What’s sexual orientation got to do with it? LGBTQI reproductive health

Co-authored by Monica McLemore, PhD, MPH, RN, assistant professor at the University of California San Francisco, and Candace W. Burton, PhD, RN, AFN-BC, AGN-BC, FNAP assistant professor at Virginia Commonwealth University.

In 2002, the first ever, Gay, Lesbian, Bisexual, Transgender, Queer and Intersex Health Summit1 was held in Boulder Colo. This was the first time bisexual people, transgender people, and intersex people were recognized on a national level at a professional conference, included funding for travel and panels/workshops specific to bisexual, transgender and intersex issues. Additionally, it was one of the first conferences exclusively devoted to health and not centered on illness and/or risk behaviors; several panels discussed the reproductive health needs of LGBTQI individuals. Much that was discussed at that conference, specifically that health care provider assumptions about gender identity, sexual orientation and behaviors can create missed opportunities to provide clients/patients with support and education, remains true today.

Amid conflicting sexual and reproductive health information2 and political discussion of what constitutes comprehensive reproductive health care3 we believe revisiting best practices in reproductive health for LGBTQI individuals is warranted.

This post aims to offer powerful tools to educate the public and decrease reproductive stigma. Understanding basic concepts necessary to provide quality reproductive health care is essential for all health care professionals working with individuals of reproductive age. As discussed in our previous blog post4, gender identity is fluid; however, sexual orientation (defined by the Human Rights Campaign5) is “an individual’s physical and/or emotional attraction to the same and/or opposite gender,” could be distinct from gender identity or expression and can also be distinct from sexual behavior. In other words, both sexual orientation and sexual behaviors can also be fluid.

Gender identity ≠ Sexual orientation ≠ Sexual behavior

A few simple considerations can enhance practitioners’ ability to provide comprehensive reproductive health care to individuals irrespective of sexual orientation, behavior and/or gender identity.

First, it is imperative that providers develop sensitivity around these issues. Providing individuals opportunities to tell you how they identify creates a “safe space” that clients can use to make the best reproductive health care decisions for themselves and their partners. Simply asking: Do you have sex with men, women or both? of all clients/patients should be routine practice and eliminates assumptions about sexual orientation and gender identity/expression.

Asking direct questions such as do you or your partner(s) need contraceptives or birth control to prevent pregnancy? or do you want to become pregnant in the next 12 months? removes assumptions about the reproductive potentials of the gender fluid and individuals with diverse sexual behaviors.

Relatedly, it is important to be aware that assumptions about monogamy are often just as problematic in reproductive health care provision as assumptions about anything else. Again, a straightforward inquiry about the nature of a client’s relationships can help guide recommendations about contraception and other reproductive health needs. We often ask: “Are you in a defined relationship with anyone? With more than one person?” Asking all clients if they are having sex with multiple partners (and if their partners are having sex with multiple partners) should be default to avoid missed opportunities to provide comprehensive reproductive health care to individuals involved in multiple or polygamous sexual relationships or polyamorous relationships.

In all cases, revising expectations about the needs of sexual minority, gender fluid, transgender, and polyamorous individuals creates an inclusive and welcoming reproductive health practice. Doing so promotes safe and effective practices for both providers and clients.



  1. https://storify.com/MLive/author-tweets-sex-ed-course-at-east-lansing-school
  1. http://www.scotusblog.com/case-files/cases/sebelius-v-hobby-lobby-stores-inc/
  1. http://lavenderhealth.org
  1. http://www.hrc.org/resources/entry/sexual-orientation-and-gender-identity-terminology-and-definitions
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American Academy of Nursing Issues 2 LGBTQ Policy Statements

This month the American Academy of Nursing has issued two important policy statements that affirm LGBTQ health!  Both statements are available for download from the Nursing Outlook web site:

American Academy of Nursing position statement on reparative therapy – this statement summarizes the conclusive evidence that reparative (conversion) therapies render lasting and serious harm, and concludes that  “

efforts to “repair” homosexuality, by any means, constitute health hazards to be avoided and are to be condemned as unethical assaults on human rights and individual identity, autonomy, and dignity.

Employment discrimination based on sexual orientation and gender identity – this statement emphasizes the negative health outcomes associated with LGBTQ minority stress that results from all forms of employment discrimination, declares opposition to employment discrimination based on sexual and gender identity, and urges all health care organizations, public and private, to adopt and enforce anti-discrimination policies on behalf of their LGBTQ employees


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Happy & Healthy Queer Vacations

With the arrival of the Memorial Day holiday in the U.S., the American vacation season begins. While some of us of a certain age will recall that “gay vacation” or “gay resort” usually meant something that was not “family friendly” in Key West, Rehoboth, Fire Island, Provincetown, Palm Springs, Russian River, Western Michigan, or coastal Maine, today our lives and our families are much more complicated than in the past.

While all of the usual healthy travel advice applies to queer vacations, we also have some additional considerations.

All travelers should recall that the most common health problems on vacation are the result of injury. These can include transportation accidents, including automotive, sports injuries (from skiing, sailing, or hiking), sunburn or other exposure injuries, dehydration, insect, jelly fish or other animal bites, or simply being in an unfamiliar physical space. Many of these are avoidable by exercising prudent precautions.

Other familiar health problems are the result of food or water-borne infection. Keep in mind that you, your partner, and your dependents are not Anthony Bourdain. Avoid questionable meal sources (like street vendors). Learn in advance what the water and food conditions are in your travel location. Have on hand over-the-counter medication for diarrhea, and, if traveling to a location with inconsistent water quality, secure an antibiotic in advance.

The Centers for Disease Control and Prevention provide guidance for all travelers: http://wwwnc.cdc.gov/travel . Its advice includes guidance for adults traveling with children and people who are immune compromised.

A nursing specialty, travel health nursing, reminds us of the value of this cadre of health professionals, supported by the American Travel Health Nurses Association: http://www.athna.org/ . Consulting with a travel health nurse in advance of your travel will provide you with greater security while traveling.

Sexual minority travelers may have additional considerations to take into account. Legal recognition of same-sex relationships and of custody of children varies by location. Within the U.S., for example, state laws vary widely. A prudent precaution is to have photocopies of relevant legal documents to ensure that you can provide medical care to a spouse or dependents in case of health emergency. The same, of course, applies to travel outside the U.S., for which the State Department provides informative resources: http://travel.state.gov/content/passports/english/go/lgbt.html

Advanced planning, careful vacationing, and informed risk calculation will increase the probability of your happy and healthy vacation.

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Docubank – An Exemplar of LGBTQ Inclusion

Although it is still rare to discover a mainstream service or organization that is clearly and openly LGBTQ-inclusive, it is, thankfully, becoming more common.  I stumbled across just such a service recently, when I was reminded to update my personal information that is on file with Docubank – a service that provides safe storage and access for your advanced healthcare directives and emergency medical information.  A number of years ago when my partner and I updated these documents, our wonderful lesbian lawyer recommended DocuBank_-_Immediate_Access_to_Healthcare_Directives___Emergency_Medical_Information_—_Anywhere__Anytime__24_7_365this service and enrolled us in it.  That was before marriage was legal anywhere in the U.S., and long before the demise of DOMA (the U.S. law that blocked federal benefits for same sex couples) – so then healthcare advanced directives, wills, and such were absolutely essential to assure that our “affairs” would be treated with respect according to our wishes when the time comes that we cannot speak for ourselves.  Now, of course, a few of the blocks that stand in the way have been removed, but having these documents in order well in advance remain one of the most important concerns for all LGBTQ people and their families.

So when I discovered that Docubank has specific information to help LGBTQ people and Hospital Visitorfamilies understand and accomplish these protections, I was thrilled!  Their dedicated page on the web, titled “DocuBank: The Living Will Registry for the LGBT Community” explains a wide range of services they offer in addition to “banking” your legal documents such as living will and advanced healthcare directives.  They also provide guidance for such documents as hospital visitation authorization, HIPPA release, and they will store your domestic partner and/or marriage license documents.

Once your documents are stored, you carry a card and store information in your contacts so that any emergency or other healthcare personnel can access your documents at any time.  There is a nominal fee to join – and I highly recommend that you consider doing so.  But more important, do not delay in getting these documents in order, and encourage any of your LGBTQ friends and relatives to do the same.  These are critical matters for all of us as individuals.  they are also important for our community, and contribute to making our community, our families and our lives visible in the world at large!

Visit the HRC information page for more information about protecting your healtcare decision-making rights.

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Award-winning article on “Caring for Transgender Patients”

We have just learned that the article “Caring for Transgender Patients” by nurse authors Laura C. Hein, PhD, RN, NP and Nathan Levitt, RN  from Nursing made Incredibly Easy’s November/December 2014 Diversity Issue has just won a 2015 American Society of Healthcare Publication Editors Bronze Award for Best Feature Caring_for___Transgender_patients___Nursing_made_Incredibly_EasyArticle!

The article provides an excellent overview of culturally appropriate care – guidelines and information that nurses everywhere need to meet the goal of improving quality of care for people and families in the transgender population.  And, there are CE credits available online!

Right now the article is available for free download now at the journal web site!  Check it out, and use this web site to contribute your comments, feedback and congratulations for this important contribution to the nursing literature!

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Trans* Health in Practice: Simple ways to be welcoming, supporting, and caring with the non-binary community

Co-authored by Candace W. Burton, PhD, RN, AFN-BC, AGN-BC, FNAP assistant professor at Virginia Commonwealth University, and Monica McLemore, PhD, MPH, RN, assistant professor at the University of California San Francisco.

This week the United State Supreme Court hears arguments in Obergfell v. Hodges, a case that could determine the fate of hundreds of same sex marriages across the country. Even as our attention is drawn to that high-stakes process, it’s critical to consider how we can create an inclusive space in our own lives, work, and communities. One means of doing so is to recognize and attend to the needs of trans* and non-binary gender individuals in health care practice. As three nurses who work in mental health, reproductive health, and emergency care, we encounter people all along the gender spectrum and strive to provide safe, effective, and nonjudgmental care. We also understand that institutional-level change occurs about as fast as you can swim through peanut butter, but there are some simple things each of us can do on a daily basis. Small changes can make a difference in how your practice welcomes trans* and non-binary people, so here are a few suggestions.

The first thing is to understand what is meant by “trans*” and “non-binary.” The asterisk after trans* indicates that what comes after could be a variety of things: transman, transwoman, transgender—it’s a way to indicate that you aren’t just referring to one group within the trans* population. Non-binary means someone whose gender isn’t completely defined by the terms man or woman. We could try to explain that in greater detail, but non-binary means non-binary so we’re not going to try to label it more than that! You may also see “gender non-conforming” used, but that term suggests that there is some ideal of gender to which to conform—this can have very negative and shaming connotations.

Next, realize that the “T” in LGBTQI isn’t silent but is often silenced. Trans* individuals have a plethora of reasons to distrust health care providers, and “coming out” may be complicated and risky, especially if a provider isn’t routinely demonstrating gender-inclusive behaviors. So, for example, though you may be perfectly well aware that Jane Smith likes feminine pronouns and forms of address, make sure sure this is confirmed at each visit. This demonstrates that you recognize it could change and that your practice can and will support any answer.

Third, recognize that there are times that sex or gender is relevant and times when it’s not. Some of the authors of this piece have practices related to reproductive health, often called “women’s health” — but we’re aware that not all people who need gynecologic or obstetric care are women. Hormone therapy, contraception, and other concerns in this area make it important for us to know each client’s history—but if we’re treating someone for a sinus infection, there’s a lot less to consider.

Fourth, understand that cisnormativity is insidious. Cis is the opposite of trans, and means that someone’s external appearance and internal experience of sex and gender are the same. Cisnormativity is the social expectation that this is true for everyone. Trans* folks are often misgendered as a result, such as when Jane Smith is called from the waiting room as “Mr. Smith” because records identify her as a male. In such a case, Jane may leave without being seen, rather than be outed to everyone present. Consider using just last names to identify clients, and make sure there are gender-neutral restrooms available.

Finally, know your gender-neutral pronouns and use them consistently. Ze or xe are commonly used if an individual’s gender preference isn’t known (ze, zir, and zir’s; xe, xyr, and xyr’s). Some non-binary folks also use they or them, but this can sound distancing if used without thought, such as when referring to “them” or “those people”. If you model these, and make clear that inclusive language is important in your practice, others will as well. Such language may not apply to every person in your practice, but it demonstrates a culture of inclusivity that can benefit more than just trans* and non-binary individuals.

Some of these suggestions are easier to implement than others, obviously, and some may take a good deal of training and effort. Recognize, however, that for trans* and non-binary individuals, these “changes” are about making life and experience visible and valued. Doing so creates a culture of inclusivity, welcome, and support for some of the most vulnerable folks we care for. Today could be the day that someone you encounter realizes you can be trusted to be supportive, thoughtful, and nonjudgmental in your care.

Check out these links for more information that can shape good practice habits around gender with your clients:





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How states discriminate

As we in the U.S. are now anticipating a Supreme Court decision that hopefully will establish marriage equality for all, it is prudent to be aware that even if/when this happens, there is still a lot of work to be done!  State-wide laws that protect against LGBTQ discrimination are all-too rare, and this absence will still have a major influence on the well-being and very lives of LGBTQ people and families.  Local and organizational policies that protect the rights of LGBTQ people are equally important – a place where YOU can take action!  Check your professional organizations, your place of employment – any club or society you belong to, to determine if these local organizations have statements of anti-discrimination based on sexual and gender identity.  Every time we join with others to protect our full human rights, we are contributing to progress that protects us all!

Watch this wonderful video produced by Vox.com that explains how most states discriminate against LGBTQ people:

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Are you prepared to take action on behalf of LGBTQ health?

As the U.S. enters another frenetic and prolonged presidential election, it is worth taking note of the positions that elected officials, and those seeking office at every level of government hold related to LGBTQ health and well-being.  Regardless of your location in the U.S. or perhaps another country that is also embroiled in ongoing political struggle to secure the rights of LGBGQ people and families, it is time to reflect on what actions are possible to participate in bringing about full human rights for everyone in our communities.

A recent example of such action came gained broad public attention, and provides an excellent and inspiring instance that is worth noting.  Early in the Obama administration, they set up a web-based portal called “We the People” for anyone to submit a petition to draw attention issues that the U.S. government should notice. Of course there are many petitions that never gain traction, or that deserve to be ignored.  Others are quite noteworthy, such as the petition to enact “Leelah’s Law.”  This petition was published on January 3, 2015, seeking help from the Administration to ban the devastatingly harmful “therapies” known as conversion, or reparative approaches that claim to “cure” people of sexual and gender identities that do not fall within the traditional binary, heterosexual expectations.  The petition was titled “Enact Leelah’s Law to Ban All LGBTQ+ Conversion Therapy.” The law commemorates the life and death of Leelah Alcorn, a 17 year old transgender youth who wrote a suicide note, posted it on Tumblr and then walked in front of a semi-truck to end her life. Leelah’s parents had forced her to attend conversion therapy in an attempt to change her gender identity. The petition was signed by over 120,000 people. The administration responded supporting this ban, and expressed their position that resources for LGBTQ+ youth , their family and friends are a priority.  Click here to see the petition and the administration’s response.

This petition, and the administration’s response has given rise to a growing movement in the U.S. to take this kind of legislative action.  The list of current actions, even though most are in the very early stages of the political process, is quite impressive.  You can follow these actions on the NCLR web site here, and follow the #BornPerfect campaign to end conversion therapies.

We may feel discouraged and frustrated with what seems to be “little we can do,” but this is not an excuse for taking the cowardly path to do nothing.  It is time to make a commitment to be well-informed of the issues that affect the well-being of our LGBTQ communities, know the public officials at every level who support us, and take every action possible to make sure they act on our behalf.  Choose an issue that you care about, find an organization and other individuals to join in taking action, and seek the changes you envision!

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The Barney Frank Story and the “Indiana” discrimination law

Barney Frank’s autobiography is a book I highly recommend for all who are interested in the political process and one gay man’s experience of struggling with the challenges of coming out as a public figure. He titled his book “Frank: A Life in Politics from the Great Society to Same-Sex Marriage.”  Frank makes it abundantly clear that political change in the U.S. democracy depends in crucial ways upon the input that citizens provide to their elected representatives.  We see this unfolding currently with the public response to theAmazonSmile__Frank__A_Life_in_Politics_from_the_Great_Society_to_Same-Sex_Marriage_eBook__Barney_Frank__Books recent Indiana law that opens the door for institutional discrimination against LGBTQ people – a response that has had far-reaching and dramatic repercussions  nationwide!

Frank’s engaging wit along with his frank opinions and insights shine through brilliantly!  There are several things about the book that to me are fascinating, not the least of which is learning about Frank’s life.  He realized he was gay at the age of 14; at the same age he became passionately interested in the political process and realized that these two facts about himself were not compatible.  He saw no way, at that young age, how he could pursue his passion for politics (a very public realm) with his gay identity.  His way of coping with this reality was to determine to remain very closeted, pursued graduate study in political science, and cultivated key friendships and connections with friends and acquaintances who had some involvement in politics.  He describes his process of coming out – a process involving many years well into his public life as a U.S. Congressman, and covering many years during which he was an avid advocate for LGBT rights.

Frank’s self-reflections about his personal struggles, as well as reflections about his judgments (both right and wrong) concerning his political battles, illuminate not only Frank as a person, but both the private and the public “gay” experience in America over the past half century.  I gained a new and more optimistic understanding of the political process, and how important it is that each and every citizen become involved in advocating those causes that are important to us.  Frank has little regard for public demonstrations and protests – he sees these as too often reversing the positive efforts that can result in positive change, even if the changes are incremental and slow to come.  This is one point that I question (I believe we need all forms of activism in the direction of change), but I have a new appreciation and understanding of Frank’s point of view – one that he supports with specific evidence.

If you read only one book in the remainder of this year, let this book be at the top of your list!  It is informative, helpful, interesting and inspiring!

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LGBT Health Awareness Week — a Good Time to Reflect on Your Personal Health

As Peggy Chinn wrote in last week’s Lavender Health blog post, it’s LGBT Health Awareness Week. Sponsored by the National Coalition of LGBT Health, the week is meant to increase awareness of LGBT health issues and to improve the competence of healthcare professionals and the healthcare system regarding LGBT health.

This seems like a good time to think about your personal health, your health promotion activities, and your routine health screenings.

Ask yourself these 10 questions:

1. Have you had an annual physical examination including gynecological exam in the last year?

2. Have you been to the dentist in the past 6 months?

3. Have you had a mammogram (if appropriate)?

4. Have you had a colonoscopy (if appropriate)?

5. Do you get the recommended amount of exercise every day or week (cardiovascular and weight/resistance training)?

6. Is your diet as healthy as it could be?

7. How much alcohol do you drink?

8. What is your weight?

9. Do you have social support (family, friends, co-workers)?

10. Do you find meaning in your life?

LGBT Health Awareness Week is now. If you have “room for improvement” in your personal health, why not take one step in the right direction, and do it today.  Why wait?

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