What do you need to know?
Recently, the acceptance of people who identify as LBGTQ+ has increased significantly. During this same period, the number of terms to describe individuals within the group has also risen. While this can make it challenging to know what each person desires to be called, it’s essential to know, especially regarding health, because many of these individuals have unique health concerns. What are these terms? What are the health concerns?
When we’re born, we’re assigned male or female based on what our bodies look like. Most of us never think about our gender identity is because it matches our sex at birth. Gender identity refers to your internal knowledge of your own gender. This is different from sexual orientation, which has to do with whom you’re attracted to. Gender stereotypes refer to the ways we expect people to act and behave based on their sex. How a person characterizes their sexuality has three distinct components: identity (I’m gay), behavior (I have sex with the same gender), and attraction (I’m sexually attracted to the same gender). For some individuals, all three might not line up.
People can realize that their gender identity doesn’t match their assigned gender at any age. Some people can trace their awareness back to their earlier memories. Others may need more time, often spending years feeling like they don’t fit in without really understanding why. Many try to avoid thinking or talking about their gender out of fear, shame, or confusion.
There were only four letters commonly used to describe gender for the longest time: L, G, B, and T. The addition of Q became increasingly popular at the beginning of the 21st. Then came I, followed by A and, most recently, + sign. So, now the term looks like: L.G.B.T.Q.I.A.+. While recognizing and accepting these changes is essential, it can be confusing to understand the different terms.
Cisgender (or cis) is someone whose gender identity matches the sex they were assigned at birth. Transgender (or trans) is a person whose gender identity or expression differs from the gender they were assigned at birth. Intersex refers to someone born with reproductive anatomy or genes that aren’t traditionally associated with male or female bodies. It doesn’t refer to sexual orientation or gender identity. Every year, an estimated one in 2,000 babies are born with a set of characteristics that can’t easily be classified as “male” or “female.” There are many different types of intersex conditions. Some people are born with XY chromosomes but have female genitals and secondary sex characteristics. Others have XX chromosomes but no uterus or might have external anatomy that doesn’t appear clearly male or female.
Gender nonconforming (or GNC) is someone who expresses gender outside traditional norms associated with masculinity or femininity. This means not following gender stereotypes for clothes, hairstyle, speech patterns, or hobbies. Gender nonconforming people may or may not be transgender. Similarly, transgender people may be gender nonconforming or conform to gender stereotypes for the gender they live and identify as. Nonbinary (or N.B. or enby) is a person who identifies as neither male nor female and sees themselves outside the gender binary. Agender is someone who doesn’t identify as any particular gender. Gender-neutral is someone who prefers not to be described by a specific gender but prefers “they” as a singular pronoun or “Mx.,” as a substitute for “Mr.” or “Ms.” Genderqueer are individuals whose gender identity can be both male and female, neither male nor female, or a combination of male and female. Gender fluid is a term used by people whose gender identity shifts or fluctuates. Gender-expansive is an umbrella term used to refer to people who don’t identify with traditional gender roles.
Gay is still sometimes used as an umbrella term, but it also refers specifically to men who are emotionally or sexually attracted to other men. A lesbian is a woman who is emotionally or sexually attracted to other women. Bisexual is a person who is emotionally or sexually attracted to people of their gender or other gender identities. Pansexual is someone who’s attracted to people of all gender identities. The prefix “pan” means “all,” rejecting the gender binary that some argue is implied by “bisexual.” Asexual (or “ace”) is someone who experiences little to no sexual attraction. They are not the same as aromantic people, who experience little or no romantic attraction. Asexual individuals may not be sexually active but still masturbate or may be attracted to people but not desire sex. Some people (asexual or otherwise) identify as having a romantic orientation different than their sexual orientation. Demisexual is someone who doesn’t experience sexual attraction unless they have formed a strong emotional, but not necessarily romantic, connection with someone. Graysexual is someone who occasionally experiences sexual attraction but usually does not.
Queer has become an umbrella term to describe the myriad ways people reject binary categories of gender and sexual orientation to express who they are. The plus symbol (+) denotes everything on the gender and sexuality spectrum that letters and words can’t yet describe.
Other Important Terms to Know
Androgynous is a person who has both masculine and feminine characteristics, which sometimes means you can’t easily distinguish that person’s gender. Misgendering refers to someone in a way that does not correctly reflect their gender identity, typically by using incorrect pronouns. Deadnaming is using the name that a transgender person was given at birth but no longer uses. Cisnormativity is a cultural bias that assumes being cis is the norm. Heteronormativity is a cultural bias that considers heterosexuality (being straight) the norm. Heterosexual privilege signifies the societal advantages that heterosexuals get, which LGBTQ+ people don’t. Heterosexism is a system of oppression that considers heterosexuality the norm and discriminates against people who don’t follow the norm. Cissexism is a system of oppression that says there are only two genders that align with their gender at birth. Intersectionality is the understanding of how a person’s overlapping identities (race, class, ethnicity, religion, sexual orientation, and disability status) impact the way they experience oppression and discrimination.
Special Consideration for Transgender Individuals
Many transgender people decide to transition to living according to their gender identity rather than the gender they were assigned to be at birth. While the process is different for every person, some steps usually include changing clothing, appearance, name, or the pronoun people use to refer to you. Gender dysphoria is the medical diagnosis for someone who experiences severe emotional distress due to the difference between the gender they are thought to be at birth and the gender they know themselves to be. It can affect the person’s health and everyday life if not addressed. It’s essential to note that not all transgender people have gender dysphoria. The condition can be relieved by expressing one’s gender in a way that the person is comfortable with.
Some transgender people choose to change their identification documents. If they don’t have identity documents that match their gender, they might not be able to do things that require an ID, like getting a job, enrolling in school, opening a bank account, or traveling. Many documents need to be changed, such as driver’s license, social security card, passport, bank accounts/records, credit cards, paychecks (other job-related documents), leases/mortgages, medical records, birth certificate, and academic records. Unfortunately, these changes are often expensive, arduous, and complicated. For instance, some states still require proof of surgery or a court order to change a gender marker. As a result, it’s estimated that only 21% of transgender people who have transitioned have updated their IDs.
Another thing some transgender people undergo is hormone therapy or other medical procedures to change their physical characteristics to make their bodies better reflect the gender they know themselves to be. Medical procedures can include hair growth or removal treatments, hormone therapy, and various surgeries to make one’s face, chest, and anatomy more in line with one’s gender identity. While not everyone needs transition-related medical treatments, there is an overwhelming agreement in the medical community that they are medically necessary and should be covered by insurance to help these individuals lead healthy, fulfilling lives. Unfortunately, this care is often denied by insurance companies.
Trying to repress or change one’s gender identity doesn’t work. It can be very painful and damaging to one’s emotional and mental health. Conversion therapy is counseling aimed at changing someone’s gender identity. Not only does it not work, but it can be extremely harmful and lead to lasting depression, substance abuse, self-hatred, and even suicide. As a result, a growing number of states have made it illegal for licensed therapists to try to change a young person’s gender identity (laws apply to those under 18). There aren’t specific steps that are required to “complete” a transition. It’s a matter of what is right for each person based on their individual needs.
LGBTQ+ individuals are at higher risk of certain conditions and have worse health outcomes than heterosexual, cisgender individuals. These disparities are seen in the areas of behavioral health, physical health, and access to care. People who are both LGBT and members of a racial or ethnic minority often face the highest level of health disparities.
Gay men, bisexual men, transgender women, black/African American, and Hispanic/Latino men have the highest risk for HIV infection. Older LGBTQ+ adults are more likely to rate their health as poor and report more chronic conditions while having less social support. Lesbian and bisexual women are more likely to be obese and have higher rates of breast cancer. LGBTQ+ individuals have higher rates of HPV infection (and related cervical/anal cancers) and other sexually transmitted diseases. They also have higher rates of substance abuse and smoking, a higher risk of mental health issues (depression and anxiety), greater risk of suicide attempts. The community also faces higher rates of homelessness and sexual assault that can negatively affect health and wellbeing.
One reason LGBTQ+ people tend to have worse health is the social stigma. They face discrimination and harassment when they tell other people who they are, sometimes from young ages. Unfortunately, this mistreatment occurs in many settings, such as at work, school, families, and communities. This leads to negative mental health outcomes, like high rates of risk-taking, eating disorders, anxiety disorders, depression, and suicide. Often, to cope, they turn to tobacco, drugs, and alcohol. According to the Human Rights Campaign Foundation, 15% of lesbian, gay, bisexual, and queer adults had drug or alcohol abuse disorders compared to 8% of heterosexual adults. LGBTQ+ individuals with affirming families had higher levels of self-esteem and overall health.
Out of fear of discrimination and provider bias, many LGBTQ+ people don’t want to disclose their sexual orientation or gender identity in healthcare settings. Also, they’re less likely to seek timely treatment. They’re more likely to report poor quality of care and unfair treatment by healthcare providers. LGBTQ+ individuals are less likely to have health insurance, too. This happens for several reasons. Part of the issue is persistent workplace discrimination and harassment, which means they’re more likely to lose or quit their jobs or not get hired in the first place. Since most people get their health insurance through their employers, these employment gaps also create insurance coverage gaps. Another huge issue is that many workplaces don’t provide health insurance benefits for the same-sex domestic partners of their employees. Given the high cost of purchasing private individual health insurance, many go without insurance. The third problem is most insurance plans don’t cover the specific care that LGBTQ+ people need.
Since cancer and heart disease are the leading causes of death in all cisgender men, regardless of sexual orientation, they should get regular screenings for blood pressure, cholesterol, Type 2 diabetes, and various cancers (ex. prostate, testicular, colon, oral, and anal cancers). Cisgender gay men and bisexual men face an increased risk of STDs, especially HIV, compared to heterosexual men. According to HIV.gov, approximately 1.1 million Americans live with HIV, and 1 in 7 don’t know they have the virus. The HIV infection rate has stabilized to about 26,000 new infections per year, but rates have risen among younger gay and bisexual men, African Americans, and Latinos. One misconception about HIV is that you can tell you have it early on. However, there are no signs or symptoms, so the only way to find out is to get tested. It usually takes about 15 minutes to get results. This is why it’s essential to know your status, get tested regularly, and practice safe sex. It’s also a good idea to talk to your provider about PrEP/PEP. PrEP (pre-exposure prophylaxis) is given to people who are HIV negative to take every day to prevent infection. If taken daily, it can reduce the risk of getting HIV from sex by up to 99%. PEP (post-exposure prophylaxis) is given as an emergency HIV prevention drug (anti-retroviral treatment) delivered within 72 hours of possible exposure to HIV. PEP is not always effective, so starting treatment as soon as possible can increase its effectiveness.
Like cisgender men, the leading cause of death for all cisgender women is heart disease, so screening for this is vital. Lesbians and bisexual women face a higher risk for breast cancer and gynecological cancers than heterosexual women. They’re also at higher risk of substance abuse, smoking, heavy drinking, weight problems, and hormone irregularities (resulting in higher incidences of polycystic ovary syndrome). Lesbians and bisexual women can get the same STDs as heterosexual women. HPV (Human Papilloma Virus) is transmitted through skin-to-skin contact regardless of gender. According to the Centers for Disease Control and Prevention (CDC), between 13 – 30% of lesbians and bisexual women had HPV DNA on the cervix, vagina, and vulva. This is concerning because HPV can lead to cervical cancer, and many people in this group are unlikely to seek treatment until it has progressed to late stages (making it harder to treat). When it comes to heavy or irregular periods, many doctors prescribe birth control. However, women who only have sex with women don’t always want this since they don’t need birth control. There are alternatives. Another concern is breast cancer because the risk is increased in women who have never breastfed or had children. Other risk factors include older age, family history, being overweight, drinking alcohol, and not being physically active. The American Cancer Society recommends that every woman between 45 – 54 (regardless of gender identity) have a mammogram yearly, and those 55 or older have one every two years.
Male to female (MTF) and female to male (FTM) transgender people who transition require hormone therapy. FTMs have to take testosterone, usually injections, topical creams/gels, implants, or oral medications. MTFs use some form of estrogen to transition, which comes in patches, pills, and injectables. MTFs who never take hormones will have the same health risks as cisgender men. Those who take estrogen or estrogen-progestin combinations have an increased risk of breast cancer. The risk goes up with the amount taken over a lifetime. FTMs who do not take hormones or have surgery have the same breast cancer risks as cisgender women. It’s important to note that removing breasts reduces but does not eliminate the risk because some breast tissue is left after surgery. MTFs who have had surgical recreation of a cervix have an increased risk of cervical cancer, so they should have annual Pap smears. FTMs who have never had fingers, toys, or a penis in their vagina have a low risk for HPV. However, if they still have a cervix and are sexually active, they should get routine Pap smears. If your sex organs have not been removed, you can still develop reproductive system cancers. Keep in mind only FTMs are at risk for ovarian and uterine cancer, and only MTFs can get prostate cancer. Check with your provider for proper tests. If your insurance doesn’t them, ask for a reduced rate so you can pay. If taking hormone treatments, make sure you ask about all the side effects and get the correct tests to ensure your levels are normal. Only take hormones prescribed by your provider.
LGBTQ+ and the Health Community
As a result of the social stigma, many members of the LGBTQ+ community don’t disclose their status to healthcare providers. Unfortunately, some LGBTQ+ people face outright hostility from their healthcare providers. So, without a clear signal from a doctor or other healthcare professional that they are comfortable treating an LGBTQ+ person, such as saying “partner’s name” instead of “spouse’s name,” many individuals don’t feel safe “outing” themselves. This means doctors and others are unaware of their LGBTQ+ patients’ specific needs, causing conditions to go undiagnosed and doctors unable to educate their patients about risky behaviors or other physical or mental health concerns. This is why coming out to your provider will ensure you have the best care and receive all the testing you need to stay healthy.
If you’re concerned about coming out to your provider, here are some tips. Ask around in the LGBTQ+ community for referrals. Before going to a provider, call their office and ask if they have LGBTQ+ patients. You don’t have to give your name if you don’t want to. If you feel uncomfortable coming out on your own, bring a friend to your appointment. Before getting undressed, ask your provider if they have time to chat. Learn specific issues that face your specific community and ask educated questions. If your provider does not respect your identity, don’t be afraid to find another provider if you can. Sometimes this can be challenging due to insurance restrictions or lack of insurance.
In recent years, laws, policies, and attitudes around the country have changed significantly, allowing more LBGTQ+ people to live fuller, safer, and healthier lives. Everyone should be treated with the same dignity and respect as anyone else and live according to their gender identity. It can be difficult for people who aren’t part of the community to imagine what it feels like. So, if you’re not sure what term someone uses to describe their gender, you should ask them politely. Despite the risks, being open about one’s gender identity, and living a life that feels authentic, can be a life-affirming and life-saving decision.
The Trevor Project (for LGBTQ+ youth in crisis) – 1-866-488-7386
Trained counselors are available 24/7. The website also offers a chat and a text for help service. Text START to 678678 to start getting help.
Trans Lifeline – 1-877-565-8860
Peer support hotline for trans people in crisis. They’re available from 10am-4am EST. Volunteers may be available during off-hours.
National Suicide Prevention Hotline – 1-800-273-8255
24-hour toll-free crisis line
Gay, Lesbian, Bisexual and Transgender National Hotline – 1-888-843-4564
Hours (Eastern Time): Monday – Friday, 4:00pm – Midnight; Saturday, Noon – 5:00pm
Peer one-on-one support related to coming out, relationship concerns, bullying, workplace issues, HIV/AIDS anxiety, safer sex information, or any other issues you’re facing.