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Lippincott Nursing Pocket Card - May 2024

Affirming Care for Patients who are LGBTQIA2+

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Background

Affirming care recognizes the significant impact of sexual and gender minority (SGM) status on a person’s health and is critical to ensuring SGM patients receive culturally competent and clinically appropriate care (McElwain & Carr, 2021; Cottrell, 2019). Meeting the needs of this vulnerable population requires a multifaceted approach and specialized clinical education including gender-inclusive terminology and trauma informed care (Shihabuddin, Lee & Casler, 2023).

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Definitions (Shihabuddin, Lee, & Casler, 2023)

Providing affirming care necessitates an understanding of terms that are unique to the SGM community. In addition to lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, two-spirit, or other minority sexual and gender identities (LGBTQIA2+), here are key terms you should know. Please note this list is not exhaustive and is ever-changing.

  • Affirmed gender: an individual’s innate gender identity

  • Ally/allyship: individuals who support marginalized groups
  • Androgenous: characteristics of both femininity and masculinity expressed through sex, gender identity, gender expression, or sexual orientation
  • Assigned sex at birth: biological status (genetic, hormonal), reproductive organs, or the appearance of external genitalia (anatomical and physiological characteristics) present at birth that correspond with male or female chromosomes.
    • AFAB: assigned female at birth
    • AMAB: assigned male at birth
    • UAAB: unassigned at birth
    • Intersex: individual born with biological sex characteristics that aren’t traditionally associated as male or female; possibly ambiguous genitalia or both male and female sex organs. Intersex individuals include a wide range of gender identities and sexual orientations. Intersexuality does not refer to sexual orientation or gender identity (see “intergender” below).
  • Gender: social, cultural, psychological, and/or emotional traits, often influenced by societal expectations, that attempt to classify individuals along a spectrum of man, woman, neither, or a blend of both.
  • Gender affirmation: healthcare, societal, or legal regulations that allow a person to safely express their gender identity (i.e., allowing an individual to select preferred pronouns; providing an individual with hormone therapy and/or surgery).
  • Gender identity: psychological sense of self with respect to femininity, masculinity, neither, or a blend of both; does not always correspond with assigned sex or biology.
    • Agender: identity dose not include gender or does not have a gender
    • Cisgender: gender identity matches the sex at birth
    • Gender diverse; gender expansive: gender identity, expression, or perception extends beyond the female/male binary
    • Gender dysphoria: discomfort or psychological distress when an individual’s gender identity does not align with their sex assigned at birth, or vice versa.
    • Gender expression: external presentation or appearance of gender identity; may include behavior, clothing, body characteristics, or voice.
    • Genderfluid: without a fixed gender identity, may identify as a mix of genders, or may fluctuate among genders.
    • Gender neutral: describes something that is not gendered such as pronouns, salutations, titles, or spaces (bathrooms, locker rooms); not used to describe people.
    • Gender queer: an individual who experiences gender as both male and female, neither male nor female, or a gender not categorized. Also known as gender expansive.
    • Intergender: gender identity that lies in the middle between the binary genders of female and male; may be a mix of both.
    • Intersectionality: multiple characteristics, experiences, and events influence a person’s identity. May include race, ethnicity, social class, age, disability status, religion, sexual orientation, and gender.
    • Multigender or bigender: more than one gender
    • Nonbinary (NB): used as an adjective for genders other than the binary man/woman.
    • Pangender: gender identity/expression is not limited to one gender and may include all genders.
    • Queer: refers to all individuals who are LGBTQIA2+ or anyone that doesn’t comform to societal norms for gender and/or sexuality. Previously a negative term, queer has been accepted by the LGBTQIA2+ community and broadly used to indicate a rejection of heteronormativity; some use “queer” to specifically describe their own fluid identities.
    • Transgender: gender differs from the sex assigned at birth; may identify as heterosexual, homosexual, bisexual, nonbinary, genderqueer or other; trans or trans+ may be used as a shortened term
      • Transgender male: assigned sex at birth was female who has a gender identity of male;
        • May still have female organs which require breast, ovarian, or cervical cancer screening
      • Transgender female: assigned sex at birth was male who has a gender identity of female
        • May still have male organs which requires testicular and prostate cancer screening
    • Transitioning: process of aligning with one’s gender identity, which may include social (i.e., mannerism), legal (i.e., name change), or medical (i.e., physical or hormonal) changes.
    • Two-spirit: leaders within Native American communities who posess both masculine and feminine spirits and are considered sacred and spiritual.
  • Sexual orientation: pattern of sexual and/or emotional attraction (i.e., physical, romantic, or emotional) to individuals of a different sex/gender, the same sex/gender, or to both sexes or more than one gender; may exist on a spectrum and is independent of gender identity.
    • Asexual: experiences little to no sexual attraction.
    • Bisexual: attracted to either those of the same gender or to those of another gender
    • Demisexual: individual does not experience sexual attraction unless there is a strong emotional, but not necessarily romantic, connection with someone.
    • Gay: individuals attracted to people of the same sex and/or gender.
    • Heteronormative: the belief that only a relationship (i.e., marriage, cohabitating) between a heterosexual cisgender man and heterosexual cisgender woman is appropriate, while all others are viewed as inappropriate.
    • Heterosexual/straight: females with an attraction to males, and males with an attraction to females.
    • Intersex: an individual with reproductive organs that are not exclusively male or female.
    • Lesbian: females who are attracted to other females and may partner exclusively with females.
    • Men who have sex with men (MSM): appropriate to use within a medical context; does not imply sexual identity or sexual orientation and is not synonymous with gay and bisexual men.
    • Pansexual: the capacity to form attraction to those of any gender identity.
    • Polyamorous: romantic or sexual relationship with more than one person, with all individuals knowing and consenting.
    • Questioning: uncertain or exploring their sexual orientation or gender identity.
    • Women who have sex with women (WSW): appropriate to use within a medical context; does not imply sexual identity or sexual orientation and is not synonymous with lesbian or bisexual women.
    • “+”: everything on the gender and sexuality spectrum that letters and words don’t yet describe.

Pronouns

Addressing an individual using correct personal pronouns shows respect and creates an inclusive environment. A person could be a male or a female or both or neither and choose any set of pronouns to use, and no pronoun choice is wrong. Pronouns may not necessarily be indicative of their gender.
  • Cisfemale: she/her/hers
  • Cismale: he/him/his
  • Transgender male: he/him/himself
  • Transgender female: she/her/herself
  • Gender diverse (non-binary): they/their/theirs/them/themselves
  • Gender neutral: ze/hir/zhe/zhim/zher/zhimself/zherself

Transgender Care (Rowe, Ng & O’Keefe, 2019)

Transgender patients may face barriers to care due to stigmatization, discrimination in insurance coverage, and healthcare professional knowledge gaps. For patients experiencing gender dysphoria, gonadotrophin-releasing hormone (GnRH) therapy helps suppress puberty hormones and may improve self-esteem and the ability to cope with stress.
 
Transgender individuals seeking to align their bodies with their gender identity (“transition”) may explore cross-sex hormone therapy (CSHT) or surgical procedures, as explained in the table below. To legally transition from one gender to another requires a legal name change, changing the sex designation on your birth certificate, Social Security card, driver’s license, and passport.

 
Transgender Care
  Transgender Woman
(Male to female transition)		 Transgender Man
(Female to male transition)
Cross-sex hormone therapy (CSHT)
  • Estradiol for feminization
  • Antiandrogen (lower testosterone levels)
  • Decreases size of male genitalia, increases development of fat around the hips, increases size of breasts, reduces facial and body hair
  • Testosterone for masculinization therapy
  • Increases facial and body hair, increases muscle development, and stops menstruation
Surgical procedures
  • Breast augmentation
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Vulvoplasty
  • Tracheal cartilage shaving
  • Masculinizing chest surgery
  • Hysterectomy
  • Metoidioplasty
  • Testicular implants
  • Phalloplasty

Transgender people have complex health needs and experience discrimination, stigmatization, and health disparities such as higher rates of substance abuse, psychiatric disorders, suicide, alcohol and drug abuse, smoking, cardiovascular disease, sexually transmitted diseases, and interpersonal violence (Margolies & Brown, 2019). Sexually transmitted infection screening and management, and mental health care and substance use disorder counseling are critical services that should be provided to the transgender community. Clinicians should remember to assess the reproductive needs of transgender patients as some will consider pregnancy. Fertility preservation consultations should be conducted prior to transition and contraception options should be discussed. In addition, cancer screening should be individualized for each person based on the stage of their transition (i.e., whether or not reproductive organs have been removed).
 

Trauma-Informed Care (Shihabuddin, Lee, & Casler, 2023)

Many LGBTQAI2+ patients who experience physical, emotional, or sexual trauma delay seeking medical care and may develop significant disease over time. A trauma-informed approach should be employed with this patient population. This is particularly important for transgender individuals who experience higher rates of sexual violence, assault and rape.
 

Collecting Sexual Orientation and Gender Identity (SOGI) Data

Collecting sexual orientation and gender identity (SOGI) data improves health screening, detection, and prevention of conditions more common in SGM groups. Use open-ended questions with an unbiased attitude and allow patients to describe their bodies, pronouns, and relationship partners in their own words. Let patients know that it’s ok if their answers change over time (Shihabuddin, Lee, & Casler, 2023).

  • “How would you like to be addressed and what are your pronouns?”
  • “To eliminate discrepancies in billing, or errors in the medical record, what name is noted on your health insurance card and driver’s license?”
  • “Can you tell me your assigned sex at birth?
  • “Have you had any surgical procedures or taken any medications to change your body to align with your gender?”
    • “It is important that we know what organs are present so we can conduct appropriate health screenings. Do you have the organs that were present at birth?”
  • “Are you attracted to males, females, both, or neither?”
  • “Are you in a relationship and, if so, how do you express physical intimacy?”
  • “Who are the important people in your life?” or “Who is family to you?”
  • “Is it ok to document this information in your medical record?”

Creating a Gender-Affirming Environment (McElwain & Carr, 2021; Rowe, Ng & O’Keefe, 2019):

Tips for creating a welcoming and gender-affirming environment include:
  • Integrate SGM/LGBTQIA2+ education into nursing curriculums.
  • Develop educational brochures for hospital staff.
  • Use appropriate terminology and a standard assessment tool for collecting SOGI to decrease stress, build rapport, and increase patients’ feeling of safety.
  • Institute non-discriminative policies that prevent discrimination against a patient because of sexual orientation or gender identity.
  • Maintain an open, reflective, and individualized approach to each patient. Avoid assumptions about sexual orientation and gender identity based on appearance.
  • Institute nondiscriminatory policies:
    • Ensure all staff address patients using their correct names and pronouns.
    • Revise intake forms to include more sexual orientations, gender identities, and neutral terms such as “partner” rather than “husband” or “wife.”
    • Display an organizational nondiscriminatory statement in waiting rooms specifically mentioning sexual orientation and gender identity.
  • Create multidisciplinary teams comprised of specialists such as endocrinologists and mental health professionals.
  • Develop patient education materials that reflect and include a diverse patient population.
  • Designate bathrooms with unisex signs and other SGM-friendly symbols.
References:
American Nurses Association (2018). Nursing Advocacy for LBGTQ+ Populations, Position Statement. www.nursingworld.org. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/nursing-advocacy-for-lgbtq-populations/
 
Centers for Disease Control and Prevention (2023, April 17). Transgender Persons. https://www.cdc.gov/lgbthealth/Transgender.htm
 
Cottrell D. B. (2019). Fostering sexual and gender minority status disclosure in patients. The Nurse practitioner, 44(7), 43–49. https://doi.org/10.1097/01.NPR.0000559846.83872.da
 
Jones, J. (2022). LGBT Identification in U.S. Ticks Up to 7.1%. Gallop. https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx
 
Margolies, L., & Brown, C. G. (2019). Increasing cultural competence with LGBTQ patients. Nursing, 49(6), 34–40. https://doi.org/10.1097/01.NURSE.0000558088.77604.24
 
McElwain, S.D. & Carr, K.L. (2021). Providing affirming care for LGBTQ patients. Nursing Made Incredibly Easy!, 19(3), 36-43.
 
Rowe, D., Ng, Y. C., & OʼKeefe, L. C. (2019). Addressing transgender patients' barriers to access care. The Nurse practitioner, 44(6), 30–38. https://doi.org/10.1097/01.NPR.0000558155.38478.8f

Shihabuddin, C. D., Lee, G., & Casler, K. (2023). Evidence-based sexual healthcare for the LGBTQIA2+ patient across the lifespan. The Nurse practitioner, 48(9), 22–30. https://doi.org/10.1097/01.NPR.0000000000000089
 

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