LGBQIA+ and gender minority pts Flashcards
natal sex, gender, sexual orientation = identity
differences between sex assigned at birth, gender identity, and sexual orientation
sexual orientation
-its possible for someone whose sexual orientation is heterosexual to be SA with same sex partner (female with a biological female that identifies as a man)
-How important is it to know the patient’s sexual orientation?
-It is more significant to know with whom pt is SA, and what sexual activities in which they participate with their partner(s)
-This permits a better opportunity to assess risk for STIs, pregnancy, and need for PrEP
other terms related to the gender minority community: trans, cis, non-binary
-Transgender- umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth
-Cisgender refers to people whose gender identity is congruent with the sex they were assigned at birth
-Non-binary or genderqueer: terms used by people who experience their gender identity and/or gender expression as falling outside the categories of man and woman.
-However, it is more inclusive to refer to this community as gender diverse or gender minority
what is LGBTQAI+
-Agender
-Asexual
-Bisexual
-Cisgender
-Gay
-Gender fluid
-Gender expansive
-Gender non-binary or genderqueer
-Gender non-conforming
-Intersex (differences of sexual development)
-Lesbian
-Pansexual
-Queer
-Questioning
-Transgender
sex assigned at birth
-The gender given to a neonate at delivery based on the appearance of the external genitalia
-Assigned male at birth (AMAB)
-Assigned female at birth (AFAB)
gender dysphoria / incongruence
-distress experienced by pts bc of incongruence between gender identity and physical gender
-was called gender identity disorder (outdated term)
-DSM-V dx of gender dysphoria:
-marked incongruence between pts experienced/expressed gender and assigned gender, -> at least 6 months
-manifested by 2+ of following:
-marked incongruence between pts experienced/expressed gender and primary or secondary sex characteristics (in young pts -> anticipated secondary sex characteristics)
-strong desire to rid of primary and/or secondary sex characteristics bc of marked incongruence with experienced/expressed gender
-strong desire for primary and/or secondary sex characteristics of other gender
-strong desire to be of other gender (or alt gender different from one’s assigned gender)
-strong desire to be treated as other gender (or alt gender different from assigned gender)
-strong conviction that one has the typical feelings and reactions of the other gender (or alt gender different from assigned gender)
-condition must be assoc with clinically significant distress or impairment in social, occupational, or other important areas of function
what percent of population is intersex
-2%
-gender minority- 1%
complete androgen insensitivity syndrome (AIS)
-common! - more common than people with green eyes
-XY but loss of function gene
-blocks recognition of testosterone production
-body make testosterone but doesnt recognize it
-these pts present as XX -> have no idea they are XY
-pt will go through female puberty without mensuration -> bc no ovaries
-testicles are internal and stay warm -> increase risk of cancer -> gonadectomy
-normally testosterone produced at 11 weeks gestation
-partial AIS- ambiguous genitals
-wait and see how that person identifies
Stats regarding health care discrimination of LGBATQAI+ pts
->50% of LGBTQAI+ pts experience some form of discrimination when seeking medical care
-20% of gender minority people have been denied care because they are transgender or gender non-conforming
->50% of gender minority pts find their practitioners are not sufficiently aware of their needs
-28% of gender minority pts have postponed medical care because of this discrimination
-LGBTQAI+ pts who are black or brown are 2x more likely to avoid medical care than white pts
-75% of lesbians report delaying or avoiding health care -> most likely to be financially challenged bc they are women
anti-LGBTQ bills
what diseases or conditions are LGB pts at increased risk?
-Lesbians:
-Alcoholism- from depression, minorities met at bars
-Obesity
-Tobacco related disorders
-Breast, ovarian and endometrial carcinomas- not ever having been pregnant
-Cardiac disease
-Depression and anxiety
-Suicide
-PTSD
-Physical violence
-Gay men:
-Alcoholism and drug use
-STIs- HIV/AIDS, Syphilis, HPV -> other STIs go up as HIV becomes less of a worry
-Hepatitis B and C
-Cardiac disease- stress
-Anal carcinoma
-Depression and anxiety
-Suicide
-Eating disorders and body dysmorphic disorders
-bisexual women:
-cardiac ds
-breast carcinoma
-obesity
-binge drinking
-tobacco dependence
-bisexual men:
-HPV
-anal carcinoma
-bisexual men and women:
-increased intimate partner violence
-alcohol
violence in the gender minority community in 2024
-TheHuman Rights Campaign reported that in 2024, at least 36 gender minority people were killed through violence
-Of these -> nearly 1/2 were black or brown transgender women
-tend to be sex workers
what diseases are gender minority pts at increased risk?
-violence:
-16-60% of transgender pts are victim of physical assault or abuse
-13-66% of transgender individuals are victims of sexual assault
-all minorities are at higher risk for sexual assault- even disabled
-suicide:
-38-65% of transgender individuals report suicidal ideation
-up to 28% of young gender non binary individuals have reported suicidal ideation
-16-32% of transgender pts attempt suicide
-mental health:
-depression, anxiety, and other psychiatric conditions
-substance abuse
-tobacco dependence
-HIV/AIDS
-STIs
how to have your office staff welcome LGBTQAI+ pts
-Practice cultural humility -> Your own experiences may not be similar to those that others have had
-Your pts may have different experiences or identities
-Do not expect pts to teach you about how to care for a LGBTQAI+ pt (or any other kind of pt)
-Help educate your staff: MAs, receptionists, phlebotomists, etc. all need to welcome all pts in a positive, affirming, compassionate and non-judgmental manner
avoid assumptions
-key principle of effective communication is to avoid making assumptions:
-Don’t assume that:
-You know a person’s gender identity or sexual orientation based on how that person looks or sounds
-You know how a person wants to describe themselves or their partners
-All of your pts are heterosexual and cisgender (not gender minority)
registration
-Registration forms should have a space for patients to enter their preferred name and pronouns
-This information should also be included in medical records
-pt’s pronouns and preferred name should be used consistently by all staff
use of pronouns
-use pts preferred names and pronouns
-transgender often change their name to affirm their gender identity
-name is sometimes diff from what is on insurance or identity documents
-If unsure about pt’s preferred name or pronouns:
-“I would like be respectful—what name and pronouns would you like me to use?”
-If pt’s name doesn’t match insurance or medical records:
-“Could your chart/insurance be under a different name?” -> make sure you confirm the pt before anything else
-“What is the name on your insurance?”
-If you accidentally use the wrong term or pronoun:
-“I’m sorry. I didn’t mean to be disrespectful.”
terms to avoid
-AVOID:
-homosexual -> gay, lesbian, bisexual, or LGBT
-transvestite; transgendered -> transgender, gender minority, gender non-binary (GNB)
-sexual preference; lifestyle choice -> sexual orientation
accountability
-Creating environment of accountability and respect requires everyone to work together
-Don’t be afraid to politely correct your colleagues if they make a mistake or make insensitive comments
-“Those kinds of comments are hurtful to others and do not create a respectful work environment.”
-“My understanding is that this patient prefers to be called ‘Jane’, not ‘John’.”
Human Rights Campaign 2024 Healthcare Equality Index Participants (n=1065)
Human Rights Campaign (HRC) Long-Term Equality Index 2023
collection of gender identity data
-all pts should be asked for following:
-chosen name
-given name
-current gender identity
-preferred pronouns
-practices can include a descriptive statement so to reduce or eliminate confusion for cisgender pts
-some EMRs do not have the flexibility to use these data
of gender minority pts in US
-approx 150,000 youth and 1.4 mil adults who identify as transgender
-approx 1.2 mil gender non-binary (GNB) adults
-These numbers may well underestimate the actual number of gender minority individuals
medical hx of the gender minority pt
-Past medical hx
-Surgical hx -> Includes but is not limited to gender-affirming surgical procedures
-Organ inventory
-Medications:
-Prescribed medications- Hormone therapy
-Over-the-counter medications
-Alternative therapies
-Family history:
-Diabetes mellitus
-Hypertension
-Thrombophilias
-Bleeding tendencies
-History of hormone-sensitive malignancies- Prostate carcinoma, Endometrial carcinoma, Ovarian carcinoma, Breast carcinoma (especially for AMAB)
-Psychosocial history
-Support- Family, friends and community
-Employment
-Housing
-Financial issues
-Sexual history
-Sexual orientation
-Sexual practices
-Need for contraception
organ inventory
-AFAB (assigned female at birth):
-Breasts
-Ovaries and Fallopian tubes
-Uterus
-Cervix
-Vagina
-Vulvar structures
-AMAB (assigned male at birth):
-Prostate
-Penis
-Testicles
screening tests for the gender minority pt
-cervical carcinoma: AFAB gender minority pts with a cervix
-prostate carcinoma: AMAB gender minority pts with a prostate
-very hard to find a prostate is a transgender female on GAHT
-breast carcinoma:
-Transgender women on gender affirming hormone therapy (GAHT) at age 50+ with risk factors
-Estrogen and/or progestin use for >5 years, family hx, obesity -> breast exam and mammo
-AFAB gender minority pts who have not had bilateral mastectomy
physical exam of the gender minority pt
-examine genitalia only if indicated regarding the complaint
-refer to genitalia either by the usual terminology or by asking pts if they have a particular term they prefer to use
-a transgender man may prefer the word canal to vagina
special considerations with gender minority pts
-General survey and skin exams may vary based on hormone therapy in gender minority pts
-may be skin manifestations due to breast binding or testicular tucking
-In transgender male pt having cervical cytology -> communicate to lab to indicate presence of cervix to avoid confusion with a gay male pt having an anal Pap
-Offer someone to provide support during exam or other distraction
-Some transgender male pts may require sedation -> -Consider administration of anxiolytic 30-60 mins in advance
-For transgender male pts, vaginal estrogens administered 2x weekly for several weeks prior to exam may also make exam more comfortable
-Allow pt to have as much control over exam as possible
-AMAB pts with vaginoplasty may benefit from use of anoscope instead of vaginal speculum -> vagina tends to narrow and shorten -> painful
-Consider delaying exam until pt is comfortable with practitioner
chest binding and tucking
In order to be recognized as the pts gender identity, AFAB gender minority pts may bind the breasts and AMAB gender minority patients may displace the testes and penis
chest binding
-May include commercially produced chest binders, Ace bandages, duct tape, etc.
-Should NOT use if cardiopulmonary ds
-May cause restrictive lung disease to worsen
-Should NOT use for > 8 hrs per day or at gym
-sequelae:
-Restricted lung capacity
-Skin irritation or skin breakdown
-Syncope
-Rib fracture
-Pleural effusion
tucking
-Displacement of testes into inguinal canal and repositioning flaccid penis and scrotum between legs and posteriorly towards anus
-Tape, tight underwear or other devices keep genitals in place
-can be gender affirming
-keeps them safe as they are more often read as female
-sequelae:
-Urinary reflux
-Testicular torsion
-Hernia
-Prostatitis
-Epididymitis
-Orchiitis
-Cystitis
-Local trauma to skin from tape
untrue statements concerning gender-affirming hormone therapy (GAHT) for gender minority pts
-Pts must want to transition entirely
-Pts must stay on hormonal regimen for life
-There are no options for GAHT for GNB pts
-There are no options for GAHT for pts with underlying medical conditions
WPATH criteria for initiation of GAHT for gender minority pts
-Persistent, well-documented dysphoria (6 months+)
-Capacity to make a fully informed decision and to consent for tx
-Age of adult
-well controlled medical and mental health
gender affirming hormone therapy (GAHT) for the gender minority pt
-Not all pts wish to have a medical and/or surgical transition
-GNB may use GAHT to reduce gender dysphoria while not fully transitioning
-you cant choose which SE of GAHT you get
-Genetics and other factors often dictate what SE occur
risks of GAHT for pts desirous of feminization
-estradiol
-DVT, PE, stroke, MI -> degree of risk is unknown
-HTN -> May use spironolactone to supplement (acts as antiandrogen) to mitigate risk
-DM -> Consider annual hemoglobin A1c or fasting glucose
-Hyperlipidemia -> Consider use of transdermal estrogen
-transdermal is always better -> bypass first pass effect & decrease risk of DVT
-Decreased risk of hyperlipidemia AND of thromboembolic events
-Osteoporosis
data and exams to obtain before and during GAHT for pts desirous of feminization
-prior to initiation:
-prolactin
-triglycerides
-bone mineral density
-Monitoring:
-every 3 months x 1 year; then every 6-12 months
-Serum testosterone and estradiol to determine results are in normal female range
-Testosterone: 30-100 ng/dL
-Estradiol: <200 pg/mL
-MAKE SURE LAB GENDER IS LABELED AS UNKNOWN -> ref ranges are diff
-Screen for breast and prostate carcinoma as indicated
GAHT for the pt desirous of feminization: estradiol and progesterone (dont need to know doses)
-Oral estradiol: orally daily
-Transdermal estradiol: daily
-Estradiol valerate: IM every 2 weeks
-Estradiol cypionate: IM every 2 weeks
-Progesterones:
-Medroxyprogesterone acetate orally daily at bedtime
-Micronized progesterone orally daily at bedtime
-make pts feel more female- gives menses
androgen blockers for the pt desirous of feminization
-Spironolactone by mouth 2x daily
-Finasteride by mouth daily
-Dutasteride by mouth daily
risks of GAHT for pts desirous of virilization
-Polycythemia
-HTN
-DM in pts with hx of PCOS ->Otherwise no risk
-Hyperlipidemia
-Increased risk of elevated LDL and lowered HDL -> Use of transdermal testosterone seems to not affect lipid levels (estradiol can decrease)
-Unclear effect on risk of cardiovascular ds
-Variable effect on risk of osteoporosis -> Depends on when pt began testosterone and whether progestins were used
-progesterone can stop menses - depo, iud
data and exam to obtain before and during GAHT for pts desirous of virilization
-Prior to initiation:
-CBC- polycythemia
-Lipid panel
-Bone mineral density if pt is at risk of osteoporosis
-Monitoring:
-every 3 months x 1 year; then every 6-12 months
-Serum testosterone to determine results are in normal male range (300-1000 ng/dL)
-Peak level drawn within 24-48 hrs if pt is using parenteral (IM, IV, subq) testosterone
-Trough levels drawn right before injection
-Screen for breast and cervical carcinoma as indicated
GAHT for the pt desirous of virilization
-Testosterone cypionate IM or subq weekly
-Testosterone enanthate IM or subq weekly
-Testosterone topical gel 1% topically every morning -> put it on bony part and dont let anyone touch
-Testosterone topical gel 1.62% every morning
-Testosterone patch every evening
-Compounded dihydrotestosterone cream topically to clitorophallus in divided doses every 8 hours
-can do biweekly but you feel it wane
GAHT for the gender minority pt
-Titrate dose based on pt goals and safety monitoring
-Be cautious regarding reference values!
-If pt is AFAB and is registered as female, the lab will report female reference values
-if your testosterone goes above normal -> turns into estrogen!!!!! and also polycythemia risk
effects of feminizing hormones
effects of virilizing hormones
contraception and fecundity
-fecundity= potential to become pregnant
-fertility= persons experience with fecundity
-Contrary to common belief, GAHT does not preclude fecundity
-pts on T still ovulate
-Be sure to ask your pt about sexual practices
-Counsel appropriately about contraception or about measures to improve possibility of conception
gender minority children and adolescents
-incidence- 0.5-3.7%, likely to be underestimated
-increasing in incidence and occurring at earlier age
-pts at 18 months may express gender dysphoria
-Sx include the desire to:
-Dress in clothes of opposite gender
-play traditional roles of opposite gender in play
-Play with toys traditionally used opposite gender
-majority who socially transition (change name) by 12yo continue to identify as transgender 5 years later
-Only 1.3% of pediatric pts detransition
-Over 19% of pts regret having bariatric surgery
uterine transplant
-max 2 kids then remove due to immunocompromise
-cant deliver vaginally
the pediatric and adolescent transgender care team
-Should include subspecialists:
-Endocrinology
-Psychiatry
-Gynecology
-Plastic surgery
-Urology
approach to the pediatric pt with gender dysphoria
-Refer to gender dysphoria clinic at presentation
-Develop trusting relationship
-Review potential for any existing risk
-Mental health
-Substance use
-Safety in the home
-Sexual behavior
-If any immediate risks -> manage as needed and refer to a transgender program
medical tx of peri-pubertal gender minority pts
-never treat a pre-pubertal pt!
-Hormone blockers
-Gonadotropin releasing hormone (GnRH) agonists with consent of parent(s) and pt
-Leuprolide 7.5 mg IM every week
-GnRH analogues give pt time to consider the gender dysphoria while avoiding continuation of puberty
-pause for 2 years
-reduces extent of tx if pt undergoes hormone therapy and/or gender-affirming surgery
-Puberty suppression should only be used in patients after they become pubertal
-“Stage, not age”: onset of puberty based on Tanner staging
effects of GnRH analogues in children and adolescents (right after puberty starts)
-Cessation of development of secondary sex characteristics
-Atrophy of breast tissue
-Amenorrhea
-Possible decrease in testicular volume
-for 2 years
adverse effects of GnRH in children and adolescents
-Possible transient decrease in bone mineralization in gender minority AMAB and AFAB pts
-Possible decrease in fertility
-Pts should consider preservation of fertility prior to puberty suppression or GAHT
-preservation of oocytes, sperm banking
GAHT for feminizing effects in adolescents
-Estrogens
-Estradiol 0.5 mg by mouth daily x 6 months
-Then increase to 1 mg by mouth daily x 6 months
-Then increase to 2 mg by mouth daily
GAHT for virilizing effects in adolescents
-Testosterone enanthate 50 mg IM every two weeks x 6 months
-Then increase to 100 mg IM every two weeks x 6 months
-Then increase to 150 mg IM every two weeks x 6 months
monitoring in adolescents using GAHT
-Vital signs
-Tanner staging
-Bone age if still growing in height
-Bone mineral density
-Testosterone and estradiol
-Electrolytes, A1c, hepatic panel
-Lipids
-LH, FSH
gender affirming feminizing surgical procedures
-Breast augmentation- sometimes in addition to hormone growth
-Penectomy
-Orchiectomy
-Vaginoplasty
-Facial feminization
-Forehead contouring
-Tracheal shave
-Vocal feminization- not common (voice therapy instead)
-medically necessary- covered
breast augmentation
-#1 regret in breast reduction is that they didnt do it sooner
-some breast development from estradiol
pre- and postoperative male to female genital confirmation surgery (penectomy, orchiectomy, scrotoplasty, vaginoplasty)
-penile skin and scrotal skin -> does not self lubricate
-perineal tissue -> self lubricates and no smell
-intestinal mucosa -> lubricates but it smells
-self dilation
vaginoplasty
-Potential sources of vaginal epithelium:
-Penile or scrotal epithelium (will not self-lubricate)
-Intestinal mucosa (will self-lubricate)
-Less common due to odor and large amount of mucus production
-Peritoneal tissue (will self-lubricate and no smell)
pre- and postoperative facial feminization
-forehead contouring
-tracheal shave
gender affirming masculinizing surgical procedures
-Mastectomy -MC
-Chest reconstruction
-Monsplasty- fatty tissue in pubic area
-Hysterectomy, bilateral salpingectomy and oophorectomy
-Vaginectomy - removal of vaginal tissue
-must have hysterectomy with vaginectomy
-no vagina and retains uterus -> abnormal bleeding -> there will be no signs of it without the vagina
-Metoidioplasty
-Phalloplasty
-Scrotoplasty- from labia majora
-Urethral lengthening
pre- operative and postoperative subcutaneous double mastectomy and chest reconstruction
masculinizing procedures: metoidioplasty
-makes a penis from clitorophallus
-Releases the clitorophallus from its suspensory ligament and labial tissues
-clitorophallus has significant growth due to testosterone (take it before surgery)
-usually results in penis of 4-6 cm in length - 2-3 inches
-Vaginal penetration may or may not be possible
-Tumescence (swelling) and orgasm are almost always preserved
masculinizing procedure: phalloplasty
-Creates a penis from donor site
-Radial forearm
-Anterolateral thigh
-Musculocutaneous latissimus dorsi
-Erection is possible with penile implant
-Sensation and orgasm are often possible
-there is no lengthening during erection
-intense scarring
gender affirming procedures for gender non-binary (GNB) pts
-For AMAB patients:
-Breast augmentation
-Penectomy
-Orchiectomy
-Scrotectomy
-Vulvoplasty
-Phallus-preserving vaginoplasty
-For AFAB patients:
-Subcutaneous mastectomy
-Vagina-preserving phalloplasty
-For AMAB or AFAB patients who identify as agender:
-Gender nullification surgery
hair removal
-Required prior to neovaginoplasty and phalloplasty- cant have hair growing in the vagina
-laser hair removal is approved -> but pts may still require electrolysis, especially for gray or white hairs
-Financial barriers are of real concern
-Pts commonly seek hair removal from nonmedical places -> not knowledgeable in needs or techniques
vocal changes
-GAHT is unlikely to yield a feminine-sounding voice in postpubertal patients
-voice therapy, phonotherapy, or both
-Voice therapy helps AMAB pts speak in a feminine manner
-Pts more commonly choose only voice therapy
-In a meta-analysis of 17 studies, 80-85% of pts stated they were satisfied with their outcomes
fertility preservation (FP) in pts considering use of GAHT
-Approx 40-54% of gender minority wish to become parents
-unknown if testosterone affects fertility adversely
-Estrogen results in smaller seminiferous tubules and abnormal appearing Sertoli and Leydig cells
-Numerous agencies recommend FP prior to beginning GAHT
-many pts may be adolescent at the time of FP
-Some theories of etiology of being transgender male suggest higher circulating androgens during fetal development
-There is evidence that this circumstance is associated with decreased fertility
-Some literature also suggests an increased incidence of PCOS in transgender men
consideration regarding FP
-oocyte cryopreservation procedure can cause significant dysphoria
-Includes potential for cessation of GnRH agonists
-Progression of puberty
-Delay or interruption of GAHT
-Cost and access to care are significant concerns for many patients
