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Various topics in medicine relate particularly to the health of lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA) individuals, also referred to as sexual and gender minorities. Some of these areas include inequities in healthcare, sexual health, mental health, substance use disorders, HIV-related cancers, intimate partner violence, issues surrounding marriage and family recognition, reproductive health, and breast and cervical cancer ^{[1] [2]}. In medicine, various nomenclature, including variants of the acronym LGBTQIA, are used as an umbrella term to refer to individuals who are non-heterosexual, non-heteroromantic, or non-cis gendered. Specific groups within this community have their own distinct health concerns, however are often grouped together in research and discussions. This is primarily because these sexual and gender minorities groups share the effects of stigmatization based on their gender identity or expression, and/or sexual orientation or affection orientation ^{[1] [3]}. Furthermore there are subpopulations among LGBTQIA groups based on factors such as race, ethnicity, socioeconomic status, geographic location, and age, all of which can impact healthcare outcomes. ^[1]

Understanding the health of LGBTQIA people requires consideration of contextual factors such as historical background, stigma, laws and policies, demographics, and barriers to care, all of which are interconnected. Historical events, like laws against same-sex marriage, can impact access to health insurance for non-heterosexual individuals ^[1]. Some barriers to care include a lack of providers trained to treat transgender patients and negative experiences within the healthcare system. Research shows sexual and gender minorities are more prone to psychological disorders, physical illnesses, and barriers to inclusive healthcare compared to heterosexual or cisgender individuals ^[4]. HIV/AIDS remains a critical health issue for subgroups within the LGBTQIA community, particularly gay and bisexual men and transgender women, and highlighted attention to stigma, disparities, and the need for research funding ^{[1] [5] [3]}. The HIV/AIDS epidemic, while devastating, also strengthened the resilience of the LGBTQIA community. This article will discuss specific topics in healthcare for sexual and gender minorities, specifically LGBTQIA people, individually and collectively.

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Issues affecting LGBTQIA people generally

According to the Committee on Lesbian, Gay, Bisexual and Transgender Health Issues and Research Gaps and Opportunities, convened by the Institute of Medicine (IOM) at the request of the NIH, there are several difficulties in conducting health research on LGBTQIA populations. These challenges include the complexity of defining sexual orientation and gender nonconformity, hesitancy among individuals to answer questions about their same-sex behavior or gender identity, and the logistical and financial challenges of recruiting a sufficient sample size for meaningful analysis due to the relatively small size of the LGBTQIA population in the United States. ^[1]

Lesbians, gay men, bisexual individuals, and transgender people are often grouped together in research and discussions despite being distinct populations and non-inclusive of all non-heterosexual or gender non-conforming ^[1]. This is because of the common stigma they face as sexual and/or gender minorities known as minority stress. In some studies, lesbians, gay men, bisexual, and queer individuals are combined under the label "non-heterosexual," while in HIV research, participants may be grouped together in categories that include various identities ^[1]. Most research focuses on lesbians and gay men, with significantly less attention given to bisexual, transgender, queer, intersex and asexual individuals. and they often face stigma as a result. ^[1]

A review of studies in North America found that LGB individuals generally reported poorer self-rated health, more physical health symptoms, and higher rates of certain health conditions, including diabetes, asthma and high blood pressure, compared to heterosexuals ^[6]. These disparities were most pronounced among adolescents and young adults, with smaller differences among older age groups. Factors such as health behaviors and experiences of discrimination, victimization, and violence among sexual minorities were found to contribute to these disparities in physical health. ^[6] Mental health appears worse among LGBT people than among the general population, with depression, anxiety, self-harm, and suicide ideation being higher than the general population ^[7]. These mental health disparities are more evident in LGBTQ+ youth, with self-harm being reported by 65% of LGBQ youth and 46% of TGNC youth ^[7]. LGBTQIA+ individuals have also been shown to have difficulty accessing competent fertility-related care or quality family planning services ^{[8] [9]}.

Causes of LGBT health disparities

Research explains healthcare disparities in LGBTQIA people is likely due to minority stress. ^{[3] [5] [4]} Minority refers to the weight of facing negative societal attitudes and reactions towards one's sexual and gender identity. It includes stressors resulting from social exclusion and stigma, leading to adverse mental health effects. The theory of minority stress explains how experiences of victimization related to gender and sexual non-conformity contribute to psychological and mental health issues among LGBTQIA+ individuals. ^{[3] [5]} This stress is rooted in negative social interactions and, when prolonged, can significantly impact mental health, leading to behaviors like substance abuse, suicidal thoughts, poor communication, and unintentional actions. Research has shown various negative mental health outcomes linked to chronic experiences of minority stress. ^[3]

A systematic review of healthcare access for LGBT individuals found that they often struggle to communicate with healthcare providers due to fear of assumptions and embarrassment about their sexual orientation. This, coupled with homophobia in healthcare, leads to exclusion and marginalization, reducing their attendance and engagement in body care and preventive health programs.

HIV/AIDS

Main article: HIV and men who have sex with men

Men who have sex with men are more likely to acquire HIV in the modern West, Japan, India, and Taiwan, as well as other developed countries than among the general population, in the United States, 60 times more likely than the general population.An estimated 62% of adult and adolescent American males living with HIV/AIDS got it through sexual contact with other men. HIV-related stigma is consistently and significantly associated with poorer physical and mental health in PLHIV (people living with HIV).The first name proposed for what is now known as AIDS was gay-related immune deficiency, or GRID. This name was proposed in 1982, after public health scientists noticed clusters of Kaposi's sarcoma and Pneumocystis pneumonia among gay males in Californiaand New York City. There is an unspoken fear of getting HIV tested in gay men. This can be because of fear of sexual rejection, not knowing where of how to get tested, and fear of friends/family distancing.

Pre-exposure prophylaxis (PrEP), is a medication used to prevent HIV infection in individuals at higher risk, such as sexually active adults or people who inject drugs ^[10]. PrEP has been shown to be highly effective, reducing the risk of HIV transmission through sexual intercourse by up to 99% and through injection drug use by 74% when used as directed ^[11]. The World Health Organization recommends different forms of PrEP, including oral PrEP for those at substantial risk, event-driven PrEP for men who have sex with men, and the dapivirine vaginal ring for women at substantial risk who do not have access to oral PrEP. ^[10]

Issues affecting asexual people

Allonormativity, which stems from the idea of allosexuality (non-asexuality), assumes that experiencing sexual attraction and desiring sexual activity are normal human traits. This perspective tends to pathologize and stigmatize asexuality, where individuals lack sexual attraction or desire ^[12]. Compulsory sexuality reinforces the idea that any form of allosexuality (such as bisexuality or heterosexuality) is superior to being asexual. These societal norms can make it challenging for people to accept and embrace asexual identities, including their own, leading some asexual individuals to adopt different labels, such as bisexuality or pansexuality, due to a lack of awareness and acceptance of asexuality ^[12]. While many studies have focused on cisgender women, research indicates that the process of recognizing and internalizing an asexual identity is similar for cisgender men, despite some gender-related differences in experiences. ^[12]

In 2018, the UK government released findings from a nationwide survey on LGBT+ life in the country. One notable but often overlooked finding was that asexual individuals had poorer outcomes compared to those identifying as other sexual orientations. Asexual respondents reported lower life satisfaction scores and were less likely to feel comfortable living in the UK. They were also the most likely to hide their sexuality due to fear of a negative response. ^[13]

Differentiation from sexual dysfunction

Recent studies are investigating biological aspects of asexuality and comparing asexual individuals with non-asexual (allosexual) groups to distinguish asexuality from sexual dysfunction and psychological disorders. Eye-tracking and penile plethysmography were used to measure responses to sexual stimuli in cisgender men ^[12]. Heterosexual men focused more on erotic images, while asexual men distributed their attention more evenly. Asexual men also showed lower genital and subjective arousal to erotic films compared to allosexual men, but both groups had similar arousal during sexual fantasy, suggesting asexuality is not linked to physiological dysfunction. ^[12]

Another study compared heterosexual cisgender women with asexual individuals who identified as women, non-binary, or trans. The heterosexual group included individuals with Sexual Interest/Arousal Disorder (SIAD). The heterosexual SIAD group fixated faster and more often on sexual stimuli compared to the asexual group, indicating that asexuality is distinct from psychological disorders like SIAD ^[12].

Issues affecting intersex people

Intersex is a term used to describe a diverse range of natural variations in sex characteristics and development that do not fit within the typical definitions of male or female. These variations can include at least 40 recognized differences in sex characteristics, some common variations are Klinefelter Syndrome, Congenital Adrenal Hyperplasia, Swyer Syndrome, and CAIS. ^[14] The medical language surrounding intersex health is complex. According to the National LGBTQIA+ Health Education Center's guide for Affirming Primary Care for Intersex People in 2020, differences of sex development (DSD) or diverse sex development, is the current medical terminology to describe these variations. ^[14] While certain intersex variations are identifiable either prenatally or at birth, others may not become apparent until puberty or even later in life. ^[14]

While most intersex individuals identify as heterosexual and cisgender, they are incorporated into the LGBTQIA+ community because of their shared experiences of discrimination based on misconceptions about gender and biology. ^[15] Additionally, there is a lack of medical and behavioral health research for intersex people often leading to gaps in understanding of their specific needs and experiences. ^{[16] [14]}

The medical needs and issues of intersex individuals vary greatly due to the diversity of intersex variations. Some may not require specialized medical attention, while others may need care at specific developmental stages and some have lifelong needs related to their unique variations. ^[14] Primary care providers play a crucial role in assisting individuals and families in finding trusted referrals and navigating specialized care ^[14]. Some common medical specialty care needs include steroid replacement for those with combined adrenal gland/gonadal variations, gynecologic, urologic, and sexual health care to address complications from prior surgeries, hormone therapy for inducing secondary sex characteristics, affirming gender identity, or replacing sex hormones after gonad removal, prevention and treatment of osteoporosis, and cancer surveillance for internal gonads. ^[14] Some individuals or families may choose to surgically remove internal gonads or gonadal streaks if there is an elevated cancer risk, although this risk may not always be present, and updated recommendations should be followed. ^[14]

Reconstructive surgery

Since the 1950s, the medical approach to intersex infants and children focused on surgically altering their genitalia to conform to typical male or female appearances and prevent non-heterosexual relationships. ^[16] This practice persists in some institutions, often pressuring families to consent to surgeries that may be unnecessary without adequate counseling or information about alternatives. ^[16] Intersex individuals often suffer adverse effects from these surgeries, including physical complications (scarring, chronic pain, loss of sensation, urinary and sexual dysfunction) and psychological distress (PTSD, depression, feelings of loneliness and fear or intimacy). ^{[17] [18]} Despite Intersex-led organizations and professional societies, including statements by the American Medical Student Association, WHO and American Academy of Family Physicians, some specialists continue to perform these surgeries, highlighting the ongoing need for advocacy and awareness. ^{[19] [20] [21]}

References