Fundamentals of Sexual and Gender Diverse Populations/Identity

Sex and Gender

• Assigned Sex at Birth

• Gendered Physical Characteristics
  (“Biological” Sex)

• Gender identities and roles

Sexuality

• Sexual orientation

• Sexual activity

• Intimacy

• Reproduction

Sexual orientation

an enduring pattern of romantic, emotional, or sexual attraction (or a combination of these) to either one gender or more

Sexual Orientation Mutability

Internal sense of orientation can develop in early childhood, but language can change and evolve over a lifetime

Sexual Orientation Terms

Lesbian, gay, bisexual, queer, straight, asexual, heterosexual, etc.

Sexual Desire

Someone’s internal experience of sexual attraction and interest (or lack thereof)

Sexual Desire & Sexual Behavior Mutability

Could change at any time due to social and/or physiological factors

LGBTQ+

lesbian, gay, bisexual, transgender, queer, asexual, intersex

Sexual Desire Terms

Allosexual or asexual

Sexual Behavior

Real-world actions and decision- making about sex (the sexual who, what, when, where, why,
how?)

Sexual Behavior Terms

Described by clinicians in terms like MSM/WSW – not used by community members

Gender Identity

• The personal sense of one's own gender—-can correlate
  with a person's assigned sex or can differ from it.

• Listen to the patient, they are the expert of their own body and identities should be respected

• Ask, use, and respect their pronouns (you can’t tell someone’s pronouns by looking at them)

Gender expression

typically reflects a person's gender identity, but this is not always the case

Assigned Sex at Birth Characteristics

“chromosomes, gonads, hormones, and genitals”

Gendered Physical Charcteristics

genitals, breasts, facial features, weight, height

Intersex Conditions

• Androgen Insensitivity Syndrome (AIS)

• Congenital Adrenal Hyperplasia (CAH)

• Klinefelter syndrome

• Turner syndrome

Intersex

a variety of conditions in which a person is born
with a reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male

(Intersex) atypical development in

• Chromosomes

• Internal organs

• External genitals

• hormones

Assigned Sex

The sex someone is labeled at birth (or in
utero) based on the visual appearance of
genitals

Assigned Sex Mutability

Defined only once (cannot be changed)

Gendered Physical Characteristics (“biological sex”) defined

Elements of physical anatomy, genetic makeup,
and hormonal profile historically associated
with “sex” (Maleness and Femaleness)

Gendered Physical Characteristics (“biological sex”) Mutability

Most characteristics can
be changed via medical
intervention (e.g.
hormone replacement,
surgeries)

Gendered Physical Characteristics
(“biological sex”) Terms

Best described with specifics, but often
shorthanded Male, Female, Intersex

Gender Identity Mutability

Internal sense of gender typically emerges by age 3, but language can change and evolve over a lifetime

Gender Identity Terms

Man, Woman,cisgender Genderqueer/ Non-
Binary, Two-Spirit, etc

Gender Expression Terms

Masculine, feminine, androgynous, butch,
femme

transgender man

someone identifying as a man with assigned sex at birth female

transgender woman

someone identifying as woman with assigned sex at birth male

Cisgender

someone who has a gender identity that aligns with their assigned sex at birth

Non-binary

someone who has a gender identity other than the binary man or woman

The health disparities that exist are directly tied to the discrimination and stigma that LGBTQ+ individuals face every day

• Political determinants of health

• Structural determinants of health

These differences in health conditions/diseases is NOT at all connected to the identity itself but…

it’s connected to how people are treated because of their identity

Discrimination and Unfair Treatment

• Higher rates of discrimination in daily lives and in health care; inequitable policies/practices

• Higher rates of being threatened and harassed in healthcare and facing negative experiences (50% of trans adults and 2x more likely if LGBQI+)

Mental Health Challenges

• The impacts of discrimination and stigma on mental health are disproportionate

• LGBTQ+ youth higher rates of suicide thoughts, attempts, and deaths compared to heterosexuals

• Trauma, post-traumatic stress disorder, depression, anxiety all higher in these populations

Physical Health Disparities

• Higher rates of HIV/AIDS

• Higher rates of some cancers

High Risk Behaviors

Higher rates of smoking, alcohol, and substance abuse

Family rejection

• 44% of trans individuals had a parent physically hurt them at least once during childhood (compared with 25% of cisgender heterosexual respondents)

• 57% trans people report conflicted relationship with parents (vs 22% cisgender heterosexual)

• 46% trans people report being bullied (vs 17% of cisgender heterosexual)

• 30% of trans individuals experience homelessness at some point (51% among Black transwomen)
   

Barriers to Economic Security

• 62% of trans respondents report income < $25,000 annually (compared to 40% cis/het respondents

• 79% of TGNC individuals in southeast US were food insecure

• Direct correlations between poverty and reported fair or poor health

• More than 50% reported postponing or not receiving medical care because they couldn’t afford it (60% of trans people of color)

• Employer-based medical insurance disproportionately affects trans populations because of their higher unemployment likelihood

• 80% report that discrimination negatively affects their ability to be hired
   

Housing insecurity and Experiences of Homelessness

• 1/3 report living in poverty vs 12% of US population

• Majority of states lack legal protections for housing based on gender identity

• 52% of trans individuals reported discrimination negatively affected their ability to rent or buy a home to some degree (vs 36% of cisgender LGBQI+ respondents)

• 70% of trans individuals who have stayed in shelters report harassment, physical assault, or removal

• 63% trans people experiencing homelessness are also unsheltered

• 60% of unsheltered trans populations are trimorbid, facing co-occurring physical, mental, and substance use disorders.
  • Which leads to increased incarceration rates

Providing a safe Environment

• Don’t assume gender or sexual orientation or pronouns 

• Use open-ended questions and a caring demeanor 

• Use gender-neutral language as much as possible 

• To gain information about relationship status, ask about a partner or significant other

• Ask about If you are unsure about gender, ask “how may I address you?

Inclusive Language/Non-gendered Language/Pronounsucing you 

• Introducing yourself with your pronouns signals that you are an affirming space to those who need to know

• It doesn’t put pressure on the patient to figure out if you are
  welcoming

• You cannot assume someone’s pronouns from how they look or their name; they are the only one who can tell you what pronouns they use

• Practice using gender-neutral pronouns with colleagues, friends,
  family or app

Don’t ask about

genitalia or gender affirmation surgery unless it is directly relevant to care

Gender Affirming Hospital Policies

• Don’t discriminate based on gender identity or gender expression.

• Transgender people should be able to receive hormone therapy according to the current standard of care

• Transgender patients will be addressed by the pronoun and gender identity that they self-identify with regardless of surgical history, appearance, or sex assigned at birth

• When room assignments are gender-based patients should be roomed based on their self-identified gender

• All patients can use the bathroom that matches their gender identity

Patient Protection and The Affordable Care Act (ACA)

• The Office for Civil Rights (OCR) enforces Section 1557 of the
  Affordable Care Act (Section 1557), which prohibits discrimination on the basis of race, color, national origin, age,
  disability, or sex (including pregnancy, sexual orientation, gender identity, and sex characteristics), in covered health
  programs or activities.

• Applies to any health program receiving federal funds (i.e. Medicaid, Medicare) and providers who receive federal funds

• Specific protections for gender diverse individuals, including the right to access services/facilities consistent with their gender identity

• Gender diverse patients CANNOT be denied services based solely on their gender identity or because their gender doesn’t match their recorded sex assigned at birth

The Affordable Care Act (ACA)

• Prohibits discrimination based on sexual orientation and gender identity in health plans 

• Requires plans that offer coverage to heterosexual spouses to also offer coverage to other-gender spouses; based on the state of celebration

• Individuals can no longer be denied coverage due to a pre- existing condition, such as HIV, mental illness, or gender- affirming medical history

• New private plans are required to cover recommended preventative services without cost-sharing, including
  screenings for HIV, STIs, depression, and substance misuse