Chapter 2: LGBTQIA Populations

Chapter 2: LGBTQIA Populations

LGBTQIA population includes lesbian, gay, bisexual, transgender, queer, intersex, asexual individuals.

Group is diverse in race, ethnicity, age, socioeconomic status.

Health care professionals must build trusting, culturally sensitive, individualized relationships to allow open discussion of gender identity and sexual orientation.

Terminology

Sexuality

• Definition: Personal expression and experience of intimacy (not limited to sexual organs).

Gender Dysphoria

• Definition: Distress caused by mismatch between gender identity and sex assigned at birth.

Transition

• Definition: Process of changing appearance or characteristics to align with gender identity.

Sexual Orientation

Attraction based on sexual, emotional, behavioral, or identity factors.

Types

• Heterosexual: Attracted to a different gender.

• Gay: Attracted to the same gender.

• Lesbian: Woman attracted to women.

• Bisexual: Attracted to more than one gender.

• Queer: Uses queer as a sexual orientation or gender identity term outside heterosexual norms.

Gender Identity

Personal sense of one’s gender; may differ from sex assigned at birth.

Types

• Cisgender: Gender aligns with sex assigned at birth.

• Gender-nonconforming: Expression/identity outside binary cultural norms.

• Transgender: Gender does not align with sex assigned at birth.

  • Trans woman: Assigned male at birth → identifies as female.

  • Trans man: Assigned female at birth → identifies as male.

• Nonbinary: Gender identity not exclusively male or female (e.g., genderfluid, genderqueer, agender).

Gender Dysphoria

Not all gender-nonconforming individuals have this condition

DSM-5-TR criteria:

• Children: Must have ≥ 6 criteria for ≥ 6 months.

• Adolescents & Adults: Must have ≥ 2 criteria for ≥ 6 months.

Diagnostic Criteria for Gender Dysphoria

Children: ≥ 6 criteria for ≥ 6 months.

• Desire to be a gender different from sex assigned at birth

• Strong preference for clothing/role-play of another gender

• Preference for playmates of another gender

• Dislike of one’s sexual anatomy

• Desire for primary/secondary sex traits that match identified gender

• Strong rejection of traditionally gendered toys/activities

---

Adolescents & Adults: ≥ 2 criteria for ≥ 6 months.

• Desire to be a gender other than sex assigned at birth

• Feeling typical emotions/reactions of a different gender

• Desire to be treated as another gender

• Desire to remove primary/secondary sex traits due to incongruence

• Desire to stop development of expected secondary sex traits

• Desire for traits of another gender

Affirming Care for Clients with Gender Dysphoria

Discuss differences in gender roles/expression
(e.g., living part-time or full-time in identified gender)

Review social affirmation
(e.g., pronouns aligned with gender identity)

Discuss medical affirmation

• Hormone use

• Gender-affirming therapeutic procedures

• Modifying primary/secondary sex characteristics
  (breast/chest tissue, internal/external genitalia, facial anatomy, body shape)

Refer for psychotherapy

• Individual, family, or group

• Explore gender identity, manage gender dysphoria, address stigma, increase coping and social support

Discuss legal affirmation

• Name change

• Gender markers on identification documents

Transition Pathways

Social transition: telling others, pronoun use, clothing, role expression

Legal transition: name changes, updating documents

Medical transition: hormone therapy or surgical interventions

Goal: Align external characteristics with gender identity and enhance comfort and well-being.

Sexually Transmitted Infections (STIs)

Recommend annual STI screening for sexually active clients (chlamydia, gonorrhea, syphilis, HIV).

Screening sites vary based on sexual behaviors (e.g., pharynx, rectum).

Exams may be uncomfortable for clients with gender dysphoria → explain each step clearly.

Encourage client participation in the care plan.

Promote consistent condom use to reduce HIV risk.

Educate at-risk clients about HIV PrEP (pre-exposure prophylaxis).

Teach proper care for sex toys

• Wash with hot soapy water/approved cleaners

• Clean between each use

• Use condoms on items when needed

Explain that condoms protect against fluid-borne STIs (HIV, gonorrhea, chlamydia, trichomoniasis).

Condoms are less effective for skin-to-skin STIs (HPV, herpes simplex virus, syphilis).

Chlamydia/Gonorrhea

Base screening on client anatomy (not gender).

Extend routine screening for all clients with a cervix, not just cisgender women under 25.

Screen rectum and pharynx based on sexual behaviors/exposure.

Syphilis

Screen at least annually, adjusted to client’s risk and behaviors.

HIV

Discuss and offer screening to all transgender clients.

Repeat testing frequency = based on risk level.

Human Papillomavirus (HPV), Cervical & Anal Cancer

Ages 21–29: cytology every 3 years

Ages 30–65: cytology every 3 years or combined cytology + HPV testing every 5 years

STI Screening Recommendations for LGBTQIA Populations (Table)

A nurse is providing teaching about STI prevention for a group of client who identify as LGBTQIA. Which of the following statements by the clients indicates understanding?

Select all that apply.

a

"Condoms are effective against herpes when lesions are present.”

b

“I should receive yearly screenings for chlamydia and gonorrhea.”

c

“Condoms should be used consistently.”

d

“The sites for STI screening can vary depending on my preference for sexual activity.”

e

“It’s considered a low risk if I have more than one partner.”

b

“I should receive yearly screenings for chlamydia and gonorrhea.”

The screening recommendations for clients who are sexually active include yearly screenings for chlamydia and gonorrhea. This would allow early identification of these conditions and prevent the possible transmission to others.

c

“Condoms should be used consistently.”

Condoms serve as a barrier of protection against certain STIs and should be used consistently to prevent the transmission of STIs such as gonorrhea, chlamydia, HIV, and trichomoniasis.

d

“The sites for STI screening can vary depending on my preference for sexual activity.”

The screening sites for STIs can vary depending on the client’s preference for sexual activity.

Healthy People 2030

Adolescent Objectives

• Decrease bullying of LGBTQIA high school students

• Decrease illicit drug use among LGBTQIA high school students

• Decrease suicidal thoughts among LGBTQIA high school students

Data Collection Objectives

• Add more national surveys collecting LGBTQIA data

• Increase the number of states/territories using standardized sexual orientation and gender identity (SOGI) modules in surveillance systems

STI Objectives

• Decrease syphilis rates in men who have sex with men

• Decrease new HIV infections

• Promote knowledge of HIV status

• Decrease new HIV diagnoses

• Increase access to HIV medical care

• Increase viral suppression (indicator of successful HIV treatment)

Social Determinants of Health (SDOH)

Economic Stability

• Financial concerns may be linked to employment discrimination

Neighborhood & Physical Environment

• Unsafe environments increase risk of violence and isolation

• Family rejection can lead to homelessness

Education

• Non-supportive school climates → increased bullying and violence toward LGBTQIA adolescents

Food

• Lower socioeconomic status → financial instability and decreased food security

Community & Social Context

• Increased social isolation

• Lack of family support → worse health outcomes

• Stigma toward gender-nonconforming youth → abuse, neglect, psychological distress

• Problems with peers/family → mental health issues

Health Care

• Discrimination and fear of disclosing identity → avoidance of care

• Limited access to health insurance

• Limited access to physical and mental health services

• Lower knowledge and comfort with health systems → poorer health outcomes

Risk Factors of LGBTQIA

Mental health conditions: depression, anxiety, eating disorders

Suicidality

BMI > 30

Cardiovascular conditions

STIs (including HIV)

Patient-Centered Care of LGBTQIA

Children

• Pre-puberty cross-gender play/expression is normal exploration, not predictive of future orientation.

• Children who are gender-nonconforming before puberty often identify as gay/lesbian later rather than transgender.

Nursing Interventions (Children)

• During routine visits (toddlers & young children):

  • Ask parents about the child’s gender play, preferences, body image, self-esteem, and gender expression

  • Normalize exploration and developmental experience

Adolescents

• Major organizations recommend routine conversations about sexuality with adolescent clients.

• LGBTQIA adolescents have increased risks:

  • Depression, suicide, substance use, bullying, sexual assault, harassment, victimization

  • Risks occur in home, school, and community

Nursing Interventions (Adolescents)

• Provide compassionate, knowledgeable, and accepting care

• Ask open questions about:

  • Gender identity, sexual identity, attraction, sexual behaviors

• Assess gender dysphoria respectfully

• Collaborate with schools:

  • Anti-bullying policies, school connectedness, advocacy, safe environments, confidentiality

• Offer family/individual counseling and psychotherapy

• Assess and manage mental health concerns

• Provide information on peer support groups

Older Adults

• ~217,000–700,000 transgender adults in the U.S. are >65

• 7 million LGBTQIA adults will be ≥65 by 2030

• Vulnerabilities include:

  • Lifelong discrimination

  • External/internalized stigma

  • Limited health care access

  • Financial stressors & employment discrimination

  • Loneliness and social isolation

  • Fear of disclosing identity → avoidance of care

  • Need for expanded caregiver support

Nursing Interventions (Older Adults)

• Respect sexual orientation & gender identity

• Recognize increased social isolation and limited resources

• Provide trauma-informed care due to possible past discrimination

• Assess mental health, coping, and support systems

• Address barriers related to mistrust and past negative health care experiences

• Support safe access to physical, mental, and social services

A nurse is discussing the care of the LGBTQIA population with a group of newly licensed nurses. Which of the following statements should the nurse include in their discussion?

Select all that apply.

a

“Adolescents who identify as LGBTQIA have an increased risk for bullying.”

b

“Older adults who identify as LGBTQIA are at risk for social isolation.”

c

“The nurse should ask the client about their sexual identity.”

d

“The nurse should respect the client’s gender identity.”

e

“The nurse should discuss the client’s gender identity with other relatives.”

a

“Adolescents who identify as LGBTQIA have an increased risk for bullying.”

b

“Older adults who identify as LGBTQIA are at risk for social isolation.”

c

“The nurse should ask the client about their sexual identity.”

d

“The nurse should respect the client’s gender identity.”

Nursing Actions (Gender-Affirming Care)

Provide gender-affirming care to reduce stigma and bias.

Promote welcoming, therapeutic, inclusive relationships.

Use inclusive terms/language.

Avoid assumptions about identity.

Ask about name and pronouns; update health records accordingly.

Obtain comprehensive history including:

• Medical background

• Support systems

• Prior transition interventions (medications, surgeries, procedures)

Physical Assessment Notes

• Review health records before exam

• Explain procedures clearly

• Remember: genitalia may not match outward gender presentation

Gender-Affirming Care

Includes gender-affirming surgeries (GAS) and therapeutic procedures that help align body with identified gender.

Some procedures produce feminizing or masculinizing changes to primary and secondary sex traits.

All clients should receive education and counseling, including options for fertility preservation before puberty suppression or hormone therapy.

Reversibility of Therapies

• Fully reversible: GnRH analogs (puberty blockers)

• Partially reversible: Hormone therapy (masculinizing or feminizing)

• Irreversible: Surgical procedures

Assessment & Guidelines for Hormone Therapy

Adolescents

• Interprofessional team must:

  • Manage therapy

  • Confirm gender dysphoria diagnosis

  • Confirm mental health capacity for informed consent

• Hormone therapy may begin after physical pubertal changes start, with gradual dose increases.

• GnRH analogs recommended to suppress puberty.

• Monitor pubertal development every 3–6 months; labs every 6–12 months during treatment.

• Depending on state laws → surgery may occur at ≥16 years with parental consent.

Adults

• Clinicians must confirm:

  • Diagnostic criteria for gender dysphoria

  • Criteria for endocrine phase of transition

• Evaluate for medical conditions that could worsen with hormone therapy.

• Provide education on expected physical changes and timeline of hormone effects.

Gender-Affirming Surgery (GAS) Requirements

Eligibility

• Providers may approve GAS after ≥1 year of consistent adherence to hormone therapy
  (unless hormones are not needed or contraindicated).

• Primary provider completes medical clearance and collaborates with surgeon.

Criteria for Adults Seeking GAS

• Satisfactory social role change

• Satisfaction with hormone effects

• Persistent desire for surgery

• Meets diagnostic criteria for gender dysphoria

• Mental health provider and clinician agree surgery is medically necessary and will improve well-being

Patient-Centered Care for Hormone Therapy

Goals

• Stimulate development of secondary gender characteristics

• Possibly stop menstruation

Gonadotropin-Releasing Hormone Analogs (GnRH)

Preferred for puberty suppression in adolescents (very expensive)

Adolescents with a penis: GnRH prevents luteinizing hormone → decreases testosterone

Adolescents with a vagina: GnRH prevents estrogen production

Continuous oral contraceptives or depot medroxyprogesterone may also suppress menses

Testosterone

Androgen hormone converted to estrogen in small amounts; promotes erythropoiesis

Therapeutic Effects

• Deepened voice

• Reduction in breast tissue

• Change in hair growth & distribution

• Enlargement of clitoris

• Increased muscle mass

• Vaginal dryness; cessation of menses

Forms of Testosterone

Available in: topical gel, topical patch, IM injections, oral form

Administration Notes

• PO: Least effective, not first-line

• IM: Initiated low dose; increased every 1–2 weeks; blood levels vary

• Sub-dermal pellets: Implanted in hip/flank/abdomen; replace every 3 months

• Buccal tablets: Placed above incisor; alternate sides; replace within 3 hrs if dislodged

• Nasal gel: Metered-dose pump; may cause rhinorrhea/epistaxis; avoid nose blowing/sniffing for 1 hr

• Topical gel/patch:

  • Gel: expensive, consistent but lower absorption

  • Patch: apply to upper arm/thigh/back/abdomen

  • Avoid covering with clothing until dry

  • Wait ≥6 hrs before swimming/showering

  • Remove from skin before water exposure

• Axillary gel: Alcohol-based, flammable; apply same time daily; wait ≥2 hrs before swimming

---

Nursing Interventions

• Educate that results may take 1 year to appear

• Monitor for adverse effects:

  • Weight gain

  • Headaches

  • Seborrhea

  • Acne

  • Edema

  • Psychosis

  • Polycythemia

  • Hypercholesterolemia

  • Liver impairment

• Check history of:

  • Heart disease (testosterone increases fluid retention → ↑ workload)

  • Liver disease (↑ liver enzymes; ↑ LDL)

• Monitor hemoglobin, hematocrit, and cholesterol every 3–6 months or as prescribed

A nurse is teaching a client who has a new prescription for testosterone gel. Which of the following statements should the nurse make? 

Select all that apply.

a

“You should have your testosterone level checked within 1 month after starting therapy and then every 3 months.”

b

“This medication can cause headaches, swelling, and weight gain.”

c

“You will notice results within 1 month of therapy.”

d

“After the gel has dried, you should cover the area with clothing.”

e

“This medication can cause your cholesterol level to increase.”

Submit

a b d e

The client should have their testosterone level checked within 1 month of starting therapy and then at least every 3 months.

Testosterone can cause adverse effects of headache, weigh gain, edema, psychosis, and hypercholesteremia.

The nurse should inform the client wash their hands before and after application and apply to dry skin as prescribed. After the gel has dried, cover the area with clothing.

Testosterone is an androgen hormone that can be taken as part of gender-affirming care to produce masculinizing effects. The nurse should inform the client about administration and adverse effects of therapy.

---

After taking testosterone, it can take at least a year to see the expected results.

Progesterone / Progestins

Medroxyprogesterone may be used early, short-term in feminizing therapy (helps with menstrual cessation).

Nursing Considerations

• Monitor for depressed mood, weight gain

Estrogen / Estradiol

Hormone used for feminization therapy

• Routes: PO, transdermal, injection

• Oral estrogen increases risk of VTE → transdermal/injectable preferred

• Increased risk for prostate and breast cancer

Therapeutic Effects

• Breast tissue development

• Decreased testicular size and erectile function

• Decreased hair growth, decreased muscle mass

• Softer skin

• Emotional changes

Nursing Considerations

• Monitor estrogen & testosterone levels

• Assess cancer risk (prostate, breast)

• Monitor adverse effects:

  • Headache

  • Nausea

  • Vomiting

  • Weight changes

  • Breast tenderness

Spironolactone

Potassium-sparing diuretic; anti-androgen that blocks androgen receptors

• Can cause: gynecomastia, irregular menses, voice deepening, impotence, hirsutism

Nursing Considerations

• Monitor blood pressure (can cause hypotension)

• Polyuria and polydipsia common

• Monitor potassium (risk: hyperkalemia)

5-α Reductase Inhibitors

Finasteride, dutasteride

• Anti-androgens that block conversion of testosterone

• Reduce prostate size

Nursing Considerations

• Watch for adverse effects: dizziness, cold sweats, chills

Surgical Procedures (GAS) Requirements

≥1 year of continuous hormone therapy

Living in desired gender role for ≥1 year

≥18 years old and capable of informed consent

A nurse is reviewing the EMR of client who is desiring gender-affirming surgery (GAS). Which of the following information from the client’s record should the nurse identify as required criteria for surgery?

a

The client has lived alone for at least 6 months.

b

The client is at least 16 years of age.

c

The client has taken continuous hormonal therapy for a least 1 year.

d

The client’s partner gives informed consent.

c

The client has taken continuous hormonal therapy for a least 1 year.

General requirements for gender-affirming surgery include that the client must be at least 18 years of age,has taken continuous hormonal therapy for at least 1 year, has lived in their identified gender identity for at least 1 year, and gives informed consent for surgery.

Non-Surgical Procedures

Hair removal: electrolysis, laser, waxing

Voice/communication therapy: supports verbal & nonverbal communication aligned with gender identity

• Referral to speech-language pathologist may be needed

Liposuction: removal of fatty tissue

Other noninvasive practices:

• Breast binding or padding

• Genital tucking or prostheses

• Padding of hips/buttocks

Face / Neck Procedures

Hair transplantation

Facial reconstruction: reshapes facial features

Chondrolaryngoplasty: reduces thyroid cartilage (Adam’s apple reduction)

Breast Procedures

Breast augmentation: implants (gel, saline, silicone) simulate breast tissue

• Possible soreness/bruising after surgery

Mastectomy: removes breast tissue

Genital Procedures

Masculinizing Procedures

• Oophorectomy / Salpingo-oophorectomy: removes ovaries ± fallopian tubes

• Hysterectomy: removes uterus

• Scrotoplasty: creates scrotum (prosthetic testes can be inserted)

• Phalloplasty: creates penis

• Metoidioplasty: elongates clitoris to form smaller phallus

Feminizing Procedures

• Orchiectomy: removes one/both testicles

• Penectomy: removes penis

• Vaginoplasty: creates vagina

Nursing Interventions for Gender-Affirming Surgical Care (Preop)

Ensure informed consent is obtained

Provide written/verbal instructions about procedure

Teach bowel preparation if needed (clear liquids, laxatives, enemas)

Encourage increased fluid intake

Teach purpose of pre-op labs (Hgb, Hct)

Prepare client for surgery:

• Insert peripheral IV

• Administer prescribed antimicrobials on surgery day

Nursing Interventions for Gender-Affirming Surgical Care (Periop)

Ensure proper positioning (often lithotomy position depending on surgery)

Monitor for adverse effects of general or epidural anesthesia

Nursing Interventions for Gender-Affirming Surgical Care (Postop)

Check pain; administer analgesics

Monitor vital signs

Provide care for catheters or drains

Monitor surgical site for bleeding/infection; perform wound care as prescribed

Administer hormone therapy as ordered

Apply ice to decrease swelling/discomfort

Monitor neurovascular status of lower limbs; encourage movement to prevent compartment syndrome

Administer anticoagulants to prevent VTE

Encourage bed rest/activity restrictions

Remove urinary catheter (post-op day 7–12) and drains (<20 mL/24 hr), depending on surgery

Apply breast binders for breast surgeries

Monitor for complications:

• VTE

• Vaginal/rectal fistulas

• Perforation

• Compartment syndrome

• Bleeding

• Wound infection

• Urinary incontinence

• Hematomas

---

Encourage attending follow-up appointments

Report leakage of stool → possible fistula

Provide social support referrals (support groups, community resources)

---

Vaginoplasty: Client Education

• No submersion baths for 8 weeks

• Avoid strenuous activity for 6 weeks

• Avoid swimming or biking for at least 3 months

• Scant vaginal bleeding/brownish drainage expected ≤ 6 weeks

• Use stool softeners

• Follow wound care instructions

• Use vaginal packing/dilators as prescribed

A nurse is planning care for a client following gender-affirming surgery (GAS) of the genitalia. Which of the following actions should the nurse implement?   

Select all that apply.

a

Remove urinary catheter within 24 hours.

b

Apply ice to affected area.

c

Remove drains when output is greater than 20 mL/hr.

d

Administer anticoagulants.

e

Perform frequent neurovascular checks.

b d e

When caring for a client following GAS, the nurse should plan to apply ice to the affected area, administer anticoagulants, and perform frequent neurovascular checks. Applying ice will decrease swelling to affected area, administering anticoagulants will prevent VTE, and performing frequent neurovascular checks will assist with identifying unexpected findings such as compartment syndrome.

---

If a client has an indwelling urinary catheter, the nurse should plan to remove it 7 to 12 days following GAS, and remove drains when output is less than 20 mL/day.