Reproductive health care for lesbian, gay, bisexual, queer, and other sexual minority individuals assigned female at birth

INTRODUCTION — 

Knowing and understanding a patient's gender identity and expression, sexual orientation, and sexual practices, as well as information about sex assigned at birth, improves health care providers' abilities to provide inclusive, quality care and recognize areas of disproportionate risk [1]. This topic focuses on reproductive health care issues experienced by individuals assigned female at birth who identify as lesbian, gay, bisexual, queer, and/or otherwise nonheterosexual. Such people may identity as cisgender or otherwise gender-diverse. For brevity, this topic will use the abbreviation SGM, for sexual and gender minority, to refer to this population. We recognize that language will continue to evolve.

Discussions specific to gay men, sexual minority youth, and transgender individuals are presented in related chapters.

●(See "Primary care of gay men and men who have sex with men".)

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

●(See "Transgender women: Evaluation and management".)

●(See "Transgender men: Evaluation and management".)

●(See "Primary care of transgender individuals".)

In this chapter, we will use the terms "woman/en," "female(s)," and "patient(s)" as used in the referenced studies but recognize that not all SGM individuals identify with these terms. We encourage the reader to learn SGM people in their geographic region refer to themselves and to consider the specific language preferences, as well as counseling and treatment needs, of each individual.

TERMINOLOGY

Importance of using patient's chosen descriptors — Clinicians are advised to directly ask patients how they choose to be identified regarding their sexuality, gender identity, and pronouns. Language and terminology are continuously evolving, and using patient-provided language allows for rapport building. We have found that it is important to repeat this conversation over time as gender identity, sexual orientation, and sexual behaviors may change.

Specific language recommendations — Many organizations have devised glossaries to help clinicians understand the multiple descriptors. We find it useful to refer to the publicly available resources through the University of California San Francisco Center of Excellence for Transgender Health and the Fenway Institute Glossary of LGBT Terms for Health Care Teams. Multiple resources are available to guide clinicians who are developing gender-inclusive clinical settings [2-5].

Some commonly used terms include (table 1) [6]:

●AFAB – AFAB is "assigned female at birth" and is used when female sex is assigned to an infant based on anatomic appearance and/or sex chromosomes.

●Sex – An individual's sex refers to the biology they are born with, including genetic, hormonal, anatomic, and physiological characteristics [7]. Related terms include "sex assigned or designated at birth" or "birth sex." This determination is typically made by the appearance of the genitals at the time of birth, or potentially through prenatal genetic assessments when indicated. Sex is typically listed as male, female, or intersex.

●Gender – Gender refers to the socially constructed characteristics of men and women, such as roles, norms, and behaviors, that are labeled by a society as male or female [8]. The concept of gender can vary by society and can change over time [8,9].

●Gender identity – Gender identity is "a person’s inner sense of being a girl/women/female, boy/man/male, or both, neither, or beyond the gender binary." Gender identity is a social construct that may be consistent with or different than the assumptions for their sex assigned at birth.

●Gender expression – Gender expression refers to how a person communicates their gender to the world through clothing, hairstyle, mannerisms, and speech; in other words, the external ways in which an individual expresses or displays their gender. Gender expression varies with culture, context, and historical period.

●Transgender – Transgender, "trans," or "trans*", refers to "people whose gender identity does not align with the sex they were assigned at birth, based on societal expectations" [6]. The umbrella term "transgender" includes: an individual assigned female sex at birth who identifies as a man (eg, trans man, transgender man), a person assigned male sex at birth who identifies as a woman (eg, trans woman, transgender woman), and also people with gender identities outside the man/woman binary (see nonbinary below).

●Cisgender – A cisgender person is one whose gender identity is consistent with their sex assigned at birth (eg, a person assigned female sex at birth whose gender identity is woman/female or a person assigned male sex at birth whose gender identity is man/male).

●LGBTQIA+ – This is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual/agender, or other nonheterosexual, noncisgender identities. The "+" indicates additional terms, including pansexual, omnisexual, gender fluid, nonbinary, Two-Spirit, among others.

●Nonbinary – Nonbinary describes a person whose gender identity falls outside of the "gender binary of female and male" [6]. Similar terms include gender-queer, gender-diverse, and gender-expansive.

●Sexual orientation – Sexual orientation refers to how an individual experiences "physical, emotional, and romantic attachments to other people" [6]. A single sexual event or expression of desire does not define one's sexual orientation.

●Sexual behavior – Sexual behavior refers to a spectrum of romantic and sexual actions; these may or may not align with one's stated sexual orientation. For example, a self-identified lesbian can also be attracted to, and engage in, sex with men and/or individuals who identify as nonbinary, transgender, etc. Moreover, a woman might have sex with another woman and not identity as lesbian.  

Sexual behavior can change over time [10]; current sexual partnership may not reflect an individual's previous or future sexual behavior.

INCLUSIVE CLINICAL-CARE ELEMENTS FOR ALL PATIENTS — 

Elements that foster a welcoming health care experience apply to all patient visits and are not specific to one patient group. We encourage clinicians to make these elements routine in their practices.

Demonstrate cultural humility and competency

●Definitions – Cultural humility implies that an individual should be committed to continuously evolving self-awareness of personal beliefs and the cultural identity of themselves as well as of others [11]. This concept is a precondition to cultural competence. Cultural competency focuses on the ability to communicate effectively and provide quality health care to patients from diverse backgrounds. Lack of cultural humility and competency by the clinician and/or health care system can complicate care delivery for SGM patients and result in unanticipated negative health outcomes [12,13]. Examples of cultural competence training programs for health care providers are available in the published literature [14,15] and available online (US Health and Human Services LGBTQ+ Resources).

●Key components – Some key components of cultural competency include [1,16-18]:

•Open attitude – An open, nonjudgmental attitude that includes not making assumptions about a patient's sexual orientation or behaviors, reproductive goals, or family planning needs.

•Curiosity – A stance of curiosity when inquiring about individuals accompanying to a clinic visit or as part of a family; using language that avoids assumptions about family or relationship structures.

•Gender-neutral language – Use of gender-neutral language (eg, avoiding gendered honorifics such as "Mr./Ms." and instead referring to patients by full names until honorific preferences are known; avoiding gendering body parts [eg, "female organs" rather than uterus/ovaries]).

Create a welcoming care environment — All patients should be treated with empathy, nonjudgmental attitudes, and openness from the moment they enter the health care environment. Specific strategies for creating a welcoming environment include displaying symbols and images important to the community (eg, pride flag, pronoun labels on name tags), performing organization-wide training, creating inclusive intake forms and resource materials, appropriately collecting sexual orientation and gender identity data, ensuring that the electronic health record captures and protects sexual orientation and gender identity/expression (SOGI) information, and consistently using inclusive language [19].

Collect sexual orientation and gender identity (SOGI) data

Data collection and limitations — Data collection on SOGI is relatively new. Accurate demographic information for SGMs has been limited by a historic lack of data as well as the conflation of information regarding gender and sexuality.

In the United States, gay and lesbian individuals were first recognized as a subpopulation on the 1990 census. In 2021, the US Census Bureau added SOGI questions to the Household Pulse Survey [20]. Based on 2022 Gallup data, 7.2 percent of US adults identify as SGMs; within this heading, the majority identify as bisexual (4.2 percent), with smaller groups identifying as gay (1.4 percent), lesbian (1.0 percent), or transgender (0.6 percent) [21]. A greater portion of individuals in younger generations identify as openly SGM compared with those in older generations. The accuracy of these statistics could vary due to individuals who may not feel comfortable identifying during telephone surveys or whose identity or sexual behaviors have not been accurately represented in these surveys.

Evidence supporting SOGI data collection — Asking patients about and understanding their sexual orientation and gender identity is important on many levels, especially as patients generally report that they want to be asked [22]. Moreover, collection of SOGI data is recommended by the National Academy of Medicine (formerly known as the Institute of Medicine [IOM]) and the Joint Commission as a key strategy in discovering and closing health disparities [23,24].  

Additional evidence supporting SOGI data collection include:

●In a 2017 United States questionnaire study, 78 percent of emergency physicians felt that patients would refuse to disclose if asked about sexual orientation; in contrast, only 10 percent of patients reported they would refuse to disclose [25]. Patients who disclose their sexual orientation to their health care providers may feel safer discussing their health and risk behaviors as well [26].

●Asking about sexual orientation and gender identity allows a patient's identity to be affirmed and seen by their provider, and helps clinicians recognize potential health disparities that should be addressed [27].

Impact of SOGI on social determinants of health

●Health disparities and reduced access to care – Gender influences access to health care [8]. SGM individuals face significant health disparities that contribute to lesser access to regular health care and resultant poorer health status. Health care survey data indicate lesbian and bisexual women are more likely than their heterosexual counterparts to report overall poor functional status, lack of access to a regular source of health care, and avoiding seeking health care services, as well as higher rates of psychological distress [28]. A study of data from the US National Health Interview Survey reported that gaps in health status and health care access between lesbian and heterosexual women did not change from 2013 to 2018 [29].

As a result of stigma, discrimination, and prior negative experiences with the health care community, SGM individuals often underutilize clinical care services and present later when they do seek health care [29-31]. In addition, differential risks for disease can arise because of adverse health behaviors, such as substance use and lack of access to regular exercise that are associated with stigma and discrimination.

●Barriers to care – Judgmental or insensitive encounters with health care providers and/or an assumption of heterosexuality have deterred many SGM individuals from seeking health care [32-35]. Consequently, SGM individuals, compared with non-SGM individuals, have experienced poorer health-related qualities of life [36].  

Additional challenges may include:

•Exposure to discriminatory laws and policies; these have been linked to increased psychosocial stress [37,38]

•Discrimination in health care encounters, such as providers making assumptions and/or dismissing concerns [39]

•Social and minority stressors, victimization, and stigmatization [40] impair health, especially for Black SGM adults compared with white individuals [39,41]

•Challenges with accessing health insurance [42]

•Delays in seeking care or difficulties paying for medications due to cost [43]

●Individual versus population health – Not all individuals within a given population have the same experience of health. For SGM individuals, other identities around race, class, ability, age, and more will impact health and health care. Rather than focusing exclusively on disparities, SGM researchers and community members are also highlighting resilience, or the ability to recover from adversity and stress in one's life.

Perform inclusive history-taking — We apply the approach below and encourage clinicians to use these for all patients.  

●Avoid assumptions – Health care providers should not make assumptions about the lived experiences of their patients, including sexual identity or sexual behaviors, based on their appearance or other demographic data [44]. There are no stereotypical profiles or markers that identify a person as an SGM individual. Clinicians are encouraged never to make assumptions about a patient's identity based on appearance, voice, clothing, or any other external features. Further, clinicians should avoid assumptions about the purpose of a given clinical visit and set the agenda with patients using shared decision-making.

●Explain the medical issue and ask the patient – If specific information is needed to provide appropriate care, such as a patient's need for contraception or protection from sexually transmitted infections (STIs), we suggest explaining the medical concern and asking the patient.

●Appropriate use of sexual history – When a sexual history is needed, questions should focus on the patient's presenting concerns and symptoms, such as abnormal vaginal bleeding. Guidance for taking a sexual history is available through multiple resources [45-47] and one commonly used system, the five Ps (partners, prevention of pregnancy, protection from STIs, practices, and past history of STIs), is presented in the table (table 2).  

Additional information on the gynecologic history is available in related content. (See "The gynecologic history and pelvic examination", section on 'Gynecologic history'.)

General principles for physical examination — Physical examination components are the same for of SGM individuals as for all other patients. We believe some best practices include:

●Prior to the examination, meet with the patient fully clothed.

●Discuss the planned examination and anatomy involved and briefly explain the clinical rationale.

●In general, we recommend use of clinical and anatomical terms, but recognize that some patients may prefer different language (eg, "chest" versus "breast" exam; "genital" versus "vaginal" exam). We use patient-preferred language as appropriate.

●Use a trauma-informed approach and be alert for signs of physical or emotional discomfort that can indicate a history of trauma or abuse.  

•(See "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

•(See "Trauma-informed care in adults".)

●For patients with concerns regarding the gynecologic examination, we discuss options to make the experience less difficult. These may include:

•Topical application of lidocaine to the introitus

•Patient insertion of the speculum

•Presence of a support person

•Use of stress-reduction techniques, music, and/or anxiolytic medications

A detailed discussion of the pelvic examination is presented separately. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

REPRODUCTIVE HEALTH ISSUES

Sexually transmitted infections (STI)

Prevention — Options for STI prevention include the following:

●Human papillomavirus (HPV) vaccination – Education regarding the benefits of HPV vaccination is important for all sexually active individuals. HPV vaccination may be offered to individuals ≤45 years of age [48,49]. The importance of HPV vaccination was demonstrated by a population-based survey of over 790,000 men and women that reported lesbians and bisexual women were over-represented among women with oropharyngeal cancer, which is typically HPV related [50]. Detailed information on HPV vaccination is available separately. (See "Human papillomavirus vaccination".)

●Pharmacologic prophylaxis for HIV – Pre-exposure prophylaxis (PrEP) is offered to those at high risk of HIV transmission (table 3) [51]. (See "HIV pre-exposure prophylaxis".)

●Suppressive therapy for prevention of herpes simplex virus (HSV) – Couples who are serodiscordant for HSV can use one of the regimens, such as valacyclovir (500 mg once daily) or acyclovir (400 mg twice a day) to help prevent transmission of genital HSV, either type I and/or II, to an uninfected sexual partner. (See "Prevention of genital herpes virus infections", section on 'Chronic suppressive therapy in discordant couples'.)

●Safer sex practices – "Safer sex" refers to strategies for avoiding mucous membrane contact with a partner's blood or secretions. Examples include using internal or external condoms, placing a dental dam or latex barrier over affected areas during oral sex, and washing sex toys with hot soapy water between uses (or covering the toy with a fresh condom). (See "Internal (formerly female) condoms".)

Risk and screening — Evaluation and treatment protocols do not differ from those for the general population. All individuals with STIs should be encouraged to inform their sexual partner(s) regarding the need for screening, diagnosis, and treatment. Detailed discussions of STI screening rationale, risk assessment, screening recommendations, and screening methods are presented in related content. (See "Screening for sexually transmitted infections".)

Specific to STI risk and screening for SGMs:

●Rationale – STIs such as chlamydia, gonorrhea, syphilis, trichomoniasis as well as HPV and HSV can be passed between female partners [52]. In addition to symptom-specific symptoms, STIs as a group increase the risk of HIV acquisition and contribute to tubal factor infertility [53].

●Risk factors and risk assessment – There are scant data looking at unique risk patterns for STI in SGMs. Risk is generally driven by an individual's sexual behavior. For all patients, it is important to ask patients to confirm the details of sexual behavior or practice rather than making assumptions about sexual behavior based on a given sexual identity. One approach to sexual history-taking is the five Ps method (partners, prevention of pregnancy, protection from STIs, practices, and past history of STIs) (table 2). Additional information on assessing risk is available in related content. (See "Screening for sexually transmitted infections" and "Screening for sexually transmitted infections", section on 'Assessing risk'.)

●Screening – Guidelines suggest STI screening for SGM individuals based on behavioral risk factors and regional disease prevalence [53,54]. An example of screening guidelines is presented in the table (table 4). Additional discussions of STI screening rationale, risk assessment, screening recommendations, and screening methods are presented in related content. (See "Screening for sexually transmitted infections".)

Bacterial vaginosis — Although not officially labeled an STI, data support sexual transmission of bacterial vaginosis (BV), including between female sex partners [55]. Routine screening is not advised but individuals with symptoms suggestive of BV and their sex partners should be evaluated [54]. Concordant infection rates of sexual partners of 25 to 50 percent have been reported [56].

●(See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

●(See "Bacterial vaginosis: Initial treatment".)

Libido and sexual dysfunction — Sexual health, pleasure, libido, and sexual dysfunction are under-studied topics in SGMs and interpretation of the available data is further complicated by study design [57]. Some studies focus on self-identified groups (ie, lesbian, bisexual, etc) while others focus on sexual behavior (eg, women who have sex with women, women who have sex with both women and men, etc). These approaches may impact our understanding of individual care needs.

Compared with their heterosexual counterparts, SGMs may be more likely to experience sexual dysfunction with aging, although definitive conclusions are limited by small sample sizes and heterogenous outcome measures [58]. While the diagnosis and treatment of sexual problems are similar for all women, clinicians should ask open-ended questions to gain understanding of the patient's specific sexual practices. This approach avoids making assumptions or mistakes about the nature of sexual practice based on a particular sexual identity.

Additional discussions can be found in related content:

●(See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation".)

●(See "Overview of sexual dysfunction in females: Management".)

Contraception — It is important to recognize that SGMs have diverse perspectives on pregnancy and family building. Therefore, it is important to inquire about potential for pregnancy in all persons with capacity to conceive. In a survey study of nearly 400 women who identified as having sex with other women, 16 percent reported having been pregnant, and of those who had been pregnant, 63 percent reported having one or more induced abortions [59].

Detailed information on contraception counseling is available separately. (See "Contraception: Counseling and selection".)

Pregnancy and parenting — SGMs have a diversity of paths to parenthood, including conception through known or anonymous donor insemination or in vitro fertilization (IVF), use of a surrogate, foster parenting, adoption, or raising children from prior relationships. It is important to recognize that SGMs are likely to face more obstacles to parenthood than their heterosexual counterparts due to persistent legal barriers in some states and countries.

Pregnancy

●Ask about intent – Pregnancy, both desired and unintended, is common regardless of sexual orientation and gender identity. A 2017 meta-analysis of 28 studies reported that the likelihood of having ever been pregnant was higher for bisexual women and lower for lesbian women compared with heterosexual women [60]. Clinicians are advised to ask persons capable of pregnancy, including SGM individuals and those in same-sex relationships, if and when they might desire pregnancy [61]. This approach opens discussions about plans for family building and optimizing reproductive health.

●Assess need for fertility care – Fertility care may include conception through known or anonymous donor insemination, IVF, and/or gestational carrier pregnancy [62]. Family building is considered a basic human right; thus, sexual orientation and gender identity should not be obstacles to fertility care [63-67]. All patients should receive information on options for fertility care and, if desired, referral to specialists with experience caring for SGM patients [61,68].

Commonly used fertility procedures include donor insemination, IVF, and gestational carrier pregnancy. These are discussed separately.

•(See "Donor insemination".)

•(See "In vitro fertilization: Overview of clinical issues and questions".)

•(See "Gestational carrier pregnancy".)

●Pregnancy care – Pregnancy care is impacted by pregnancy-specific risk factors, such as underlying hypertension or diabetes, but not otherwise altered for SGM patients. However, clinicians and programs are encouraged to ensure that these spaces are welcoming to diverse families.

As examples:

•Avoid assumptions about family structure on intake forms and history questions

•Provide individuals with the opportunity to indicate their roles/titles (eg, language should not be restricted to "mother" and "father")

•Be aware that "women's" care centers may not feel welcoming to all individuals and families

Outcomes

●Live birth rate – In a retrospective chart review of 306 lesbian couples who sought reproductive assistance with either intrauterine insemination (IUI) or IVF, 85 percent attempted single-partner conception and 68 percent had a live birth [69]. An additional 15 percent of couples elected dual-partner conception, and 89 percent had a live birth. An average of 3.0±1.1 cycles were completed for women who conceived with IUI and an average of 6.0±1.4 IUI cycles plus 1.7±0.3 IVF cycles for women who conceived with IVF. Both IUI and IVF are presented in detail separately. Not surprisingly, lesbians and bisexual women using assisted reproductive health services are more likely to be successful than heterosexual women, who typically use these services after a diagnosis of infertility [60,70]. (See "Donor insemination" and "In vitro fertilization: Overview of clinical issues and questions".)

●Obstetric outcomes – A population-based cohort study in California showed that SGM individuals (particularly "birthing mothers with mother partners") experienced worse obstetrical outcomes than non-SGM patients for the following: multifetal gestation, labor induction, severe morbidity, and postpartum hemorrhage. This difference in outcomes was independent of comorbidities, multifetal gestation, and sociodemographics [71]. In another sample, lesbians and bisexual women had higher risk for stillbirths and miscarriages compared with heterosexual women [72]. Adverse obstetric outcomes may be a reflection of the cumulative impact of stigmatization and resultant psychological stress, decreased access to services, cost of getting pregnant, and discrimination by health care providers. (See 'Social, health, and legal challenges' below.)

●Child health and development – Multiple studies have reported similar outcomes in sexual or gender identity, personality traits, or intelligence in children raised by lesbians compared with children of heterosexual parents [61,73-75]. Similarly, children conceived through donor insemination for lesbian parents have similar mental health outcomes compared with a normative sample of the United States population [76,77]. Health outcomes for children born through assisted reproductive technology are discussed separately. (See "Assisted reproductive technology: Infant and child outcomes".)

Social, health, and legal challenges — Providers should be aware that SGMs may encounter additional challenges when planning for pregnancy and/or parenthood including stigma, assumptions about normative family structures, potential family rejection, insurance limitations, and/or lack of access to fertility services/sperm banks. Studies suggest pregnant SGMs are more likely to be uninsured and experience a higher frequency of mental distress and/or depression compared with heterosexual pregnant women [70,78]. As the legal landscape around fertility services, adoption, and other paths to parenthood is constantly evolving and dependent on geography, we advise patients to consult with legal specialists with expertise in this area [38].

Exposure to violence

●Intimate partner violence – Intimate partner violence (IPV) refers to abuse or aggression that occurs in a romantic relationship and may include violence (physical or sexual), stalking, and/or physical aggression [79]. IPV can occur among heterosexual or same-sex couples and does not require sexual intimacy. A systematic review of eight studies reported that societal biases may make "it difficult for lesbian women victims of intimate partner violence to seek help or access support services" [80].

We screen all patients for IPV; individuals who screen positive are assessed for safety and referred for counseling and help with intervention. More information on IPV is available separately:

•(See "Intimate partner violence: Epidemiology and health consequences".)

•(See "Intimate partner violence: Diagnosis and screening".)

•(See "Intimate partner violence: Intervention and patient management".)

●Sexual and other violence – Compared with heterosexual women, SGMs have reported more severe victimization and higher rates of sexual revictimization [81]. In a study of over 7600 women undergoing pregnancy termination in 2014, those women who identified as bisexual, lesbian, or otherwise were two to nine times more likely to report physical violence by the man involved in the pregnancy compared with heterosexual women [82]. In addition, lesbian women were 18 times more likely than heterosexual women to report sexual abuse by the man involved in the pregnancy, and 10 percent of lesbian women noted the pregnancy was a result of forced sex.

Additional information related to sexual violence is available separately. (See "Date rape: Identification and management".)

CANCER SCREENING AND CARE — 

While cancer screening and care are not altered by sexual orientation or gender identity, cancer screening and treatment may be harder for SGMs to access. Reported obstacles to care include lack of health insurance, prior negative health care experiences, and beliefs that such care was not necessary [83-85]. Reduced access may explain lower screening rates for cervical cancer [86,87] and increased risk of delayed diagnosis of breast cancer [88] for SGMs. While some data suggest that SGMs have an increased risk of breast cancer, this is likely a reflection of other breast cancer risk factors (eg, being overweight or obese, nulliparity, and/or excessive alcohol intake) [89,90].  

An overview of preventive care in adults is available separately. (See "Overview of preventive care in adults".)

HEALTHY AGING — 

As LGBTQ+ individuals may experience a combination of health and social issues (eg, the experience of discrimination and mistreatment), the addition of physical aging can exacerbate existing health disparities and result in an increased need for health care access and resources [91-94]. Clinicians are encouraged to inquire about these issues [95]. Services and Advocacy for GLBT Elders (SAGE) is a national organization that has many resources for LGBTQ+ elders and caretakers.

Additional information on normal aging is available separately. (See "Normal aging".)

SUB-POPULATIONS OF INTEREST

Children and adolescents — Gender and sexuality are independent but intersecting facets of human development that evolve rapidly during adolescence and young adulthood [96,97]. SGM youth have additional unique care needs [96,97]. These issues are presented in detail separately.

●(See "Sexual development and sexuality in children and adolescents".)

●(See "Gender development and clinical presentation of gender diversity in children and adolescents".)

●(See "Management of transgender and gender-diverse children and adolescents".)

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)

Racial and ethnic underrepresented groups — Research on the intersection of race/ethnicity and sexual minority status is limited. SGM individuals of racial or ethnic underrepresented groups may be at higher risk of poor health behaviors and outcomes [28]. More health policy work is being done on these disparities in the United States [98,99].

Transgender individuals — Discussions of health care for transgender individuals are presented in related chapters, including:

●(See "Primary care of transgender individuals".)

●(See "Transgender women: Evaluation and management".)

●(See "Transgender men: Evaluation and management".)

●(See "Gender-affirming surgery: Masculinizing procedures".)

●(See "Gender-affirming surgery: Feminizing procedures".)

Homeless and incarcerated individuals — Challenges faced by SGM individuals may be further exacerbated by homelessness or incarceration. Additional discussions about the health care of homeless and incarcerated persons are presented separately.

●(See "Health care of people experiencing homelessness in the United States".)

●(See "Clinical care of adults during incarceration".)

●(See "Prenatal care: Incarcerated females".)

People living with disabilities — In the 2019-2020 National Survey on Health and Disability, SGM adults with disabilities reported having poorer health status than their heterosexual peers [100]. Additional discussion of health care for individuals living with disability is available in related content:

●(See "Disability assessment and determination in the United States".)

●(See "Primary care of the adult with intellectual and developmental disabilities".)

Veterans — The Veterans Administration (VA) has policies and guidelines for affirming care for SGM veterans [101]. One study suggested that veterans would be comfortable disclosing this information and would then be more likely to receive culturally appropriate care [102].

Sexual minority immigrants, political refugees, and/or displaced persons — The safety and health care of SGM persons varies around the globe. SGM persons may be subjected to sexual assault, "corrective rape" [103], imprisonment [104], abuse, and torture. This marginalization and stigmatization, combined with higher rates of poverty and abuse, are major chronic stressors that can lead to mental health disorders and significant health morbidity [105].

Detailed information on the health care needs of immigrants and refugees is presented separately. (See "Medical care of adult refugees, immigrants, and migrants to the United States".)

RESOURCES FOR PATIENTS AND CLINICIANS

●Websites

•GLMA – Formerly known as the Gay & Lesbian Medical Association, the GLMA is an association of LGBT health care professionals that provides free resources for patients and providers.

•National LGBTQIA+ Health Education Center – Provides free online training, including videos and webinars, and education.

•National Institutes of Health: Sexual and Gender Minority Research Office: Strategic Plan to Advance Research on the Health and Well-being of Sexual and Gender Minorites, 2021-2025

•United States Department of Health and Human Services | LGBTQI+ Health & Well-being

•SAGE (Services and Advocacy for LGBT Elders)

●Videos

•Association of American Medical Colleges (AAMC) – Videos and Resources about LGBT Health and Health Care

●Books

•Lesbian, Gay, Bisexual, and Transgender Healthcare: A Clinical Guide to Preventive, Primary, and Specialist Care, 1^st ed, Eckstrand KL, Ehrenfeld JM (Eds), Springer, 2016.

•LGBT Health: Meeting the Needs of Gender and Sexual Minorities, Smalley KB, Warren JC, Barefoot KN (Eds), Springer, New York, 2017.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Health care for lesbian, gay, and other sexual minority populations" and "Society guideline links: Sexually transmitted infections".)

SUMMARY AND RECOMMENDATIONS

●Terminology – Sexual and gender minority (SGM) refers to individuals assigned female at birth (AFAB) who identify as nonheterosexual and/or noncisgender. Many organizations have devised glossaries to help clinicians understand the multiple descriptors. We find it useful to refer to the publicly available resources through the University of California San Francisco Center of Excellence for Transgender Health and the Fenway Institute Glossary of LGBT Terms for Health Care Teams. (See 'Terminology' above.)

●Inclusive care elements – Elements that foster a welcoming health care experience apply to all patient visits and are not specific to one patient group. We encourage clinicians to make cultural humility and competency, inclusive data collection and history-taking, and use of a trauma-informed approach routine in their practices. (See 'Inclusive clinical-care elements for all patients' above.)

●Reproductive health issues – For all people, reproductive care generally includes discussions of sexually transmitted infection (STI) risk and prevention, sexual dysfunction, contraceptive need, and fertility and pregnancy. Within these categories, the reproductive care of SGM individuals should recognize both individual behaviors and societal inequities, including social stigma, discrimination, and insurance restrictions. As one example, SGM are more likely to face obstacles to parenthood than their heterosexual counterparts because of reduced access to care and legal barriers. (See 'Reproductive health issues' above.)

●Cancer screening and care – Sexual orientation or gender identity do not alter guidelines for cancer screening and treatment, but they may make it more difficult for individuals to access these services. (See 'Cancer screening and care' above.)

●Exposure to violence – SGM individuals may be at increased risk for intimate partner violence (IPV) and sexual violence, which is further compounded by reduced access to care. (See 'Exposure to violence' above.)