Why It’s Important for AAPI Communities to Be Vigilant About Breast and Colon Cancer Screening

May 8, 2024 | Diversity and Inclusion, Featured, Your Health

As the country celebrates the cultural diversity of Asian Americans, Native Hawaiians, and Pacific Islanders in May for Asian/Pacific American Heritage Month, it is time for a reminder for members of those communities to keep up with their cancer screenings. Specifically, experts at the Mount Sinai Health System are calling on Asian American and Pacific Islander (AAPI) people to be vigilant about breast and colorectal cancer screenings.

“Breast cancer is the leading cause of cancer death for women worldwide, and the second leading cause of cancer deaths for women in the United States,” says Desiree Chow, MD, Assistant Professor of Medicine (General Internal Medicine) at the Icahn School of Medicine at Mount Sinai. “However, for Asian Americans and Pacific Islanders, these groups have been found to consistently score lower than their non-Hispanic white counterparts for breast cancer screening.”

A similar theme echoes in colorectal cancer, notes Sanghyun (Alex) Kim, MD, Chief of Colon and Rectal Surgery at Mount Sinai Beth Israel, Mount Sinai-Union Square, and Mount Sinai Morningside. “Not only are we seeing lower screen rates for AAPI communities in colon cancer, but over the last 20 years, we’ve seen a twelvefold increase in colon cancer rates in these populations,” says Dr. Kim. “This is why it’s very important for physicians who see AAPI patients to be proactive in reminding them to be screened regularly.”

Left: Desiree Chow, MD. Right: Sanghyun (Alex) Kim, MD.

What are the disparities in cancer screening rates among different races/ethnicities?

While breast and colorectal cancer screening rates have steadily grown over the years, Asian American and Pacific Islander (AAPI) populations screen at a lower rate than the non-Hispanic white population. Here’s a snapshot of how each group screens for those cancers from 2008 to 2018, according to a report from the Centers for Disease Control and Prevention (CDC).


Source: Health, 2019, National Center for Health Statistics, CDC

As the COVID-19 pandemic hit, screening rates declined in 2020—by as much as 97 percent for breast cancer for AAPI communities compared with the previous five-year average, according to an April 2023 memo from the CDC. To address the decline in screening among certain populations, the agency is partnering with health care providers to resume timely use of preventive tests for early detection of breast, cervical, colorectal, and lung cancers.

Drs. Chow and Kim share their thoughts on the importance of being up to date with breast and colorectal cancer screenings, respectively.

Why are we calling for our AAPI communities to be vigilant about breast and colorectal cancer screening?

Dr. Chow: In general, Asian American women tend to have dense breasts, which is an independent risk factor for breast cancer and it decreases the ability for mammograms to detect small lesions. So in addition to the higher risk, Asian Americans having lower rates of screening, which is concerning and needs to be addressed.

Dr. Kim: Some 20 years ago when I went into colorectal surgery, the number of surgeries for colorectal cancer for Asian Americans was lower than for their white, Hispanic, or Black counterparts. Since then, that number has increased 12 times—not 12 percent—in America. On top of that, AAPI individuals are known to be less up to date on colorectal screening. Part of it could be a greater focus on other kinds of cancers—such as stomach and liver—instead, and part of it could be attributed to a tendency to play down illnesses and not be very good at following up with doctors.

Who should be thinking about screening? How often should it be done?

Dr. Chow: The United States Preventive Services Task Force (USPSTF), the body that sets guidelines for screening in the country, has recently updated their recommendation for women to start screening for breast cancer at the age of 40, every two years. However, there are other factors that could push one to start screening earlier or screen more frequently, and that is a conversation to have with a health care provider. These could include having a family history of breast cancer or having a genetic predisposition to breast cancer, such as a BRCA gene mutation.

Dr. Kim: The USPSTF recommends screening for colon cancer as early as the age of 45. Colonoscopies are the gold standard and would only have to be done every five to ten years. There are stool-based tests, which would have to be done every one to three years to provide comprehensive detection. This recommendation is the same for both men and women, although men have a higher prevalence of colon cancer. If a patient has a family history of cancer—could be of various types, including pancreas, stomach, liver, breast, endometrial or bladder—that person should consider early screening as well. A simple guideline would be: whatever age the family member had the cancer, the patient’s screening should be done at an age 10 years below that—thus for a patient whose family member had pancreatic cancer at age 50, the patient should get a colonoscopy at age 40.

What is involved in breast and colorectal cancer screenings? Is it painful/time-consuming?

Dr. Chow: The mammogram is the only screening method that has been shown to decrease mortality related to breast cancer. The best way to get a mammogram would be to get a referral from your primary care provider, or your OB/GYN. Under the Affordable Care Act (ACA), public and private insurance must provide preventive women’s health screening with no cost sharing. For those who do not have health insurance, there are ways to obtain low- or no-cost mammograms, as New York City and New York State have programs, such as free mammogram buses, that provide such screening.

The procedure itself is pretty simple, and a technician helps the patient position their breast in a machine that takes images of the breast tissue. Most women do not report significant pain—perhaps some discomfort as they might have to hold certain positions for imaging. But from start to finish, a patient could be in and out of the clinic in about 30 minutes.

Patient service representative Monet Douglas at the Mount Sinai Mammogram Screening Unit Truck

Want to learn more about mobile mammogram services from Mount Sinai? Click to learn more.

Dr. Kim: For stool-based tests, such as Cologuard®, a patient sends a stool sample to a lab, where it’ll be studied to see if it contains blood products and/or polyp components. However, such tests might miss some polyps, hence a need to do them more frequently. A colonoscopy, in which a tube with a camera is put into the rectum and colon, can not only discover polyps and cancerous tumors, but also treat and remove them. Under the ACA, colorectal cancer screening must be covered by public and private insurance without cost-sharing.

A colonoscopy does involve some preparation. The patient is instructed not to eat for about half a day, and to take a concoction that would rinse out the bowels. For the actual procedure, the patient is put to sleep and the doctor would examine the colon and rectum for polyps or signs of cancer. If polyps are removed, or cancer tumors are biopsied, there might be some pain or bleeding afterwards, but for most patients, colonoscopies are very well tolerated. The actual procedure itself takes about 30 minutes, although a patient might take an hour to recover after the exam.

What might be the consequences for not being vigilant about breast and colorectal cancer screening?

Dr. Chow: Missed breast cancer is the biggest consequence. By the time women feel a lump in their breast, the cancer is at a later stage, is harder to treat, and may have already spread to other parts of the body. The point of screening is to detect these cancers at an early stage, when they are still easily treatable and even curable. At an early stage, a patient is more likely to be offered breast conserving surgery, where only a portion of the breast is removed, rather than a mastectomy, where the entire breast is removed.

Dr. Kim: The thing about colon cancer is that it is a preventable cancer. If you can screen and detect signs before it presents as colon cancer, you can avoid more intensive treatment. When the cancer has penetrated into deeper layers of the colon, the surgery needed means you’ll lose more length of colon. If the cancer has advanced even more and spreads out of the colon, you will need not only surgery, but chemotherapy and radiation, and these are very intense on the body. For patients who get rectal cancer—that risk is higher for smokers—if not picked up early, there’s a chance to lose the anus, and that could mean needing a colostomy bag—a pouch in which stool comes out of the abdominal wall.

Any other advice for our AAPI communities to stay on top of their cancer screening?

Dr. Chow: I’ve noticed that some segments of the AAPI population might be less willing, or less able, to access health care. They should still try to form a close relationship with a primary care doctor, so that the doctor is aware of their risk factors and can advise them accordingly. For Asian Americans specifically, there’s a misconception that Asian women don’t get breast cancer as frequently. That’s not so true anymore, as the incidence of breast cancer has been steadily rising since 2000. And lastly, there’s a misconception that if a patient leads a healthy lifestyle, with no family history of breast cancer, they won’t get it. That’s great in that they’re at lower risk, but the majority of breast cancer cases are de novo, meaning the mutation happens for reasons we don’t know. If you meet the guidelines for breast cancer screening and have not done it, do seek it out as soon as you can.

Dr. Kim: I’ve noticed among my Asian patients that the cultural tendency of not wanting to speak up about pain or discomfort is actually working against them for their health. Keeping concerns to yourself hinders proper care. Another thing I’ve noticed is that some—usually older, immigrant individuals—trust their doctors too much and expect their doctors to know and handle everything, while others—sometimes younger, American-born individuals—don’t trust their doctors enough, might have a distrust of the system, or believe they know their body better than the doctor does. Either extreme is not good. The solution to break through to both is patient education and building trust. First, getting information out there about why cancer screening is important helps patients understand the risks. Then, the primary care doctor needs to build a close relationship with the patient, so that the patient actually goes to the screening, but just as importantly, trusts the doctor enough to come back for any follow-ups.

Celebrating Asian/Pacific American Heritage Month: Why Diversity Matters in Health Care

Updated on May 13, 2024 | Diversity and Inclusion, Featured, Your Health

Alex Ky-Miyasaka, MD, Professor of Surgery at The Mount Sinai Hospital, seeing patients at the Chinatown clinic in Manhattan.

Asian American, Native Hawaiian, and Pacific Islander Heritage Month, also known as Asian/Pacific American Heritage Month, is observed in May in the United States. It celebrates the culture and historical contributions of Asian Americans and Pacific Islanders (AAPI) to the country, as the month marks the arrival of the first Japanese immigrants in 1843 and commemorates the completion of the transcontinental railroad in 1869, whose tracks were largely laid by Chinese immigrants.

AAPI people in this country are extremely diverse and represent a wide range of races and ethnicities, socioeconomic and educational backgrounds, and ability to access health care. In New York City, this group encompasses more than 1 million people from more than 30 different ethnicities, speaking more than 50 different languages. Providing effective health care to such a varied group can be challenging, but it is important for health care institutions and providers to keep diversity at top of mind as they connect with patients.

“It is our responsibility to ensure we’re evaluating how we can best provide care to all of our patients,” says Amanda Rhee, MD, Professor of Anesthesiology, Perioperative and Pain Medicine, and Inaugural Director of the Center for Asian Equity and Professional Development at Mount Sinai. “There’s a growing body of evidence that people receive different care based on gender, disability, and language spoken.” When it comes to conversations about the differences in care that patients receive, AAPI communities are often left out—for example, some may not know that 24 percent of AAPI individuals in New York City live in poverty, and as a result might be unable to access appropriate care, says Dr. Rhee, citing a report on poverty in New York City.

“Specifically for Asian Americans and Pacific Islanders, from our patient satisfaction surveys, we know that our patients are telling us that we have room to improve, and how we can deliver care for them better,” says Dr. Rhee. “I say this in the overarching context of approaching all our patients with an open mind, so that we can understand anyone’s background better, and do our best to meet people where they are.”

In this Q&A, Dr. Rhee explains the importance of culturally sensitive and compassionate care, and how Mount Sinai is working to improve that competence.

Why is it important to consider cultural needs of a patient when providing care? Might there be consequences for failing to do so?

Communication between our clinical teams and patients is so critical, not only for the medical side of the care, but also compassion and empathy. Cultural and language barriers could present a challenge for some of our AAPI patients. There could be certain sorts of traditions that may seem different to our clinical providers or teams, which could appear obstructive.

For example, in some Asian cultures, there’s a belief that drinking warm fluids can help people who are feeling ill, and they or their family members might want to bring in warm soups and drinks for the patient. But if the patient is in a situation where they should not eat or drink anything, such as before a procedure, these well-intentioned family members may not understand that, and conflicts and challenges in communication can lead to confusion and dissatisfaction. It would be better if our clinical teams, patients, and family members could better align expectations and help understand each other better.

What does it take for a health system or organization to provide culturally sensitive and inclusive care?

Normalizing things or traditions that seem different, and highlighting the diversity of the people whom we take care of, is an important way to do that. Having really engaging educational sessions or tabling events at an institution are effective ways to help providers understand how these different traditions are meaningful in these different cultures—and understanding these differences can have an impact on whether a patient gets better or not. And I think that better understanding also leads to more empathy and improved connections between provider and patient.

What work might be needed to improve AAPI communities’ care experience?

An important piece boils down to building trust. Patients and their families want to know they are being listened to. Our clinical teams have to be open-minded to cultural differences and communicate to patients and their families that they’re there to help and receive feedback. Once that trust is established, when we need to explain how certain rituals or traditions might run counter to care, that advice might be better received by the patients and family members.

What has Mount Sinai been doing toward providing culturally sensitive care for AAPI communities?

In recent months and years, Mount Sinai Health System has dedicated resources and launched initiatives toward improving competence and cultural sensitivity for its AAPI patients. Here’s a snapshot of what we have done:

  • Asian Health Services
    Initially launched at Mount Sinai Beth Israel to serve the population in Chinatown and lower Manhattan, the team providing personalized care for AAPI communities has been expanded systemwide, across all eight hospitals. Asian Health Services includes multilingual Asian providers in different medical specialties, medical interpreters, and culturally competent staff to help patients navigate health care. The website has been updated to include information about specialists, their locations, and languages spoken.
Click here to learn more about Asian Health Services
  • Guidance on translation services
    Mount Sinai has been working with its Language and Communication Access Services to provide more culturally competent translation and interpretation services for AAPI patients, including guidance on cultural differences and cues. The service is provided free of charge and can be arranged through clinical teams to be made available during care.
  • Cultural cue handouts for providers
    Cultural cue handouts that were originally available for providers under Asian Health Services are in the process of being rolled out systemwide. These resources include information about differences between traditional remedies and Western health care and various cultural norms that might affect decision-making.
  • Educational events
    For Asian/Pacific American Heritage Month, there is a series of events to celebrate and raise awareness of AAPI culture, held across all eight hospital campuses. These seek to deploy education in a meaningful way, by highlighting similarities and differences across cultures. The Center for Asian Equity and Professional Development also hosts webinars and events throughout the year.
  • Curriculum for cultural sensitivity training
    In its early stages, the Center for Asian Equity and Professional Development is developing a program to train providers who wish to be more informed about caring for AAPI patients. The goal is to eventually improve health equity among AAPI communities.
  • Partnerships with community organizations
    Mount Sinai is working with community partners, such as the Chinatown YMCA, to provide health information and education. These include preventive care, tips on healthy living, and resources to access care at Mount Sinai.

“I hope that what we can build is heightened awareness about the specific needs of our AAPI patients,” says Dr. Rhee. “I would hope these efforts will create a way of thinking for all of our care providers to identify any kind of disparity that a patient may be experiencing, so that we can address challenges in this space for all of our patients.”

Amanda Rhee, MD, Professor of Anesthesiology, Perioperative and Pain Medicine, and Inaugural Director of the Dean’s Center for Asian Equity and Professional Development at Mount Sinai

Who are the Asian Americans/Pacific Islanders in New York City?

Asian American/Pacific Islander (AAPI) is a broad term, but it is not a monolithic description of their experiences and situations. In New York City, the largest and one of the most diverse cities in the country, understanding the diverse socioeconomic and health access conditions of AAPI people is crucial to population health. Pulling from two city agency reports, here’s a snapshot of Americans and immigrants of Asian and Pacific Islander descent in New York City.

>1 million

AAPI people in NYC; 14 percent of the city’s 8.5 million population.

>30 different ethnicities

A group speaking more than 50 different languages.

13 percent

of immigrants of Asian/Pacific Islander descent are undocumented, compared to 16 percent of NYC immigrants overall.

46 percent

of AAPI households report having limited English proficiency, compared to NYC’s overall average of 23 percent. For Asian/Pacific Islander immigrants specifically, that number is 59 percent.

40 percent

of AAPI individuals in NYC on average have income below 200 percent of the federal poverty level, compared to the city’s average of 39 percent. However, subgroup variances are large, with lows including Filipino (20 percent) and Japanese (23 percent) individuals, and highs including Bangladeshi (58 percent) and Pakistani (53 percent) individuals.

AAPI people in NYC by the numbers

Advancing Heath Equity With Data: Collaborating With Stakeholders at Mount Sinai Queens

Apr 5, 2024 | Diversity and Inclusion, Featured, Research

Jill Goldstein, MA, MS, RN

At Mount Sinai, a key pillar in advancing health equity focuses on the collection and use of self-reported patient demographic data to identify gaps in care. The Health Equity Data Assessment (HEDA) team is engaging key stakeholders across the Health System and collaborating to address variances.

A highlight of these efforts is the Mount Sinai Queens Nurses Against Racism (NAR) system council, which endeavored to evaluate incidences of hospital-acquired pressure injuries (HAPI) using an equity lens.

A pressure injury is a localized injury to the skin and/or underlying tissue, resulting from compression between a bony prominence and an external surface for a prolonged time. Monitoring HAPI specifically focuses on the occurrence of these injuries during an inpatient hospital stay.

According to Jill Goldstein, MA, MS, RN, Deputy Chief Nursing Officer, Vice President of Nursing at Mount Sinai Queens, and NAR sponsor, their collaboration with HEDA began in January 2023, combining subject matter expertise and data modeling to evaluate differences in HAPI rates across patient populations. She  noted that the interdisciplinary team explored the impact of race, gender, age, language, payor, length of stay, clinical service, and other factors on the incidences of hospital-acquired pressure injuries.

Further, the data showed that in terms of race, there were no meaningful differences observed between white, Black, or Hispanic patients in any model.

Notably, the most actionable finding was the elevated risk for patients who prefer to speak a language other than English or Spanish. In these patients, 40 percent were more likely to have documented HAPI when compared to English-speaking patients.

With the data the HEDA team helped to collect and interpret, the system-wide nursing team will seek interventions to eliminate this disparity. This interdisciplinary approach serves as a model to incorporate an equity lens into other quality work, according to Ms. Goldstein.

Access the Health Equity Data Assessment (HEDA) Portal

Mount Sinai’s Million Dollar Circle Recognition Honors Underrepresented Vendors

Updated on Mar 22, 2024 | Community, Diversity and Inclusion, Featured

From left: Tiffany Oloke, Sourcing Lead II–Value Analysis; Patrice Gordon-Poyser, Supplier Diversity Manager; Carlos Maceda, Chief Supply Chain Officer; and Lynn Oxner, Director, Supply Chain, at the Million Dollar Circle Recognition event on February 9

Mount Sinai recently held its inaugural Million Dollar Circle Recognition event—celebrating 28 underrepresented vendors that each provided more than $1 million in products and services to the Health System in 2022 and 2023. More than $70 million was spent with the Million Dollar Circle vendors in each of those years.

“Supplier diversity is embedded in the culture, even the DNA of Mount Sinai,” Edward Robinson, Senior Vice President and Chief Resource Officer, Mount Sinai Health System, said at the event, which was held on February 9 at Mount Sinai’s Corporate Services Center. “This is our mission, to advance health equity and socioeconomics in the communities we serve.”

The event, attended by vendors and Mount Sinai staff and leadership, was moderated by Patrice Gordon-Poyser, Supplier Diversity Manager, Mount Sinai Health System. Leaders from three of the vendor honorees participated in the Million Dollar Journey panel. They discussed the services they provided to Mount Sinai, the effect of their long-standing business relationship on the growth of their companies, and ways in which they have been giving back to communities through charitable initiatives.

One of these vendors, a technology procurement fulfillment company that is Asian-American owned, was tasked with procuring iPads for patients, which allowed them to communicate with their loved ones while they were isolated during the COVID-19 pandemic.

“Getting there, not just from the technological perspective, but from one of procurement, putting it together, and delivering it, was one of the areas that I feel really stood out during our relationship with Mount Sinai,” said the vendor’s chief technology officer.

Another vendor on the panel, a veteran-owned staffing business, provided 50 crisis nurses for the Health System during the pandemic. “We all came together, Mount Sinai, our company, everybody here,” said the company’s chief executive officer. “It was an amazing New York moment, and something we are very proud of.”

The third vendor, a woman-owned office supply business, worked with Mount Sinai’s architectural design team to redesign Health System spaces that support employee well-being, including ergonomic chairs for nursing staff. As a health care provider, Mount Sinai posed unique challenges that helped the business evolve.

“Our client is not just Mount Sinai, our client is also the patient,” said the company’s director of marketing and workplaces strategy during the panel. “It really prompted us to develop a whole new health care department. Our staff all have more training and understanding in health care specifically.”

Carlos Maceda, Chief Supply Chain Officer, Mount Sinai Health System, commended the vendors for reaching the $1 million milestone. “I ask you to never forget where you came from, and to never forget your roots to be able to always help someone,” said Mr. Maceda.

Pamela Abner, Senior Vice President, Health Equity Officer, and Chief Diversity Operations Officer, Mount Sinai Health System, said that community vendors provide solutions through innovation and creativity in ways that would have been challenging for larger companies. She also noted how Mount Sinai’s relationship with local vendors helps New York City.

“By building community wealth, we build community health,” she explained.

To learn more about Mount Sinai’s commitment to supplier diversity, please visit Supplier Diversity or email supplierdiversity@mountsinai.org.

Learn more about Supplier Diversity at Mount Sinai.

New Opera on a Gender-Affirmation Pioneer Is Authored by Mount Sinai Neuroradiologist

Updated on Mar 9, 2024 | Community, Diversity and Inclusion, Featured

A new opera, Lili Elbe, tells the story of one of the earliest recipients of gender-affirming surgery in 1930. The opera is a collaboration of Grammy Award-winning composer Tobias Picker and Aryeh Lev Stollman, MD, a neuroradiologist at Mount Sinai, who wrote the story and lyrics. Photos: Edyta Dufaj

“It’s a love story,” says Aryeh Lev Stollman, MD, a neuroradiologist at Mount Sinai, and the librettist for a new opera, Lili Elbe, which tells the story of one of the earliest recipients of gender-affirming surgery, in 1930. The opera, commissioned by the Theater St. Gallen of Switzerland, was named “Best World Premiere of 2023” at the OPER! AWARDS ceremony on January 29 at the Dutch National Opera in Amsterdam.

Lili Elbe focuses on a successful Danish painter who was married to another painter, Gerda Wegener. Though their marriage was eventually annulled by the King of Denmark and Lili’s name and sex were legally changed, they remained in love with each other. Lili’s case drew international attention, and a semi-autographical account of her story was captured in a book, Man Into Woman: An Authentic Record of a Change of Sex. Another book, The Danish Girl, was loosely based on her story and has become an important text in LGBQT+ literature and the basis for a film.

“We based our story on historical sources,” emphasizes Dr. Stollman. “The Danish Girl was highly fictionalized. But Lili Elbe was quite famous in her day, so we relied on her own writings and news accounts from the time.”

The opera Lili Elbe, in addition to being acclaimed for its artistry, is a significant milestone. It stars Lucia Lucas, a baritone, in the first grand opera for and about a person with trans experience. The Grammy Award-winning composer Tobias Picker, who is married to Dr. Stollman, befriended Lucia when he cast her in Don Giovanni in a Tulsa Opera production—the first time a transgender singer had played the leading role in an American opera. Mr. Picker, Dr. Stollman, and Lucia wanted to collaborate on an original project, and the story of Lili Elbe was chosen.

Tobias Picker, left, and Aryeh Lev Stollman, MD, taking a bow after a performance of the new opera at the Theater Saint Gallen in Switzerland. “This resonates with our work as physicians, health care workers, and support staff, because behind our work is love for humanity,” says Dr. Stollman. “We serve people, no matter their physical appearance, their background, or gender identity. And we do it through all types of difficult times and situations.”

“Tobias asked me to write the libretto—or the story and lyrics,” Dr. Stollman says. “But I worked very closely with Lucia as the dramaturg, to gain the insight of her experience and authenticity.” This is the second time Mr. Picker and Dr. Stollman have collaborated. The first was the inspiring opera Awakenings, based on the story of Oliver Sacks, MD, and his efforts to treat patients with sleeping sickness. That opera opened in June 2022 at the Opera Theatre of Saint Louis.

“Like Awakenings, we wanted Lili Elbe to have a mythic undercurrent,” Dr. Stollman says. “In Awakenings, we used the story of Sleeping Beauty. In Lili Elbe, the myth of Orpheus leading his lover, Eurydice, out of the underworld is a motif that reoccurs. I believe that myths have a strong emotional truth. In the myth, Orpheus is saying, ‘Don’t look back, you cannot return to your old life, but you are coming into a new life.’ And our characters are always moving to the future, to a new life, a new realization. And that’s the mythological underpinning.”

Lili Elbe discovers her true nature as a woman when her wife, Gerda, asks her to stand in for a female model who was delayed for a painting session. Gerda is entranced with the beauty of her husband, then called Einar Wegener, and it is she who bestows the name Lili. And as Lili embraces her identity, she says, “When you paint me now, I feel I have always been her.” Lili becomes a muse to Gerda, whose paintings of Lili win acclaim. But Gerda wrestles with how much space to allow Lili in their marriage. At first, she insists that Lili transition back to Einar in the evening. But as Lili makes her true identity known among their circle of friends, Lili wants to experience all the feelings of womanhood, including marriage and motherhood. And even though their marriage is annulled and they become involved with other lovers, their love for each other endures.

Lili becomes engaged to Claude LeJeune, a young man whose passion is creating perfumes from flowers through a delicate process called enfleurage. The symbolism of the flowers living on becomes a motif as Lili dies as a result of complications of one of her surgeries. And the life and story of Lili Elbe still resonate today.

“The opera is more than about love with a transgender person,” Dr. Stollman says. “It’s about love and transcending difficulties. It’s about a tragic heroine’s journey that starts with self-knowledge. And it’s about loss, because Gerda loses Lili. But also because Lili dies in the end, as many tragic heroines do.”

The staging and choreography of the opera are innovative, witty, and symbolic. As Gerda exhibits her paintings of Lili, they are symbolized by actors suspended above the stage, swirling in evocative poses. The prominent German newspaper Die Welt gave it an enthusiastic review, calling it “emotionally gripping, a delicate work of musical theater that unfolds as an Art Nouveau arc, amidst a bright, symbolist stage.” A leading Austrian paper, the Voralberger Zeitung, called it “an emotionally charged masterpiece.”

Dr. Stollman related the theme of love transcending all to the mission of Mount Sinai, which was founded to care for underserved people and is home to the Center for Transgender Medicine and Surgery, a world leader in gender-affirming care. “This resonates with our work as physicians, health care workers, and support staff, because behind our work is love for humanity. We serve people, no matter their physical appearance, their background, or gender identity. And we do it through all types of difficult times and situations.”

View the trailer here
Watch the full opera, courtesy of OperaVision, co-sponsored by the European Union, through June 8, 2024
Read about an earlier collaboration that produced the opera Awakenings, which made its debut in June 2022

Preparing Physicians to Treat the LGBTQI+ Community With Dignity as It Ages

Updated on Feb 23, 2024 | Diversity and Inclusion, Featured

Noelle Marie Javier, MD, left, with Roy Noy, MD, during Dr. Noy’s four-month observership at Mount Sinai to learn more about LGBTQI+ medicine and geriatrics.

The field of LGBTQ+ medicine has slowly been developing over the past decade, but a crucial intersection with a subspecialty has often been overlooked—geriatric medicine.

Throughout history, LGBTQI+ medicine has been underdeveloped and under-prioritized for several reasons, among them being that few people were historically willing to disclose and seek care as LGBTQI+ individuals, and that many members in the community lost their lives to the HIV/AIDS epidemic during the 1980s.

“There have been gaps in training at medical schools, residency, and fellowship training programs from the past until now,” says Noelle Marie Javier, MD, Associate Professor of Geriatrics and Palliative Medicine, and Medical Education, at the Icahn School of Medicine at Mount Sinai.

Across the majority of MD programs throughout the country, the average time devoted to training in LGBTQI+ medicine is about five hours in total across the four-year program, as cited in a 2011 JAMA paper. “That’s simply not enough,” says Dr. Javier.

These days, with increasing acceptance and awareness of diverse sexual orientations and gender identities in society, and modern advances in medicine, LGBTQI+ people are growing older and living longer—some with unique health concerns and disparities. These could include how older adults living with HIV are aging, or long-term effects of having received marginalized care or faced barriers to care. “Now, more than ever, we need to be prepared as physicians and allied health professionals to take care of them in a way that’s culturally humble, sensitive, and responsive,” Dr. Javier says.

The Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai is committed to providing inclusive and affirming care for older LGBTQI+ adults, which includes training and education for staff, students and trainees. Inspired by this work, the leadership at the Tel Aviv Sourasky Medical Center (Ichilov) reached out to the Mount Sinai LGBTQ+ Medicine Fellowship program to arrange a pilot program where a resident in geriatrics could gain knowledge and training through an observership for the care for older LGBTQI+ adults. During the fall of 2023, Roy Noy, MD, chief geriatrics resident at Ichilov, collaborated with Dr. Javier in expanding his geriatrics skills and developing a curriculum that he could use to train staff back in Tel Aviv.

Read more about Dr. Noy’s observership at Mount Sinai and the importance of focusing on geriatric LGBTQI+ medicine.

Dr. Noy is helping the Tel Aviv Sourasky Medical Center (Ichilov) set up an LGBTQI+ clinic for older adults. He spent four months at Mount Sinai observing various models of care in geriatrics and LGBTQI+ medicine.

How did this program come about?

Dr. Noy: We are trying to establish an LGBTQI+ service for older adults in our hospital at Tel Aviv. The head of the program, Roy Zucker, MD, was the inaugural fellow at the Mount Sinai LGBTQ+ Medicine Fellowship. He came up with the idea of trying to establish an observership for me to learn more from Mount Sinai about what is needed to start such a specialized service.

Dr. Javier: I was invited to be a plenary speaker at GLMA: Health Professionals Advancing LGBTQI+ Equality last year when Dr. Zucker and I first got acquainted. He wanted to set up a collaboration for one of his residents in the hopes of expanding his medical knowledge and clinical skills to take care of older LGBTQI+ adults.

What went into this observership?

Dr. Noy: The program had several parts to it.

  • On the broader geriatrics side, I did a lot of observing with different doctors and other team members working in the Brookdale Department Geriatrics and Palliative Medicine, and I joined them on their daily rounds. I also got to join the departmental educational programs.
  • For the LGBTQI+ medicine side, I observed Antonio Urbina, MD, Medical Director of Mount Sinai’s Institute for Advanced Medicine, in the HIV clinic. I got to train in Mount Sinai’s Center for Transgender Medicine and Surgery with Joshua Safer, MD, who is Executive Director of the Center. And I also got to shadow Angela Condo, MD, Assistant Professor of Geriatrics and Palliative Medicine, in the geriatrics clinic for people living with HIV.
  • In addition, I was connected with people and organizations who play an important role in LGBTQI+ health, such as SAGE, an advocacy and services group for LGBTQI+ elders, and MJHS Hospice and Palliative Care.
  • On the training side, I was connected to Mount Sinai’s Office for Diversity and Inclusion, to see what they are doing for new and current employees, how they are implenting sexual orientation and gender identity data gathering, and how the Health System connects with the LGBTQI+ community.
  • There was also an academic side where I got to work with Dr. Javier on writing a chapter focused on affirming care, and we have an ongoing project concerning educational training programs.

Dr. Javier: The idea was to expose Dr. Noy to different models of care within the geriatric and palliative medicine landscapes—not just inpatient geriatrics and palliative care, but also neurology and memory care, outpatient clinics, urgent care, and chronic illnesses. By the time we were done with the observership, we had developed several deliverables, including submitting a chapter titled “Affirming Care for LGBTQ+ Patients” to Clinics in Geriatric Medicine that is currently in process for publication, and a scoping review research project titled “A Scoping Review Protocol of Educational Training Programs in Medical and Health-Related Professions Caring for Older LGBTQI+ Adults, November 2023 to Present.”

What were your takeaways?

Dr. Noy: Now that we’re starting our own LGBTQI+ older-adults service here in Tel Aviv, having been at Mount Sinai has helped us figure out what we need to focus on, as well as what are topics unique to us.

One big thing I learned is about communication in the way we address the community. It is important for everyone in the medical field, but it’s especially important in geriatrics because we do need to see the full picture of the person sitting in front of us and understand where they’re coming from. That involves knowing what are things that had been problematic, the history of what had been in the way of them getting treatment, and you can’t do that without good communication.

I also learned that connection with the community is important if we are going to be successful. The way community organizations work with health care in New York, I want us to be able to work as closely knit with them like that too.

Dr. Javier: I like mentoring people who want to be trained in LGBTQI+ medicine and health care. But just as I had helped Dr. Noy with his training, he had helped me too. Prior to this observership, I had several ideas in mind about developing a curriculum, but when Dr. Noy arrived and we started talking about what the program should look like, it helped to create more concrete ideas. I learned a lot from him in terms of what the community is like in Israel and what health services are available to them.

The amazing thing that came from this was: I want this same enriching experience for my fellows here in the department. We have 30-plus fellows in the department and are the largest ACGME-accredited fellowship program in geriatrics and palliative medicine in the country, but creating a LGBTQI+-focused curriculum had been on the back burner for quite some time. There is no formalized curriculum as of yet. This observership catalyzed the need to start working on this curriculum and make it a priority. In some serendipitous way, I got the outcome—a formalized program—before I got the template, and now I’m tracing our steps back of what we did and achieved in this pilot trial.

Why is it important that we focus on training physicians to care for LGBTQI+ older adults now?

Dr. Noy: Similar to the United States, in Israel, older LGBTQ+ people were less likely to identify as such than younger people. And we know that the LGBTQ+ population tend to face more barriers to accessing health care than the general population—this could include avoiding seeking treatment because of previous bad experiences, or even just from stigma.

As they age, the problems could accumulate, and they might end up needing more comprehensive treatment, when they could have preventive treatments earlier. There are general things like cancer, hypertension, or diabetes surveillance that could be done earlier, but there are also conditions more likely within the LGBTQI+ community, such as depression and mental health, that could get ignored.

Then there’s the fact that thanks to advances in medicine, we now have people with HIV living to old ages—even into their 80s and beyond. There’s still so much we don’t know about how they age, such as cognitive decline, frailty, effects of polypharmacy, and more. It’s not just about managing their medication, but also understanding their wellness as a whole. It’s important that we start integrating that training from medical school onwards. And also that we work with the community to show that we do exist—we’re here for everyone in the community.

Dr. Javier: When I was training as a fellow, I was not trained in LGBTQI+ medicine. Even today, that’s still not the case in many institutions. We need to change that and fast. The fellows in my department are knowledgeable enough to be able to take care of the needs of patients and be culturally responsive, but competencies around optimal LGBTQI+ medical care is not a requirement for them to graduate. The integration of LGBTQI+ care should be reflexive in geriatrics and palliative care curriculums across the country.

There continues to be a lot of disparities and inequities in care, especially for older LGBTQI+ adults and people of color. According to the 2015 U.S. Transgender Survey, 40 percent of respondents have attempted suicide in their lifetime. There are many other unique health concerns in the community, and if you did not ask about the sexual orientation and gender identity of a person, you can miss out on the big picture of why they’re seeking care in the first place while being clouded by our own biases and prejudices in helping them.

Read more about how Mount Sinai is empowering health care for LGBTQI+ communities

The Importance of Affirming LGBTQI+ Health

How to Find an LGBTQI+ Experienced Medical Provider and Why That’s Important

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