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Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care

Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care
Literature review current through: Jan 2024.
This topic last updated: May 30, 2023.

INTRODUCTION — Health care providers and patients come from a wide variety of cultures, races, religions, education, ethnicities, and socio-economic backgrounds that all have an impact on the provider-patient relationship, making knowledge of others' cultures critical to best practices. Knowing and understanding a patient's sexual identity, orientation, and behavior improves health care providers' abilities to provide inclusive, quality care and recognize areas of disproportionate risk [1]. There is no stereotypical profile that identifies a person as a lesbian, gay, bisexual, transgender, queer, and/or other woman (LGBTQ+); therefore, when providing care, clinicians are encouraged never to make assumptions about a patient's identity.

In this chapter, we use and define the term "sexual and gender minorities" (SGM) in the broad sense of women with a nonheterosexual sexual orientation who may be self-identified as lesbian, gay, bisexual, transgender, queer, or other. This can also be inclusive of racial/ethnic minorities. In this topic, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to learn how SGM people in their country refer to themselves and to consider the specific language preferences, as well as counseling and treatment needs, of each individual.

Additional discussions of health care issues for other groups of sexual and gender minority individuals are presented in related chapters.

(See "Primary care of gay men and men who have sex with men".)

(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

EPIDEMIOLOGY

Data and limitations — Obtaining accurate information about the prevalence of SGM is challenging because gender, sex, and behavior are not the same, and national census surveys have historically not asked about sexual orientation or gender identity. In the United States, gay and lesbian individuals were first recognized as a subpopulation on the 1990 census. Results of the Gallup Daily Tracking Survey place the prevalence of LGBT people as 4.5 percent of the population with a gender ratio of 42 percent men to 58 percent women [2]. The accuracy of these statistics could vary due to individuals who may not feel comfortable identifying, or whose identity or sexual behaviors have not been accurately represented in these surveys.

Rates of same-sex sexual behavior are higher than rates of self-identification as lesbian or bisexual. As an example, analysis of the 2011 to 2013 National Survey of Family Growth reported that 1.3 percent of women identified as gay or lesbian but 17.4 percent of women reported sexual activity with individuals of the same sex, which includes a single or frequent encounters [3].

Disclosure of sexual orientation — Asking patients about and understanding their sexual orientation is important on many levels, especially as patients generally report that they want to be asked [4].

In a 2017 United States questionnaire study, 78 percent of emergency physicians felt that patients would refuse to disclose if asked about sexual orientation; in contrast, only 10 percent of patients reported they would refuse to disclose [5]. Lastly, patients who disclose their sexual orientation to their health care providers may feel safer discussing their health and risk behaviors as well [6].

Asking about sexual orientation allows a patient's identity to be affirmed and seen by their provider, and helps clinicians recognize potential health disparities that should be addressed [7].

Barriers to care — Although the label "homosexual" is no longer acceptable [8], prior to 1973, "homosexuality" was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This historical pathologic paradigm greatly contributed to isolation and stigmatization of sexual minority individuals by the health care community [9]. Additionally, judgmental or insensitive encounters with health care providers and an assumption of heterosexuality have deterred health-seeking behaviors [10,11] and contributed to patients' unwillingness to disclose sexual orientation [12] and feelings of invisibility. High cost and difficult access are major barriers.

CULTURAL COMPETENCY

Components — Cultural competency focuses on the ability to communicate effectively and provide quality health care to patients from diverse backgrounds. Lack of cultural competency by the clinician and/or health care system can complicate care delivery for SGM [13,14]. Consensus panels have been suggested as a means to identify the specific issues of SGMs' needs within their communities [15,16].

Key components of cultural competency include [1,17-19]:

An open, nonjudgmental attitude that includes not making assumptions about a patient's sexual orientation or behaviors.

Acknowledging that we have implicit biases that inform our diverse behaviors as clinicians and limitations that may need intervention.

Awareness and education that cultural differences and world views represent unique perspectives that are valuable and valid.

Education to enhance listening skills and adapt communication styles to the needs of others.

Implementation of actionable plans to improve cross-cultural skills and competency within a workplace to enhance patient trust and comfort.

Additional resources include:

HHS LGBTQI+ Resources

(See "The patient’s culture and effective communication".)

LANGUAGE AND TERMINOLOGY

Importance of using patient's preferred descriptors — Clinicians are advised to directly ask patients how they prefer to be identified regarding their gender identity, pronouns, and sexual partner. Language and terminology are continuously evolving, and there are numerous terms in use. We have found that it is important to repeat this conversation over time as gender identity and sexual orientation, and behaviors, can change.

Specific terminology — We find it useful to refer to the publicly available resources through the University of California San Francisco Center of Excellence for Transgender Health and the Fenway Institute Glossary of LGBT Terms for Health Care Teams. A multidisciplinary group of clinicians and researchers has described barriers to sexual and reproductive health care and proposed detailed "Recommendations for Building Gender-Inclusive Clinical Settings" and "Recommendations for Conducting Gender-Inclusive Research" in 2020 [20].

Some commonly used terms include [8]:

Gender – The concept of gender can vary by society and can change over time [21,22]. Gender refers to the socially constructed characteristics of men and women, such as roles, norms, and behaviors, that are labeled by a society as male or female [23].

Gender identity – An individual's gender identity can be the same or different from their sex assigned at birth [9]. Gender identity is one's innermost concept of self from the perspective of one's gender [24]. It can be described as an internal self label. Furthermore, since identity is an internal perception, it can be unrecognized by others. Gender is often thought of as a male/female binary, meaning that individuals identify as either male or female. However, gender is an umbrella term, and many identify outside of this construct, including no gender [9]. Gender identity encompasses transgender identities (trans women and trans men), nonbinary, gender-queer, intersex, etc [9,25].

Transgender – An umbrella term, transgender is sometimes shortened as "trans" or "trans*," and refers to a person whose gender identity differs from their sex assigned at birth [9,26]. Transgender individuals may be referred to as transwomen or transgender women (a genetic male who self-identifies as a woman) or transmen or transgender men (a genetic female who self-identifies as a man). Transgender individuals may choose to receive hormone therapy and/or undergo various gender-affirmation surgeries, or not. Transgender is a gender identity and should not be confused with sexual orientation.

Nonbinary – When gender identity and gender expression do not align with the categories of male or female, man or woman, the term nonbinary is used and includes identities such as gender-queer, agender, androgynous, etc.

Gender expression – How that gender identity is lived constitutes gender expression. In other words, "The outward manner in which an individual expresses or displays their gender" [26]. This can include characteristics such as clothing, hairstyle, mannerisms, and speech and may differ from one's gender identity. This may be reflected in an individual's desire for the use of specific pronouns: she/her/hers; he/him/his; they/them/theirs; or some personally chosen combination of these.

Sex – An individual's sex refers to the biology they are born with, including genetic, hormonal, anatomic, and physiological characteristics [9]. Related terms include "sex assigned at birth," "natal sex," "biologic sex," or "birth sex." Sex characteristics result in being labeled as female or male gender at birth.

Sexual orientation – Sexual orientation is self-defined and refers to one's inherent emotional, romantic, and sexual attractions to other people [8,24-26]. Thus, a single sexual event or desire does not define one's sexual orientation. Historically, sexual orientation has been thought of as one of several categories including heterosexual, lesbian or gay, and bisexual. However, many perceive their attractions as more fluid (readily reshaped) than this and do not identify within these categories. Once a derogatory label, the term "queer" has been adopted as a positive self-label and is recognized to be more fluid (less limiting) than choosing one of the above categories, although some individuals find the term offensive [8]. Other categories of sexual orientation that have emerged are pansexual, asexual, and omnisexual.

Sexual behavior – Sexual behavior embraces a spectrum of romantic and/or sexual activities and therefore is not clearly categorized.

Sexual behavior is not the same as sexual orientation. For example, the phrase "women who have sex with women" describes an action.

Sexual behavior can also change over time. Studies surveying self-identified lesbians show a wide range of sexual behaviors (eg, same-sex partners, opposite or different sex partner, or both) [27]. Additionally, a current partnership may not reflect an individual's previous sexual behavior.

Behavior may not be concordant with self-identification. [9]. For example, a self-identified lesbian can also be attracted to, and engage in, sex with men and/or individuals who identify as nonbinary, transgender, etc.

IMPACT OF SEXUAL ORIENTATION ON SOCIAL DETERMINANTS OF HEALTH

Disparities — When individuals do not conform to established heteronormative gender definitions, relations, or roles, their access to and control over resources that contribute to health can be reduced [21]. This can lead to barriers, disparities, and health risks that could be mitigated by health care provider awareness and education. These disparities continue to persist. A study of data from the US National Health Interview Survey reported that gaps in health status and health care access between lesbian and heterosexual females did not change from 2013 to 2018 [28].

Disenfranchisement — As a result of disparities, stigma, discrimination, and prior negative experiences with the health care community, SGM often underutilize clinical care services and present later for health care than heterosexual women [28-30]. In addition, differential risks for disease can arise because of behaviors that may be more common among SGM.

Consequently, SGM individuals, compared with non-SGM individuals, have experienced poorer health-related qualities of life [31] in association with higher rates of the following conditions:

Denial of civil and human rights [32,33]

Gender discrimination [34] and mood disorders

Social and minority stressors and stigmatization [35]

Feelings of less dignity and safety

Work force discrimination or unemployment

Lack of or lower income and other resources

Being uninsured [36] and unable to access partner's health insurance [37,38]

Untreated medical conditions [36]

Delays in seeking care due to cost [39]

Inability to pay for medications due to cost [39]

Reduction in preventive health visits and screening, such as mammograms [36]

Impact of resilience on outcomes — Not all people within a specific category or group experience the same adverse outcomes. Where SGM find communities of support, they have more strength and access to care. Historically, LGBTQ+ research has focused on poor health outcomes or risk behaviors within the LGBTQ+ community due to minority stressors. However, researchers and the sexual minority community themselves are increasingly turning attention toward individual and community resilience. Resiliency is defined as one's ability to adjust, recover, or overcome adversity or significant stress in one's life [40]. This term can be further defined as the "dynamic process encompassing positive adaptation within the context of significant adversity" [41]. This important shift in perspective allows health care providers, as well as patients, to consider a strength-based approach, rather than just focusing on one's deficits, when considering health needs and outcomes [42]. Characteristics that can positively impact one's individual resiliency are positive self-esteem, self-efficacy, cognitive ability to mediate stress, self-acceptance, proactive coping, self-care, shamelessness, and spirituality. Larger community and environmental factors include social support and connectedness, positive LGBTQ+ role models, positive representation of LGBTQ+ populations in the media, family acceptance, positive school and/or work environments, having access to safe spaces, and social activism.

CLINICAL CONDITIONS AND RISK FACTORS FOR ADVERSE HEALTH OUTCOMES — While there are no diseases specific to SGM, the health disparities that result from identification with a minority group and the risks associated with specific health behaviors require attention and consideration. Several issues that warrant discussion with SGM include mental health stressors, obesity and body image, cardiovascular and pulmonary diseases, breast and gynecologic cancer risk and screening, risk for sexually transmitted infections (STIs), substance and alcohol misuse, and intimate partner violence [1,32,43].

Mental health stressors — We advise asking SGM about their mental health, support networks, and individuals in their lives who may not be supportive. Sources of stress for SGM include stigmatization and nonacceptance by family members, peers, and friends [44,45]. Higher rates of suicidality, anxiety, and depression are more common for SGM in general and specifically for those who have not disclosed their sexual orientation [46-48]. A systematic review of 25 studies comparing mental health in LGBTQ and heterosexual individuals reported that LGBTQ individuals had a 1.5-fold increased risk of depression and anxiety and a 2.5-fold increased risk of suicide attempt [49].

Detailed information on suicide, depression, and substance misuse are presented separately.

(See "Suicidal ideation and behavior in adults".)

(See "Screening for depression in adults".)

(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

Obesity — A study of the 2013 and 2014 National Health Interview Survey data comparing SGM with heterosexual women reported SGM had a 20 percent higher prevalence of obesity (defined as a body mass index of ≥30 kg/m2) [50]. The relationship between sexual minority stress and obesity is layered and complex. There is some evidence that chronic minority stress, depression, and alcohol use contribute to a high prevalence of obesity among sexual minority woman [51,52]. Weight gain and having a higher body mass index may be more culturally acceptable to lesbians. One reason may be that the lesbian community may not share the mainstream media-driven goal of low body weight as the ideal [53]. Therefore, in addressing weight with SGM, it is important to emphasize the health implications of being either overweight or obese, including diabetes, cardiovascular disease, and hypertension.

(See "Overweight and obesity in adults: Health consequences".)

(See "Overview of established risk factors for cardiovascular disease".)

(See "Prevention of type 2 diabetes mellitus".)

Cancer risk, screening, access, and conduct of care — A 2019 study of over 1900 cancer survivors (female and male) reported that SGM not only had challenges to screening for cancers but also reduced access to care once diagnosed with a cancer [54].

Breast cancer – SGM are advised to undergo breast cancer screening according to guidelines published for the general female population. (See "Screening for breast cancer: Strategies and recommendations".)

SGM appear to have an increased risk and incidence of breast cancer, possibly attributable to their greater incidence of being overweight or obese, nulliparous, or having excessive alcohol intake) [36,55-58]. In a study of over 400 women, being SGM was independently associated with 1.43 percent higher lifetime Gail scores for breast cancer risk [56]. (See "Screening for breast cancer: Strategies and recommendations", section on 'Breast cancer risk determination'.)

Cervical cancer – Cervical cancer screening and human papillomavirus (HPV) vaccination should be offered according to established guidelines regardless of a person's sexual orientation or practices [59]. (See "Human papillomavirus vaccination", section on 'Importance of cancer screening' and "Screening for cervical cancer in resource-rich settings".)

Cervical cancer screening – Despite their risk for HPV infection, SGM have lower rates of screening for cervical cancer compared with heterosexual women [60-62]. In a study of nearly 250 SGM, reasons given by women for not having cervical cancer screening included lack of health insurance, prior negative health care experiences, and belief that Pap tests were unnecessary [63,64]; thus, it is essential to offer age-appropriate cervical cancer screening to natal women (ie, born with a cervix) regardless of sexual orientation or behavior.

HPV infection risk – SGM are at risk for HPV infection from both male and female partners [65]. In a study of 149 SGM, HPV DNA was detected in 19 percent of women who reported no prior male sexual partners [66]. For comparison, a United States National Health and Nutrition Examination Survey study on HPV reported that up to 40 percent of women in the general population were infected with any genital HPV during 2013 to 2014 [67].

Ovarian cancer screening and risk reduction – We discuss ovarian cancer risk factors with all patients. Screening and preventive measures for those who are carriers for hereditary and/or familial breast and ovarian cancer syndromes are discussed in detail separately. (See "Screening for ovarian cancer" and "Overview of hereditary breast and ovarian cancer syndromes" and "Lynch syndrome (hereditary nonpolyposis colorectal cancer): Screening and prevention of endometrial and ovarian cancer".)

SGM have higher theoretical risks of developing ovarian cancer compared with heterosexual women because of increased rates of nulliparity and decreased hormonal contraceptive use [68]. There are no formal guidelines for ovarian cancer prevention for SGM with potential reproductive risk factors (eg, early menarche, nulliparity, and infertility). However, clinicians can discuss the potential benefits of using estrogen-progestin hormonal contraception for ovarian cancer risk reduction [69,70]. Ovarian cancer screening is generally not recommended for women at average risk for ovarian cancer, including women with a family history of ovarian cancer who do not have a confirmed ovarian cancer syndrome.

Sexually transmitted infection

Screening — A few studies suggest that some SGM, particularly younger women and women who also have sex with men, may be at increased risk for STIs, including human immunodeficiency virus (HIV) [71-74]. However, it is not yet clear if SGM should have distinct STI screening guidelines, in part because the data on risk of female-to-female STI transmission are limited [59]. Screening for STIs should be performed in women with symptoms or in those with risk factors [59]. (See "Screening for sexually transmitted infections".)

Behavioral risk factors include [59]:

New sex partner in the past 60 days

Multiple sex partners or sex partner with multiple concurrent sex partners

No or inconsistent condom use for any penetrative item (eg, sex toys) outside a mutually monogamous sexual partnership

Trading sex for money or drugs

Sexual contact (oral, anal, penile, or vaginal) with sex workers

Meeting anonymous sex partners on the internet

These demographic groups have a high prevalence of STIs [59].

Young age (15 to 24 years old)

History of a prior STI

Lower socioeconomic status, or high school education or less

Admission to correctional facility or juvenile detention center

Illicit drug use

SGM with STIs should be encouraged to inform their sexual partner(s) regarding the need for screening, diagnosis, and treatment. Sexual transmission between women has been reported for trichomoniasis, HIV, HPV, herpes simplex virus, hepatitis C, syphilis, chlamydia, and bacterial vaginosis (BV) [59,75-77]. Infectious agents can be transmitted through sexual behaviors that result in the exchange of vaginal secretions on hands or objects (eg, finger-to-vagina contact, genital-to-genital contact, or sharing objects such as sex toys without condom use or cleaning between partners) [78]. Sex toys, oral-genital contact, and fingers can also transmit bacteria from the anal region to the vagina. STIs can be acquired from female sexual partners even when there is a remote or no history of male sexual partners [66,79-85].

Bacterial vaginosis — Although BV is common in SGM, routine screening is not advised [86]. SGM in monogamous relationships are usually concordant for the presence or absence of BV; this has led some investigators to believe that BV, which is not considered a STI in heterosexual women, is probably transmitted between female sexual partners through exchange of vaginal secretions [81,87]. A systematic review of 14 studies that assessed risk factors for BV among SGM reported an association between BV and higher numbers of female sexual partners, both lifetime and in the prior three months [88]. (See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

For reasons that remain unclear, oral-genital sex, oral-anal sex, and sex toys may be more important risk factors for infection than penile penetrative sex. Screening asymptomatic female partners is not recommended, but women with symptomatic BV should encourage their female partners to be aware of the signs and symptoms of BV, given the high risk of concordant infection (25 to 50 percent) [89]. Treatment of confirmed infection is indicated for relief of symptoms.

(See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

(See "Bacterial vaginosis: Initial treatment".)

Prevention of sexually transmitted infections — Studies report that sexual activity among SGM frequently occurs without prophylaxis against STIs [76,90,91]. Options for STI prevention include the following:

Hepatitis A and B vaccination is indicated for SGM by specialty care groups [92]. Of note, the United States Centers for Disease Control and Prevention (CDC) do not include SGM as one of their high-risk groups [93]. (See "Hepatitis A virus infection: Treatment and prevention" and "Hepatitis B virus immunization in adults".)

HPV vaccination – Education regarding the benefits of HPV vaccination is particularly important for SGM, as the perceived need for vaccination has been reported to be lower for SGM than for heterosexual women [94,95]. In one study of over 12,000 United States women from 2006 to 2010, of women who were aware of the HPV vaccine, 8 percent of lesbian women had initiated vaccination compared with 28 percent of heterosexual women and 32 percent of bisexual women [96]. In an English population-based survey of over 790,000 men and women, SGM were over-represented among women with oropharyngeal cancer, which is typically HPV related [97]. These studies highlights the need to discuss HPV vaccination and modes of transmission with all women. (See "Human papillomavirus vaccination".)

Pharmacologic prophylaxis for HIV – Pre-exposure prophylaxis (PrEP) is offered to those at high risk of HIV transmission. There are no formal guidelines for starting Truvada (PrEP) for SGM. However, CDC guidelines do state that PrEP can be considered for HIV-negative individuals who are at substantial risk for HIV transmission. This includes people who are in a sexual relationship with a partner living with HIV (sero-discordant couples), who have penetrative intercourse with male-bodied individuals and do not regularly use condoms and who do not know the HIV status of their sexual partner(s), are engaged in commercial sex work, have had a recent bacterial STI, or use injections drugs and (1) share drug equipment, or (2) were recently in a drug treatment program [98]. In these situations [98], PrEP with tenofovir disoproxil fumarate-emtricitabine can reduce the risk of HIV transmission by more than 90 percent [99]. (See "HIV pre-exposure prophylaxis".)

Suppressive therapy for prevention of herpes – Similarly, couples who are sero-discordant for herpes simplex virus can use valacyclovir (500 mg once daily) to help prevent transmission of herpes simplex virus-2 to an uninfected sexual partner. (See "Prevention of genital herpes virus infections", section on 'Chronic suppressive therapy in discordant couples'.)

Safer sex – "Safer sex" refers to strategies for avoiding mucous membrane contact with a partner's blood or secretions. Examples include using male or female condoms, placing a dental dam or latex barrier over affected areas during oral sex, and washing sex toys with hot soapy water between uses (or covering the toy with a fresh condom). Couples who are mutually monogamous should still practice "safer sex" to limit possible transmission of BV. (See "Internal (formerly female) condoms".)

Substance misuse — As SGM report higher rates of tobacco use, exposure to secondhand smoke, and alcohol and drug use, we ask all patients about their substance use habits [47,49,100-102]. Limited research suggests that there is some association between higher rates of anxiety, substance abuse, and depression due to gender minority stressors [103]. A systematic review of 25 studies comparing LGBTQ and heterosexual individuals reported that lesbian and bisexual women had nearly fourfold increased risk of substance misuse [49]. The Population Research in Identity and Disparities for Equality (PRIDE) study, which asked over 1700 participants about substance use behaviors, reported different substance use patterns among different gender and sexual minority groups [104]. For example, asexual individuals had reduced likelihood of reporting binge alcohol or marijuana use within the past year while queer participants had an increased odds of marijuana use in the same time period. With varied and potentially increased prevalence of substance use in sexual and gender minority populations, it is important that providers and organizations offer inclusive material and resources for substance use education and treatment. Information regarding smoking cessation that is specific to LGBTQ tobacco users can be found at LGBT HealthLink and elsewhere. (See "Overview of smoking cessation management in adults" and "Screening for unhealthy use of alcohol and other drugs in primary care".)

Screening and treatment for substance use disorders can be found separately.

(See "Screening for unhealthy use of alcohol and other drugs in primary care".)

(See "Substance use disorders: Clinical assessment".)

(See "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis".)

Intimate partner violence — Intimate partner violence (IPV) refers to actual or threatened psychological, physical, or sexual harm by a current or former partner or spouse. IPV can occur among heterosexual or same-sex couples and does not require sexual intimacy. The CDC National Intimate Partner and Sexual Violence Survey 2010 reported that IPV (rape, physical violence, and/or stalking) was experienced by 61 percent of bisexual women, 44 percent of lesbian women, and 35 percent of heterosexual women [105]. Thus, we screen all women for IPV. Women who screen positive are assessed for safety and referred for counseling and help with intervention.

(See "Intimate partner violence: Diagnosis and screening".)

(See "Intimate partner violence: Intervention and patient management".)

CONDUCTING THE CLINICAL ENCOUNTER

Communication — All patients should be treated with empathy, nonjudgmental attitudes, and openness. Steps to create a welcoming environment for clinical care can include training of frontline staff regarding unique care needs of sexual and gender minority patients, creating gender-inclusive intake forms and resource materials, and using gender-inclusive language.

Sexual history-taking — Health care providers should not assume a patient has a particular gender or sexual identity or engages in particular sexual behaviors [106].

Tailored level of detail – When obtaining a sexual history, the appropriate level of detail depends on what is applicable for the patient's medical evaluation. The United States Centers for Disease Control and Prevention (CDC) Guide to taking a sexual history to taking a sexual history offers information on taking a nonjudgmental sexual history, including frank questions about partners, sexual practices, prevention and history of sexually transmitted diseases, and prevention of unintended pregnancy [107]. For example, the CDC advises starting with a statement such as, "I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health… I ask these questions to all of my adult patients, regardless of age, gender, or partnership/marital status. These questions are as important as the questions about other areas of your physical and mental health. Like the rest of our visits, this information is kept in strict confidence. Do you have any questions before we get started?" [107]. (See "The gynecologic history and pelvic examination", section on 'Gynecologic history'.)

Explain use of information – The Institute of Medicine and the Joint Commission recommend routine documentation of a patient's sexual orientation. First and foremost, in our practice, it is important to normalize this question and let patients know why you are asking, such as to better understand sexual risk and safety or determine whether contraception needs to be discussed. If patients are told why these questions are being asked and that this information is safe and confidential, most will be more forthcoming with this disclosure [108].

How to ask – Information on sexual orientation and behavior should be obtained using open-ended questions, gender-neutral questions and terms, and with nonjudgmental acceptance [92,109,110]. Use of inclusive-language forms may aid discussion. One cohort study of 540 patients with a mean age of 36 years who were evaluated in an emergency department reported greater patient comfort and improved communication when sexual orientation and gender identity information was collected by nonverbal registration form compared with nurse verbal collection [111].

Physical examination — The components of the physical examination of SGM are the same as for non-SGM. As with any patient, the clinician should be alert for signs of physical or emotional discomfort that can indicate a history of trauma or abuse. A trauma-informed care approach can reduce the potential to trigger or retraumatize a patient. (See "Intimate partner violence: Diagnosis and screening", section on 'Clinical presentation' and "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

Prior to starting any component of physical examination, we discuss whether or not a pelvic examination with speculum is indicated and explain the rationale. For patients who have had prior negative experiences or who have not had penetrative vaginal sexual activity, we discuss options including application of topical lidocaine to the introitus, use of topical lubricant, selection of a narrow/small speculum, and asking the patients if they would prefer to insert the speculum. Additionally, we discuss bringing a support person, distractions such as music, or use of anxiolytic medication to reduce the stress of a visit and aid muscle relaxation. A detailed discussion of the pelvic examination is presented separately. (See "The gynecologic history and pelvic examination".)

Lastly, for transgender men or nonbinary/gender-queer individuals it is helpful to ask if they have any particular terminology they use for their genital anatomy prior to the examination. Using gender neutral language, such as genital examination versus vaginal examination, etc can also be helpful.

REPRODUCTIVE HEALTH AND PARENTING ISSUES

Societal and financial issues — SGM encounter special obstacles in fulfilling their desires to become parents, including homophobic stigmatization and potential rejection by family. They may have limited access, finances, and availability of resources such as sperm banks and insurance coverage. These obstacles exist despite evidence from studies that have examined the psychosocial development of children raised by SGM and found no differences in sexual or gender identity, personality traits, or intelligence compared with children of heterosexual parents [112-115]. The National Longitudinal Lesbian Family Study: Mental Health of Adult Offspring reported no significant differences in the mental health status of children conceived through donor insemination compared with a normative sample of the United States population [116,117].

SGM who choose to have children have some needs similar to those of heterosexual couples and other needs unique to their circumstances [20,118].

Issues for the clinician – Clinicians should not assume that individuals in same-sex relationships do not desire pregnancy [115]. A 2017 meta-analysis of 28 studies reported that, compared with heterosexual women, the likelihood of having ever been pregnant was lower for lesbian women but higher for bisexual women [119]. We inquire about plans for family building and discuss optimizing reproductive health. Additionally, the clinician might need to address logistics, safety, effectiveness, and family/legal ramifications of various parenting options as well as referral to appropriate providers of fertility and parenthood services. The goal is to optimize fertility and minimize pregnancy complications. Due to health disparities recognized within the SGM community, it is important, much like with heterosexual patients, to screen and discuss risks, such as age at conception, chronic stressors, body mass index, as well as substance use [120].

Legal and contractual issues around parenting – Depending on one's route to parenthood, there are specific issues that patients will need to address. Issues that SGM must address include contracts regarding parenting, durable power of attorney, health proxies, second parent (or co-parent) adoption, custody issues in the event of death or separation, as well as issues regarding either known or anonymous sperm donor's rights [121,122]. In the United States, the 2015 Supreme Court ruling in the case of Obergefell v. Hodges stated that the fundamental right to marry is guaranteed for same-sex couples under the 14th Amendment of the United States Constitution [123]. The ability of individuals in same-sex couples to adopt varies by state. Advising patients to seek consultation with an attorney knowledgeable in this area is recommended.

Parenting options — SGM have several possible paths to parenthood including conception through known or anonymous donor insemination or in vitro fertilization (IVF), use of a surrogate, foster parenting, adoption, or raising children from prior heterosexual relationships [124].

Services aimed at LGBTQ+ individuals – Some LGBT clinics and LGBT-friendly health care providers in the US, Canada, and some European countries have protocols to offer SGM a safe pathway to pregnancy. Services may include screening for STIs, education about ovulation detection, instruction on home insemination techniques or availability of office insemination, and provision of access to frozen semen through sperm banks in the US which offer this service to all patients.

Fertility treatment – Both the Ethics Committees of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists have affirmed the right of single or coupled gay and lesbian persons to have access to fertility services [120,125]. For women who desire parenthood, we provide information regarding preconception care, prenatal care, and fertility services. The patient's female partner is included in all discussions if she is present. Issues concerning legal relationships with both the sperm donor and the nonbiologic same-sex parent should be addressed before starting fertility treatment.

Fertility services typically used by lesbian couples include intrauterine insemination (IUI) and IVF with donor sperm. Patients can elect fertility treatment for one partner (single partner), both partners (dual partner), or co-maternity, in which the egg of one partner is aspirated, fertilized as in an IVF procedure, and then transferred to the uterus of the other partner, who is the gestational carrier [126]. Although this allows both partners to biologically participate in the pregnancy, it is more costly and risky than simple insemination.

In a retrospective chart review of 306 lesbian couples who sought reproductive assistance with either IUI or IVF, 85 percent attempted single-partner conception and 68 percent had a live birth [127]. An additional 15 percent of couples elected dual-partner conception, and 89 percent had a live birth. An average of 3.0±1.1 cycles were completed for women who conceived with IUI and an average of 6.0±1.4 IUI cycles plus 1.7±0.3 IVF cycles for women who conceived with IVF. Both IUI and IVF are presented in detail separately. Not surprisingly, lesbians using assisted reproductive health services are more likely to be successful than heterosexual women who typically use these services after a diagnosis of infertility [119,128]. (See "Donor insemination" and "In vitro fertilization: Overview of clinical issues and questions".)

Adoption – Issues related to adoption are reviewed in detail separately. (See "Adoption".)

Foster parenting – Foster care is reviewed in detail separately. (See "Epidemiology of foster care placement and overview of the foster care system in the United States".)

Prenatal care – Components of prenatal care are the same regardless of sexual orientation or practice. However, clinicians should be aware of common needs and medical issues of SGM patients. As with heterosexual couples, the presence of a partner is welcomed at antenatal visits, childbirth preparation classes, during labor, and postpartum.

Assess potential medical needs – A study of the 2014 to 2016 Behavioral Risk Surveillance System reported that pregnant SGM patients experienced more depression, mental distress, chronic health issues, and poorer quality of health, and were more likely to smoke daily, compared with pregnant heterosexual patients [128].

Potential for worsening gender dysphoria – Pregnancy can worsen gender dysphoria for some SGM patients. Cessation of hormone therapy, physical changes of pregnancy, labor pain, lactation, and invasive physical examinations are but some of the potential challenges for SGM individuals that should be addressed by obstetric providers [129].

Components of prenatal care are presented in detail separately.

(See "Prenatal care: Initial assessment".)

(See "Prenatal care: Second and third trimesters".)

Prevention of unintended pregnancy — SGM are less likely to take advantage of low-cost gynecologic care, frequently provided by family planning clinics. Since SGM can have sex with men or male-bodied individuals, we inquire about and address each woman's need for contraception as appropriate to their history and needs [9]. A focus group study of 22 individuals who identified as SGM revealed that SGM, especially adolescents, are at higher risk of having an unintended pregnancy than heterosexual women [130]. In a survey study of nearly 400 SGM, 16 percent reported having been pregnant, and of those who had been pregnant, 63 percent reported having one or more induced abortions [76]. Contraception counseling is presented in related content. (See "Contraception: Counseling and selection".)

Exposure to sexual violence – Compared with heterosexual women, SGM have reported more severe victimization and higher rates of sexual revictimization [131]. In a study of over 7600 women undergoing abortion in 2014, women who identified as bisexual, lesbian, or something else were two to nine times more likely to report physical violence by the man involved in the pregnancy compared with heterosexual women [132]. In addition, lesbian women were 18 times more likely than heterosexual women to report sexual abuse by the man involved in the pregnancy, and 10 percent of lesbian women noted the pregnancy was a result of forced sex.

Additional information related to sexual violence can be found in:

(See "Intimate partner violence: Epidemiology and health consequences".)

(See "Intimate partner violence: Diagnosis and screening".)

(See "Intimate partner violence: Intervention and patient management".)

(See "Date rape: Identification and management".)

UNIQUE SUBPOPULATIONS

Racial and ethnic minorities — There is a paucity of research on the subject of how race and ethnicity of SGM may be associated with higher risk of poor health behaviors and outcomes. More health policy work is being done in the US on these disparities [133,134].

Adolescents — LGBTQ youth issues are presented separately.

(See "Sexual development and sexuality in children and adolescents".)

(See "Gender development and clinical presentation of gender diversity in children and adolescents".)

(See "Management of transgender and gender-diverse children and adolescents".)

(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)

Older women — While there are no medical guidelines unique to the care of older SGM, clinicians should be aware of the potential impact of lifelong stigmatization, victimization, and discrimination on older SGM and inquire about these issues [135]. A population-based study in Washington affirmed that, when compared with heterosexual women, older LGBTQ individuals have higher rates of obesity, mental health issues, smoking and alcohol use, and cardiovascular disease [136]. In addition to these mental and physical health challenges, older LGBTQ patients can face significant life-changing issues, including sexual issues; isolation and lack of social support; problems with financial security; end-of-life issues with housing, long-term care, and palliative care; and the experience of discrimination and mistreatment in these situations [137]. These health disparities, estrangement from family, and lower rates of parenting and/or partnering result in a group that can require more access to health and human services as they age [136,138,139]. The long-term care issues of older LGBTQ women requires more study. SAGE (Services and Advocacy for GLBT Elders) is a national organization that has many resources for LGBTQ elders and caretakers.

Transgender individuals — Routine care for transgender individuals should include assessment of contraceptive needs and discussion of fertility goals. Examples of issues to address include gamete preservation prior to gender-affirming hormone therapy or surgery and need to stop testosterone during pregnancy as it is teratogenic to female fetuses [129,140].

Although data are limited, transgender men who become pregnant and give birth do not appear to be at increased risk for poor obstetric outcomes. A study evaluating birth outcomes for trans men (total n = 1907) and cisgender people (total n = 2,721,507) from two national US databases (Medicaid and a commercial insurer) reported transgender men had similar rates of severe morbidity and preterm birth as well as a lower rate of cesarean birth despite an overall higher prevalence of chronic medical conditions and increased rates of anxiety or depression [141]. While study limitations included a relatively small number of transgender birthing people, potential gender misclassification, and low frequency of severe morbidity, we find this study helpful when counseling transgender male patients desiring or experiencing pregnancy.

Discussions of specific needs of transgender individuals include:

(See "Primary care of transgender individuals".)

(See "Transgender women: Evaluation and management".)

(See "Transgender men: Evaluation and management".)

(See "Gender-affirming surgery: Female to male".)

(See "Gender-affirming surgery: Male to female".)

Homeless and incarcerated — Challenges faced by SGM may be further exacerbated by homelessness or incarceration. Additional discussions about the health care of homeless and incarcerated persons are presented separately.

(See "Health care of people experiencing homelessness in the United States".)

(See "Clinical care of incarcerated adults".)

(See "Prenatal care: Incarcerated females".)

Disabled people — In the 2019-2020 National Survey on Health and Disability, SGM adults with disabilities reported having poorer health status than their heterosexual peers [142].

(See "Disability assessment and determination in the United States".)

(See "Primary care of the adult with intellectual and developmental disabilities".)

Veterans — The US Department of Defense has a policy of nondisclosure of sexual and gender minority identity. Therefore, the Veterans Health Administration (VHA) has not inquired about or documented veterans' sexual orientations and gender identities. However, one study suggested that veterans would be comfortable disclosing this information and would then be more likely to receive culturally appropriate care [143].

Immigrants, political refugees, and other disenfranchised sexual minorities — The safety and health care of sexual minority persons varies around the globe. Sexual minority persons may be subjected to sexual assault, "corrective rape" [144], imprisonment [145], abuse, and torture. This marginalization and stigmatization, combined with higher rates of poverty and abuse, are major chronic stressors that can lead to mental health disorders and significant health morbidity [146]. Detailed information on the health care needs of immigrants and refugees is presented separately. (See "Medical care of adult refugees, immigrants, and migrants".)

RESOURCES FOR PATIENTS AND CLINICIANS

Websites

National LGBTQIA+ Health Education Center – Provides free online training, including videos and webinars, and education on many LGBT health topics.

National Institutes of Health: Sexual and Gender Minority Research Office: Strategic Plan to Advance Research on the Health and Well-being of Sexual and Gender Minorites, 2021-2025

United States Department of Health and Human Services

Centers for Disease Control and Prevention

GLMA – Formerly known as the Gay & Lesbian Medical Association, the GLMA is an association of LGBT health care professionals that provides free resources for patients and providers.

Fenway Health – "The mission of Fenway Health is to enhance the well-being of the LGBTQIA+ community and all people in our neighborhoods and beyond through access to the highest quality care, education, research, and advocacy."

HealthyPeople.gov

Institute of Medicine

National Alliance on Mental Illness

American Academy of Pediatrics

SAGE (Services and Advocacy for LGBT Elders)

Centers for Medicare and Medicaid Services, Office of Minority Health

Books

Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health, 2nd ed, Makadon HJ, Mayer KH, Potter J, Goldhammer H (Eds), American College of Physicians, Philadelphia 2015.

Lesbian, Gay, Bisexual, and Transgender Healthcare: A Clinical Guide to Preventive, Primary, and Specialist Care, 1st ed, Eckstrand KL, Ehrenfeld JM (Eds), Springer, 2016.

Lesbian Health 101: A Clinician's Guide, 1st ed, Dibble SL, Robertson PA (Eds), UCSF Nursing Press, 2010.

LGBT Health: Meeting the Needs of Gender and Sexual Minorities, Smalley KB, Warren JC, Barefoot KN (Eds), Springer, New York 2017.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Health care for lesbian, gay, and other sexual minority populations" and "Society guideline links: Sexually transmitted infections".)

SUMMARY AND RECOMMENDATIONS

Sexual orientation and behavior – Sexual orientation refers to one's innermost emotional, romantic, and sexual attractions to other people. Historically, sexual orientation was thought of with three main categories including heterosexual, lesbian or gay, and bisexual. However, sexual behavior embraces a complex spectrum of patterns of romantic and/or sexual activities and may not be so clearly categorized. Many perceive their attractions as more fluid than this, and do not identify within these binary categories and instead identify as queer, pansexual, etc. (See 'Language and terminology' above.)

Sexual and gender minority women – The term "sexual and gender minorities" (SGM) is used to broadly include those who identify as women, have a non-heterosexual sexual orientation, and who may be self-identified as lesbian, gay, bisexual, transgender, queer, or other. SGM are a heterogeneous group of individuals from a multiplicity of backgrounds regarding race, ethnicity, education, socioeconomic status, etc. (See 'Introduction' above.)

Epidemiology – Obtaining accurate information about the prevalence of SGM is challenging because gender, sex, and behavior are not the same, and national census surveys have historically not asked about sexual orientation or gender identity. In the United States, gay and lesbian people were first recognized as a subpopulation on the 1990 census. Rates of same-sex sexual behavior are higher than rates of self-identification as lesbian or bisexual. (See 'Data and limitations' above.)

Impact of sexual minority status on health care received – Societal stigma, discrimination, and denial of civil and human rights can result in health care and other disparities. When individuals do not conform to established heteronormative gender roles, their access to and control over resources that contribute to health can also be reduced. Recognizing women who identify with sexual minority groups is important because it allows patients to be known and affirmed by their provider, and it allows the provider to be aware of potential health disparities such as SGMs' increased risk for adverse health outcomes, including mood disorders, tobacco and substance use, and sexually transmitted infections (STIs). (See 'Impact of sexual orientation on social determinants of health' above.)

Cultural competency – Cultural competency focuses on the ability to communicate effectively and provide quality health care to patients from diverse sociocultural backgrounds. Not making assumptions about patient's sexual orientation identity or behaviors is fundamental in providing inclusive care. Professionalism, confidentiality, being aware of internal assumptions, and an unbiased approach are key components for enabling women to identify themselves as well as for better interactions between them and their health care providers. (See 'Components' above.)

Areas of known health care disparities – While there are no diseases specific to SGM, the health disparities that result from identification with a minority group and the risks associated with specific health behaviors require additional consideration. Specific issues that warrant discussion with SGM include mental health and support systems, obesity, cardiovascular and pulmonary diseases, cancer screening and prevention, STIs, protection from unplanned pregnancy, plans for pregnancy, substance use, and intimate partner violence. (See 'Clinical conditions and risk factors for adverse health outcomes' above.)

Taking a sexual history – When obtaining a sexual history, the appropriate level of detail depends on what is applicable for the patient's medical evaluation. The United States Centers for Disease Control and Prevention (CDC) Guide to taking a sexual history offers information on taking a nonjudgmental sexual history, including frank questions about partners, sexual practices, prevention and history of sexually transmitted diseases, and prevention of unintended pregnancy. (See 'Sexual history-taking' above.)

Physical examination and screening tests – The components of the physical examination and age-appropriate screening guidelines for SGM are the same as for non-SGM. As with any patient, the clinician should be alert for signs of physical or emotional discomfort that may indicate a history of trauma, and be aware of how to provide trauma-informed care. (See 'Physical examination' above.)

Pregnancy and parenting – SGM encounter special obstacles in fulfilling their desires to become parents, including homophobic stigmatization, potential rejection by family or communities, and limited access to and availability of resources such as sperm banks and insurance coverage. SGM have several possible paths to parenthood including conception through donor insemination or in vitro fertilization, use of a surrogate, foster parenting, adoption or raising children from prior heterosexual relationships. Both the Ethics Committee of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists have affirmed the right of single or coupled, gay, and lesbian persons to have access to fertility services. (See 'Reproductive health and parenting issues' above.)

Unique subpopulations – Within the diverse group of individuals who identify as SGM, subpopulations with specific health care needs include adolescents, older individuals, transgender individuals, homeless or incarcerated people, disabled individuals, veterans, immigrants and refugees. (See 'Unique subpopulations' above.)

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Topic 5426 Version 62.0

References

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