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Lippincott Nursing Pocket Card - May 2023

Affirming Care for Patients who are LGBTQ+

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Background

Affirming care recognizes the significant impact of sexual and gender minority (SGM) status on a person’s health and is critical to ensuring SGM patients receive culturally competent and clinically appropriate care (McElwain & Carr, 2021; Cottrell, 2019).

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Definitions

Providing affirming care requires an understanding of terms that are unique to the SGM population. In addition to lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual (LGBTQIA+), here are additional key terms you should know. Please note this list of terminology is not exhaustive and is ever-changing.

  • Affirmed gender: an individual’s innate gender identity
  • Ally/allyship: individuals who support marginalized groups
  • Androgenous: characteristics of both femininity and masculinity expressed through sex, gender identity, gender expression, or sexual orientation
  • Assigned sex at birth: male or female based on biological status, reproductive organs, or the appearance of external genitalia present at birth
    • AFAB: assigned female at birth
    • AMAB: assigned male at birth
    • UAAB: unassigned at birth
    • Intersex: individual born with biological sex characteristics that aren’t traditionally associated as male or female; possibly ambiguous genitalia or both male and female sex organs. Intersex individuals include a wide range of gender identities and sexual orientations. Intersexuality does not refer to sexual orientation or gender identity (see “intergender” below).
  • Gender: social, cultural, psychological, and/or emotional traits, often influenced by societal expectations, that attempt to classify individuals along a spectrum of man, woman, neither, or a blend of both
  • Gender identity: psychological sense of self with respect to femininity, masculinity, neither, or a blend of both; does not always correspond with assigned sex or biology
    • Cisgender: gender identity matches the sex assigned at birth
    • Gender diverse; gender expansive: gender identity, expression, or perception extends beyond the female/male binary
    • Gender dysphoria: discomfort or psychological distress when physical attributes do not align with gender identity
    • Gender expression: presentation or appearance of gender identity; may include behavior, clothing, body characteristics, or voice
    • Genderfluid: without a fixed gender identity
    • Gender neutral: describes something that is not gendered such as pronouns, salutations, titles, or spaces (bathrooms, locker rooms); not used to describe people
    • Genderqueer: gender is both male and female, neither male nor female, or a gender not categorized
    • Intergender: gender identity in the middle between the binary genders of female and male; may be a mix of both
    • Multigender or bigender: more than one gender
    • Nonbinary (NB): used as an adjective for genders other than the binary man/woman
    • Transgender: gender differs from the sex assigned at birth; may identify as heterosexual, homosexual, bisexual, nonbinary, genderqueer or other; trans or trans+ may be used as a shortened term
      • Transgender male: assigned sex at birth was female who has a gender identity of male;
        • May still have female organs which require breast, ovarian, or cervical cancer screening
      • Transgender female: assigned sex at birth was male who has a gender identity of female
        • May still have male organs which requires testicular and prostate cancer screening
    • Transitioning: process of aligning with gender identity, which may include social (i.e., mannerism), legal (i.e., name change), or medical (i.e., physical or hormonal) changes
  • Sexual orientation: identifies who a person is sexually attracted to (i.e., physical, romantic, or emotional); may exist on a spectrum and is independent of gender identity
    • Asexual: experiences little to no sexual attraction.
    • Bisexual: attracted to either those of the same gender or to those of another gender
    • Demisexual: individual does not experience sexual attraction unless there is a strong emotional, but not necessarily romantic, connection with someone
    • Gay: individuals attracted to people of the same sex and/or gender
    • Heteronormative: the belief that only a relationship (i.e., marriage, cohabitating) between a heterosexual cisgender man and heterosexual cisgender woman is appropriate, while all others are viewed as inappropriate
    • Heterosexual/straight: women with an attraction to men, and men with an attraction to women
    • Lesbian: women who are attracted to other women and may partner exclusively with women
    • Men who have sex with men (MSM): appropriate to use within a medical context; does not imply sexual identity or sexual orientation and is not synonymous with gay and bisexual men
    • Pansexual: the capacity to form attraction to those of any gender
    • Questioning: uncertain or exploring their sexual orientation or gender identity
    • Queer: broadly used to indicate a rejection of heteronormativity and used by some to be inclusive of the entire LGBTQ+ community; some use “queer” to specifically describe their own fluid identities.
    • Women who have sex with women (WSW): appropriate to use within a medical context; does not imply sexual identity or sexual orientation and is not synonymous with lesbian or bisexual women
    • “+”: everything on the gender and sexuality spectrum that letters and words don’t yet describe.

Pronouns

Addressing an individual using correct personal pronouns shows respect and creates an inclusive environment. A person could be a man or a woman or both or neither and choose any set of pronouns to use, and no pronoun choice is wrong. Pronouns may not necessarily be indicative of their gender.
  • Cisfemale: she/her/hers
  • Cismale: he/him/his
  • Transgender male: he/him/himself
  • Transgender female: she/her/herself
  • Gender diverse (non-binary): they/their/theirs/them/themselves
  • Gender neutral: ze/hir/zhe/zhim/zher/zhimself/zherself

Transgender Care (Rowe, Ng & O’Keefe, 2019)

Transgender patients may face barriers to care due to stigmatization, discrimination in insurance coverage, and healthcare professional knowledge gaps. For patients experiencing gender dysphoria, gonadotrophin-releasing hormone (GnRH) therapy helps suppress puberty hormones and may improve self-esteem and the ability to cope with stress.
 
Transgender individuals seeking to align their bodies with their gender identity (“transition”) may explore cross-sex hormone therapy (CSHT) or surgical procedures, as explained in the table below. To legally transition from one gender to another requires a legal name change, changing the sex designation on your birth certificate, Social Security card, driver’s license, and passport.

 
Transgender Care
  Transgender Woman
(Male to female transition)		 Transgender Man
(Female to male transition)
Cross-sex hormone therapy (CSHT)
  • Estradiol for feminization
  • Antiandrogen (lower testosterone levels)
  • Decreases size of male genitalia, increases development of fat around the hips, increase in size of breasts, reduces facial and body hair
  • Testosterone for masculinization therapy
  • Increases facial and body hair, increases muscle development, and stops menstruation
Surgical procedures
  • Breast augmentation
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Vulvoplasty
  • Tracheal cartilage shaving
  • Masculinizing chest surgery
  • Hysterectomy
  • Metoidioplasty
  • Testicular implants
  • Phalloplasty

Transgender people have complex health needs and experience discrimination, stigmatization, and health disparities such as higher rates of substance abuse, psychiatric disorders, suicide, alcohol and drug abuse, smoking, cardiovascular disease, sexually transmitted diseases, and interpersonal violence (Margolies & Brown, 2019). Sexually transmitted infection screening and management, and mental health care and substance use disorder counseling are critical services that should be provided to the transgender community.

Collecting Sexual Orientation and Gender Identity (SOGI) Data

Collecting sexual orientation and gender identity (SOGI) data improves health screening, detection, and prevention of conditions more common in SGM groups. Use open-ended questions with an unbiased attitude and allow patients to describe their bodies, pronouns, and relationship partners in their own words.

  • “How would you like to be addressed and what are your pronouns?”
  • “To eliminate discrepancies in billing, or errors in the medical record, what name is noted on your health insurance card and driver’s license?”
  • “Can you tell me your assigned sex at birth?
  • “Have you had any surgical procedures or taken any medications to change your body to align with your gender?”
    • “It is important that we know what organs are present so we can conduct appropriate health screenings. Do you have the organs that were present at birth?”
  • “Are you attracted to males, females, both, or neither?”
  • “Are you in a relationship and, if so, how do you express physical intimacy?”
  • “Who are the important people in your life?” or “Who is family to you?”
  • “Is it ok to document this information in your medical record?”

Creating a Gender-Affirming Environment (McElwain & Carr, 2021; Rowe, Ng & O’Keefe, 2019):

Tips for creating a welcoming and gender-affirming environment include:
  • Integrate SGM/LGBTQIA+ education into nursing curriculums.
  • Develop educational brochures for hospital staff.
  • Use appropriate terminology and a standard assessment tool for collecting SOGI to decrease stress, build rapport, and increase patients’ feeling of safety.
  • Institute non-discriminative policies that prevent discrimination against a patient because of sexual orientation or gender identity.
  • Maintain an open, reflective, and individualized approach to each patient. Avoid assumptions about sexual orientation and gender identity based on appearance
  • Institute nondiscriminatory policies:
    • Ensure all staff address patients using their correct names and pronouns.
    • Revise intake forms to include more sexual orientations, gender identities, and neutral terms such as “partner” rather than “husband” or “wife.”
    • Display an organizational nondiscriminatory statement in waiting rooms specifically mentioning sexual orientation and gender identity.
  • Create multidisciplinary teams comprised of specialists such as endocrinologists and mental health professionals.
  • Develop patient education materials that reflect and include a diverse patient population.
  • Designate bathrooms with unisex signs and other SGM-friendly symbols.
References:
American Nurses Association (2018). Nursing Advocacy for LBGTQ+ Populations, Position Statement. www.nursingworld.org. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/nursing-advocacy-for-lgbtq-populations/
 
Centers for Disease Control and Prevention (2023, April 17). Transgender Persons. https://www.cdc.gov/lgbthealth/Transgender.htm
 
Cottrell D. B. (2019). Fostering sexual and gender minority status disclosure in patients. The Nurse practitioner, 44(7), 43–49. https://doi.org/10.1097/01.NPR.0000559846.83872.da
 
Jones, J. (2022). LGBT Identification in U.S. Ticks Up to 7.1%. Gallop. https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx
 
Margolies, L., & Brown, C. G. (2019). Increasing cultural competence with LGBTQ patients. Nursing, 49(6), 34–40. https://doi.org/10.1097/01.NURSE.0000558088.77604.24
 
McElwain, S.D. & Carr, K.L. (2021). Providing affirming care for LGBTQ patients. Nursing Made Incredibly Easy!, 19(3), 36-43.
 
Rowe, D., Ng, Y. C., & OʼKeefe, L. C. (2019). Addressing transgender patients' barriers to access care. The Nurse practitioner, 44(6), 30–38. https://doi.org/10.1097/01.NPR.0000558155.38478.8f
 

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