Psychiatric Annals

CME Article 

Health Services for LGBTQ+ Patients

Shauna M. Lawlis, MD; Kevin Watson, MD; Erin M. Hawks, PhD; Angela L. Lewis, LCSW; Landon Hester, BS; Britta K. Ostermeyer, MD, MBA, FAPA; Amy B. Middleman, MD, MSEd, MPH

Abstract

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) people often struggle to find quality medical and mental health care. It is important that mental health providers have a general knowledge of the specific needs of the LGBTQ+ population. This article describes how to establish a safe environment for LGBTQ+ patients, as well as how to address their specific mental health and medical needs. Knowledge of these needs can decrease overall morbidity and mortality, thus improving outcomes for this population. [Psychiatr Ann. 2019;49(10):426–435.]

Abstract

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) people often struggle to find quality medical and mental health care. It is important that mental health providers have a general knowledge of the specific needs of the LGBTQ+ population. This article describes how to establish a safe environment for LGBTQ+ patients, as well as how to address their specific mental health and medical needs. Knowledge of these needs can decrease overall morbidity and mortality, thus improving outcomes for this population. [Psychiatr Ann. 2019;49(10):426–435.]

Understanding the true proportion of adults and youth who identify as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) or other sexual/gender identities is difficult. Questions on various national surveys differ and may elicit different data; estimates vary by state, gender, and age. In addition, self-reported data related to culturally sensitive issues are difficult to validate; existing laws and discrimination likely change the responses to questions related to sexual orientation and gender identity. Given these caveats, current estimates exist based on various data sources but may not reflect truly valid data in this fluid area of study. Per Gallup poll data collected in 2018, the proportion of adults age 18 years or older that identify as LGBTQ+ is estimated as 4.5% (5.1% among women and 3.9% among men); members of the “millennial generation” (born from 1980–1999) are more likely to identify as LGBTQ+ than older generations.1 On the 2017 Youth Risk Behavior Surveillance survey, which is administered anonymously to private and public high school students throughout the United States, 2.4% of youth surveyed identified as gay or lesbian, 8% identified as bisexual, and 4.2% indicated that they were not sure of their sexual orientation.2 The 2016 Minnesota Student Survey estimates 2.7% of youth surveyed identify as transgender and gender nonconforming.3 Using data sources from 2014, a 2016 report by the Williams Institute estimates the rate of adults identifying as transgender as 0.6%.4 As the issues related to sexual orientation and gender continue to gain visibility and acceptability in our culture and around the world, estimates of those identifying as LGBTQ+ will likely become more accurate, even if fairly dynamic, over some time.

Establishing a Safe Environment

Historically, LGBTQ+ people have experienced significant issues with access to quality medical and mental health care, including refusal of care, substandard care, and mistreatment.5,6 For this reason, several leading medical organizations and administrations have called for improved care for LGBTQ+ people5,7–9 and have set forth guidelines for improving LGBTQ+ care starting with the recommendations related to the waiting room, medical forms, and front staff training as well as providers' word choice and documentation strategies for critical information in the electronic health record.

To create a welcoming environment, The Joint Commission5 as well as the Gay and Lesbian Medical Association8 recommend clearly posting the organization's nondiscrimination policy where it can be seen by both employees and patients. Signage, posters, brochures, and available educational materials should reflect and be inclusive of LGBTQ+ patients and families, including clear displays for multi-gender, single stall, or family restrooms, if possible. Graphics representing the racially and ethnically diverse population as well as same-gender and transgender couples can contribute to the subtle cues that an office is a welcoming place.8 Displaying a rainbow flag, LGBTQ+ specific media, information on World AIDS day or Pride month, as well as local LGBTQ+ resources can demonstrate to patients that an office is inclusive toward their population. Intake forms should also use gender neutral and inclusive language such as partner/spouse instead of husband/wife, parent(s) instead of mother/father, and there should always be an option for genders other than male/female. Using a two-step method to collect both gender identity and sex assigned at birth can clarify identity versus biological sex for transgender and gender-nonconforming patients. Including appropriate name(s) and pronouns can also be helpful. Staff from the front desk to the back office should all be trained on how to address diverse patients respectfully and sensitively. Providers should avoid making assumptions, particularly around sexual orientation and gender identity, and create an open dialogue regarding the need to share accurate and relevant information about such issues. Reflecting the language choice used by the patients and clarifying terminology when needed can help to establish trust between patients and providers. Table 1 provides a list of current appropriate terminology.

Gender Identity Terms and Definitions

Table 1:

Gender Identity Terms and Definitions

After providers have established a safe environment for patients, they can address the mental health and medical aspects of LGBTQ+ patient care using a developmental perspective as detailed below.

Mental Health Services

General Mental Health

The American Psychiatric Association clearly states that being lesbian, gay, transgender, or queer/questioning is not a mental disorder.10 However, there is a dramatically increased prevalence of certain mental illnesses in LGBTQ+ people; these include a 2-fold rate of any mental illness, increased rates of heavy drinking, and rates of depression and suicide ranging from 2 to 13 times those of heterosexual and cisgender people.10 One factor contributing to this increased morbidity is negative external stigma or prejudice, which can be internalized, leading to poor self-esteem.11 LGBTQ+ people are often afraid of being open with health care providers about their sexual orientation or gender identity.11 For that reason, it is important to create an open and affirming health care environment (as described above).

Many LGBTQ+ patients, and particularly transgender patients, may have been traumatized in the past by providers and their offices, causing fear and mistrust of the medical community; therefore, developing rapport may take extra time with these patients. The therapeutic relationship is key to working with LGBTQ+ people, and taking the extra time to get to know these patients and listen to their stories are essential components in developing good rapport. It is important to ask about (1) the patient's comfort with being LGBTQ+, (2) whether or not they are “out” to family and friends, (3) whether or not they are supported by those who know their LGBTQ+ status, and (4) any other issues pertaining to their LGBTQ+ status.

Advocating for LGBTQ+ people to have open access to care with providers that are committed to serving this underserved population is a priority for future projected outcomes. Remembering that LGBTQ+ people have formed unique strengths developed over a lifetime of maltreatment is essential to building the foundation for change. Fostering their resilience and empowering their strengths is key to working with sexual minorities. Table 2 lists various resources for providers, patients, and families.

Resources for LGBTQ+ Providers and Their PatientsResources for LGBTQ+ Providers and Their Patients

Table 2:

Resources for LGBTQ+ Providers and Their Patients

Transgender Mental Health

Gender dysphoria is a mental illness that some but not all transgender and gender-nonconforming people experience. It should be noted that a person does not have to display gender dysphoria to consider themselves transgender. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),12 criteria for gender dysphoria in adolescents and adults includes the following themes: (1) a strong desire to be, to be treated as, and to have the primary sex characteristics of another gender; (2) to be rid of the primary sex characteristics of one's assigned gender; (3) incongruence of sex characteristics with gender experience/expression; and (4) a strong conviction of having the typical feelings and reactions of another gender resulting in significant distress or impairment.13

Mental health screening or assessment may be required to assess the patient's consistent desire and commitment to change and their capacity to give informed consent prior to hormone therapy or surgery aimed at gender affirmation.13 The World Professional Association for Transgender Health14 does not recommend a minimum number of sessions prior to hormone therapy or surgery as it may be an unnecessary barrier to care.8 Many transgender people are subject to intense violence and social and family exclusions. In a study by James et al.,6 10% of transgender adults reported that a family member was violent towards them, 8% were kicked out of the house, and 10% ran away from home.

Child & Adolescent LGBTQ+ Mental Health

Family support has been shown to be protective for LGBTQ+ youth against high-risk behaviors and even suicide.15,16 Although it is never the provider's job to “out” a patient to their family, building an alliance with the family is important and can help to move a family forward toward acceptance using a strengths-based approach. Family therapy may be necessary to achieve this alliance, which speaks to the benefit of interdisciplinary teams in the care of LGBTQ+ children and adolescents. For LGBTQ+ youth, it is particularly important to assess for bullying and violence both at home and at school. Therefore, getting an accurate trauma history is also essential to their care.

Transgender youth, particularly prepubertal children, should be affirmed in their gender identity yet allowed to explore what this means to them. Although studies show that about 25% of youth with gender dysphoria age 5 to 12 years will have persistent gender identity disorder, many do not persist with their gender identity but may fall somewhere else within the LGBTQ+ spectrum.17 It can be difficult to predict which youth will have persistent gender dysphoria. However, evidence suggests that intensity of early gender dysphoria may be predictive of persistence, and if dysphoria persists through puberty then the estimates of likelihood of being transgender as an adult climb to more than 90%.18 Even though being transgender (or LGBTQ+ in general) is not in itself a mental disorder, it does not preclude the need for support from an interdisciplinary team to support the child and their parents. Table 2 list resources that can help.

Medical Services

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

The American Academy of Family Physicians21 and Centers for Disease Control and Prevention (CDC)22 recommend routine STI screenings for men who have sex with men (MSM). To prevent HIV infection, many MSM are now using pre-exposure prophylaxis (PrEP), which is composed of two antiretroviral medications. PrEP does not protect against other STIs. Safe sex practices, such as using condoms and engaging in less risky behaviors, are recommended.21

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.

Gender-Affirming Hormones

Table 3:

Gender-Affirming Hormones

Gender-Affirming Surgeries

Table 4:

Gender-Affirming Surgeries

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.

Conclusions

Caring for LGBTQ+ patients requires specific knowledge about the risk factors and specific needs of this population. Providers who do not feel comfortable treating LGBTQ+ patients have an obligation to refer them to another knowledgeable provider. Creating a welcoming environment via signage and even wording used by staff and providers can help establish a safe place where LGBTQ+ patients can be honest with their providers. Although identifying as LGBTQ+ is not itself a mental disorder, this patient population has higher rates of mental health illness, including anxiety, depression, suicide, and substance use. Addressing these issues, as well as other health risk factors, can help decrease morbidity and mortality for this population. For children and adolescents, it is important to have an interdisciplinary treatment team including medical and mental health providers to better support the patient and their family, who may be struggling as well. Family support helps reduce overall risk behaviors and is protective for this vulnerable group.

References

  1. Newport F. In U.S., estimate of LGBT population rises to 4.5%. https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx. Accessed September 10, 2019.
  2. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance - United States, 2017. MMWR Surveill Summ.2018;67(8):1–114. https://doi.org/10.15585/mmwr.ss6708a1 PMID: doi:10.15585/mmwr.ss6708a1 [CrossRef]29902162
  3. Rider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and care utilization of transgender and gender nonconforming youth: a population-based study. Pediatrics. 2018;141(3):e20171683. https://doi.org/10.1542/peds.2017-1683 PMID: doi:10.1542/peds.2017-1683 [CrossRef]29437861
  4. Flores AR, Herman JL, Gates GJ, et al. . How many adults identify as transgender in the United States? https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf. Accessed September 10, 2019
  5. The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: a field guide. https://www.jointcommission.org/lgbt/. Accessed September 10, 2019.
  6. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. transgender survey. https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF. Accessed September 10, 2019.
  7. Healthy People 2020. Lesbian, gay, bisexual and transgender health, 2014. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health. Accessed September 10, 2019.
  8. Gay and Lesbian Medical Association. Guidelines for care of lesbian, gay, bisexual, and transgender patients. https://npin.cdc.gov/publication/guidelines-care-lesbian-gay-bisexual-and-transgender-patients. Accessed September 10, 2019.
  9. U.S. Department of Health and Human Services. Advancing LGBT health & well-being: 2015 report. https://www.hhs.gov/sites/default/files/dhhs-lgbt-2015-annual-report.pdf. Accessed September 10, 2019.
  10. American Psychiatric Association. Mental Health Disparities: LGBTQ. Arlington, VA: American Psychiatric Publishing; 2017.
  11. Cabaj RP. Working with LGBTQ patients. https://www.psychiatry.org/psychiatrists/cultural-competency/education/best-practice-highlights/working-with-lgbtq-patients. Accessed September 10, 2019.
  12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  13. Byne W, Karasic DH, Coleman E, et al. . Gender dysphoria in adults: an overview and primer for psychiatrists. Transgend Health. 2018;3(1):57–70. https://doi.org/10.1089/trgh.2017.0053 PMID: doi:10.1089/trgh.2017.0053 [CrossRef]29756044
  14. Coleman E, Bockting W, Botzer M, et al. . Standards of care for the health of transsexual, transgender, and gender-nonconforming people. Int J Transgenderism. 2012;13(4):165–232. https://doi.org/10.1080/15532739.2011.700873 doi:10.1080/15532739.2011.700873 [CrossRef]
  15. Substance Abuse and Mental Health Services Administration. A practitioner's guide: helping families to support their LGBT children. https://store.samhsa.gov/product/A-Practitioner-s-Resource-Guide-Helping-Families-to-Support-Their-LGBT-Children/PEP14-LGBTKIDS. Accessed September 10, 2019.
  16. Ryan C. Supportive Families, healthy children: helping families with lesbian, gay, bisexual & transgender children. https://familyproject.sfsu.edu/sites/default/files/FAP_English%20Booklet_pst.pdf. Accessed September 10, 2019.
  17. Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry.2008;47(12):1413–1423. https://doi.org/10.1097/CHI.0b013e31818956b9 PMID: doi:10.1097/CHI.0b013e31818956b9 [CrossRef]18981931
  18. Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry.2013;52(6):582–590. https://doi.org/10.1016/j.jaac.2013.03.016 PMID: doi:10.1016/j.jaac.2013.03.016 [CrossRef]23702447
  19. Knight DA, Jarrett D. Preventive health care for women who have sex with women. Am Fam Physician. 2017;95(5):314–321. PMID:28290645
  20. Mravcak SA. Primary care for lesbians and bisexual women. Am Fam Physician. 2006;74(2):279–286. PMID:16883925
  21. Knight DA, Jarrett D. Preventive health care for men who have sex with men. Am Fam Physician.2015;91(12):844–851. PMID:26131944
  22. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1–137. PMID:26042815
  23. Manrique OJ, Adabi K, Martinez-Jorge J, Ciudad P, Nicoli F, Kiranantawat K. Complications and patient-reported outcomes in male-to-female vaginoplasty-where we are today: a systematic review and meta-analysis. Ann Plast Surg. 2018;80(6):684–691. https://doi.org/10.1097/SAP.0000000000001393 PMID: doi:10.1097/SAP.0000000000001393 [CrossRef]29489533
  24. Wiepjes CM, Nota NM, de Blok CJM, et al. . The Amsterdam cohort of gender dysphoria study (1972–2015): trends in prevalence, treatment, and regrets. J Sex Med. 2018;15(4):582–590. https://doi.org/10.1016/j.jsxm.2018.01.016 PMID: doi:10.1016/j.jsxm.2018.01.016 [CrossRef]29463477
  25. Deutsch MB. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. http://www.transhealth.ucsf.edu/protocols. Accessed September 10, 2019.
  26. Substance Abuse and Mental Health Services Administration. Top health issues for LGBT populations information & resource kit. https://store.samhsa.gov/product/top-health-issues-lgbt-populations/sma12-4684. Accessed September 10, 2019.
  27. Levine DA; Committee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013;132(1):e297–e313. https://doi.org/10.1542/peds.2013-1283 PMID: doi:10.1542/peds.2013-1283 [CrossRef]23796737
  28. Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. https://www.nap.edu/catalog/13128/the-health-of-lesbian-gay-bisexual-and-transgender-people-building. Accessed September 10, 2019.
  29. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine Society. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–3154. https://doi.org/10.1210/jc.2009-0345 PMID: doi:10.1210/jc.2009-0345 [CrossRef]19509099
  30. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. . Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–3903. https://doi.org/10.1210/jc.2017-01658 PMID: doi:10.1210/jc.2017-01658 [CrossRef]28945902
  31. Rosenthal SM. Approach to the patient: transgender youth: endocrine considerations. J Clin Endocrinol Metab. 2014;99(12):4379–4389. https://doi.org/10.1210/jc.2014-1919 PMID: doi:10.1210/jc.2014-1919 [CrossRef]25140398

Gender Identity Terms and Definitions

Term (Part of Speech) Definition
Sex (noun) Refers to the anatomical, physiological, and/or genetic characteristics associated with being male, female, or intersex; sex assigned at birth or biological sex are synonymous
Intersex (adjective) or differences/disorders of sexual differentiation (plural noun) A variety of conditions that lead to atypical development of physical sex characteristics
Gender identity (noun) One's basic sense of being male, female, or other gender
Gender expression (noun) Characteristics in appearance, personality, and behavior, culturally defined as masculine or feminine How one presents one's gender to others
Gender dysphoria (noun) The distress that accompanies the incongruence between one's gender identity and their assigned sex
Transgender (adjective) A descriptive term for someone whose gender identity differs from that of their sex assigned at birth
Cisgender (adjective) Someone whose gender identity is the same as their sex assigned at birth
Gender nonconforming (adjective) Behavior, expression, or identity that does not conform to prevailing societal expectations for one's gender
Gender diverse/genderqueer (adjective) A term used by some people who identity as neither entirely male nor entirely female, often choosing to live outside expected gender norms; can be an umbrella term or a specific identity
Genderfluid (adjective) A gender identity that may change, so that one day they may feel more like a man and at another time more like a woman
Nonbinary (adjective) Transgender or gender-nonconforming person who identifies as neither male nor female—they may reject the binary classification of male or female
Sexual orientation (noun) An individual's physical and/or emotional attraction to the same and/or opposite gender; not directly related to gender identity
LGBTQ+ (acronym) A commonly used acronym referring to the community and encompassing lesbian, gay, bisexual, transgender, queer, and other gender/sexual minorities

Resources for LGBTQ+ Providers and Their Patients

Organization Information Type Source
Substance Abuse and Mental Health Services Administration Top health issues for LGBTQ+ providers and patients; information and resource kit <ext-link ext-link-type="uri" xlink:href="https://store.samhsa.gov/system/files/sma12-4684.pdf" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://store.samhsa.gov/system/files/sma12-4684.pdf</ext-link>
Substance Abuse and Mental Health Services Administration Practitioners guide to helping families support their LGBTQ+ children <ext-link ext-link-type="uri" xlink:href="https://store.samhsa.gov/system/files/pep14-lgbtkids.pdf" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://store.samhsa.gov/system/files/pep14-lgbtkids.pdf</ext-link>
Substance Abuse and Mental Health Services Administration For providers, introduction to substance abuse treatment for LGBTQ+ patients <ext-link ext-link-type="uri" xlink:href="https://store.samhsa.gov/system/files/sma12-4104.pdf" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://store.samhsa.gov/system/files/sma12-4104.pdf</ext-link>
Substance Abuse and Mental Health Services Administration Training curricula for behavioral health and primary care practitioner <ext-link ext-link-type="uri" xlink:href="https://www.samhsa.gov/behavioral-health-equity/lgbt/curricula" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.samhsa.gov/behavioral-health-equity/lgbt/curricula</ext-link>
American Medical Association For providers, creating an LGBTQ+ friendly practice <ext-link ext-link-type="uri" xlink:href="https://ama-assn.org/delivering-care/population-care/creating-lgbtq-friendly-practice" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://ama-assn.org/delivering-care/population-care/creating-lgbtq-friendly-practice</ext-link>
American Medical Association For providers and patients about preventing suicide in LGBTQ+ youth <ext-link ext-link-type="uri" xlink:href="https://www.ama-assn.org/delivering-care/population-care/preventing-suicide-lgbtq-youth" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.ama-assn.org/delivering-care/population-care/preventing-suicide-lgbtq-youth</ext-link>
Centers for Disease Control and Prevention For providers serving LGBTQ+ patients <ext-link ext-link-type="uri" xlink:href="https://npin.cdc.gov/stdawareness/lgbtresources.aspx" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://npin.cdc.gov/stdawareness/lgbtresources.aspx</ext-link>
Centers for Disease Control and Prevention Resources for providers and patients <ext-link ext-link-type="uri" xlink:href="https://www.cdc.gov/lgbthealth/index.htm" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.cdc.gov/lgbthealth/index.htm</ext-link>
It Gets Better Project For patients about crisis, health, education, housing, family, legal <ext-link ext-link-type="uri" xlink:href="https://itgetsbetter.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://itgetsbetter.org</ext-link>
National LGBT Health Education Center Comprehensive resources and suggested readings for patients and providers <ext-link ext-link-type="uri" xlink:href="https://lgbthealtheducation.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://lgbthealtheducation.org</ext-link>
LGBTQ Resources New York City-based resource for patients about health and wellness programs and community connections <ext-link ext-link-type="uri" xlink:href="https://gaycenter.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://gaycenter.org</ext-link>
Outcare Public LGBTQ+ health care resources organized by state <ext-link ext-link-type="uri" xlink:href="https://outcarehealth.org/resources/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://outcarehealth.org/resources/</ext-link>
Stanford Medicine For providers, LGBTQ+ medical education research group <ext-link ext-link-type="uri" xlink:href="https://med.stanford.edu/lgbt/resources.html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://med.stanford.edu/lgbt/resources.html</ext-link>
Johns Hopkins Medicine Resources for providers and patients <ext-link ext-link-type="uri" xlink:href="https://hopkinsmedicine.org/lgbt-resources/index.html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://hopkinsmedicine.org/lgbt-resources/index.html</ext-link>
Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health Comprehensive resources for patients Makadon HJ, Mayer KH, Potter J, Gold-hammer H. Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. Philadelphia, PA: American College of Physicians; 2008
I'm From Driftwood For patients; support and LGBTQ+ stories <ext-link ext-link-type="uri" xlink:href="http://imfromdriftwood.com/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">http://imfromdriftwood.com/</ext-link>
LGBT National Youth Talk Line Free and confidential talk line for youth <ext-link ext-link-type="uri" xlink:href="https://www.glbthotline.org/talkline.html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.glbthotline.org/talkline.html</ext-link> Toll-free 1-800-246-PRIDE (1-800-246-7743)
The Trevor Project Trained counselors available 24/7 for a young person in crisis, feeling suicidal, or in need of a safe and judgment-free place to talk <ext-link ext-link-type="uri" xlink:href="https://www.thetrevorproject.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.thetrevorproject.org</ext-link> TrevorLifeline 1-866-488-7386 TrevorText text START to 678678
UCSF Center of Excellence for Transgender Health Online access to information regarding comprehensive, effective, and affirming health care services for trans communities <ext-link ext-link-type="uri" xlink:href="https://prevention.ucsf.edu/transhealth" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://prevention.ucsf.edu/transhealth</ext-link>
PFLAG (Parents and Friends of Lesbians and Gays) The nation's largest family and ally organization <ext-link ext-link-type="uri" xlink:href="https://pflag.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://pflag.org</ext-link>
Human Rights Campaign Largest national lesbian, gay, bisexual, transgender and queer civil rights organization. <ext-link ext-link-type="uri" xlink:href="https://www.hrc.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.hrc.org</ext-link>
National Center for Transgender Equality National organization for transgender rights including information by state on name and gender marker change laws <ext-link ext-link-type="uri" xlink:href="https://transequality.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://transequality.org</ext-link>

Gender-Affirming Hormones

Hormone Effect Expected Onset Expected Maximum Effect
Masculizing hormones
  Skin oiliness/acne 1–6 months 1–2 years
  Facial/body hair growth 3–6 months 3–5 years
  Scalp hair loss >12 months Variable
  Increased muscle mass/strength 6–12 months 2–5 years
  Body fat redistribution 3–6 months 2–5 years
  Cessation of menses 2–6 months Not applicable
  Clitoral enlargement 3–6 months 1–2 years
  Vaginal atrophy 3–6 months 1–2 years
  Deepened voice 3–12 months 1–2 years

Feminizing hormones
  Body fat redistribution 3–6 month 2–5 years
  Decreased muscle mass/strength 3–6 months 1–2 years
  Softening of skin/decreased oiliness 3–6 months Unknown
  Decreased libido 1–3 months 1–2 years
  Decreased spontaneous erections 1–3 months 3–6 months
  Male sexual dysfunction Variable Variable
  Breast growth 3–6 months 2–3 years
  Decreased testicular volume 3–6 months 2–3 years
  Decreased sperm production Variable Variable
  Thinning and slowed growth of body/facial hair 6–12 months >3 years
  Male pattern baldness No regrowth, stops 1–3 months 1–2 years

Gender-Affirming Surgeries

Surgery Procedural Summary Key Outcomes
Feminizing vaginoplasty (“bottom” surgery) The pelivic floor muscles are used to create a vaginal vault. An orchiectomy is performed, a labia majora is created from scrotal skin, and the clitoris is created from the glans penis. The penile skin is used to create the vaginal lining. The prostate is left intact Sexual sensitivity should not be adversely affected. In one study, 86% of postoperative patients were orgasmic. Preoperative sexual function is an important indicator, but nonorgasmic patients may become orgasmic after vaginoplasty
Masculinizing phalloplasty and scrotoplasty (“bottom” surgery) A hysterectomy and vaginectomy are often performed. A penis is created from any one of a variety of procedures, often using a free flap of skin from the arm or thigh. A scrotum may be created using skin flaps and a testicular implant is possible Depending on the surgical approach, the penis may or may not have intact erotic sensation
Metoidioplasty (“bottom” surgery) A hysterectomy and vaginectomy may be performed. Testosterone causes growth of the clitoris. Local tissue is used to create a small (1 to 3 inch) phallus with the approximate girth of a thumb. The labia majora may be used to create a scrotum Erections are possible since the procedure uses natal clitoral and genital tissues
Masculinizing chest surgery (“top” surgery) Different techniques and procedures may be used to create a masculine looking chest with pectoral definition that is shaped to the patient's general appearance In general, complications are rare
Augmentation mammoplasty (“top” surgery) As with nontransgender women, a silicone shell with a saline or cohesive silicone filler is placed underneath the breast tissue or the pectoralis muscle. Some sources recommend waiting 6 months after starting hormones to perform an augmentation mammoplasty to allow for maximal breast development from hormones; 2 to 3 years is more likely to maximize hormonal breast development In general, results are durable and complications are rare
Hysterectomy/oophorectomy Hysterectomy may be combined with other gender-affirming surgeries on the same day and modifications may be made, such as making the vaginal closure more exterior so that less of a vaginal orifice remains Decisions on whether to retain or remove ovaries and fallopian tubes at time of surgery is a personal decision that incorporates fertility considerations
Authors

Shauna M. Lawlis, MD, is an Assistant Professor, Department of Pediatrics, Section of Adolescent Medicine. Kevin Watson, MD, is an Assistant Professor, Department of Psychiatry and Behavioral Sciences. Erin M. Hawks, PhD, is an Assistant Professor, Division of Child & Adolescent Mental Health, Department of Psychiatry and Behavioral Sciences. Angela L. Lewis, LCSW, is a Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences. Landon Hester, BS, is a Medical Student. Britta K. Ostermeyer, MD, MBA, FAPA, is a Practicing Board-Certified Forensic Psychiatrist; the Paul and Ruth Jonas Chair in Mental Health; a Professor and the Chairman, Department of Psychiatry and Behavioral Sciences; and the Chief of Psychiatry for OU Medicine and the Mental Health Authority of the Oklahoma County Detention Center. Amy B. Middleman, MD, MSEd, MPH, is the Professor and the Section Chief of Adolescent Medicine, and The Richard Kasterke/Connie Griggs Chair, Department of Pediatrics. All authors are affiliated with the University of Oklahoma College of Medicine and the University of Oklahoma Health Sciences Center.

Address correspondence to Shauna M. Lawlis, MD, Department of Pediatrics, Section of Adolescent Medicine, University of Oklahoma Health Sciences Center, 1200 Children's Avenue, Suite 12200, Oklahoma City, OK 73104; email: Shauna-lawlis@ouhsc.edu.

Disclosure: Amy B. Middleman receives royalties as a section editor for UpToDate.com and is the principal investigator on a grant her institution received from Pfizer Medical Research. The remaining authors have no relevant financial relationships to disclose.

10.3928/00485713-20190910-01

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