Health Communication and Sexual Orientation, Gender Identity, and Expression

Summary

LGBTQIA persons and communities often encounter unique obstacles in life and continue to face discrimination from healthcare systems. Clinicians are poised to accept shared responsibility for eliminating disparities and developing systemic interventions to improve the health and well-being of LGBTQIA persons and communities. Creating and fostering the patient-clinician relationship can mitigate challenges. Diction matters, and clinicians should use language that does not assume patient orientation, gender, or relationship to other persons, and that allows an open dialogue to address a variety of issues unique to this population.

Introduction

An open dialogue built on trust is required to provide competent and compassionate care for patients and communities. It is the responsibility of clinicians and healthcare leaders to build and re-build relationships with individual patients and communities and ensure the healthcare encounter is welcoming. This chapter will provide an overview of the experiences of sexual and gender minority (SGM) persons in health care (BOX 1). SGM communities include lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons and includes anyone who does not identify as straight or cisgender (Table 1). Meeting the healthcare needs of SGM persons requires an understanding of sexual orientation, gender identity, and expression of both. Additionally, providing a competent and compassionate clinical encounter requires an understanding of the historical, social, and cultural context of SGM persons.

BOX 1: National Institutes of Health Definition of Sexual and Gender Minorities⁴⁴.

SGM populations include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex. Individuals with same-sex or - gender attractions or behaviors and those with a difference in sex development are also included. These populations also encompass those who do not self-identify with one of these terms but whose sexual orientation, gender identity or expression, or reproductive development is characterized by non-binary constructs of sexual orientation, gender, and/or sex.

Table 1.

Definitions

Asexual	A term use to describe someone who has little or no sexual attraction to others. Asexual people can experience other forms of attraction.
Bisexual	Someone who experiences sexual, romantic, physical, and/or spiritual attraction to people of their own gender as well as toward another gender. (sometimes shortened to “bi”)
Cisgender	A term used to describe people whose gender identity is congruent with what is traditionally expected based on their sex assigned at birth.
Gay	A term used to describe boys/men who are attracted to boys/men, but often used and embraced by people with other gender identities to describe their same-gender attractions and relationships as well. Often referred to as ‘homosexual,’ though this term is no longer used by the majority of people with same-gender attractions.
Gender diverse	A term used to describe people whose gender identity is not constrained by binary concepts of gender.
Gender expression	The ways in which a person communicates femininity, masculinity, androgyny, or other aspects of gender, often through speech, mannerisms, gait, or style of dress. Everyone has ways in which they express their gender.
Gender identity	A person’s inner sense of being a girl/woman, a boy/man, a combination of girl/woman and boy/man, something else, or having no gender at all. Everyone has a gender identity.
Gender minority	A broad diversity of people who experience an incongruence between their gender identity and what is traditionally expected based on their sex assigned at birth, such as transgender and gender diverse persons.
Gender non-binary	A term used by some people who identify as a combination of girl/woman and boy/man, as something else, or as having no gender. Often used interchangeably with “gender non-conforming.”
Gender non-conforming	A term used by some people who identify as a combination of girl/woman and boy/man, as something else, or as having no gender. Often used interchangeably with “gender non-binary.”
Lesbian	Used to describe girls/women who are attracted to girls/women; applies for cisgender and transgender girls/women. Often referred to as ‘homosexual,’ though this term is no longer used by the majority of women with same-gender attractions.
Queer	Historically a derogatory term used against LGBTQ people, it has been embraced and reclaimed by LGBTQ communities. Queer is often used to represent all individuals who identify outside of other categories of sexual and gender identity. Queer may also be used by an individual who feels as though other sexual or gender identity labels do not adequately describe their experience.
Sex assigned at birth	Usually based on phenotypic presentation (i.e., genitals) of an infant and categorized as female or male; distinct from gender identity.
Sex	Biological sex characteristics (chromosomes, gonads, sex hormones, and/or genitals); male, female, intersex. Synonymous with “sex assigned at birth.”
Sexual minority	A broad diversity of people who have a sexual orientation that is anything other than heterosexual/straight, and typically includes gay, bisexual, lesbian, queer, or something else.
Sexual orientation	A person’s physical, emotional, and romantic attachments in relation to gender. Conceptually separate from gender identity and gender expression. Everyone has a sexual orientation.
Straight	A boy/man or girl/woman who is attracted to people of the other binary gender than themselves; can refer to cisgender and transgender individuals. Often referred to as heterosexual.
Transgender man	Someone who identifies as male but was assigned female sex at birth.
Transgender woman	Someone who identifies as female but was assigned male sex at birth.

Adapted from Streed et al. 2021.⁷

History and Background

Although the science of sexuality and gender acknowledges the existence of same-sex attraction since at least the mid-19^th century, most clinicians of the time saw this an abnormality to be cured or resolved.^1,2 Similarly, while the historical record acknowledges the existence of a diversity of gender identities and gender modalities throughout human existence, Western notions of binary, immutable categories for gender and sex have dictated what is “normal” and “allowable” at many points throughout history.^3,4 While health professions have largely moved from pathologizing to acceptance and support of the full diversity of sexual and gender identities,^5,6 more is needed to ensure SGM persons are able to lead healthy lives that allow them to thrive. This requires clinicians to understand the current landscape of SGM health and policy affecting the lives of SGM persons and communities.

Epidemiology and Outcomes

In comparison with heterosexual and cisgender populations, SGM populations have less favorable overall health and higher rates of cardiovascular disease,^7,8 certain cancers,^9–11 exposure to violence,^12–14 and HIV and other sexually transmitted infections.^15,16 Mental health disparities in SGM populations include higher rates of anxiety, depressive symptoms and suicidality than among their heterosexual and cisgender counterparts. However, because many studies do not include measures of sexual orientation, gender identity, or intersex status, the full magnitude of health disparities and their effects on SGM populations is not well described. The health and well-being of SGM communities is particularly affected by factors such as discrimination, stigma, prejudice, and other social, political, and economic determinants of health.¹⁷

Considerations: Minority Stress

Individual and institutional discrimination cause direct harm to the well-being of persons and communities.¹⁸ Research demonstrates the harmful effects of discrimination among several marginalized groups including racial and ethnic minority adults.^19,20 The stress of experiencing and facing discrimination and structural inequity based on identity is posited as one the main drivers of health disparities experienced by SGM persons and communities.^7,8,17,21 The predominant theory to explain SGM health disparities is the minority stress model (FIGURE 1) which describes how, in addition to general life stressors we all may face, SGM persons are exposed to minority stressors that contribute to disparities in health outcomes. Originally developed to study mental health disparities in sexual minorities, the minority stress model was later adapted for gender minority health.^8,22 In addition, the social ecological model recognizes how a person’s health is influenced by factors in their social environment, such as interpersonal (e.g. family, friends), community, and societal factors.²³

Figure 1: Minority Stress Model.

Adapted from Caceres et al. 2020⁸

General stressors faced by SGM persons and communities include:

• Higher likelihood of reporting physical and sexual abuse in childhood.^24,25

• Higher prevalence of interpersonal violence in adulthood.^26,27

• Higher rates of poverty than cisgender heterosexual people (21.6% vs. 15.7%) with poverty rates highest among bisexual men (19.5%) and women (29.4%), transgender people (29.4%), and SGM people living in rural areas.²⁸

When exploring the intersection of SGM identity with racial and ethnic identities, within the SGM population, Latine (37.3%), Black (30.8%), and American Indian/Native Alaskan (32.4%) adults are more likely to live in poverty compared to their White peers (15.4%).²⁸

Minority stressors that relate to SGM status exist at multiple levels with decades of research highlighting the disparities and inequities faced by SGM persons and communities. Data from a 2017 nationally representative, probability-based survey of over 3,000 adults conducted for National Public Radio, the Robert Wood Johnson Foundation, and Harvard T.H. Chan School of Public Health found that SGM adults reported significant individual and institutional experiences of discrimination, across many aspects of life.²⁹

Looking specifically at individual experiences of discrimination, a majority of all SGM people have experienced slurs (57%) and insensitive or offensive comments (53%) about their sexual orientation or gender identity. A majority of LGBTQIA people say that they or an SGM friend or family member have been threatened or non-sexually harassed (57%), been sexually harassed (51%), or experienced violence (51%) because of their sexuality or gender identity. Over a third (34%) of all SGM people say that they or an SGM friend or family member have been verbally harassed in the bathroom or been told or asked if they were using the wrong bathroom.

These experiences of discrimination are part of the larger context of structural discrimination when we examine experiences of institutional discrimination. At least one in five SGM people report being personally discriminated against because of their sexuality or gender identity when applying for jobs (20%), when being paid equally or considered for promotion (22%), or when trying to rent a room or apartment or buy a house (22%). More than a quarter of SGM people say that they or a friend or family member who is also SGM have been unfairly stopped or treated by the police (26%) or unfairly treated by the courts (26%) because they are part of the SGM community.

Perhaps most damning is the experience of discrimination in healthcare. Roughly one in six SGM people say they have avoided medical care (18%) due to concern that they would be discriminated against because of their SGM identity. One in ten transgender persons reported being personally discriminated against because they are transgender when going to a doctor or health clinic. Over one in five (22%) transgender persons say they have avoided a doctor or health care out of concern that they would be discriminated against because they are transgender. Nearly a third (31%) of transgender persons reported not having a regular doctor or healthcare professional that provides most of their health care when sick or having a health concern.

As sexual orientation, gender identity, and expression intersect with other marginalized identities, it is critical to know the experience of SGM persons of color. SGM persons of color are at least twice as likely as white SGM persons to have been personally discriminated against because they are SGM when applying for jobs and when interacting with police.

Specific to the importance of communicating with SGM persons in clinical settings, clinicians must understand the stress associated with incorrect names and pronouns; or rather the power of correctly utilizing a patients name and pronouns. Data from a community cohort sample of transgender youth from across three U.S. cities found that, after adjusting for personal characteristics and social support, correct name use in more contexts was associated with lower depression, suicidal ideation, and suicidal behavior. Notably, depression, suicidal ideation, and suicidal behavior were lowest when chosen names could be used in all studied contexts.³⁰ Essentially, for transgender youth who use a name different from the one given at birth, use of their chosen name in multiple contexts affirms their gender identity and reduces mental health risks.

Recognizing the disparate experiences of SGM persons and the ways in which individuals, communities, institutions, and society treats SGM persons is critical to addressing their health and well-being. With Minority Stress Theory as a framework to understand the health of marginalized populations such as SGM persons and communities, we can begin to build a better healthcare experience and system to meet their unique needs.

Application

Access

Access to comprehensive, affirming, and high-quality healthcare services, and laws that guarantee access to healthcare services, health insurance coverage, and healthcare for all, regardless of sexual orientation, gender identity, and intersex status, are critical to the health and well-being of SGM persons and communities. As negative experiences with healthcare are common for SGM persons, they are looking for some indication that their clinical care will be, at minimum, not traumatizing, and, ideally, be competent and compassionate. As such, the ways in which institutions and clinicians signal their inclusion and competency to care for SGM persons matters. There are various rating systems for healthcare institutions to assess their ability to provide competent and compassionate care to SGM persons and communities. The Human Rights Campaign Health Equality Index, for example, offers healthcare facilities a powerful way to affirm that they comply with Joint Commission and Centers for Medicare and Medicaid Services requirements as well as Section 1557 of the Affordable Care Act (ACA). Designation as a leader on the Health Equality Index also signals to SGM persons that the facility is committed to SGM care.

Further, potential patients will be looking at specific environmental cues in the clinic space, particularly symbols of inclusion. These include diverse representations of relationships in office décor, gender-neutral facilities, and explicit cues that SGM persons are welcome (e.g., rainbow flag).

Intake

The intake process, particularly intake forms, signal the general preparedness of a clinical setting to care for SGM persons. Through intake forms, patients can be given the opportunity to share upfront their correct name, pronouns, sexual orientation, and gender identity. Whenever possible it is best to use open-ended questions; it may be better to offer a blank space for the patient to fill in an answer instead of check boxes that only offer a limited number of responses.^31,32

Despite recommendations to collect sexual orientation and gender identity data and the requirement that electronic health records be capable to collect this data,^33,34 many have not expanded data fields to include all aspects of data relevant to patient care. While provider discomfort is often cited as a reason for low sexual orientation and gender identity data collection,^35,36 all patients report high levels of acceptance and satisfaction when personal sexual orientation and gender identity data is collected.³⁷ Opportunities for provider training exist through the National Center for LGBT Health Education and the Human Rights Campaign. Additional resources are found in collaboration with local SGM community organizations as well as professional organizations (e.g., American Medical Association, American College of Physicians, American Academy of Pediatrics). Patients want to provide this information and are comfortable sharing this part of their identity with welcoming clinicians.

Encounter

Once the patient has arrived at a healthcare institution and navigated the intake process, it is up to the clinical team to ensure the patient has a welcoming experience. Staff should always look at name and pronoun data prior to interacting with patients to ensure their proper use for the patient. If staff are unsure about name or pronouns, they can simply ask patients politely what they would like to be called and what pronouns they use. Staff can also be trained to address patients in a gender-neutral manner, such as “the patient is in the waiting room,” rather than “he/she is in the waiting room.”

The clinician leading the encounter must demonstrate competence in welcoming the patient and gathering information in a non-judgmental, affirming, and open manner (TABLE 2). With every patient encounter, greeting the patient and whomever may be accompanying them sets the tone for the entire visit. The purpose of including complete data collection on intake is to avoid making assumptions about gender identity or sexual orientation. Specifically, the gender identity or sexual orientation of the patient should never be assumed based on name or outward appearances or even name in the medical chart; transgender patients may still be in the process of aligning their legal name with their gender identity. It is therefore important that until the patient’s pronouns or correct name is known, they should be addressed by their full name, not as “Mr. Smith” or “Ms. Smith.” Further, never presume to know the relationship of anyone accompanying the patient; too often are significant others mistaken for “brother,” “sister” or “friend.” Making an assumption, no matter how benign and unintentional, can signal to the patient that the healthcare provider is at best not trained to manage SGM patients and at worst intolerant or hostile. If the clinician unintentionally makes an assumption, providing an immediate apology often corrects the faux pas and can allow the provider and the patient to set the encounter on the right path.

Table 2:

Helpful Hints During the Clinical Encounter

Use Correct Name	This should be addressed on intake and noted in all future visits
Use Correct Pronouns	This should be addressed on intake and noted in all future visits If pronouns are not known, avoid binary pronouns in documentation
Do Not Make Assumptions About Gender	If the patient notes that they are not single, do not assume the gender of their significant other. Avoid “girlfriend, “boyfriend,” “wife,” and “husband” unless the patient uses these terms.
Do Not Make Assumptions About Relationships	Do not say, “and is this your sister [brother/mother/father]?” Say, “and who has joined you today?” and allow the companion to identify themselves and their relationship to the patient
Use Open-Ended Questions	Utilize open-ended questions to elicit information about your patient and their health, behaviors, and social support.

After greetings, introductions, and establishing rapport, the clinical encounter can transition to eliciting the chief concern of the patient. Providing undivided attention and exhibiting interest with non-verbal cues will signal engagement, and maintaining an appropriate level of eye contact will allow the patient to feel more welcome. Too often have SGM patients been dismissed by providers who looked at the patient with a degree of disgust or judgment or never looked them in the eye.

Documentation

Recognizing the individual- and population-level value of sexual orientation and gender identity data collection, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator of Health Information Technology require all electronic health record systems certified under Stage 3 of the Meaningful Use program to allow users to record, change, and access structured data on sexual orientation and gender identity.^38,39 Further, the Human Resources Services Administration (HRSA) Bureau of Primary Health Care began requiring federally funded community health centers to collect and provide sexual orientation and gender identity data in 2016 as part of their annual Uniform Data Systems report. However, a secondary analysis of sexual orientation and gender identity data collection from 2016 reported by 1367 US health centers caring for nearly 26 million patients in the U.S. and territories indicates disappointing uptake of sexual orientation and gender identity data collection. Over three-quarters (77.1%) of patients did not have sexual orientation and gender identity status documented in their electronic health records.⁴⁰ The delay in proper documentation of sexual orientation, gender identity, name, and pronouns for patients is a failure to meet the needs of SGM persons and communities. Without appropriate data collection and documentation, identifying disparities and addressing the unique needs of SGM persons is made more difficult.

These requirement from HRSA, CMS, and the ACA can motivate the appropriate collection and documentation of sexual orientation and gender identity patient information in the electronic health record. To achieve this, it is necessary to build a coalition of support at your organization and address the various steps of implementation. For many organizations, implementation of sexual orientation and gender identity data collection can seem like an overwhelming task. Thankfully, there are numerous guides to help facilitate this process and no organization need re-invent the wheel to meet the needs of SGM persons.^37,41–43

Discussion

Given the extensive history of discrimination and abuse experienced by SGM persons when accessing health care, a positive clinical encounter will begin to address the health disparities experienced by SGM communities. To that end, it is also important to be open to feedback from SGM patients; often they are in a position to educate their providers and have had to do so in the past. Additionally, it is important to note that SGM patients have long been providing one another referrals to providers that have demonstrated culturally competent and compassionate care; the best referral comes from a satisfied patient. If the encounter has provided for at least the beginning of an open dialogue, SGM patients will continue to seek care. The more positive encounters that occur between the healthcare professions and SGM population, the sooner disparities in healthcare outcomes in SGM patients will be understood and addressed.

FIGURE 2:

Intake Form Header from Howard Brown Health, Chicago, IL

FIGURE 3:

Sexual Orientation and Gender Identity Questions on Intake Form From Howard Brown Health, Chicago, IL

Box 2: Additional Resources for Sexual Orientation and Gender Identity Data Collection.

• The Nuts and Bolts of SOGI Data Implementation: A Troubleshooting Toolkit: https://assets2.hrc.org/files/assets/resources/Implementing_SOGI_Data_Collection_Practices.pdf

• Ready, Set, Go! A Guide for Collecting Data on Asexual Orientation and Gender Identity: https://www.lgbtqiahealtheducation.org/wp-content/uploads/2018/03/TFIE47_Updates-2020-to-Ready-Set-Go-publication_6.29.20.pdf

Key Points.

• Recognize the unique obstacles often encountered by LGBTQIA persons and communities.

• Create and foster the patient-clinician relationship with a population that has and continues to face discrimination from health care systems.

• Use language that does not assume patient orientation, gender, or relationship to other persons and allows an open dialogue with patients to address a variety of issues unique to LGBTIA persons and communities.

• Accept shared responsibility for eliminating disparities and developing systemic interventions to improve the health and well-being of LGBTQIA persons and communities.

Synopsis/Purpose:

The purpose of this chapter is to provide guidance on completing a thorough, competent, and culturally appropriate health history with details specific to the care of LGBTQIA persons and communities.

Clinics Care Points.

• Minority Stress Theory tells us that the way society treats SGM persons affects their health now and in the future

• Use Correct Name—do not assume patient’s legal name is their correct name

• Use Correct Pronouns—use gender-neutral pronouns until the patient indicates otherwise, then use the correct pronoun

• Do Not Assume Gender—gender expression and gender identity are related but one does not dictate the other

• Do Not Make Assumptions About Relationships—ask about the patient’s relationships with other people, who is their support system, and who has accompanied them to the clinical encounter

• Collect Patient Information—implement the appropriate collection of sexual orientation, gender, identity, patient name, patient pronouns. Patients want to share this information to improve their clinical care.

• There Is No Such Thing As “Normal”—embrace the diversity of sexuality and gender and your practice will be more inclusive