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. 2019 Dec 10;26:53–59. doi: 10.1016/j.echu.2019.08.005

Sexual Orientation and Gender Identity in Patients: How to Navigate Terminology in Patient Care

Suzanne D Lady a,∗, Kara D Burnham b
PMCID: PMC8074683  PMID: 33911987

Abstract

Objective

The purpose of this paper is to describe how health care providers can improve their practice environments to be more welcoming for patients on the spectrum of gender and sexual identity.

Methods

Literature searches were performed in WorldCat, PubMed, and nongovernmental organizations and Gallup polls. The years searched were from 2005 to 2018. Key words used included sexual orientation, transgender, and health care. The PubMed MeSH termed searched included gender identity and sexuality, both in combination with patient care.

Results

Terminology that patients use to identify their gender may vary. Understanding the terminology that patients use to self-identify is a first step to becoming more sensitive to the needs of gender and sexual minority patients. Minority patients on the spectrum of gender and sexual identity experience discrimination when accessing health care. Therefore, an accepting doctor–patient relationship especially benefits these patients. When communication competency and fluency is established, health care providers provide a more inclusive, accepting environment. Addressing patients based on their preferences and using inclusive forms and patient handouts are some recommendations that are made to create an open, patient-centered environment.

Conclusion

This article provides health care providers with terminology that facilitates communication and the healing environment for sexual and gender minority patients. Understanding and using this may create a more welcoming environment to all patients.

Introduction

Patients who identify as part of sexual or gender minority groups can experience challenges or discrimination when seeking health care.1,2 Persons that identify as part of sexual and gender minority groups are part of every race, ethnicity, religion, age, and socioeconomic group. Gender identity and sexual orientation are not the same, and as such, each is discussed with the appropriate attention to epidemiology and patient care. To provide patient-centered care, clinicians should develop an understanding of the terminology used in these minority populations and learn how to approach these patients with understanding and compassion.

Health care has used the societal gender binary concept, the option of “male or female,” with no acknowledgment of nonbinary gender identities, which sometimes are grouped together under the term transgender. In 2015, a US Transgender Survey reported 27 715 adult respondents who identified as transgender.3 In 2017, a meta-regression model based on surveys from 2007 to 2015 estimated that 390 adults per 100 000 may identify as transgender. In this analysis, more than 50% of the respondents were younger adults (born between 1980 and 1998). This suggests that younger Americans may be more likely to express a gender identity that is different than the gender they were assigned at birth.4 However, there is little information to indicate how many adults in the United States identify using other identifiers such as queer, genderfluid, or asexual.

There is a body of literature that addresses providing medical care for gender and sexuality minority patients.5, 6, 7 In the chiropractic literature, Maiers et al reported best practices for addressing transgender patients and barriers to care for this population.8 However, a guide regarding the terminology of gender and sexual identity is currently not available. Due to the evolution in the understanding of sexual orientation and gender identity, doctors of chiropractic need to develop an awareness of and sensitivity to patient needs. Therefore, the purpose of this article is to describe terminology that patients may use to identify their gender as well as provide information on how to improve the practice environment to be more welcoming for patients on the spectrum of gender and sexual identity.

Methods

Literature searches were performed in the WorldCat database and in the peer-reviewed literature. Search terms used in WorldCat included “sexual orientation and health care” and “transgender and health care.” These searches were conducted for the years 2005 to 2018. These searches resulted in discovering textbooks that were valuable in developing this paper. The PubMed database was searched using the Medical Subject Headings terms “gender identity” and “sexuality” and each of those terms in conjunction with the keywords “patient care.” The searches in PubMed were also conducted for the years 2005 to 2018. Further information regarding current statistics and trends were obtained using documents published by nongovernmental organizations such as the National Center for Transgender Equality and the National LGBT Health Education Center, part of the Fenway Institute.3,9,10 The Gallup US poll was searched from 2016 to 2018 to establish information regarding how Americans identify regarding sexual orientation and gender.11,12 All searches were limited to the English language.

Discussion

Sexual orientation terms used to describe minority sexual orientations include lesbian, gay, or bisexual. In 2016 in the United States, there were an estimated 10 million adults who identified as lesbian, gay, bisexual, or transgender (LGBT), which represents 4.1% of the US population. This estimate is derived from a random sample of 1.6 million adults, 49 000 of whom answered “yes” when asked if they personally identify as LGBT. This survey indicated that millennials (adults born between 1980 and 1998) are more than twice as likely to identify as LGBT compared to previous generations.11 This is an increase from the estimate in 2012 when 3.5% of Americans identified as LGBT. Recent results from 2018 indicate that of 4.5% of Americans, or 11 million, identify as LGBT.12 These surveys indicate that the rise in LGBT identification continues to be in the cohort of Americans classified as millennials. The continued increase in the number of individuals identifying as LGBT highlights a need for chiropractors to be attentive to patients’ sexual orientations and gender identities.

This attention to sexual orientation and gender identity is necessary, because discrimination can create health disparities for patients who are part of a gender or sexual minority.13 Of those patients who identify as nonbinary, 19% have been refused care based on their gender identity. Further, 23% have not accessed care out of fear of discrimination.13 Among lesbian, gay, and bisexual individuals, 6% report being refused care owing to sexual orientation, and 8% failed to access care out of fear of discrimination.14 To provide equal care, it is essential to understand how patients view themselves and how they behave as a result of their self-view. Not only are there health issues related to sexual orientation and behavior, some patients may also struggle with their gender identity or sexual orientation. Individuals may grapple with the decision to reveal their gender or sexual orientation to their chiropractor. Because self-acceptance may also be an issue for some patients,15 the chiropractor’s ability to accept and support patients’ gender and sexual orientation allows the patient to feel comfortable in discussing these issues.16

The terminology used to describe gender and sexual orientation is changing and evolving, which can create challenges for chiropractors. The Trans Student Educational Resources national organization is composed of adults and young people who advocate for gender nonconforming individuals. This organization notes that the terminology is often changing and that a variety of new terms exist to embody gender identity.17 The number of new terms that allow individuals to express their identities can seem daunting, yet it is critical to attend to these individual expressions of self in patients. It is important for the chiropractor to assist transgender, nonbinary, lesbian, gay, and bisexual patients to feel comfortable with their gender and sexual orientation to maximize their overall health and self-fulfillment.18

Gender identity and sexual orientation can be important components of establishing successful doctor-patient relationships. Patients who identify outside the traditional gender binary use language to self-identify that may be new to some practitioners. Patients who identify as part of sexual or gender minority groups can experience challenges when seeking chiropractic care and other types of health care. These challenges may include, and begin with, a lack of awareness on the part of the practitioner. Persons who identify as part of the minority groups are part of every race, ethnicity, religion, age, and socioeconomic group. The first step for all clinicians is to develop an understanding of the terminology used in these minority populations and how to approach these patients with understanding and compassion.

Gender Identity

Gender identity is not dictated by chromosomes or by the anatomical appearance of an individual’s genitals. Chromosomes and genitalia determine an individual’s biological sex assigned at birth; historically, this assignment has been a binary choice, male or female. Rather, gender identity is dictated by an individual’s internal understanding of self, whether male, female, or nonbinary.9 The idea that gender is expressed on a continuum was first described in 1948.19 However, the concept of a continuum is not understood by all individuals, as it is true that the majority of individuals do express a gender identity that is consistent with their biological sex.20 Those individuals who express a gender that is consistent with their biological sex are referred to as cisgender. Individuals whose biological sex is not congruent with their gender identity are defined as transgender. This may be an individual designated male at birth who desires to express a female identity or vice versa. These individuals “transcend” the gender binary.21 Although some transgender individuals identify exclusively with the “opposite” sex, others express gender identities that are not fixed in the male–female binary. These individuals are referred to as gender nonconforming or nonbinary. Nonbinary individuals may also identify as genderqueer or genderfluid, meaning they identify as neither male nor female, or have gender that is other.20 The terminology used regarding gender identity can be even more detailed and complex with some patients; additional identifiers that might be used are listed in Table 1.9,22,23

Table 1.

Commonly Used Gender Identity Terminology9,37

Term Definition
Sex The biological sex assigned at birth. This is often based on external anatomy. Sex may also be referred to as “birth sex, natal sex, biological sex, or assigned sex at birth”32 as male or female.
Gender A social construct that is a continuum used to designate an individual’s masculine or feminine identity with male and female as binary endpoints.
Cisgender Gender identity is congruent with biological sex assigned at birth.
Transgender Umbrella term meaning gender identity is not consistent with the biological sex assigned at birth. Some transgender individuals identify with the “opposite” sex that they were assigned at birth, others do not.
Some individuals may choose to use the terms trans man or trans woman.
Gender nonconforming
Nonbinary
Genderqueer
Genderfluid
Agender
Third gender		 These 5 terms are used by individuals who do not identify with the gender binary; they identify as neither male nor female. Others may have multiple genders or identify as not having a gender.
Two-spirit Culturally specific term used among some Native American and First Nations peoples. Describes a person who personifies both a male and female spirit.
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Sexual Orientation

Sexual orientation is not the same as gender identity. Although gender identity is about self, sexual orientation refers to emotional and sexual attraction to others.20 Historically, 3 sexual orientations are recognized in the literature: heterosexuality, defined as attraction to individuals of the opposite sex; homosexuality, defined as attraction to individuals of the same sex; and bisexuality, defined as attraction for either sex.24 Given the current understanding of gender identity, these definitions should be updated to include sex or gender (eg, heterosexuality is the attraction to those of the opposite sex or gender, homosexuality is attraction to same sex or gender, and bisexuality is attraction to both sexes or genders.) Additionally, asexuality should be added, defined as not sexually attracted to either sex or gender. These definitions are still rooted in the binary of male and female, so some individuals choose to use the sexual orientation queer, which can also be used as a gender identity. The term queer has a negative historical connotation but is currently popular among some wishing to avoid the gender binary.20 Sexual orientations can be acted on behaviorally or remain attractions or desires. As such, it is possible that an individual’s sexual orientation and sexual behavior may not be congruent. In patient care, it is necessary to be cognizant of and address both sexual identity and behavior.24 Like gender identity, there are a variety of terms individuals may use to describe their sexual orientation, aside from those described earlier (Table 2).

Table 2.

Commonly Used Sexual Orientation Terminology9

Term Definition
Lesbian A person who identifies as female who is sexually and emotionally attracted to others who identify as female.
Gay A person who identifies as male who is sexually and emotionally attracted to others who identify as male.
Bisexual A person who is emotionally and sexually attracted to individuals of either sex or gender (in the binary system).
Straight A person who is emotionally and sexually attracted to individuals of the opposite sex or gender (in the binary system).
Asexual A person who experiences little or no sexual attraction to others.
Queer
Pansexual
Omnisexual		 A person who is emotionally and sexually attracted to individuals without regard to their gender identity or sexual orientation.
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Intersex

Biological sex assigned at birth is typically male or female; however, if an individual’s chromosomes, gonads, or anatomy are not standard for male or female, the individual should be regarded as intersex. Many intersex individuals experience surgery at birth or shortly thereafter based on the clinician’s and parents’ desires to ensure that their genitals conform to the standard male or female anatomy.25 In 2006, a new standard of care for intersex disorders was published. This consensus statement calls for patient-centered care, caution when considering surgery, and moving away from misleading language.26 Intersex is not a gender identity or a sexual orientation, rather a biological manifestation. Surgery, if considered, should be postponed until the individual can participate in their own health care decisions.27 The inclusion of intersex in the LGBT community is not universal. Some organizations, often college or university groups, include both queer and intersex identifiers (LGBTQI), whereas others do not. One reason for advocating inclusion is that intersex individuals are, in fact, a sexual minority. The United Nations secretary-general included intersex in his statement calling for equality and asking for prevention of violence and discrimination.28

Doctor-Patient Relationship

Navigating relationships with patients who do not fall within the gender binary or whose sexual orientation is a departure from the majority of the population can be challenging. The leaders in providing health care to gender and sexual minority patients are in the disciplines of medicine and nursing.9,20,24,29 Both of these professions have multiple textbooks and many peer-reviewed articles that address standards of care, barriers to care, health disparities, and simply the need to understand sexual and gender minority populations. Other health care professions have fewer internal resources that address the needs of these groups. For example, the dental profession has little data regarding the oral health needs of LGBT people, and occupational therapists have also noted a lack of information from within their profession regarding LGBT health care.30,31 In both of these instances, dentists and occupational therapists call for their colleagues to learn from the disciplines of medicine and nursing. Chiropractic literature is similarly sparse regarding LGBT health care. Maiers et al addressed culturally sensitive chiropractic care in the transgender communities, but little exists in the chiropractic literature regarding care for LGBT patients.8 Chiropractors should emulate colleagues in other disciplines to incorporate LGBT care into chiropractic medicine.

Clinical Applications

According to standards of care established by the World Professional Association for Transgender Health, a health care practitioner should exhibit respect for patients with nonbinary/nonconforming gender identities.18 The World Professional Association for Transgender Health released a statement in May 2010 urging the de-psychopathologization of gender nonconformity worldwide (World Professional Association for Transgender Health board of directors). This statement noted that “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.”

Chiropractors should not make assumptions regarding a patient based on presentation or appearance.18 As an example, a patient may mix the typical binary characteristics in a single presentation (wear a beard and a skirt), or express different typically binary presentations at different times. No assumption should be made about the patient; rather, the patient should be addressed by their name until a pronoun (he, she, they) is communicated by the patient. When gender dysphoria (the lived experience of feeling an incongruence with one’s gender assignment) is present in a patient, a chiropractor should be knowledgeable about the health care needs of the patient, including benefits and risks of treatment options for gender dysphoria.18 The treatment approach should match the specific needs of the patient, particularly being attentive to the patient’s goals for gender expression.18 Chiropractors should help facilitate access to appropriate care by forming interdisciplinary relationships with other health care providers that specialize in transgender health.32

A chiropractor may also serve as an advocate for patients within their families and communities. To effectively advocate for and serve patients, a chiropractor should be willing to engage in discussion and to learn directly from a patient about their gender identity and sexual orientation.10 This paper offers a checklist that can be used to self-evaluate the health care providers and health care environment (Fig 1).

Fig 1.

Fig 1

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Checklist for how providers can improve their health care environments to be more welcoming for patients with nonbinary/nonconforming gender identities. For any item not marked as “yes,” consider creating a plan to educate providers and staff and to transform your health care environment to be more patient-centered and welcoming to all genders.

Changing the Health Care Environment

In addition to listening to and learning from patients, chiropractors can make changes in the health care environment, change or evolve organizational intake and health history forms, and improve their own knowledge and sensitivity to LGBT issues.32

A welcoming environment starts with the waiting room, where patients initially develop their first impressions. Displaying posters of a variety of genders, such as same-sex couples, and offering informational brochures for LGBT support groups or information that addresses LGBT health issues can signal to an individual who identifies as part of a minority group that they are in a safe space.32 Posters or patient handouts that detail nondiscrimination policies can also serve to communicate that a clinic is accepting of LGBT individuals.32 Avoiding the use of gendered pronouns, such as he or she, until a doctor-patient relationship is established is advisable. Additionally, using a preferred or chosen name, rather than a legal name, for a patient will limit stress for a nonbinary patient.32 Addressing a patient using their correct name is particularly important for nonbinary patients; however, using preferred names is important for all patients regardless of their gender identity. Lastly, providing non-gendered or gender-neutral toilets is an important part of ensuring that LGBT individuals feel safe and included.32

Improve Organizational Intake and Health History Forms

Destigmatizing language helps to make the office setting an affirming place for transgender and nonbinary patients. Intake paperwork should include all options for gender expression, including cisgender, transgender, and nonbinary.8,32,33 Additionally, a patient’s correct name and preferred pronoun should be used in medical records and/or in interactions with the patient.22,32,34 Well-designed intake forms that allow for multiple gender and sexual orientation options as well as providing additional space for patients to write in their own expression of gender or sexual orientation can signal to the patient that the chiropractor is informed about and supportive of sexual minorities.32,33 This helps patients normalize their expression of sexual orientation and gender identity in the often heteronormative health care environment.

Knowledge and Sensitivity

Although a patient may choose to discuss their identity or sexual orientation with their chiropractor, it is not the patient’s responsibility to educate the doctor.13 Rather, the chiropractor should seek training and resources from local LGBT community organizations. Specific to health care, standards of care and educational materials are available from the World Professional Association for Transgender Health and the National LGBT Health Education Center (https://www.wpath.org/publications/soc).32,35

Evaluation and Management

Appropriate standard-of-care guidelines should be used when evaluating and managing care of an individual who is part of the LGBT community. Chiropractors should inquire, respectfully, about the reproductive anatomy that a patient possesses.13 This can be done initially on a new patient’s intake form and can simply ask the patient to identify what reproductive organs they currently possess. This helps the clinician develop a proper differential diagnosis and management as well as helping to encourage patients to receive the proper screening evaluations. As an example, a nonbinary patient possessing a cervix and breasts should receive proper screening evaluations, such as pap smears and mammograms.13

A chiropractor should be aware of the risks of disease that may exist for transgender or nonbinary patients taking gender-affirming hormones. Individuals who were assigned male at birth and are taking estrogen are at an increased risk of cardiovascular disease, venous thromboembolism, and osteoporosis.30,35 Individuals who were assigned female at birth and are taking testosterone are at a risk for an increase in particular liver enzymes, loss of bone mineral density, and, in those with ovaries, increased risk for ovarian cancer.30 In addition to physical health risks, mental health disorders such as depression are seen more often in sexual minority youth than in heterosexual youth; the proportion increase ranges from 2.3% to 12%.36 Similarly, older LGBT adults are at an increased risk for mental health issues, such as depression or anxiety.37

Limitations

This paper does not address barriers to chiropractic care for sexual and gender minority patients. However, there is a need to examine access to chiropractic care for these groups of individuals. This perspective paper is intended to be a starting point for improving care by helping chiropractors develop a better understanding of the lexicon that is developing within the sexual and gender minority communities. Future studies are needed to improve knowledge within chiropractic education and chiropractic health care to inform the practitioner on ways to communicate and interact with these minority group patients in a chiropractic setting.

Conclusion

Increasing awareness of the developing terminology used by individuals to describe themselves regarding sexual orientation and gender identity may help doctors of chiropractic to better connect to their patients and create a stronger doctor-patient relationship. By recognizing individuals in ways that make them feel seen, understood, and respected, chiropractors can provide better care to patients. Once this recognition is in place, chiropractors can then begin to develop an appreciation for some of the barriers that may exist for these patients. Recognizing these challenges is the first step to developing a body of literature to help overcome barriers to care for sexual and gender minority patient populations.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): S.D.L., K.D.B.

Design (planned the methods to generate the results): S.D.L., K.D.B.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): S.D.L., K.D.B.

Literature search (performed the literature search): S.D.L., K.D.B.

Writing (responsible for writing a substantive part of the manuscript): S.D.L., K.D.B.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): S.D.L., K.D.B.

Practical Applications

  • •

    Knowledge of the commonly used vocabulary may benefit the clinician in establishing more successful doctor-patient relationships.

  • •

    Information about creating a welcoming environment for individuals who identify as part of a sexual or gender minority may aid in the development of a more inclusive chiropractic practice.

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Supplementary Data

Data Profile
mmc1.xml (264B, xml)

References

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Associated Data

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Supplementary Materials

Data Profile
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