Since that time, many organizations, including the American Medical Association, the American Academy of Pediatrics, and the American Counseling Association, have issued statements condemning conversion therapy and supporting gender-affirming care. Furthermore, scientists and clinicians now understand that identifying with a gender that does not align with sex assigned at birth, as well as a gender expression that varies from that which is stereotypical for one’s gender or sex assigned at birth, is not inherently pathological. 4 However, people may experience distress associated with discordance between their gender identity and their body or sex assigned at birth (i.e., gender dysphoria) as well as distress associated with negative social attitudes and discrimination. This shift in the understanding of gender identities and expressions was reflected in the replacement of the category “Gender Identity Disorder” with “Gender Dysphoria” in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. 8 The diagnosis of Gender Dysphoria, which is marked in children and adolescents by clinically significant distress associated with the discordance between biological sex and gender identity that disrupts school or social functioning, depathologizes diverse gender identities and expressions. This newer definition focuses instead
on the potential psychosocial challenges associated with gender diversity. Sexual orientation questions are included in 11 federal surveys and, of these, seven also have an inquiry regarding gender identity. 9 Gender identity questions were added to the National Health Interview Survey (NHIS), a principal source of US population health, beginning in 2013, 3 and in the National Survey on Drug Use Abuse and Health (NSDUH) in 2015. It is important for healthcare providers to understand the differences between gender identity, sexual orientation, and sex assigned at birth and how these factors are important. The 2020 census was the first census that included a question specifically about same-sex relationships. Optional answers included opposite OR same-sex husband/wife/spouse and opposite OR same-sex unmarried partner. 10 Use of census data assists in determining federal funding to states. In 2015, $175 million in funding for Housing Opportunities for Persons with AIDs, $312 billion for Medicaid, and $71 billion in money for food stamps was received through census data. 11 LGBTQ people are among those most likely to rely on these programs, and under-representation may affect financial assistance. 11 Unfortunately, a single question is unable to reflect this diverse population.
EPIDEMIOLOGY
The most accurate and current information about LGBTQ demographics is based on independent polling and survey organizations. The most recent large-scale survey was a 2021 Gallup report based on interviews with a random sample of approximately 15,000 U.S. adults, which showed that the proportion of American adults identifying as LGBTQ increased to 5.6% from 4.5% in 2017. Millennials (born 1981- 1996) and Generation Z (born 1997-2002) are more likely to identify as bisexual compared to lesbian, gay, transgender, or other. 12 As the general population ages, the number of older LGBTQ adults will increase as well. By 2030, there will be an estimated 2 million to 6 million LGBTQ adults ≥65 of age in the United States (vs. an estimated 1 million to 2.8 million in 2000), approximately 120,000 of whom are projected to be living in nursing homes. 13 These individuals will have distinct healthcare needs and face well-documented health- related disparities including disability, poor mental health, smoking, and increased alcohol consumption. In addition, older lesbians have a higher risk of developing metabolic syndromes and cardiovascular disease (CVD). Older transgender adults are at significantly higher risk of poor physical health,
disability, depression, and perceived stress compared with cis-gender patients. 13,14 Terms to Avoid These terms may have been used in the past but are now considered outdated and may be offensive. In addition, while patients may use these terms, when in doubt, the provider should ask the patient which terms they prefer. Unacceptable Acceptable Berdache (to Two-spirit
describe gender non-conforming indigenous people) Gender reassignment surgery
Gender assignment surgery
Homosexual
Gay or lesbian Disorders of sex development
Intersex/ hermaphrodite
Sex change
Gender affirmation surgery
Sexual preference Transgendered/a transgender
Sexual orientation
Transgender
RISK IDENTIFICATION
To identify risk, healthcare providers need to see, talk to, and examine patients. This point sounds obvious, but there are many barriers that may prevent this examination and communication from occurring. One of the most common barriers in caring for LGBTQ
people is the lack of provider training and experience in caring for sexual minority persons. 15,16 This lack of training may cause a fear of missing or doing something wrong or result in inadvertently doing or saying something offensive.
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Book Code: CT24CME
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