Patients who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, two-spirit, or other minority sexual and gender identities (LGBTQIA2+) are often hesitant to seek health services due to social discrimination, stigma, and lack of access to patient-centered, quality care.1 Moreover, this population experiences higher rates of mood disorders, stress, sexually transmitted infections (STIs), substance use, and suicide. Health disparities related to gender identity and sexual orientation are worsened in the absence of psychological safety and LGBTQIA2+ patient-centered care.2-5 Therefore, it is crucial that NPs prioritize evidence-based care for this vulnerable population.

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Background

The LGBTQIA2+ population is incredibly diverse. A patient may identify as one or multiple sexual orientations and gender identities, of which there are many, each with its own unique perspective (Table 1).6-8 Additionally, a patient's culture influences their sexual orientation and gender identity expressions.9,10 Although sexual orientation has traditionally been thought of as occurring in distinct categories such as heterosexual, homosexual, and bisexual, many individuals do not fit within these categories. For example, pansexuality is defined as attraction to people of all gender identities and expressions.11 Furthermore, the identity of two-spirit individuals from Native American communities typically encompasses cultural, sexual, gender, and spiritual aspects in one.11,12

Table 1. LGBTQIA2+ terms and definitions

Whereas "sex" refers to genetic, hormonal, anatomical, and physiological characteristics, "gender" is a social construct that tends to refer to the characteristics, behaviors, and roles associated with the sex assigned at birth. However, people may not always identify with these socially constructed cultural norms and categories, and they can experience other gender identities or expressions. When individuals identify as something other than what is generally prescribed by heteronormative gender definitions, their access to evidence-based healthcare can be threatened.13,14

Several historical policies have influenced the LGBTQIA2+ community's hesitancy to seek healthcare services and disclose sexual orientation or gender identity. Initially, HIV was known as gay-related immunodeficiency (GRID) because it was believed that only gay men could be infected.15 As understanding of HIV eventually expanded, the virus was renamed; however, the stigma persisted. Until 2003, some areas of the US criminalized certain acts such as anal or oral intercourse, and until 2015, same-sex marriage was not legal in some states.16,17 Although there has been progress in reducing stigma and social, legislative, and cultural discrimination, new attempts, in some cases successful, have been made through legislation to limit gender-affirming care, gender identity and sexual orientation education in public schools, and forms of artistic expression, such as dressing in drag. Proposed and passed legislation includes bans on gender-affirming hormone therapy. These efforts are likely to continue to hinder the LGBTQIA2+ population from seeking healthcare.18,19

The LGBTQIA2+ population's hesitation to seek healthcare results in several health disparities.20 LGBTQIA2+ individuals have higher rates of depression and stress compared with cisgender heterosexual adults and adolescents.3,4 Perceived discrimination, gender dysphoria, and coming out were cited as key factors underlying stress and depression in this population, with transgender communities reporting the highest rates of depression and stress as well as poorer health overall.21,22 A school-based survey in Boston, Mass. polled 1,032 students and found that LGBTQIA2+ youth scored higher in depressive symptomatology and were more likely to report suicidal ideation and self-harm.23 Older LGBTQIA2+ people face similar disparities in mental health: In a different study, older LGBTQIA2+ Americans were found to have a two to three times higher rate of depression compared with older cisgender heterosexual Americans.24

Substance use disorders also disproportionately affect the LGBTQIA2+ community. A historic meta-analysis found that sexual minority youth have a 190% higher risk of substance use compared with heterosexual youth.25 LGBTQIA2+ participants reported several sources of pressure to engage in alcohol consumption such as the desire to be accepted by the community, social stereotypes regarding LGBTQIA2+ drinking behaviors, and the desire to cope with identity-related anxiety and stress stemming from unique issues such as coming out.26

In addition to issues with mental health, the LGBTQIA2+ community faces disparities in sexual health as well. Historically, men who have sex with men (MSM) have accounted for a disproportionate number of HIV infections in the US. In 2020, 71% of new HIV infections were among MSM, with 39% in Black populations and 31% in Hispanic populations.27 In addition to HIV, the LGBTQIA2+ community is disproportionately affected by STIs. The 2021 CDC STI surveillance report showed that a greater percentage of MSM, as compared with men who have sex with women, were diagnosed with chlamydia (16.5% versus 14.6%), gonorrhea (22.7% versus 12.2%), and syphilis (31.1% versus 20.9%).28

Sexual health disparities that resulted from increased exposure to sexual and physical violence during adolescence and adulthood may be compounded by previously experienced provider bias, discrimination, and healthcare that was inappropriate or perceived to be inappropriate.28,29 Transgender individuals experience high rates of sexual violence, with 47% of respondents in the 2015 US Transgender Survey indicating that they had experienced sexual assault or rape during their lifetimes.30 Relative to straight women, bisexual women were at a higher risk of experiencing forced, coerced, or substance-facilitated rape; sexual assault; and unwanted sexual experiences within their lifetimes.31 For gay and bisexual men, the risk of coerced rape, sexual assault, and unwanted sexual experiences is double that for straight men.31

Considering the disparities that affect the health of LGBTQIA2+ patients, LGBTQIA2+ sexual healthcare must be more strongly integrated into clinician education. Though improving, clinician education is still fundamentally lacking. Studies have found that primary care NPs are unprepared to provide health counseling to LGBTQIA2+ patients.32,33 A 2015 survey of nurses revealed that 80% recalled no education on LGBTQIA2+-related issues.34 Similar issues exist in medical student education; a study including medical students at three universities across the US reported few interactions with LGBTQIA2+-identifying patients and few LGBTQIA2+-related curricular hours.35

Addressing the problem

Addressing the needs of the LGBTQIA2+ population requires a multifaceted approach. To effectively address health disparities impacting this population, actions must be taken at various levels, including those of the provider, educational institution, and government agency, among others. Initiatives should aim to resolve the many underlying issues that contribute to the larger problem. Healthcare providers should receive specialized clinical education pertaining to the LGBTQIA2+ population, including training in gender-inclusive terminology and trauma-informed care. Health institutions should foster welcoming spaces for all persons. Providers should ensure that they are up-to-date on cancer screening guidelines and sexual and reproductive health guidelines. Lastly, it is important to address the specialty needs of both the pediatric and adult populations, which may differ depending on the age of the patient.

Clinical education. Many health professional programs are beginning to provide supplemental experiences to increase awareness and competency of new graduates in LGBTQIA2+ health.36 Once in practice, all clinicians and clinic staff should routinely receive training on the care of the LGBTQIA2+ population.37,38 This is especially important for NPs who practice in rural and suburban areas, as there is less access to LGBTQIA2+-specific clinics in these areas.37 Organizations such as the Fenway Institute have LGBTQIA2+-specific educational modules that have been accredited and could be used to provide inclusive training (Box 1). Extension for Community Health Outcomes (ECHO) education programs have also been shown to improve patient-centered quality care for LGBTQIA2+ patients.40

Health institution measures. In addition to clinical education for NPs, health institutions should make changes to foster safe and inclusive spaces for the LGBTQIA2+ population. This includes the use of LGBTQIA2+-friendly decor and accessories such as pronoun pins, rainbow flags/pins, and other affirming posters/materials that can help facilitate access to care and build trust between LGBTQIA2+ patients and their healthcare clinicians.32 In addition, designating and training a staff member as an LGBTQIA2+ liaison can also be helpful.40 Maintaining accurate sexual orientation and gender identity (SOGI) records in the electronic health record can help match patients to appropriate health services and remind clinicians of specific health needs.41 Advocating at the community level for access to affordable housing, mental health services, and transportation is critical, as is partnering with schools and parents to provide inclusive sexual education.10,42 Efforts to develop more dedicated LGBTQIA2+ clinics and recruit clinicians who identify as members of this population are also cited by the LGBTQIA2+ population as initiatives that would improve their access to care.3,38,43

Cancer screening guidelines. NPs must ensure that they are knowledgeable about screening recommendations for all members of the LGBTQIA2+ community, including transgender patients and/or those who have undergone gender-affirming surgeries, such as top or bottom surgeries. Transgender-specific cancer screening guidelines do not currently exist, and therefore, NPs must apply screening guidelines created for the cisgender population to the transgender population, which may have different risk factors due to medical, surgical, or medication histories. No significant evidence exists to properly understand the risk of long-term gender-affirming hormone therapy (GAHT).44 Additionally, these risks vary depending on the patient's stage of transition. For example, if the patient has had surgical removal of some or all of their reproductive organs, the risks and screening recommendations are different from those for a transgender patient who has not had surgical removal of their reproductive organs.44

Researchers are still trying to understand the long-term effects of GAHT, as it differs from hormone replacement therapy for the cisgender population. For example, when GAHT is initiated before surgical removal of birth-sex gonads, the patient may have elevated serum levels of both masculinizing and femininizing hormones, resulting in the need for different sex-related cancer screenings. Additionally, effective doses of GAHT can vary from patient to patient, resulting in some transgender patients having significantly higher serum levels of a particular hormone than others. This can increase or decrease the risk of certain hormone-sensitive cancers.44 Therefore, NPs need to be vigilant to ensure that they are completing a thorough health history, including assessing for previous surgeries and GAHT use. NPs should be sure to remain up-to-date on all evidence-based recommendations-including certain screenings-as new research is published and clinical practice guidelines are updated in order to ensure that they deliver appropriate care to this population. Use of the latest recommendations to guide patient care is vital in this patient population, as it enables early detection of potential disease.

Lesbian women may be at higher risk of breast and ovarian cancer due to increased rates of obesity, alcohol use, and smoking; decreased parity; and decreased likelihood of breastfeeding. Additionally, lesbian women are less likely to have used combined hormonal contraceptives (CHCs); CHCs may slightly increase breast cancer risk and may decrease ovarian cancer risk.45 Lesbian women are also less likely than heterosexual women to utilize cancer screening services. The cancer screening guidelines for the lesbian population are identical to those for heterosexual women; however, many lesbian women do not receive the recommended screening services.46 Ensuring that patients assigned female at birth are receiving the same cancer screening opportunities regardless of SOGI is essential to reduce the progression of many cancers that are curable if caught early.

Assessment of reproductive health needs. The reproductive needs of LGBTQIA2+ patients must also be assessed. Many LGBTQIA2+ individuals desire pregnancy at some point in their lives. NPs should frequently assess reproductive needs and desires and offer fertility preservation consults prior to gender transition.47,48 Additionally, for patients interested in contraception, hormonal, nonhormonal, and permanent options should be discussed. The Reproductive Health Access Project provides resources for birth control options across the gender spectrum and is a great resource for NPs caring for LGBTQIA2+ patients.49

STI screening. NPs should be familiar with the CDC's latest STI guidelines update, released in 2021.50 NPs should obtain comprehensive sexual health and social histories, but many report barriers to comprehensive history completion and appropriately tailored STI screenings such as lack of time during clinic visits.51 Screening for gonorrhea and chlamydia should occur at least annually for sexually active MSM at the sites of contact (urethra and rectum for chlamydia; urethra, rectum, and pharynx for gonorrhea), regardless of condom use. Screening recommendations should be adapted based on anatomy (for example, the recommendation for annual, routine screening for chlamydia in cisgender women younger than 25 years should be extended to all transgender men and gender-diverse people with a cervix; individuals age 25 years and older with a cervix should be screened if at increased risk).50 NPs who do not routinely care for non-cisgender patients may not be familiar with the recent changes in recommendations for STI screenings, resulting in missed opportunities for screening and potentially missed capture of STIs.

LGBTQIA2+ patients are at higher risk of human papillomavirus (HPV) infection; vaccination for prevention is key to reducing the incidence of HPV-associated diseases, such as anal and cervical cancers, and should be offered to patients at higher risk who are not adequately vaccinated through age 45 years.52 Anal dysplasia, which can progress to anal cancer if untreated, can occur in men and women with and without a history of receptive anal intercourse. More than 90% of anal cancers are caused by HPV infection. Annual screening for anal disease with anal cytology, high-resolution anoscopy, and a digital anorectal examination for patients over age 35 years who are living with HIV is recommended.53 While screening of other asymptomatic individuals at elevated risk of anal cancer-such as MSM without HIV and patients with a history of cervical dysplasia-is not currently recommended due to insufficient data, it can be considered.50 Evaluation for anal disease should be undertaken for individuals of any age whenever anal symptoms (such as anorectal bleeding or pain) are present.

If also screening for rectal gonorrhea and chlamydia, such screening should be done after the collection of anal cytology. A digital rectal examination is performed last.53 HPV testing should be performed for individuals with abnormal anal cytology results.53

Use of PrEP. The CDC recommends that all sexually active patients, regardless of sexual orientation or sexual behavior, be offered and counseled on the benefits of pre-exposure prophylaxis (PrEP) for HIV prevention as a means of reducing new HIV infections.54 When taken correctly, PrEP reduces the risk of contracting HIV from sex by about 99% and from injecting drugs by at least 74%.55 NPs, especially primary care NPs, should offer all patients HIV prevention as part of primary care screening initiatives.

For children and adolescents. Appropriate care for LGBTQIA2+ youth, especially adolescents, is imperative. Pediatric NPs should inquire annually about SOGI beginning at age 12 years because SOGI can change over time.28,37,42 Conducting the health history with the adolescent in private and using gender-neutral language are important.56 Further, explaining that SOGI information is being collected to recommend preventive care and identify specific healthcare needs can help to facilitate trust.28 Because adolescents who have a minority sexual orientation are more likely to experience unintended pregnancy and STIs, time must be made to educate these patients. Education should include provision of information on consistent condom/dental dam use and contraceptive options.56,57 A contraceptive counseling tool for gender-diverse youth is available from the Reproductive Health Access Project.49

Adolescents should be screened annually for depression starting at age 12.37 Care should be taken to interview the adolescent privately to avoid causing undue familial conflict, and NPs should facilitate familial conversation to disclose the status to parents only when the adolescent is ready, since premature disclosure of SOGI minority status can increase the risk of harm for these patients.37,41 When the adolescent patient is comfortable disclosing to parents or guardians, clinicians should provide support services to the family, as much of the adolescent's mental well-being is contingent on parent/guardian coping and the support/psychological safety they provide for their adolescent.56-58

For adults. Previous trauma-physical, emotional, or sexual-at the hands of the lay or medical population may result in adult LGBTQIA2+ patients failing to receive any healthcare for several years. Therefore, these patients may have a significant illness or disease pathology by the time they seek care. Not only does this result in patients presenting with more advanced diseases, but it also makes treatment more difficult and costly.13 NPs should bear these issues in mind in caring for adult patients from the LGBTQIA2+ population and should consider use of a trauma-informed approach to care delivery.

For transgender patients. As reported in the 2015 US Transgender Survey, transgender individuals experience high rates of sexual violence, including sexual assault and rape.30 Therefore, providing trauma-informed care and assessing for a history of experiencing sexual violence need to be priorities for this patient population. Additionally, assessing for high-risk sexual behaviors is an important consideration for transgender patients; some individuals may require more frequent screening for STIs than their cisgender counterparts.

Conclusion

In summary, the diverse needs of the LGBTQIA2+ population cannot be understated. As each patient within the LGBTQIA2+ community is unique with specific needs, a thorough medical, surgical, and social history is essential for identification of risk factors and implementation of preventive screening measures. NPs and other healthcare providers must factor into their approach the fact that LGBTQIA2+ patients have a greater likelihood of previous trauma than their cisgender counterparts who are not sexual minorities. Clinicians should make every effort to assess their personal biases and should ensure that their approach is free of bias; they should also engage in efforts to enhance their knowledge and clinical skills with relation to this population's diverse and unique needs, particularly in relation to sexual and reproductive health. Finally, NPs must continue to advocate for policy reform to reduce the ongoing and existing discrimination, stigma, and bias that interfere with LGBTQIA2+ patients' access to care.

Box 1. Tips for providing LGBTQIA2+-affirming care6,7,39

* Let patients know that it is okay if their answers change over time.

* Make questions about gender, sexuality, and sex at birth open ended.

* Explain the rationale for asking about these topics.

* Ask about gender identity, gender expression, and sexual orientation in separate questions.

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