Dermatologic Care for Lesbian, Gay, Bisexual, and Transgender Persons. Part I. Terminology, Demographics, Health Disparities and Approaches to Care

Abstract

Over 10 million lesbian, gay, bisexual, and transgender (LGBT) persons live in the United States. Improving their health is a public health priority. LGBT persons have specific health concerns and face health disparities. Awareness of those issues and disparities can enable dermatologists to provide medically appropriate and culturally competent care to LGBT patients. This review highlights terminology important in caring for LGBT persons; LGBT demographics in the United States; healthcare disparities faced by LGBT persons; and approaches to caring for LGBT patients.

I. Introduction

Over 10 million lesbian, gay, bisexual, and transgender (LGBT) persons live in the in the United States.¹ Improving LGBT health has become a public health focus. A landmark report by the Institute of Medicine, published in 2011, highlighted gaps in understanding LGBT health and suggested expanded research efforts to help bridge those gaps.² Healthy People 2020, which outlines the federal government’s public health priorities, specifically includes improving LGBT health.³ The federal government has also taken steps to require electronic health records to include data on sexual orientation and gender identity and to prohibit discrimination in healthcare settings on the basis of sex or gender.^4–6 Organizations including the National Institutes of Health, the American Association of Medical Colleges, the American College of Physicians, and the Joint Commission have targeted LGBT health in policy proposals, best practice recommendations, and/or funding opportunities.^7–10 Additionally, Washington, D.C., passed a law in 2016 requiring 2 hours of LGBT health-related continuing medical education credit for medical license renewal.¹¹ In dermatology, the Gay and Lesbian Dermatology Association (or its forebear organization) has existed since 1980, and in 2016 the American Academy of Dermatology established an Expert Resource Group on LGBT / Sexual and Gender Minority Health.

LGBT health is not new to many dermatologists. In the early 1980s, dermatologists recognized clusters of Kaposi sarcoma and other opportunistic infections among gay men as harbingers of the AIDS epidemic.^{12, 13} Since then, dermatologists have treated LGBT patients and have described LGBT health issues, related to infectious diseases and, increasingly, non-infectious diseases, in the medical literature.^{14, 15} A broader awareness of LGBT health needs and disparities can better enable dermatologists to provide medically appropriate and culturally competent care to LGBT patients.^{14, 15} This review covers terminology important to caring for LGBT persons; LGBT demographics in the United States; healthcare disparities faced by LGBT persons; and approaches to caring for LGBT patients.

II. Terminology important to caring for LGBT persons

Key Points:

• Terminology important in caring for LGBT persons relates to sexual orientation, sexual behavior, sex assigned at birth, gender identity, and gender expression.

• Terminology is complex and fluid and might not be used uniformly by all LGBT persons.

Terminology related to LGBT health is complex and evolving. The term “LGBT,” for example, includes three sexual orientations – the “L,” “G,” and “B” for lesbian, gay, and bisexual – as well as “T” for “transgender,” which relates to gender identity (regardless of sexual orientation). Other letters have been added to the “LGBT” abbreviation, including “Q” for “queer” or “questioning,” “I” for intersex (also referred to as “DSD,” for disorders (or differences) of sexual development), and “A” for asexual. To more efficiently encompass that alphabet soup of biology, identity, behavior, and expression, some – including the NIH – have embraced the term “sexual and gender minorities” (SGM) as an inclusive and consistent umbrella term.⁷ In this article, we use the term “LGBT,” which is likely more familiar to dermatologists, as synonymous with SGM.

Terminology important in caring for LGBT persons is listed in Table 1. Clinicians should understand sex, sexual orientation, sexual behavior, gender identity, and gender expression as distinct concepts. For example, sexual orientation might not align with sexual behavior.^{10, 16} A self-identified straight woman might have sex with men and women, and a self-identified gay man might not be sexually active. Men who have sex with men (MSM) and women who have sex with women (WSW) are terms primarily used by researchers and clinicians to categorize persons engaging in same-sex sexual behaviors, regardless of sexual orientation or other sexual behaviors. LGBT persons themselves rarely identify as MSM or WSW. Homosexual is a term historically used to refer to same-sex sexual behaviors, attraction, and/or identity; many LGBT persons now consider it a derogatory term and we recommend not using it.^{10, 16}

Table 1.

Terminology important to caring for LGBT persons.¹⁶

Term	Definition	Examples	Comments
Sex	Sex assigned to a person at birth, typically based on anatomy (genitalia and/or reproductive organs) and/or biology (chromosomes and/or hormones)	Male Female Intersex1	Might or might not align with current gender identity
Sexual orientation	How a person characterizes their emotional and sexual attraction to others	Straight/Heterosexual Gay2 Lesbian Bisexual	Might or might not align with sexual behavior
Sexual behavior	Describes the sexual activity of a person relating to the gender(s) of their sex partner(s)	Men who have sex with men (MSM) Men who have sex with women (MSW) Women who have sex with men (WSM) Women who have sex with women (WSW)	Might or might not align with sexual orientation. Typically used by clinicians and researchers, not by people themselves. Not exclusive terms (e.g., some MSM may also have sex with women)
Gender identity	A person’s sense of being a man, woman, or other gender	Man Woman Gender non-conforming3	Might or might not align with sex assigned at birth.
Gender expression	A person’s method to communicate gender through appearance, personality, or behaviors	Masculine Feminine Androgynous Gender non-conforming3	Might or might not align with sex assigned at birth or with gender identity.
Transgender	Persons whose gender identity or expression, to varying degrees, diverges from sex assigned at birth.	Transgender man, female-to-male (FTM) transgender person, or trans man4 Transgender woman, male-to-female (MTF) transgender person, or trans woman4	A transgender man is someone whose sex assigned at birth was female and identifies as a man. A transgender woman is someone whose sex assigned at birth was male and identifies as a woman. Transgender identity is independent of surgical or medical treatments.
Cisgender	A person whose gender identity aligns with sex assigned at birth	Cisgender man or cis man Cisgender woman or cis woman
Transition	For transgender people, the process of coming to recognize, accept, and express one’s gender identity		Sometimes referred to as gender affirmation process. Might or might not include surgical or hormonal treatments

¹Intersex, also known as disorders (or difference) of sexual development, includes persons who are born with external and/or internal genitalia that vary from typical male or female genitalia, or a chromosomal pattern that varies from XX (female) or XY (male).

²Homosexual is not a preferred term for gay.

³Some gender non-confirming persons may identify as genderqueer, agender, bigender, genderqueer, pangender, or two-spirit.

⁴Commonly interchangeable terms for transgender persons. Transgender should be used as an adjective, not a noun (e.g., “a transgender person,” not “a transgender”), and “transgendered” is not a preferred term.

Gender identity refers to a person’s sense of gender, such as being a man, a woman, neither gender, other gender, or identifying somewhere along the spectrum between man and woman (Table 1). Gender identity might or might not align with sex assigned at birth. The term “cisgender” describes persons whose gender identity aligns with their sex assigned at birth. For example, a cisgender woman is a person whose sex assigned at birth was female and who identifies as a woman. The term “transgender,” by contrast, describes persons whose gender identity does not align with their sex assigned at birth. For example, a transgender woman (also called a male-to-female [MTF] transgender person or trans woman) is a person whose sex assigned at birth was male and who identifies as a woman. Of note, the term “transgender” should be used as an adjective, not a noun, and the term “transgendered” should not be used. Some transgender persons experience gender dysphoria, defined as distress from incongruence between one's sex assigned at birth and gender identity.¹⁷ Transitioning (sometimes referred to as gender affirmation) is the process by which transgender persons recognize, accept, and express a gender identity that does not align with their sex assigned at birth. It includes individualized combinations of behavioral, social, or legal changes and/or medical or surgical treatments. Gender identity does not dictate sexual orientation or sexual behavior.^{10, 16} For example, a transgender man might identify as heterosexual and have sex only with women. Transsexual is a term sometimes used to refer to transgender persons who desire or have undergone medical and/or surgical treatment; it is used less commonly today, with “transgender” preferred.^{7, 18} Cross-dressing or “drag” (terms preferred to “transvestite”) refers to behavior in which a person wears clothing associated with a gender that differs from their sex assigned at birth. Cross-dressers do not necessarily identify as transgender.¹⁸

III. LGBT demographics in the United States

Key Points:

• Approximately 10.1 million adults in the United States (4.1%) identified as LGBT.

• Over 8 million (3.5%) adults identified as lesbian, gay or bisexual and 1.4 million (0.6%) adults identified as transgender.

• Over 19 million (8.2%) adults reported ever having engaged in same-sex sexual behaviors.

LGBT populations are growing in the United States in size and visibility. Approximately 10.1 million adults over age 18 in the United States, or 4.1% of the total U.S. population, self-identified as LGBT in 2016.¹ That figure increased from 8.3 million persons, or 3.5% of the population, in 2012.¹⁹ So-called “millennials” – persons born between 1980 and 1998 – had the highest increase in LGBT self-identification, to 7.3% in 2016 from 5.8% in 2012.¹

Based on sexual orientation, over 8 million (3.5%) U.S. adults identified as lesbian, gay, or bisexual in 2011.¹⁹ Based on gender identity, 1.4 million (0.6%) U.S. adults identified as transgender in 2014.²⁰ Based on sexual behavior, over 19 million (8.2%) Americans reported ever having engaged in same-sex sexual behavior in 2011.¹⁹ Based on marital status, approximately 780,000 adults (0.3%) were in same-sex marriages and 1.2 million (0.5%) were in same-sex domestic partnerships in 2015.²¹

IV. Healthcare Disparities Among LGBT Persons

Key Points:

• LGBT individuals face substantial disparities in physical and psychosocial health conditions.

• Disparities in health risk factors, barriers in healthcare access, discrimination, and minority stress may contribute to LGBT health disparities.

• The minority stress model proposes that prejudice and stigma can generate chronic psychosocial stressors that mediate health disparities.

Compared with non-LGBT persons, LGBT persons experience disproportionately higher burdens of physical and psychosocial health conditions.³ Health disparities specifically related to dermatology are separately reviewed (See Part II. Epidemiology, Screening, and Prevention of Skin Diseases). Other disparities include the following:

• LGBT persons have higher rates of tobacco, alcohol, and other substance use and mental health issues including depression, anxiety, and suicidality;^{2, 3}

• LGBT persons are more likely to rate their general health as poor, have more chronic health conditions, and have higher rates and earlier onset of disabilities;²²

• MSM account for more than half of all people living with HIV and 67% of new HIV infections in the United States.²³ MSM also experience higher rates of STDs, eating disorders, and body image disorders;²

• WSW are more likely to be obese or overweight and are less likely to receive cancer preventive services, such as breast and cervical cancer screening;^{2, 3} and

• Transgender individuals experience higher rates of HIV and STDs, violence and victimization, and mental health issues.^{2, 3} Notably, 41% of transgender individuals have attempted suicide.²⁴

LGBT individuals also encounter significant healthcare access barriers, including lower rates of health insurance, higher rates of cost-related barriers, and more gaps in insurance coverage.^25–27 Fear of stigmatization and previous negative experiences with the health care system – sometimes due to receiving inappropriate treatment from providers unfamiliar with LGBT health concerns, or to perceived or frank discrimination – may cause patients to delay seeking medical care.² Little time has been dedicated to LGBT-related content in medical school curricula and many recent graduates do not feel comfortable taking care of LGBT patients.^{28, 29} A survey of U.S. academic faculty practices showed the majority of institutions had no LGBT-related training.³⁰ Implicit biases against LGBT individuals among physicians and nurses are widespread.³¹ In a survey of LGBT physicians, 65% had heard derogatory comments about LGBT patients in the workplace and 34% had witnessed discriminatory care of an LGBT patient.³² In a national survey of 6,450 transgender and gender non-conforming patients, 19% of respondents reported being denied care due to their gender identity and 28% were subjected to harassment in medical settings.³³

The “minority stress model” is an important framework for understanding the multiple contextual factors contributing to LGBT health disparities.^{2, 22, 34} It proposes that experiences of prejudice and stigma directed toward LGBT persons can generate unique and chronic social stressors and stress responses that mediate higher likelihood of psychological distress, health risk behaviors, and adverse mental and physical health outcomes.^{22, 34} For example, measures of internalized homophobia, discrimination experiences, and expectations of rejection were associated with sexual risk behavior, substance use, and depressive symptoms.³⁵ It is also important to note that the health status and health care access of LGBT individuals are also influenced by complex intersections with other social identities such as age, race/ethnicity, and socioeconomic status, as well as interactions with family, relationships, community, and structural environment.²

V. Approaches to Caring for LGBT Patients

Key Points:

• Eliciting a sexual history, including gender(s) of sex partners, and asking about gender identity can enable dermatologists to provide medically appropriate and culturally competent care to LGBT patients

• Using non-judgmental language and avoiding assumptions are important to creating a welcoming care environment for LGBT patients

Dermatologists’ awareness and openness to the use of appropriate and patient-preferred terminology are essential to elicit relevant information on sexual orientation, gender identity, and sexual behaviors; demonstrate respect and affirmation to patients; build therapeutic rapport; and provide specific risk behavior counseling.^{8, 10, 36} Dermatologists should provide patient-centered, culturally competent care and to create a welcoming environment for LGBT patients. Multiple national medical societies have issued position statements and guidelines to implement clinical and organizational changes to improve medical care for LGBT patients (Table 2). We highlight several important strategies to improve LGBT care in dermatology clinics:

Table 2.

Additional Resources on LGBT Health

American Academy of Dermatology’s Expert Resource Group on LGBT/Sexual and Gender Minority Healtha
Gay and Lesbian Medical Association	www.glma.org
Gay and Lesbian Dermatology Association	www.glderm.org
Fenway Community Health Center	www.fenway-health.org
University of California, San Francisco Center of Excellence for Transgender Health	www.transhealth.ucsf.edu
Centers for Disease Control and Prevention	www.cdc.gov/lgbthealth
Association of American Medical Colleges	www.aamc.org/lgbtdsd
American College of Physicians (ACP) position statement9
The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health42
American Academy of Pediatrics (AAP) guidelines43

^aAll AAD members, residents, and medical students with an interest in LGBT health are welcome to participate in the Expert Resource Group, regardless of sexual orientation, gender identity, or pre-existing expertise in LGBT health issues. The Expert Resource Group has a Facebook page; contact Dr. Katz at Kenneth.Katz@gmail.com to be added to the group (please include the email address you use on Facebook) or for more information.

1) Use inclusive and patient-preferred language. The use of inclusive and neutral language is an integral part of providing culturally competent care. It allows dermatologists to demonstrate equality and respect to LGBT patients in order to facilitate the delivery of appropriate medical care and cultivate the physician-patient relationship. Since any patient in clinic may be LGBT, it is important to avoid making assumptions about sexual orientation and gender identity. Examples of questions free of assumptions include: “To be respectful, how would you like for me to address you?”, “Which pronouns do you use?”, and “Do you have a significant other?” Physicians and staff should pay attention to patients’ preferred terminology, be willing to ask respectfully for clarification when needed, and apologize for any miscommunication. For example, if a female patient openly identifies as “lesbian” and address “her” partner as her “wife”, it is appropriate to use the same language during the clinical encounter. Patients’ process of disclosure as LGBT is individualized and complex; we recognize that, and we are grateful to patients if and when they choose to share that intimate information with us.

2) Elicit sexual history, including sexual orientation, gender identity, and sexual behaviors. While some patients may not necessarily expect dermatologists to inquire about sexual history, it is a critical part of taking a complete medical history and often improves diagnosis and management of skin diseases.^{14, 37} Sexual history should be elicited whenever clinically appropriate, given its high impact on the clinicians’ understanding of the health needs of LGBT individuals and appropriate clinical decision-making. We will elicit a comprehensive sexual history if the information contributes to understanding the pre-test probability of skin and sexual health issues and/or relevant medical decision-making – e.g. screening for HIV and STDs, recommending vaccinations, and/or considering HIV pre- or post-exposure prophylaxis (See Part II. Epidemiology, Screening, and Prevention of Skin Diseases). Clinicians who may be apprehensive in asking about sexual orientation, sexual behavior, and/or gender identity should know that their routine data collection in electronic medical records (Figure 1) is highly acceptable to both LGBT and non-LGBT patients in diverse clinical settings in the United States^38–40 and is advocated by national agencies.^{2, 3} One emergency department study of 400 clinicians and 1,516 patients found that 78% of clinicians believed that patients would decline to disclose their sexual orientation, while only 10% of patients stated they would decline to provide that information.³⁸ Sexual history taking can be normalized with statements such as: “I routinely ask about sexual history in patients with a rash like this.” Depending on the context, it may be necessary, before broaching the subject, to request that persons accompanying the patient leave the examination room. If the patient is amenable to discussing sexual history, we ask relevant questions, which might include: “Are you currently sexually active?” or “Do you have sex with men, women, or both?” Additional questions may be warranted, with selected examples shown in Table 3. For transgender patients, it may be relevant to ask if the patient has undergone or planned any gender-affirming medical and/or surgical treatments, including cross-sex hormone therapy and/or surgical or non-invasive treatments. Some transgender persons may not report their hormones as a medication, analogous to how some patients do not routinely disclose oral contraceptive or supplement use. Some patients may not be comfortable disclosing sensitive information, especially during a first visit, and sometimes relevant history may be elicited only once rapport is further established.

Figure 1.

Example of intake form for routine collection of sexual orientation and gender identity.⁴⁰

Table 3.

Selected examples from the “Five P’s” Approach to Eliciting a Sexual History^{44, 45}

Partners	Are you currently sexually active? Do you have sex with men, women, or both? How many sexual partners have you had in the past year?
Practices	I am going to be more explicit here about your sexual health to better understand if you are at risk for HIV and other STDs. What kind of sexual contact do you have or have you had? Oral sex? Vaginal sex? Anal sex (insertive “top”, receptive “bottom”, or both “versatile”)?
Protection from HIV and other STDs	Do you and your partner(s) use any protection against HIV and other STDs? If so, what kind of protection do you use? How often? If no, there are a lot of reasons why people don’t use protection. Can you tell me why you are not using them?
Past history of HIV and other STDs	Have you (or your partner(s)) ever been diagnosed with HIV or other STDs? When? How were you (or your partner(s)) treated? Have you (or your partner(s)) ever been tested for HIV or any other STDs? Would you like to be tested?
Pregnancy Plansa	Do you have any plans or desires to have (more) children? Are you currently practicing birth control?

^aIt should not be assumed the LGBT patients would not want to have children. Transgender persons who have female natal reproductive organs can become pregnant, even when taking testosterone.

3) Create a welcoming environment. Establishing a safe and welcoming environment for all patients is vital to improving health care for LGBT persons.^{8, 10, 18} We recognize the wide diversity of identities and experiences that LGBT patients may have, demonstrate respect for each patient’s preferences on name, pronoun and gender identity, and avoid stereotypes about sexual orientation or gender identity based on appearance or other factors. When encountering patients whose name or gender identity does not match the sex or gender indicated on legal or insurance documents, we ask patients how they want to be addressed. Medical intake forms, electronic health records, and documentation should reflect this diversity by including LGBT-specific demographic information, or inclusion of “other, please specify” categories, to help normalize the process of disclosing LGBT status (Figure 1). We ask staff members to acknowledge that patient’s family members may include persons who maintain supportive relationships, regardless of biological relationship and/or marital status, and may include spouses, domestic partners, and/or significant others of any gender. Patients may use restrooms of their own choice; ideally, gender-neutral or unisex restrooms should be available. We make non-discrimination policy and inclusive images visible in the office or waiting area to reinforce a welcoming environment for LGBT patients. A summary of action items is in Table 4. LGBT patient-centered care environment among large healthcare facilities are annually assessed by the Human Rights Campaign Healthcare Equality Index to establish benchmarks for promoting health equity and inclusion.⁴¹

Table 4.

Action items for providing culturally competent care for LGBT patients.⁴⁶

Action item	Examples
Ask about names and pronouns. Avoid assuming the gender of a patient	“How may I help you?” “I would like to be respectful -- how would you like to be addressed? Which pronouns would you like us to use?” Avoid terms such as “sir” or “miss” until the patient’s gender identity is ascertained Use gender-neutral terms such as “they” or “the patient” when referring to new patients. Do not use the pronoun “it”
Ask if a patient’s name does not match a name in the medical record	“What is the name on your insurance / records?”
Avoid assuming gender(s) of a patient’s partner or parents	“Who did you bring with you today?” “Are you in a relationship?” “What are the names of your parents?”
Use a patient’s terms	If the patient refers to his “boyfriend”, use the same term (rather than “friend”)
Apologize for errors	“I apologize for using that word. I did not mean any disrespect.”
Respect support system	Interact appropriately with a patient’s partner, caretaker(s), or other persons within the patient’s support system appropriately
Provide gender-neutral restrooms	Allow patients to use restrooms corresponding to their gender identity. If possible, make, gender-neutral or unisex restrooms available
Welcoming cues	Consider posting non-discrimination policy and inclusive images in the office or waiting
Creating accountability	Provide staff training on LGBT cultural competence, including the items above Convey a zero-tolerance environment for discrimination

VI. Conclusion

Dermatologists can and should provide medically and culturally competent care to LGBT persons. Dermatologists may the first or only healthcare provider with whom people will interact for specific dermatoses, sexually transmitted diseases, or other conditions. By recognizing and addressing LGBT health needs and disparities and creating an LGBT-friendly environment to provide care, dermatologists can play important roles in improving the health of LGBT persons.

Abbreviations and Acronyms

LGBT

lesbian, gay, bisexual, and transgender

SGM

sexual and gender minority

NIH

National Institutes of Health

MSM

men who have sex with men

WSW

women who have sex with women

FTM

female-to-male transgender

MTF

male-to-female transgender

HIV

human immunodeficiency virus

STDs

sexually transmitted diseases