Summary
Sexual and gender minority community members face considerable barriers to healthcare that place them at risk for adverse events and poor outcomes. Learn about issues this community faces to help enhance patient care.
Gender identity and sexual orientation are self-identified classifications that represent about 7.1% of the United States’ adult population. These classifications can spark social and political uncertainty and create potential risks to patient safety. The acronym SGM (sexual and gender minorities) aligns with the more commonly used acronym LGBTQ+ (lesbian, gay, bisexual, transgender, and queer/questioning) but reflects a more comprehensive approach to understanding these communities.
While the sexual minority community focuses on physical and emotional attraction, the gender minority community focuses on the individual’s gender identity and expression (e.g., masculine, feminine, nonbinary). Though these vulnerable populations often intersect, neither sex nor gender relates to sexual orientation.
Traditionally, the notion of sex/gender was that sex is binary and determines gender. In recent years, however, the nature of sex/gender has been bifurcated into separate concepts. Sex refers to biological determinants or sex assigned at birth, including intersex. Gender, on the other hand, is a social construct of male, female, or nonbinary roles that an individual chooses and expresses to reflect their personal identity.
An individual whose sex and gender align is cisgender. An individual is transgender when their sex and gender do not align (e.g., biologically male but identifies as female). Nonbinary individuals do not identify as either gender. Bigender individuals identify as both male and female. The spectrum is broad, and many gender terms are used within the SGM community.
SGM communities face a host of negative social reactions that impact their daily lives and self-esteem, including such micro- and macroaggressions as implicit bias, marginalization, stigmatization, recurrent trauma, and violence/exploitation. These experiences result in fear and mistrust of healthcare institutions and providers, internalized emotional distress (depression, anxiety, suicidal ideations), and delayed healthcare access. Negative experiences that impact the SGM community include:
In addition to the social determinants of health noted above, healthcare institutional practices that can increase the risk of harm to SGM patients include:
Resources
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.
While the sexual minority community focuses on physical and emotional attraction, the gender minority community focuses on the individual’s gender identity and expression (e.g., masculine, feminine, nonbinary). Though these vulnerable populations often intersect, neither sex nor gender relates to sexual orientation.
Sex and Gender
Traditionally, the notion of sex/gender was that sex is binary and determines gender. In recent years, however, the nature of sex/gender has been bifurcated into separate concepts. Sex refers to biological determinants or sex assigned at birth, including intersex. Gender, on the other hand, is a social construct of male, female, or nonbinary roles that an individual chooses and expresses to reflect their personal identity. An individual whose sex and gender align is cisgender. An individual is transgender when their sex and gender do not align (e.g., biologically male but identifies as female). Nonbinary individuals do not identify as either gender. Bigender individuals identify as both male and female. The spectrum is broad, and many gender terms are used within the SGM community.
Social Determinants of Care
SGM communities face a host of negative social reactions that impact their daily lives and self-esteem, including such micro- and macroaggressions as implicit bias, marginalization, stigmatization, recurrent trauma, and violence/exploitation. These experiences result in fear and mistrust of healthcare institutions and providers, internalized emotional distress (depression, anxiety, suicidal ideations), and delayed healthcare access. Negative experiences that impact the SGM community include:
- Cisnormativity and heteronormativity/heterosexual privilege. The practice of assuming and using cisgender and heterosexual terms as a default within institutions and social situations. This type of microaggression reduces trust with the institution and the provider by supporting the notion that the individual is different, and their identity is unworthy of respect.
- Misgendering and deadnaming. Intentionally identifying a patient as a gender they do not align with (misgendering) or using a name the patient does not identify with (deadnaming) are microaggressions. These practices are degrading and can lead to safety issues.
- Violence. SGM communities are at high risk of violence perpetrated against them. In 2019, the American Medical Association declared violence against transgender and gender-nonconforming individuals an epidemic. Black and Latinx transgender women experience the majority of this violence.
- Depression and suicide. Studies indicate that 82% of transgender youth have had serious suicidal thoughts, and 40% have attempted suicide at least once, compared to 4.6% of the general population.
Healthcare Practices That Impact Safety
In addition to the social determinants of health noted above, healthcare institutional practices that can increase the risk of harm to SGM patients include:
- Electronic health record (EHR) terminology. Many EHR platforms do not accommodate differences in an individual’s assigned-at-birth sex and their gender identity, which may have administrative and clinical repercussions. Patient identification and insurance verification can be complicated when sex assigned at birth and gender identity are misaligned. For example, a patient who identifies as male may have a uterus and need a Pap smear. The insurance company may deny those services if their system identifies the patient as male. The use of reference intervals or benchmarks in laboratory screenings can result in errors or delays when the identified sex and sex assigned at birth are confused.
- Hormone therapy risks. Gender-nonconforming individuals receiving hormonal therapy are at increased risk of heart disease, stroke, and cancer. For example, hormonal therapy to reduce muscle mass and redistribute body mass may elevate the risk of hypertension and metabolic disorders in a patient who was assigned male at birth. Patients who are assigned female at birth may have increased risk of breast and ovarian cancer due to hormonal therapy. Additionally, because of the difficulty in accessing gender-affirming care, many transgender individuals take hormonal therapy that is not prescribed for them.
- Refusal of care. SGMs still face violations of their rights and denial of care due to individual moral objections and convictions. The precise limits of a physician’s right/ability to refuse care for a patient are mostly undefined, which can lead to discrimination against patient groups found to be socially unacceptable. In these cases, physicians often invoke conscience clauses using arguments based on religious freedom and the First Amendment.
Risk Recommendations
- Be aware of your own biases. Everyone has biases. Conduct an honest inventory of your feelings and experiences to identify biases, attitudes, and assumptions. Some of them may surprise you. When they arise, take a moment to step back and reflect. Self-reflection helps to differentiate your opinions from the values of the patient.
- Ask your patients. Inquire about sexual orientation and gender identity as it relates to your care of and relationship with the patient. Don’t focus on the anatomy unless it is medically indicated. Gender-nonconforming people are often asked about their anatomy, which can be embarrassing and intrusive. Don’t assume or challenge someone’s gender or sexual orientation, and never “out” (reveal the sexual or gender identity of) someone without their permission. It’s their story to tell.
- Create a welcoming culture. Establish a cultural expectation within the organization that the SGM community is welcome. This could include SGM-affirming policies, welcoming language on websites and communication, open dialogues with staff, Just Culture principles, anti-discrimination policies, or an employer-sponsored SGM employee group. Use gender-neutral language on signage and in your environment (e.g., bathrooms).
- Implement policies. Develop targeted policies on staff training and scripting around microaggressions, social justice, and social determinants of health.
- Interact with sensitivity and compassion. Be comfortable asking patients for their preferred pronouns. Introducing yourself using pronouns first lets a patient know that you are willing to affirm their gender. Use gender-neutral language (people who lactate, those who menstruate, you or your partner/spouse) in conversation. If you make a mistake, quickly apologize, correct yourself, and move on.
- Refer when necessary. Refer patients who are depressed or suicidal to community support resources such as the Trevor Project, suicide hotlines, local crisis response teams, or the emergency department, depending on the patient’s level of acuity and/or risk.
Resources
- Centers for Disease Control and Prevention
- Fenway Health
- Gay and Lesbian Medical Association (GLMA)
- The LGBT Community Center
- National Center for Transgender Equality
- Transgender Law Center
- University of California San Francisco, Center for Excellence for Transgender Health
- World Professional Association for Transgender Health
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.