Medical care for the LGBTQ+ population should include the same aspects of care as for any patient, as well as some additional tailored care. It is important to provide sex education to all patients, including LGBTQ+ patients who may not have received appropriate or comprehensive sex education in school or from their parents/guardians. For example, safe sex recommendations for women who have sex with women may not have been reviewed, including the use of barriers during oral sex such as a dental dam or nonlubricated condom cut lengthwise to form a sheet, or covering penetrative sex toys with a new condom before each use to prevent transmission of sexually transmitted infections (STIs).19,20
LGBTQ+ people who desire children should be referred to an appropriate fertility specialist or adoption agency. Children who have one or two gay or lesbian parents do not differ from children with heterosexual parents in emotional, cognitive, sexual, or social functioning.19,20
Transgender Medical Care
It's important for psychiatrists to have general knowledge about hormone therapies and surgeries for people who are transgender. These are listed in Table 3 and Table 4.
Treatment with exogenous estrogen or testosterone carries a risk for medical side effects but is often associated with improvements in mood, mood stability, anxiety, and overall satisfaction with and quality of life.13 Surgery has been found to be effective in alleviating gender dysphoria, and patients endorse high overall satisfaction rates (92%) and low rates of regret (0.3% to 3%) after undergoing gender-affirming surgeries.13,23,24 Prior to or instead of surgery, many patients opt for other methods of physical modifications. For example, those desiring a more feminine contour may choose to “tuck,” in which the testicles may be moved into the inguinal region, and the penis and scrotum moved posteriorly into the perianal region, held in place by tight underwear or a gaff (safer method), duct tape, or adhesives (less safe). Providers should be aware of possible urinary tract trauma or infections and testicular complaints.25 Those who desire a masculine effect may opt to use “packers” or prosthetic genitals to give an outward appearance of external genitals and even allow for standing urination. Chest “binding” can be achieved with specially made garments, sports bras, or even less safe options such as tight bandages to provide a flatter, more masculine chest contour. Providers should assess for chest/rib pain, difficulty breathing, and skin irritation.25
Adolescent LGBTQ+ Medical Care
Multiple organizations recommend incorporating periodic private and confidential discussions with all adolescents on health-related issues including sex, sexuality, and harm reduction.26–28 LGBTQ+ youth are no different but may require additional attention given this population has higher rates of substance and tobacco abuse, anxiety, suicide, HIV/AIDS infection, and disordered eating.8,11 It is important for providers to spend time discussing sexual practices with any adolescent patient, but particularly those who identify as LGBTQ+, to address (1) number of partners; (2) genders of those partners; (3) what kinds of sex (oral, vaginal, anal) is practiced; and (4) what kinds of protective measures, including barriers as well as contraception, are used.
Based on appropriate screening for risk behaviors, a provider then needs to offer corresponding preventive care, such as (1) age-appropriate vaccinations (human papillomavirus; tetanus, diphtheria and pertussis; meningococcal A, C, W, and Y serogroups; hepatitis A and B); (2) screening and treatment for STIs; (3) contraception and barrier methods of protection; (4) screening and treatment for mental health issues, particularly anxiety, depression, and suicidal ideation/attempts; and (5) substance use counseling. The CDC notes that prevalence rates of many STIs are highest among adolescents and young adults, and thus recommends routine screening for STIs in sexually active adolescents,22 particularly among sexual and gender minority youth (who are at higher risk).8,11,22 Routine screening for Chlamydia trachomatis and Neisseria gonorrheae is recommended (at least annually) for all sexually active females younger than age 25 years, young men having sex with men (YMSM), and in any setting with a high prevalence of these infections. HIV screening should be discussed and offered to all adolescents, and frequency of screening should be based on level of risk, with those who have multiple partners, unprotected sex, or receptive anal intercourse having more frequent screening and prescribing PrEP, if appropriate. Screening for syphilis should be performed in YMSM and pregnant female adolescents. Cervical cancer screening of those with a cervix should begin at age 21 years regardless of sexual activity.22
The care for transgender patients may vary depending on the stage of adolescence. Interventions can be divided into completely reversible, partially reversible, and irreversible. For prepubertal children and those early in the process of discovering their gender identity, providers recommend that families start with reversible interventions, such as supporting the use of different names and pronouns or changing one's hair and clothing. Providers can also advocate for school interventions, such as safe bathroom options and appropriate use of name and pronoun. The goal is to support safe environments for identity development and exploration.25 When available, a qualified mental health provider should be incorporated into any treatment plan for transgender youth, not because being transgender is a mental health disorder but because transition can be an emotionally difficult process and professional support can be beneficial and should be readily available to the patient.
Children who have recently entered puberty (ie, sexual maturity rating 2 or 3) may be candidates for puberty blockade with gonadotropin-releasing hormone (GnRH) analogues, which can temporarily pause puberty by suppressing the hypothalamic-pituitary-gonadal axis until the patient, the family, and treatment team decide to proceed with their natal puberty or pursue gender-affirming treatment for a different gender identity. GnRH analogues should not be started prior to the initiation of puberty, and providers should closely monitor the patient for bone mineral density, weight gain, and further development of pubertal symptoms while taking the medication. Although GnRH analogs have many benefits, they can be cost prohibitive if not covered by insurance. There are several excellent sets of guidelines available to assist providers in their care for transgender youth, including monitoring parameters and dosing of medications.14,25,29,30
Older adolescents may consider more irreversible gender-affirming treatment in a developmentally appropriate discussion with their parents, medical, and mental health care providers. The correct age of initiation of gender-affirming hormones is controversial; although the Endocrine Society currently recommends waiting until age 16 years, there are concerns that leaving a patient on GnRH analogues for a prolonged period without the add-back of sex steroids can adversely affect bone mineralization, causing long-term health consequences. In addition, entering puberty significantly later than one's peers can further isolate the patient and thus affect their mental well-being.31
Prior to starting hormones, it is important to discuss the implications for fertility and provide appropriate referral for fertility preservation if desired. For those assigned female gender at birth who have entered puberty, patients may consider menstrual suppression as a first step in gender-affirming care. A variety of methods for this are available, including oral progestins, combined oral contraceptive pills, depo-medroxyprogesterone acetate injections, levonorgestrel intrauterine device, or etonorgestrel rod implants. The rate of amenorrhea is different for each of these options and must be discussed with the patient along with contraceptive efficacy, potential side effects, advantages, and disadvantages. For those who then move to gender-affirming transition with masculine changes, testosterone often also suppresses menses so other methods can be phased out as testosterone levels rise; however, it is important to assess whether the patient may also need contraception based on their sexual practices. Testosterone is available in injectable and topical formulations; topical formulations may be cost prohibitive as transgender-related medications and services are often not covered by insurance. Dosing may be less for those receiving concurrent puberty blockers. See Table 3 for the timeline of hormonal effects. Dosing and monitoring parameters can be found in well-established guidelines.14,25,29,30
For those assigned male gender at birth, estradiol is the primary medication to induce feminine changes. Those who have not received puberty blockers will likely need higher doses of estradiol in addition to antiandrogens to block the effects of testosterone. In the United States, spironolactone is the most commonly used androgen blocker and has completely reversible effects. It can often be used prior to the patient being ready to start feminizing hormone therapy to block the further development of secondary sex characteristics. Estradiol is available in oral/sublingual formulation as well as transdermal patch or injection formulations. See Table 3 for timelines of effects. Specific guidelines for dosing and monitoring parameters are available.14,25,29,30
Many transgender patients consider “top” and/or “bottom” surgery (examples can be found in Table 4). Surgeons and insurance companies may have specific, varying requirements prior to initiating surgical interventions regarding patient age, clinical and psychological/psychiatric assessments, time living in accordance with their gender identity, and time on hormones. Speaking to the proposed surgeon and the patient's insurance company beforehand can help prevent delays and set realistic expectations.