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 that explains how most states discriminate against LGBTQ people:

Posted in Activism, Legal Issues, LGBTQ Human Rights | 1 Comment

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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13th Annual LGBT Health Awareness Week March 23-27, 2015

LGBT Health Awareness Week was established by the National Coalition for LGBT Health to promote increased health awareness and outcomes in the LGBT community and LGBT-Health-Poster-ss-with-border-184x300promote the need for greater cultural competency in the healthcare system. This year’s theme is “Time to Come Together: Trust, Transparency, Truth.” The emphasis is on using social media to build greater responsiveness and sensitivity to LGBT issues in the health care system (Trust), improved access to care for LGBT people and data collection that reflects sexual orientation and gender identity (Transparency), and underpinning these goals, support for all LGBT people to be open and honest about their sexual orientation and gender identities within the health care system (Truth).

Everyone can participate using your own social media connections!  Everyone is welcome to share the coalition’s social media campaign materials and use the hashtags: #TIMETOGETHER, #TIME4TRUST, #TIME4TRANSPARENCY, #TIME4LGBTTRUTH, and #LGBTHealthWeek throughout the week.  You can follow events and promotions throughout the week on the Coalition’s Facebook page.

You can also register here for a Webinar  focusing on “Trusting Relationships: Lessons from LGBT Health Centers Building Trust With Their LGBT Clients.” The webinar will be held on Wednesday, March 25, 2015, 4:00-5:00 pm EST.

For more information and even more ways to be involved, visit the Coalition web site!

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Let’s get tobacco smoking out of the closet!

Tobacco smoking is the LGBTQ Community’s biggest health burden.  In 1964 the US Surgeon General issued the first report on smoking and health – a landmark report thathealth began a process of heightened awareness and action, about the health consequences of smoking tobacco.  But it was not until 2001 that the annual report mentioned LGB smoking disparities, and in 2014 the report finally clearly delineated what many LGBTQ researchers and health care professionals already knew — that smoking disproportionally affects all LGBT communities.The American Lung Association has also recognized the urgent health risks of smoking for LGBT people, identifying the LGBT community as a priority population for tobacco control.

In addition, we now know that there are many intersecting identities that add to the burden of stress for LGBT people and families, multiplying the health risks associated with smoking. Within our own community, youth, people of color, and people who are economically disadvantaged have a much higher rate of smoking and smoking-related health problems. As a community, we spend more on tobacco every year than is spent on programs to benefit LGBTQ people and famlies.  The smoking rate in the LGBT population is 68% higher than the rest of the population.  So it is time for all us – smokers and non-smokers alike, to speak out and reach out to raise awareness and participate in positive action.

Here is a typical story:

My smoking history is closely tied to my coming out as a lesbian – I smoked for about 10 years, off and on, during the early years of my lesbian life.  I cannot tell you which of these experiences was supposedly more closeted for most of those years – being a lesbian or smoking!  Some part of me felt that both were bad and struggled to come to terms with both, not ever realizing how closely related the two actually were although of course only one of them was “bad!”  Eventually, I began to realize that my sexual orientation was a part of me that I valued, I began to connect with a group of lesbian friends who were out and proud, and finally managed to stop smoking!

This story holds a key to understanding how we can all address this issue — we can live out and proud, and support those around us who may be ready to take the really difficult steps to stop smoking!  There are effective programs for smoking cessation, but they are sadly underused.  In the San Francisco Bay area, “The Last Drag” program offers free smoking cessation course 4 times a year .. the next session starts on April 1!  If you can’t find a local LGBT-focused cessation program, the American Lung Association offers help for all!  If you know of something that might help other LavenderHealth readers, share your comments and ideas here!  We welcome any and all suggestions!


Click image to download this Infographic from LGBT Healthlink!

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Marriage Equality is a Health Issue!

In recent years, many health profession organizations have issued policy statements in support of marriage equality, including the American Academy of Nursing, the American gay-marriagePsychiatric Association, the American Medical Association, the American Academy of Pediatrics, and the American Psychological Association.  Their support for marriage equality has been a response to growing social acceptance of same-sex marriage, but also has been a major factor in affirming the fact that committed relationships, and including the legal/social recognition of these relationships in the form of marriage, has important health benefits.

I for one have always had misgivings about the institution of marriage as we know it, primarily because of the fact that it is grounded in heteronormativity that perpetrate gender roles and gender stereotypes, and because of the close ties to religious views and beliefs that have not been kind to LGBTQ people.  But despite these drawbacks, the fact remains that many LGBTQ people have sustained committed relationships for years, even decades, and have benefited from many of the health-related benefits that come from intimate, sustained daily connections that provide support, love, and nurturance that contribute to health and well-being. Of course no long-term relationship is without its challenges and problems!  But for LGBTQ people who have sustained these relationships in a social context of disapproval and denial of their relationships, the challenges have been multiplied many times over!

Now that the majority of LGBTQ people in the United States, and all in several other countries, live where their committed relationships can be openly and legally recognized, some of the challenges and stressors around same-sex relationships have gradually being lifted.  While it is true that even in northern California, on of the most liberal geographic areas in the world, we still approach every public encounter wondering if our relationship will be accepted, gradually the reality is coming through that we can now enjoy the same kinds of social acceptance that many heterosexual couples have enjoyed for their entire lives.

As a recent article in Psychiatry Advisor notes: “multiple studies have found that psychosocial stress associated with having a lesbian, gay, bisexual, or transgender identity is implicated in the increased rate of mental health disorders found in LGBT persons. This stress comprises discrimination, concealment of sexual identity, and internalized negative attitudes about sexual or gender identity. Other studies more specific to marriage bans report that lesbians and gay men living in states where such bans were implemented had increased rates of mood and anxiety disorders, compared with lesbians and gay men living in states without constitutional amendments.”

The social, psychological and physical benefits of marriage equality have yet to be fully researched and documented, and much of the evidence to date is anecdotal. But now that more and more couples are emboldened to be “out,” the research evidence is mounting that the social/legal recognition of same-sex relationships does provide a substantial degree of mental health protection and resilience – health benefits that are vital to the well-being of LGBTQ people, couples and families.

Here at, we will report on reearch findings along this line from time to time, and will include in our resources information related to this important issue.  So watch this space!  We welcome your comments, and if you have information to share with us at any time, let us know!

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I Am Joe’s Man Gland (Revised): Prostate Health for Queer Men

Readers of a certain age will recall that present in almost every physician’s office from the 1950s to 1980s were back issues of the monthly Reader’s Digest, a compendium of condensed literature and non-fiction, including a semi-regular feature on human anatomy and physiology, “I Am Joe’s ___” or “I Am Jane’s ___,” with the relevant body part or system filling in the blank.

It’s time to update the tactfully euphemistic “I Am Joe’s Man Gland” for a queer male readership, particularly because the prostate occupies a special place in men’s sexual lore and practice.

Nestled between the rectum and the bladder, this walnut-size organ produces the fluid that carries sperm (produced in the testes), and its smooth muscles squeeze during orgasm to ejaculate the seminal fluid.

Infamously, the prostate is also susceptible to cancer, but typically it is a slow-growing cancer. Most men, if they live long enough, will develop a prostate cancer that is usually managed with watchful waiting. We usually die from other conditions.

Bad news and good news for gay men: While according to one 2011 study gay men are twice as likely to be diagnosed with cancer, we are significantly less likely to be diagnosed with prostate cancer (Boehmer, Miao, & Ozonoff, 2011).

Other prostate problems are more benign. A slightly enlarged prostate (known by the medical term benign prostatic hyperplasia, or BPH), normally accompanying aging, may cause some inconvenience. According to the National Library of Medicine’s Medline Plus:

Less than half of all men with BPH have symptoms of the disease. Symptoms may include:

  • Dribbling at the end of urinating

  • Inability to urinate (urinary retention)

  • Incomplete emptying of your bladder

  • Incontinence

  • Needing to urinate two or more times per night

  • Pain with urination or bloody urine (these may indicate infection)

  • Slowed or delayed start of the urinary stream

  • Straining to urinate

  • Strong and sudden urge to urinate

  • Weak urine stream (National Library of Medicine, 2013).

The wise patient, however, will bring up these symptoms with his primary care provider in order to rule out other more serious problems.

Prostatitis, an inflammation of the prostate, may be the product of an infection or other cause and is usually temporary. Some men find prostate massage a source of sexual pleasure. Whether it can also bestow a health benefit for men with chronic prostatitis is still not clear; Shoskes and Zeitlin (1999) found a benefit to a combine antibiotic and massage therapy, but more recently Ateya et al. (2005) could not find a significantly improved response and recommended antibiotics only. Prostate massage, moreover, may entail some risk if done too vigorously, and one risks tearing the delicate wall of the rectum.

A variety of anal probes designed to stimulate the prostate are commercially available as sex toys. Paradoxically, product web sites consulted for this article all provided disclaimers waiving the manufacturers from liability from harm in their use, with one announcing “not for internal use.”

Harvard Medical School (2011) provides advice on exercise and diet for prostate health, with benefits for cancer and prostatitis risk reduction.

In addition, some women and men find helpful exercises to strengthen the pelvic floor muscles,  the so-called Kegel exercises, both to strengthen urinary continence and for sexual pleasure (Mayo, 2012).

In conclusion, remember: A healthy prostate is a happy prostate.


Ateya, A., et al. (2005). Evaluation of prostatic massage in treatment of chronic prostatitis. Urology, 67, 674-678. doi:10.1016/j.urology.2005.10.021

Boehmer, U., Miao, X., & Ozonoff, A. (2011). Cancer survivorship and sexual orientation. Cancer, 117, 3796-3804.

Harvard Medical School. (2011, October 4). 10 diet & exercise tips for prostate health. Harvard Health Publications.

Mayo Clinic. (2012, September 25). Kegel exercises for men can help improve bladder control and possibly improve sexual performance: Here’s a guide to doing Kegel exercises correctly. Healthy Lifestyle: Men’s health.

National Library of Medicine. (2013). Enlarged prostate. Medline Plus.

Shoskes, D. A., & Zeitlin, S. I. (1999). Use of prostatic massage in combination with antibiotics in the treatment of chronic prostatitis. Prostate Cancer and Prostatic Diseases, 2(3), 159-162. doi:10.1038/sj.pcan.4500308

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3 more days to enroll!

February 15th is coming soon – the deadline to enroll in a health care plan of your choice!  Where-to-Start-What-to-Ask-coverIf you or someone you know is not yet covered, get the information and the help you need to make sure this happens!  Medical coverage for LGBTQ people and our families is important as never before — because now it can happen!  Visit the Strong Families web site today for specific information about LGBTQ coverage – do it now!

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