Caring for the LGBTQIA+ Patient: A Best-Practices Primer on Language, Sexual Function Considerations, and Health Disparities in Gynecologic Care.

While gay cisgender men are unlikely to present for minimally invasive gynecologic services, this term is also adopted by some cisgender women, transgender men and women, and nonbinary people to describe a same-gender sexual orientation. Recognizing the fluidity and inclusivity of this label is important when designing patient intake forms and engaging with patients. Plurisexuality is an umbrella term to concisely refer to people who have the capacity for attraction to more than one gender, including bisexuality, pansexuality, and other less common identity labels such as heteroflexible or bicurious [ 36 , 37 ]. While “plurisexuality” is a helpful scientific term commonly used in research, patients are more likely to self-identify with terms like “bisexual” or “pansexual.” Bisexual and pansexual are overlapping yet distinct identity labels. While they have both been defined in many ways, both by scholars and by the people that hold these identities, there is some consensus that bisexuality refers to attraction to people of one’s own gender and other genders (breaking from assumed binaries of “attraction to men and women”) while pansexuality refers to attraction to people regardless of gender [ 36 , 38 ]. Put another way, bisexual people may be attracted to people of multiple genders, but gender is a factor in their attraction, whereas gender is not a factor in pansexual attractions. Although plurisexual people are the largest sexual minority group, representing more than half of the total queer community [ 39 ], they are critically understudied [ 40 ]. Many studies with gay and lesbian samples exclude plurisexual participants, and others group plurisexual participants with gay and lesbian participants [ 41 – 44 ]. However, plurisexual people experience unique stressors and have discrepant sexual health and function outcomes compared to their lesbian and gay counterparts, including higher risk of sexual victimization and sexual dysfunction [ 40 , 45 , 46 ]. Notably, the experiences of plurisexual people may differ depending on the gender of their partner(s): being in same-gender relationships may mean they are perceived as queer thus increasing risk for overt discrimination, while being in mixed-gender relationships may mean they are perceived as straight thus increasing concealment stress and jeopardizing support from the queer community [ 40 , 41 , 47 ]. It may be helpful for clinicians to collect information about sexual orientation and partner gender (instead of assuming one from the other) and consider their interactions [ 48 ].

In more recent years, “queer” has been reclaimed as an umbrella identity within LGBTQIA+ communities, signifying diverse sexual orientations and, in some cases, gender identities [ 99 ]. While historically used as a slur, many now embrace it as an empowering term, with some studies estimating that between 5% and 20% of non-heterosexual people identify as queer [ 100 ]. However, it is important to recognize that while some individuals use “queer” alongside other identities such as lesbian, bisexual, or pansexual, others may not identify with the term at all. Providers may encounter patients who identify as queer on intake forms or in clinical settings and should be aware that the term encompasses a broad range of identities and experiences. While this approach is important for all patients, it is especially critical to ask about both sexual orientation and sexual behavior, as these may vary across queer patients. Understanding queer as both a reclaimed and stigmatized identity—and approaching discussions with openness and nuance—can help foster affirming gynecologic healthcare and build patient trust.

Asexuality , or being “ace,” is a sexual orientation defined by little to no sexual attraction or desire [ 49 ]. Asexuality exists on a spectrum and can be fluid, meaning some asexual people experience sexual interest or engage in sexual activity at various points of their lives [ 49 ]. Asexuality is distinct from romantic attraction; many asexual people pursue romantic relationships. Similarly, the term “aromantic” (aro) describes people who experience little to no romantic attraction [ 50 ]. This distinction highlights the importance of recognizing that romantic and sexual attraction are separate, often overlapping, experiences [ 50 ]. Additionally, ace/aro people may add other labels such as heterosexual, lesbian, or queer to capture other aspects of their identity. It is crucial for providers to understand that asexuality is not a sexual desire disorder [ 51 ], as asexual people do not experience personal distress about their lack of sexual attraction or desire [ 52 ]. Distress may arise from fighting against societal assumptions of low desire as a marker of poor mental or physical health [ 53 ], particularly in healthcare environments where ace identities are questioned or misunderstood [ 52 ]. For example, one study in young adults found that ace participants reported their healthcare providers’ assumptions that “healthy, normal teenagers” would be interested in sex was a significant barrier to health communication [ 54 ]. Research also indicates that asexual patients are more likely to disclose their identity to mental health providers than to medical providers due to prior negative experiences in medical contexts [ 52 ]. When patients disclose asexuality, it is essential for healthcare providers to respond positively and with a genuine willingness to understand their experiences [ 55 , 56 ]. As with all patients, it is important to check assumptions about ace/aro (lack of) relationship(s) or sexual activity: as noted above, asexuality is an identity that may or may not correspond to (behavioral) celibacy. A patient-led approach is best when discussing sexual desire with asexual patients. While asking about sexual desire is generally appropriate, comfort with these conversations may vary based on patient’s awareness and comfort with their own asexuality and previous experiences of judgements from medical providers [ 56 ]. To ensure a respectful approach, providers can ask about desire neutrally and avoid assumptions about associated distress. For example, consider preceding questions about sexual activity or functioning with statements such as: “ We ask all patients these questions to better understand their needs and support their health. ” This framing normalizes questions without singling out asexual patients or implying that their identity is a problem.

Minimally invasive gynecologic teams are more likely to discuss sexual activity and sexual function with their patients than many other surgeons and providers, requiring careful consideration of queer identity to avoid assumptions or judgements that impede the doctor-patient relationship and jeopardize care [ 5 ]. Research in both heterosexual and queer populations shows that patients often do want to discuss sex with their providers but prefer the provider to initiate the discussion [ 5 , 101 ]. While many aspects of sexual experiences and many components of sexual responses are common to all people regardless of identity, queer people engage in various sexual behaviors at different rates [ 102 ], are guided by different social expectations for their sexual encounters [ 102 – 104 ], receive different sex education [ 105 ], and even define sex differently [ 106 , 107 ]. Queer people may also experience sexual function and dysfunction, as well as pleasure, differently than their cisgender, heterosexual counterparts [ 108 , 109 ]. Gender affirming hormones and surgeries may also impact sexual function [ 67 , 110 , 111 ]. Queer people are more likely to be in sexual or romantic relationships with multiple partners, often referred to polyamory (poly), open relationships, or consensual non-monogamy [ 112 ]. Queer people are also more likely to report engaging in kink practices—generally defined as activities associated with bondage or restraint, consensual power differentials such as dominance and submission, fetish, and intense sensations such as pain, all of which are often but not always related to sex and eroticism [ 113 ]. Having multiple partners and engaging in kink behaviors are practices that are generally safe and pleasurable and do not cause outsized harm [ 114 , 115 ]. Providers interested in learning more about poly and kink lifestyles, and their intersection with clinical care, may consult the clinical practice guidelines created by the Alternative Sexualities Health Research Alliance [ 115 ].

The term ‘ lesbian ’ typically refers to women—including cisgender and transgender women and some gender-fluid people—who are sexually and/or romantically attracted to others who identify as women. While sexual orientation and gender identity are distinct concepts, they often intersect in meaningful ways; providers should be mindful that some patients may identify as lesbian although they, or their partners, identify outside a gender binary [ 29 ]. Fear of judgment or receiving inadequate care often leads lesbian patients to avoid disclosing their sexual orientation to providers [ 30 ]. Additionally, lesbian women are more likely than heterosexual women to delay routine care due to concerns about stigma, dismissive attitudes, or perceptions that their symptoms are not serious enough [ 31 ]. Heteronormative assumptions in healthcare can lead to gaps in provider trust and informed decision-making for lesbian patients seeking gynecologic care [ 32 – 34 ]. If a lesbian patient requests a hysterectomy or a provider suggests one, it is important to avoid assumptions about reproductive goals or sexual practices based on the patient’s sexual orientation. Providers should offer comprehensive information about fertility and reproductive options without questioning or undermining the patient’s needs and should use inclusive language when referring to partners, if appropriate. Additionally, discussions about intercourse in relation to post-surgical sexual health or conditions related to vaginal pain should not be limited to penile-vaginal intercourse [ 35 ] but may also include considerations of toys, oral, and anal sex.

Intersex refers to being born with sex characteristics that do not align with traditional binary definitions of male or female. These characteristics often involve a combination of biological traits, such as minimally-differentiated or mixed genitalia, but can also include variations in chromosomes, hormones, or internal/external reproductive anatomy [ 57 ]. Historically, the medical field has ignored the broad natural diversity of sex characteristics and instead classified intersex as necessarily pathological (under the term Differences in Sex Development; DSD), often directing patients to engage in interventions designed to align their bodies to social notions of binary gender [ 58 ]. However, the medicalized classifications of intersex status have been increasingly challenged and there is an evolving recognition of intersex identities beyond strictly a “medical condition.” Intersex advocacy groups emphasize de-pathologizing intersex bodies, reducing stigma, and centering the experiences of intersex people as whole rather than solely as medical subjects [ 59 ]. While controversy abounds and more research is needed, there is some evidence that medical interventions – particularly surgeries performed during childhood or adolescence aimed at “normalizing” perceived sexual characteristics – can have negative psychological and physical consequences for intersex patients [ 60 , 61 ]. One study demonstrated that intersex patients who underwent “normalizing” genital surgeries reported lower satisfaction with their bodies, increased pain during sex, difficulty with vaginal penetration, and reduced orgasmic response compared to those who did not undergo surgery [ 62 ]. Another found that intersex people with “ambiguous genitalia” who were assigned female at birth reported higher rates of sexual dysfunction, with those who had surgery facing worse outcomes [ 60 ]. In this study, one in four participants whose clitoris was surgically altered reported being unable to orgasm [ 60 ]. Another study found that while sexual function after feminizing genitoplasty was similar to controls without DSD, those with DSD had less frequent sexual activity and later sexual initiation [ 63 ]. However, there is also some evidence that medical interventions to alter genital structures in ways that permit intercourse can improve sexual function in intersex patients, with the strongest evidence supporting minimally invasive interventions (such as use of vaginal dilators [ 64 , 65 ]). The experiences of intersex people can be highly heterogeneous. Because intersex people can use many different labels to describe themselves and their bodies [ 66 ], practitioners can support intersex patients by allowing autonomy in identity labels that feel most authentic to them, using intake forms that offer options for identifying “choose all that apply” for biological sex and gender identity, and avoiding assumptions on a patient’s anatomy or medical needs based on their gender presentation. Further, recognizing that intersex people may choose identity labels distinct from the medical terms historically applied to them can help avoid stigmatization and enhance the quality of care.

Rather than an expectation of a fixed set of core knowledge on minoritized identities, research on providing culturally competent healthcare increasingly supports cultural humility, an orientation of respectful, other-oriented curiosity and continued learning [ 116 , 117 ]. In other words, no one expects providers to know everything about all queer identities, especially as norms and practices are constantly changing. Rather, it is expected that we develop a basic foundation in familiarity with queer people and practices, but more importantly, continue to seek out opportunities to learn more, both from patients themselves (if they are willing to share), and from internal or external continuing education resources like trainings, webinars, and medical society guidelines. While an exhaustive list of resources is beyond the scope of this review, care guidelines for TGD patients can be found in the World Professional Association for Transgender Health Standards of Care Version 8 [ 118 ], the Endocrine Society Clinical Practice Guideline [ 119 ] and the American College of Obstetricians and Gynecologists Committee Opinion on TGD patients [ 120 ]. More general collections of queer health resources include the National LGBTQIA+ Health Education Center at the Fenway Institute [ 121 ], the GLMA: Health Professionals Advancing EGBTQ+ Equality Resources for LGBTQ+ Health Equity [ 122 ], and the Trevor Project Resource Center [ 123 ]. When seeking out additional resources, ideally ensure that the materials have been created with collaboration from the queer community. And when in doubt, ask: research on cultural humility in medical and psychological practice has demonstrated that it is better to ask – demonstrating genuine interest in learning – and be corrected, rather than avoiding any questions for fear of offending [ 124 ]. For example, one study found that among queer patients seeking trauma care, the provider behavior most often identified as a microaggression was failing to acknowledge identity-related issues, which in turn significantly impaired treatment outcomes [ 125 ]. In contrast, being seen as culturally humble and openly acknowledging one’s lack of experience with a particular queer subculture (when combined with genuine willingness to learn) is strongly associated with better treatment alliance and patient satisfaction with care [ 126 ].

Gynecologic healthcare providers must recognize that sexual orientation and gender identity intersect meaningfully with sexual health, function, and overall well-being. Creating affirming healthcare environments requires implementing specific practices such as using appropriate terminology, understanding the unique health considerations of different queer populations, and recognizing how minority stress and intersecting marginalized identities shape health outcomes. We propose that the unique focus of minimally invasive gynecology – a specialty that has historically led the field in patient-centered treatment planning, collaboration with other treatment disciplines including behavioral health and endocrinology, and lifelong provider education in cutting edge innovations – poses the field to similarly lead in providing inclusive and affirming care for the queer patient. For example, minimally invasive gynecologists may more readily understand the wishes of trans patients who wish to receive minimally invasive gender affirming care, including care plans that may not include surgery – despite the common (mis)perception that surgery is a necessary part of gender transition [ 127 ]. As such, we hope this simple primer has been a useful review that will spur interest in deeper learning. LGBTQIA+ people have always been part of gynecological care, regardless of whether this was explicitly acknowledged at the time. As awareness of the unique needs of queer patients grows, so too does our responsibility to meet those needs. This includes the need to educate ourselves on understanding, addressing, and working with queer patients, and we hope that this article and the others of this special issue will contribute to this ongoing education. Beyond this, however, our responsibility as clinicians and researchers extends to supporting patients as they navigate healthcare systems that are not designed to acknowledge their existence, let alone unique care needs; conducting critical research that centers queer patients’ medical needs rather than simply documenting health disparities; and advocating for changes in health insurance and policy to support equitable access across the LGBTQIA+ spectrum. By moving away from heteronormative and cisnormative assumptions and toward inclusive, evidence-based care practices and health policies, gynecologic care teams can better serve their queer patients and work to address the significant health disparities this population continues to face.

Transgender (trans) refers to people who do not identify with the binary gender assigned to them at birth based on their apparent sex. This includes people who identify as trans women (or transfeminine/transfem), trans men (or transmasculine/transmasc) and people who identify outside of the gender binary with terms such as nonbinary and gender nonconforming [ 67 ]. Gender identity is distinct from sexual orientation—gender identity describes who someone is, while sexual orientation describes who they are attracted to—and transgender people can have any sexual orientation (for an illustration that may be helpful to share with patients or families, see the Gender Figure by Treat it Queer [ 68 ]). Transgender and gender diverse (TGD) people may experience gender dysphoria (i.e., distress surrounding the incongruence between gender identity and sex/gender assigned at birth), and may (or may not) undergo gender transition. Transition may involve one or more of the following: changes in name, pronouns, gender expression and presentation, gender affirming hormone treatment, and gender affirming surgery [ 67 ]. In the English language, we use either second-person gendered pronouns (she/her; he/him) or third-person gender neutral pronouns (they/them) [ 69 ]. Some TGD people may switch from he/him to she/her or vice versa; adopt gender neutral pronouns such as they/them; use a combination such as he/they or she/they; or choose other pronouns (referred to as neopronouns) [ 70 ]. Recognizing and using the pronouns someone chooses is crucial to indicating to them that their identity is being supported in medical spaces—and unwillingness to do so can dramatically impact patient satisfaction and quality of care [ 71 ]. While specific situations may require different approaches, we recommend introducing yourself with your name and pronouns to your patients, then asking them for their name and pronouns, if they are comfortable sharing. If there is not an immediate opportunity to ask, consider defaulting to they/they until you receive further clarification [ 72 ]. Careful consideration must be used when documenting identity markers in electronic medical records to ensure trans patients consent to their identity becoming part of their medical record [ 73 , 74 ]. In particular, some TGD patients may be concerned with how their identity is communicated to insurers, leading to concealment of this and other health information during medical visits (i.e. withholding information that may be relevant for care due to privacy or security concerns regarding their medical records) [ 75 ]. Despite a 2016 Affordable Care Act clarification prohibiting discrimination based on gender identity, variations in legal interpretations and state laws continue to limit access to gender-affirming treatments [ 5 , 76 , 77 ]. Other TGD patients may not want their identity as a part of their records because family members or other medical providers who are not aware of their TGD identity have access to their records [ 74 , 78 ]. Guidelines recommend a “two-step” process–querying about gender identity before sex assigned at birth [ 71 ] as well as preferred name (if different from legal) and pronouns [ 79 ] and entering all this information in the chart—but asking patients if they are comfortable with that information being entered into their medical record [ 80 ]. Gynecology has predominantly focused on cisgender women, resulting in systemic and interpersonal barriers for TGD patients in need of gynecologic care [ 5 ]. For some TGD patients – particularly trans men – gynecologic care is perceived as “women’s health” and thus may induce gender dysphoria [ 81 ]. Such discomfort or dysphoria may be compounded for care that necessitates examinations of “female” reproductive organs and genitalia [ 82 ]. Indeed, while trans men may require screening examinations, reproductive care, and surgical care that would typically be the purview of gynecology, they may avoid routine care—likely explaining the increased risk for cervical cancer in this population [ 5 , 82 , 83 ]. However, research and expert clinical guidelines suggest that adjusting medical language like “vagina,” “uterus,” and “breasts” to medically accurate but gender neutral labels like “genitals,” “internal organs” and “chest” when further specificity is not required can substantially improve trans patients’ satisfaction with care [ 84 – 86 ]. Additional guides to gender neutral terminology can be found in [ 85 – 87 ]. Additional considerations may be relevant depending on the type of gender affirming care, if any, TGD patients seek. To be able to provide appropriate gynecologic care, it is crucial to know any current and past hormonal and surgical treatments, as well as plans for future gender transition, as these factors may impact future surgical planning, hormone related risk factors like cancer or cardiovascular risk, sexual history taking, and postoperative care such as extended dilation [ 10 ]. Estimates suggest that 60–70% of TGD people in the United States receive some type of gender affirming hormone therapy (GAHT) and around 25% have received at least one gender affirming surgery (GAS) [ 88 – 90 ]. This means that gynecologic care teams will see patients who identify as TGD but do not want to medically transition, those who do not have the resources or safety to transition, those who only desire hormonal care, and those who receive surgical procedures—all of whom will require different treatment considerations [ 77 ]. For those who do not choose or are not able to seek surgery, for example, providers should be prepared to discuss options like safe chest binding and undergarment packing [ 11 ]. For those who do seek medical transition, minimally invasive gynecologists may (depending on their medical context) interact with trans women seeking post-operative care after gender affirming surgery, trans men retaining natal reproductive structures seeking surgical procedures such as elective hysterectomies, and gender diverse patients seeking any combination of these and other treatments [ 10 ]. Other considerations for minimally invasive gynecologists may include the impacts of GAHT on conditions such as fibroids, endometriosis, and PCOS [ 77 ], managing ovarian cysts [ 91 ] and chronic pelvic pain [ 5 , 10 ], familiarity with perioperative and delayed postoperative care needs of trans women undergoing vaginoplasty such as vaginal dilation and pelvic floor therapy [ 7 ], carefully examining abnormal bleeding for evidence of endometrial activity in patients on GAHT [ 5 , 10 ], and elective gender affirming hysterectomy [ 10 ]. Despite these needs, most providers report discomfort with treating TGD patients, are unaware of relevant care guidelines, and are even unsure of which routine screening procedures are necessary [ 10 , 11 , 92 , 93 ]. One recent study found that almost 1 in 4 transgender adults report needing to teach their doctor about trans health needs [ 94 ]. In general, TGD people experience significant physical, mental, and sexual health disparities, often accounted for by minority stress [ 95 , 96 ], and significant research has demonstrated that all of these aspects of health can be positively impacted by gender affirming care [ 67 , 97 , 98 ].