Lesbian, Gay, Bisexual,Transgender, Queer or Questioning, Intersex, Asexual, and More (LGBTQIA+) Health¶

Chapter 412 | Part 12: Endocrinology and Metabolism · Part 12 – Endocrinology & Metabolism · Chapter 412

Key Clinical Points¶

Distinguish gender identity (internal sense) from sexual orientation (attraction/behavior/identity).
MSM account for 68% of all new HIV diagnoses in the United States (2020).
Anal cancer rates in MSM are 17 times higher than in heterosexual men.
42% of LGBTQIA+ youth (ages 13-24) seriously considered attempting suicide in 2021.
Substance abuse prevalence is 20-30% in LGBTQIA+ youth vs. ~9% in the general population.
Use preferred pronouns and names; avoid outdated terms (e.g., Berdache → Two-spirit).
Minority stress (chronic exposure to discrimination) contributes to poor health outcomes.
EHR collection of sexual orientation and gender identity data is critical for personalized care.
Discuss PrEP/PEP and condom use for MSM at high risk for HIV/STIs.
Ensure equal visitation policies for same-sex partners and family.

DEFINITION & OVERVIEW¶

• Core Distinction: Providers must distinguish gender identity from sexual orientation to address health disparities and create positive healthcare experiences. • Gender Identity: A person's internal sense of their gender (e.g., girl/woman/female, boy/man/male, both, neither, or beyond the binary). - Not to be confused with sex assigned at birth (based on anatomy and biology). - Includes individuals who do not identify with the gender that correlates with their sex assigned at birth (transgender, trans-male, trans-female). • Sexual Orientation: How one thinks of their physical or emotional attraction to others. - Three dimensions: Attraction (desire), Behavior (interactions), and Identity (self-definition). - Common terms include gay, lesbian, bisexual, straight, heterosexual, homosexual, and asexual.

Verbatim Definitions (Harrison's 22e)¶

• Gender identity: > Definition (Harrison's 22e): Gender identity is a person's inner sense of being a girl/woman/female, boy/man/male, both, neither, or beyond the gender binary. • Sexual orientation: > Definition (Harrison's 22e): Sexual orientation refers to how a person experiences their physical, emotional, and romantic attachments to other people. • Transgender: > Definition (Harrison's 22e): An umbrella term for people whose gender identity does not align with the sex they were assigned at birth, based on societal expectations. • Gender dysphoria: > Definition (Harrison's 22e): Distress experienced by some people whose gender identity does not align with their sex assigned at birth based on societal expectations; or distress experienced when a person's gender identity and/or gender expression is not affirmed. • Gender expression: > Definition (Harrison's 22e): The ways in which people present their gender identity to others, such as through gait, mannerisms, voice, dress, and hairstyle. • Cisgender: > Definition (Harrison's 22e): A person whose gender identity is consistent in a traditional sense with their sex assigned at birth; for example, a person assigned female sex at birth whose gender identity is woman/female. • Intersex: > Definition (Harrison's 22e): Describes a group of congenital conditions in which the reproductive organs, genitals, and/or other sexual anatomy do not develop according to traditional expectations for females or males.

Terminology & Definitions (Table 412-1)¶

• Key Terms: - Agender: Identifying as having no gender, or does not experience gender as a primary identity component. - Asexual: Experiencing little or no sexual attraction to others; may still engage in sexual activity. - Assigned female at birth/assigned male at birth (AFAB/AMAB): Refers to the sex assigned to an infant based on anatomic and biological characteristics. - Bisexual: A sexual orientation describing a person who is emotionally and physically attracted to more than one gender. - Cisgender: A person whose gender identity is consistent in a traditional sense with their sex assigned at birth. - Cisnormativity: The assumption that everyone is cisgender; can manifest as cissexism (the belief that cisgender identity is superior). - Gay: A sexual orientation describing people who are primarily emotionally and physically attracted to people of the same gender identity as themselves. - Gender-affirming hormone therapy (GAHT): Feminizing and masculinizing hormone treatment to align secondary sex characteristics with gender identity. - Gender-affirming surgery (GAS): Surgeries to modify a person's body to be more aligned with their gender identity (e.g., chest, genital, facial feminization). - Gender-affirming genital surgeries: Includes clitoroplasty, hysterectomy, labiaplasty, metoidioplasty, oophorectomy, orchiectomy, penectomy, phalloplasty, scrotoplasty, urethral lengthening, vaginectomy, vaginoplasty, and vulvoplasty. - Gender expression: The ways in which people present their gender identity to others (gait, mannerisms, voice, dress, hairstyle). - Gender queer: Describes people whose gender identity goes beyond the gender binary. - Heteronormativity: The assumption that everyone is heterosexual; can manifest as heterosexism. - Lesbian: A sexual orientation describing a woman or non-binary person who is primarily emotionally and physically attracted to women. - Pangender: Describes a person who has multiple gender identities. - Pansexual: A sexual orientation describing a person who can be emotionally and/or physically attracted to people of any gender identity or expression. - Pronouns: Words used in place of a person's name (e.g., she/her, they/them, he/him). Includes neopronouns (e.g., xe/xem/xyr). - Queer: An umbrella term for those who think of their sexual orientation or gender identity as outside of societal norms.\ - Questioning: Describes an individual who is unsure about or is exploring their own sexual orientation and/or gender identity. - Same-sex attraction (SSA): Experience of being emotionally and/or physically attracted to people of the same gender; often used in religious contexts.\ - Sexual orientation: How a person experiences their physical, emotional, and romantic attachments to other people.

EPIDEMIOLOGY¶

• Health Disparities: - Cancer: Lesbian and bisexual women are less likely to receive standard cancer screenings (breast, cervical, colorectal). - HIV: MSM account for 68% of all new HIV diagnoses in the United States (2020). - Anal Cancer: Rates in MSM are 17 times higher than in heterosexual men. • Mental Health & Substance Use: - Suicide Risk: 42% of LGBTQIA+ youth (ages 13-24) seriously considered attempting suicide in 2021. - Substance Abuse: Prevalence is 20-30% in LGBTQIA+ youth vs. ~9% in the general population. • Structural Barriers: - Minority Stress: Chronic exposure to discrimination as a primary driver of poor health outcomes. - Barriers to Care: Lack of awareness, stigma, and perceived threat in healthcare settings.

ETIOLOGY & PATHOPHYSIOLOGY¶

• Minority Stress: - Definition: Chronic exposure to high levels of stress from real or anticipated discrimination. - Impact: Primary driver for poor health outcomes in LGBTQIA+ populations. • Structural Barriers: - Reduced access to medical care due to lack of provider awareness and stigma.

CLINICAL FEATURES¶

• Cancer Risks: - LB Women: Lower rates of preventive screenings (breast, cervical, colorectal). - MSM: 17x higher rate of HPV-associated anal cancers compared to heterosexual men. • Infectious Disease Risks: - MSM: High risk for HIV (68% of new cases in 2020) and other STIs. • Mental Health & Substance Use: - Higher rates of depression, anxiety, and substance use compared to the general population. - Significant suicide risk among youth (42% of those aged 13-24 considered attempt in 2021).

DIFFERENTIAL DIAGNOSIS¶

• Conceptual Distinction: - Must distinguish Gender Identity (internal sense) from Sexual Orientation (attraction/behavior). • Community Variability: - Definitions vary across communities and change over time; not all individuals agree on specific definitions.

DIAGNOSTIC APPROACH¶

Screening for Cancer Risk:
LB women → Assess eligibility/status for breast, cervical, and colorectal screenings.
MSM → Screen for HPV-associated anal cancers.
Screening for Infectious Disease:
MSM → Screen for HIV and other STIs.
Data Collection:
Collect sexual orientation and gender identity in EHR to facilitate personalized care.

MANAGEMENT & TREATMENT¶

Communication Strategies:
Use preferred names and pronouns.
Avoid outdated terms (e.g., use 'transgender' instead of 'transgendered').
Environmental Modifications:
Create a welcoming environment by making no assumptions about identity or orientation.
Ensure equal visitation policies for same-sex partners and family members.
Infection Prevention:
Discuss PrEP, PEP, and condom use for MSM at high risk for HIV/STIs.

COMPLICATIONS & PROGNOSIS¶

• Suicide Risk: High among youth (42% of those aged 13-24) and transgender individuals. • Substance Abuse: Prevalence in LGBTQIA+ youth is 20-30% vs. ~9% in the general population. • Long-term Barriers: - Stigma and discrimination lead to avoidance of care or withholding of medical information.

SPECIAL CONSIDERATIONS¶

• Life Cycle: - Youth: Higher risk of suicide and substance abuse. • Transgender Specifics: - Higher prevalence of HIV and higher risk of suicide compared with other groups. • Geographic Limitations: - Data is more limited outside the US and Europe.

KEY PEARLS & CLINICAL TRAPS¶

• Communication Pearls: - Use preferred names/pronouns to build trust. - Avoid assumptions about identity or orientation. • Terminology Pearls (Table 412-2): - Berdache → Two-spirit - Cross-sex hormone therapy / HRT → Gender-affirming hormone therapy - FTM/MTF → Transgender man / Transgender woman - Hermaphrodite/ambiguous genitalia → Intersex - Legal name → Administrative name or name on legal documents - Preferred pronouns → Pronouns - Sexual preference/lifestyle → Sexual orientation

Reference Tables¶

TABLE 412-1 Common LGBTQIA+ Terminology and Definitions TERM Agender Asexual Assigned female at birth/ assigned male at…¶

Harrison's 22e, p.3179

TERM	DEFINITION
Agender	Identifying as having no gender, or does not experience gender as a primary identity component.
Assigned female at birth/ assigned male at birth	Refers to the sex that is assigned to an infant, most often based on the infant’s anatomic and other biological characteristics. Commonly abbreviated as AFAB (assigned female at birth) or AMAB (assigned male at birth).
Cisgender	A person whose gender identity is consistent in a traditional sense with their sex assigned at birth; for example, a person assigned female sex at birth whose gender identity is woman/female. The term cisgender comes from the Latin prefix cis, meaning “on the same side of.”
Gay	A sexual orientation describing people who are primarily emotionally and physically attracted to people of the same gender identity as themselves. Commonly used as an umbrella term for “not straight.”
Gender-affirming surgery (GAS)	Surgeries to modify a person’s body to be more aligned with that person’s gender identity. Types of GAS include chest and genital surgeries, facial feminization, body sculpting, and hair removal.
Gender-affirming genital surgeries	Surgeries that help align a person’s genitals and/or internal reproductive organs with that person’s gender identity, including: • Clitoroplasty (creation of a clitoris) • Hysterectomy (removal of the uterus; may also include removal of the cervix, ovaries, and fallopian tubes) • Labiaplasty (creation of inner and outer labia) • Metoidioplasty (creation of a masculine phallus using testosterone-enlarged clitoral tissue) • Oophorectomy (removal of ovaries) • Orchiectomy (removal of testicles) • Penectomy (removal of the penis) • Phalloplasty (creation of a phallus) • Scrotoplasty (creation of a scrotum and often paired with testicular implants) • Urethral lengthening (to allow voiding while standing) • Vaginectomy (removal of the vagina) • Vaginoplasty (creation of a neo-vagina) • Vulvoplasty (creation of a vulva)
Gender expression	The ways in which people present their gender identity to others, such as through gait, mannerisms, voice, dress, and hairstyle. Cultural and historical contexts influence how people interpret and express gender identity.
Gender queer	Describes people whose gender identity goes beyond the gender binary.
Heteronormativity	Heteronormativity is the assumption that everyone is heterosexual, or that being heterosexual is the only “normal” sexual orientation. Heteronormative social systems incentivize conforming to the behavior and appearance of heterosexuality. Heteronormativity can manifest as heterosexism, the biased belief that heterosexual identity is the only valid sexual orientation. Individuals, communities, policies, and institutions can perpetuate heteronormativity and heterosexism, and thus marginalize queer people and communities.
Lesbian	A sexual orientation describing a woman or non-binary person who is primarily emotionally and physically attracted to women.
Pangender	Describes a person who has multiple gender identities.
Pronouns	Pronouns are words used in place of a person’s name. Examples of pronouns are she/her/hers, they/them/theirs, he/him/his. Neopronouns are new pronouns that people may use to affirm their gender identity; examples include: xe/xem/xyr and ze/hir/hirs. Some people use their name instead of pronouns.

TABLE 412-2 Outdated and Insensitive Terms to Replace¶

Harrison's 22e, p.3180

OUTDATED TERM	RECOMMENDED TERM
Berdache	Two-spirit
Cross-sex hormone therapy; hormone replacement therapy	Gender-affirming hormone therapy
Female-to-male (FTM) and male-to- female (MTF)	Transgender man and transgender woman
Hermaphrodite/ambiguous genitalia	Intersex
Legal name	Administrative name or name on legal documents
Preferred pronouns	Pronouns
Sexual preference/lifestyle	Sexual orientation