Some individuals choose to bank eggs prior to initiating hormone therapy, we generally refer to Boston IVF https://www.bostonivf.com/
• Risks: increase in blood pressure and higher cholesterol, increase in hemoglobin and hematocrit that may increase the risk of heart attack and stroke,
• Breast, Ovarian, Uterine, and Cervical cancer is not eliminated by going on testosterone therapy. As long as an individual has the organ, it is important to continue appropriate age-related cancer screening.

In addition to gender-affirming hormone management, we help our patients with referrals to surgical specialists for gender-affirming procedures and help guide patients through the complex process of changing the name and/or gender on birth certificates, driver’s license, social security card, and other forms of identification.

Schedule your consultation in Boston

Boston Direct Health provide a safe, judgement-free environment, delivering specialized LGBTQ+ health care service. Boston primary care physician Dr. Steve Zivich and his staff proudy serve LGBTQ+ patients in vital prevention, assessment, and treatment services. When you’re ready for LGBTQ+ health services, call our office 617-304-1965 in Back Bay today to schedule an appointment.