Introduction to LGBTQ+ Studies A Cross-Disciplinary Approach LGBTQ+ Health and Wellness People

Health and Wellness Thomas Lawrence Long , Christine Rodriguez , Marianne Snyder , and Ryan . Watson LEARNING OBJECTIVES Upon completion of this chapter , students will be able to do the following Summarize the history of genders and , including homosexuality , bisexuality , and transgender identity , as well as queer identity and activism . Describe the connections between identities and embodied experiences . Describe from an perspective . Analyze how key social institutions shape , and force structures of inequality . INTRODUCTION The health and wellness of and other sexual minority people in the United States is by many factors access to health care and health insurance ability for open with a health professional knowledge about the unique health challenges of people , including disease prevention and health promotion and a sense of about their health , or the that they know how to live a healthy life , along with the intention , necessary knowledge , and resources to do so . According to the Institute of of the US . National Academy of Sciences , health can be understood through four lenses 233

234 Introduction to Studies Minority stress stress that sexual and gender minorities routinely experience can contribute to physical and mental health problems . at each stage of life subsequent stages , with people being particularly vulnerable in adolescence and young adulthood . individual multiple ties and the ways they interact may compromise health so that gender and sexual identity may be complicated , for ample , by racial or ethnic identity or economic status . Health disparities are already among racial and ethnic populations , which queer sexual orientation is likely to intensify further . Social are surrounded by spheres of and support , including families , friends , communities , and society , that shape and In this chapter we keep in mind these four overlapping dimensions while exploring the following topics people and the history and culture of medicine . Vulnerabilities of people across the lifespan and across intersectional identities ( including race and ethnicity ) Transgender people health . Guidelines for being a smart patient and health care consumer . HISTORY AND CULTURE OF MEDICINE AND PEOPLE people often have complicated relationships with medicine , and these relationships have histories that extend back to the . The Michel famously ( and controversially ) suggested that queer in the ancient and medieval worlds were judged in an exclusively legal or religious category but that in the 18005 became From this perspective , in historical terms , people in Western society went from being criminal or immoral to being mentally ill .

Health and Wellness 235 Viewed as a pathology rather than just a moral failing or legal lation , queer sexuality became the object of medicine study What is its cause , and if it is a pathology or disease , how might it be cured ?

This moment occurred in the second half of the when medical research and practice had absorbed enormous cultural power and authority through its first modern groundbreaking discoveries , including the development of germ theory , surgical antisepsis , and anesthesia . All things seemed possible to medicine . DEVELOPING TERMINOLOGY The term homosexual appears to have been coined by the Hungarian journalist ( in an 1869 pamphlet criticizing a German law The term was taken up by the psychiatrist Richard Von ( in his a Mental illnesses related to sex ( 1886 ) The term entered English through a translation of work and through the advocacy writing of John and Havelock Ellis in England . The term bisexual , in contrast , had been used in botany since the to denote plants with both male and female anatomy ( also referred to as hermaphrodite ) but was adapted in the late Figure . Public domain . homosexual A person with a romantic attraction to , sexual attraction to , or sexual behavior with others of the same sex or gender . bisexual Romantic attraction , sexual attraction , or sexual behavior toward both males and females or toward more than one sex or gender . hermaphrodite Biologically , an organism that has complete or partial reproductive organs and produces normally associated with both male and female sexes .

236 Introduction to Studies intersex People born with any of several variations in sex characteristics , including chromosomes , gonads , sex hormones , or genitals . third sex A concept in which individuals are categorized , either by themselves or by society , as neither man nor woman . degeneracy Also known as degeneration theory theory that homosexuality and bisexuality were akin to criminality , alcoholism , and drug addiction . to denote a person with roughly equivalent attraction to men and women . The term intersex , used as a synonym for homosexual , was adapted in the early twentieth century from biology , where it indicated the sion of both female and male anatomical features , and it is now the term frequently used by people born with ambiguous genitalia . THEORIES OF SEXUAL VARIATION These attempts to name this unique species of human beings and nose what they viewed as sexual pathology , or disease , led physicians , and psychiatrists to a search for causality and treatment . David explanatory categories that emerged over time homosexuality as innate , degeneracy theory , Darwinian theory , psychoanalytic theory , and advances in embryology and genetics may have what had often been an assumption since that sexuality was innate , leading to a theory of the third sex , which was also encouraged by movements for social tolerance and legal reform . In contrast , proponents of degeneracy theory viewed homosexuality and bisexuality as akin to criminality , alcoholism , and drug addiction . suggests that the gene pool had become exhausted as a result of modern life or personal vice and indulgence inherited from a ous generation . Similarly , the application of Darwinian theory evaluated people and behavior , characterizing homosexual and bisexual people as evolutionary , akin to primitive peoples whom Europeans had colonized throughout the world and whose sexual mores were at odds with Western notions of morality . Perhaps no theories of sexual identity have been more than psychoanalytic theory and behaviorism . Although various theories were espoused in the late and early , Sigmund Freud , often called the father of modern psychoanalysis , postulated that infants are polymorphous perverse , deriving pleasure from many parts of their body and regardless of gender . The function of society , for Freud , was to channel pleasure into an acceptable , productive heterosexuality . However , traumas or inner could arrest a child psychosexual development or cause a young adult to regress into homosexuality ( for example , an overly attentive mother and distant father for boys ) The role of psychotherapy was to expose the trauma or and allow growth toward heterosexuality to resume . Nonetheless , Freud was less inclined to view homosexuality as a sickness than as a form of psychosexual immaturity . Behaviorism , in contrast , has been inclined to view sexual

Health and Wellness 237 orientation generally as a learned behavior , which means that sexuality can be Whereas psychoanalytic theory prefers talk therapy , behaviorism has tended to employ rewards and punishments to reprogram sexual behavior , including and hormone . gay conversion therapy , the subject of increasing legal rejection by states today , has a history . EMERGING Throughout the twentieth century the medical establishment in the United States generally considered queer as mental illnesses . ever , early descriptive research by Alfred and his colleagues closed both a surprising number of persons and a spectrum of human sexual response . What they called a homosexual rating scale a range from exclusively heterosexual ( to equally heterosexual and homosexual ( otherwise known as bisexual , to exclusively homosexual ( This scale was applied to each individual according to the participants sexual behavior and psychic is , thoughts , feelings , and It is no wonder , then , that by the and the emergence of the gay rights movement , many people had come to distrust the ical establishment . Health care providers often either exhibited hostility or acknowledged ignorance about the unique health concerns of people ?

Many gay men and lesbians in particular had come to reject the notion of their sexual orientation as a pathology and had begun to seek the rare health care providers who were of their . Feminists and the women movement had shown how this might be done with health , like the one in Boston that produced the book Our Bodies , Ourselves , part of a movement in the United States in the late and early for homegrown books . One groundbreaking book for queer people included chapters on alcohol safety , venereal diseases ( now called sexually transmitted infections ) and other health topics , many of which had been previously published in local queer newspapers and In major urban areas , health clinics for people formed to serve this vulnerable When the first published reports of an infectious epidemic that would come to be called acquired immune syndrome ( AIDS ) appeared in 1981 , queer communities were wary of uncertain medical explanations and advice , aware of the stigmatization of their that was now exacerbated by AIDS , but also more prepared for community organizing around health concerns . Grassroots organizations at least in large or sexually transmitted . infections Pathogens that are commonly spread by sexual activity , especially vaginal intercourse , anal sex , and oral sex .

238 Introduction to Studies sex reassignment surgery Also known as surgery surgical procedures by which a transgender physical appearance and function of their existing sexual characteristics are altered to resemble those socially associated with their gender . surgery Also known as sex reassignment surgery surgical procedures by which a transgender person physical appearance and function of their existing sexual characteristics are altered to resemble those socially associated with their gender . Read The Wellcome Collection is a free museum and library that aims to how we all think and feel about health . Its article The Shocking Treatment to Make Lesbians Straight ( describes the efforts of two researchers to uncover whether and how women were treated for lesbianism in England in the and . What were some of the challenges that the authors faced in conducting their research ?

How did the beliefs of the health care community at the time affect the treatments designed to cure their patients ?

A former patient pointed out that lesbians were being tested against heteronormative ideas of sexual ! What did she mean by this ?

midsize metropolitan New York ( Gay Men Health Crisis ) and Tidewater AIDS Crisis Taskforce of Norfolk , educated , and cared for people infected with HIV . Chapters of the AIDS Coalition to Unleash Power ( ACT UP ) blossomed in cities , New York and San Francisco , bringing demonstrations against government and medical inaction . AIDS activists changed the ways that the medical establishment conducted research and ered care by insisting on the participation of people living with AIDS in decisions about drug approvals and MEDICINE AND THE HISTORY OF TRANSGENDER CARE The celebrity of Christine ( who began her physical transition from male to female in the early and who led a bold public life as a writer , lecturer , and entertainer , brought the transgender experience to wide Beginning in 1965 , Johns Hopkins in Baltimore was the American medical school to study and perform what was called sex reassignment surgery ( now more aptly known as surgery ) or in popular parlance , sex change operations . However , despite this pioneering role , the Hopkins clinic ended the practice in 197 , in part because of

Health and Wellness 239 Figure . Christine , Public domain , Maurice Seymour . research . Only recently has it resumed its transgender and In the decade and a half of the century , almost forty thousand patients sought transgender care , with 11 percent of them seeking surgery and an increasing percentage using health insurance rather than payments as had been typical in the Medicine relationship to people has been complicated enough over the last century and a half , but considering a persons place in the human lifespan and intersectional identities makes it even more so . We explore these considerations next . VULNERABILITIES ACROSS THE LIFESPAN AND ACROSS INTERSECTIONAL IDENTITIES Decades of research have indicated that populations face a proportionate burden of health problems and stigma , including higher els of depression , lower , compromised academic achievement , and more substance These disparities are documented across the lifespan , from childhood to young adulthood and even into late Researchers have minority stress , or and stressors , as the mechanism through which these health problems can be

240 Introduction to Studies minority stress model A sociological model , as proposed by Meyer , explaining why sexual minority individuals , on average , experience higher rates of mental health problems relative to their straight peers . Overlapping or intersecting social identities , such as race , class , and gender , and related systems of oppression , domination , or discrimination . pansexual The sexual , romantic , or emotional attraction toward people regardless of their sex or gender identity . Minority Stress Model Being a marginalized or minority person in a society produces personal and group stress , sometimes invisible but always with both ical and physiological effects . The Institute of Medicine report proposed the minority stress model as a strong framework to understand health disparities among populations . In particular , the report highlights how minority stress has been found to affect the lives and health of individuals across the This minority stress can be distal ( victimization from others because of a sexual minority identity ) or proximal ( concealment of sexual identity , internalized homophobia ) Therefore , strategies to promote health and should consider multiple types of stressors . Intersecting Identities In addition to minority stress , the Institute of Medicine recommended a focus on as an imperative consideration for researchers , and other stakeholders invested in health . sectionality at its broadest meaning proposes that race , ethnicity , ability status , and other oppressed identities can amplify health In addition to being aware how oppressed and intersecting identities can compound health outcomes , researchers are increasingly measuring and considering all demographic characteristics among youth to better understand how multiple identities ( being Black , gay , and residing in the South ) might be related to the holistic . For example , a study collected data from youth across the United States and documented distinct sexual and gender Additionally , youth who were transgender and nary were more likely than youth to identify with an emerging sexual identity label , such as pansexual ( figure ) These patterns also differed by identity , suggesting that youth of color are using different terms , compared with their white counterparts , to describe their sexual attractions and gender identities . The next step is to better understand how intersecting identities may be uniquely associated with health outcomes , given that a large focus of research has focused on disease prevention and health promotion among populations . The Institute of Medicine also points out that couples and their children are less likely to have adequate health insurance , which is ally provided through employers , especially when they are unemployed or .

Health and Wellness 241 Figure . The pansexual pride . Public domain , DISEASE PREVENTION AND HEALTH PROMOTION Recent research on health disparities that the gap in disparities between some and heterosexual youth continues to grow across a number of Emerging research has moved beyond ing these disparities to examining the risk and protective factors that may help prevent disease and promote health among people . With respect to youth , research has consistently family and parent support to be the strongest buffer against negative health experiences , above and beyond other support systems . In addition to families , a number of other support systems are known to protect against negative health ( and thus disease later in life ) such as clubs , supportive peers , and supportive policies and The protective role of these support systems extends into young adulthood and across a lifespan , but the magnitude by which certain supports ( school peers ) affect health may change . Among older adults , there has been a strong focus on ally transmitted disease and HIV prevention . Given HIV disproportionate burdens on the community , and in particular the ate impact on African American men who have sex with men , research funding and attention have focused on reducing this stark disparity ( ure ) Medical advancements in preventing HIV have proliferated in the recent past , and one method in particular , prophylaxis ( PrEP ) has been the focus of many studies . However , a vexing dilemma exists although there is a drug that can prevent HIV infection , why more men who have sex with men ( and individuals ) taking the drug ?

After all , Tony Kirby and Michelle find that the rates of HIV acquisition in the United States are still high and similar to 242 Introduction to Studies Black White Black Women , Heterosexual Contact Black Men , Heterosexual Contact Women , Heterosexual Contact White Women , Heterosexual Women Figure . Diagnoses of HIV infection in the United States and dependent areas , 2015 . representing percent or less of HIV diagnoses are not in this chart . men who have sex with men . Public domain , Centers for Disease Control and Prevention . the rates in other countries . Researchers continue to consider how stigma , a history of medical mistrust , and other factors might thwart the uptake of lifesaving drugs that prevent HIV among populations ?

See table for a summary of the critical health concerns over the life course . Table . Health concerns across the lifespan Life stage Health concerns Adolescence HIV infection , particularly among Black or Latino men who have sex with men depression , suicidal ideation , suicide attempts smoking , alcohol , substance use homelessness violence , bullying , harassment Early to Mood and anxiety disorders using preventive health resources less frequently smoking , alcohol , substance use Later adulthood hormone use among transgender people HIV infection stigma , discrimination , violence in health care institutions ( nursing homes ) The research literature also suggests that older adults may possess a high degree of resilience , having weathered the difficulties of adolescence and earlier adulthood Source Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and People Building a Foundation Better Understanding ( Washington , National Press , 2011 )

Health and Wellness 243 A long history of health professionals insensitivity or even hostility to people , as described in the beginning of this chapter , continues to have consequences . Disparities are particularly evident among transgender people , who are a uniquely vulnerable population and whose health and wellness concerns we discuss next . TRANSGENDER AND HEALTH CARE The transgender and community has suffered , often in silence . Numerous studies have depicted the barriers these patients face with respect to health care , which include mistreatment by health care providers and providers discomfort or inexperience regarding patients health care needs , as well as patients lack of adequate insurance coverage for health care Owing to these barriers , transgender and patients are often left to navigate health care on their own . For example , the National Center for Transgender Equality reported that 33 percent of respondents who had seen a health care provider in the preceding year suffered at least one negative experience related to being transgender , and 23 percent of respondents did not even seek a medical provider when they needed one for fear of being mistreated . ally , a staggering 39 percent of respondents experienced psychological distress , and 40 percent have attempted suicide in their lifetimes , which is nearly nine times the percent rate of the general Seeking routine or preventive physical and mental health care , let alone services for those who seek to transition , is . INCIDENCE AND PREVALENCE Several attempts have been made to determine how many Americans identify as transgender ?

A 2016 estimate postulates that percent of the population , or million Americans , are However , the gender construct is complex , and more rigorous epidemiological studies are needed on a global scale to delineate the incidence ( percentage of the population ) and prevalence ( total number of people ) of this . Historically , transgender and individuals have been marginalized , and the disparities discussed earlier in this ter may instill a sense of fear within the community , thus leading to greater difficulty in obtaining an accurate estimate . Additionally , cultural differences among societies shape the behavioral expressions of gender incidence A measure of the probability of occurrence of a given medical condition in a population within a period of time . prevalence The proportion of a particular population affected by a condition ( typically a disease or a risk factor such as smoking or seat belt use )

244 Introduction to Studies gender dysphoria The distress a person can feel because of a mismatch between their gender identity and their sex assigned at birth . gender nonconformity A behavior or gender expression by an individual that does not match masculine or feminine gender norms . gender identity The personal sense of ones gender , which can correlate with assigned sex at birth or can differ from it . Watch In a video in the series , Angelica Ross maps out the history of the word transgender , tracing its origins from the words transvestite and transsexual to the contemporary term transgender ( Why is understanding the difference between sex and der important when learning about the history of the word transgender ?

What different identities fall under the transgender umbrella ?

Why is there debate about whether some identities do or do not belong ?

What information was new or surprising to you in the video ?

How does it affect your understanding of transgender needs in health care ?

identities , masking gender For instance , certain cultures may revere and consider as sacred such behaviors , leading to less Moreover , as the literature suggests , the prevalence of gender dysphoria is unknown . There has been great controversy within the gender and community regarding this diagnosis because in earlier years the phenomenon was deemed On the one hand , gender nonconformity refers to the extent to which a person gender identity , expression , or role differs from the cultural norms that designate for people of a particular sex . On the other hand , gender dysphoria , described by Fisk in 1974 , is the discomfort or distress that is caused by a discrepancy or incongruence with a son gender identity and that very same person sex that was assigned at birth . 35 Therefore , not every transgender and individual experiences gender dysphoria . As a result , the World Association of Transgender Health released a statement in 2010 that urged the of gender nonconformity The goal of the health care professional is thus to assist transgender and patients who suffer from gender dysphoria by their gender identity and collaboratively investigating the array of options that are at their disposal for expression of their gender identity . THERAPEUTIC OPTIONS FOR TRANSGENDER AND PATIENTS An array of therapeutic options must be considered when collaboratively working with transgender and patients . Transition ,

Health and Wellness 245 for those who seek it , does not follow a linear model but is , rather , an individualized process based on the patient needs . Interventions and their sequence differ from person to person . A collaborative approach between the health care professional and patient is of the utmost . Additionally , a approach , one that encompasses primary care providers , mental health , surgeons , and speech pathologists , results in the best outcomes . The following lists tic options that a transgender and patient may undertake Changing gender expression or role , whether living or in the gender expression that aligns with the current gender identity . This may involve chest binding to create a chest contour , padding of the hips and buttocks , genital tucking , wearing gaff underwear , or wearing a thesis . Changing a name and gender marker on identity documents . Seeking psychotherapy to understand and investigate the constructs of gender , such as gender identity , gender role , gender attribution , and gender expression . Psychotherapy may also address the positive or negative impacts of such feelings as stigma and address internalized , if present . Undergoing hormone therapy to either or masculinize the patients body . Choosing surgeries to alter primary or sex characteristics . Finding groups and community organizations that provide social support , as well as advocacy . Attending speech or voice and communication therapy that facilitates comfort with gender identity or expression and the stress associated with developing verbal and nonverbal behaviors or cues when interacting with others . Removing hair through laser treatments , electrolysis , waxing , or shaving . The options may seem overwhelming to review , but it is the goal of the health care professional to assist the patient through the journey , less of what therapeutic options the patient ultimately chooses . Access to those services requires that the transgender person live in an area where gender expression A person behavior , mannerisms , interests , and appearance that are associated with gender in a particular cultural context , with the categories of femininity or masculinity .

246 Introduction to Studies hormone therapy Hormone therapy in which sex hormones and other hormonal medications are administered to transgender or nonconforming individuals to more closely align their secondary sexual characteristics with their gender identity . they are available and have adequate health insurance , which is usually provided by employers . Transgender people , particularly trans people of color , however , are less likely to be employed than people , thus are often deprived of the health insurance that they need . CRITERIA FOR HORMONE THERAPY hormone therapy consists of the administration of exogenous endocrine agents to elicit or changes . While some transgender and patients may seek maximum changes , others may be content with a more androgynous . The of this construct should not be minimized , because hormonal therapy must be individualized on the basis of a patient goals and thorough understanding of the risks and of medications and an review of a patient other existing medical conditions . Furthermore , initiation of hormonal therapy may be undertaken after a psychosocial assessment has been ducted and informed consent has been obtained by a health professional . The criteria for mone therapy are as follows . Persistent , gender dysphoria . Capacity to make a fully informed decision and to consent for treatment . Age of majority in a given country . If medical or mental health concerns are present , they must be reasonably Common agents used for feminization are estrogen and , and the common agent used for masculinization is testosterone . are controversial in , and can cite only anecdotal evidence for the hormones use in full breast development . A clinical comparison of with and without the use of found that these agents did not enhance breast growth or reduce serum levels of free Additionally , adverse effects outweigh their because depression , weight gain , and lipid changes have been seen with these ever , do play a role in and when used in early stages of hormonal therapy assist in the cessation of menses .

Health and Wellness 247 PHYSICAL EFFECTS OF HORMONE THERAPY A thorough discussion regarding the physical effects of hormone therapy between the health care professional and the patient is warranted . Using endocrine agents to achieve congruency with a patients gender identity will induce physical changes , which may be reversible or irreversible . Most physical changes occur within two years , with several studies estimating the process to span years . The length of time attributed to such changes is unique to each individual . Tables and outline the estimated effects and the course of such changes . Table . Effects of hormone therapy with agents Effect Onset ( months ) Acne Facial and body hair growth Scalp hair loss Increased muscle mass Fat redistribution Cessation of menses Clitoral enlargement Vaginal atrophy Deepening of voice Table . Effects of hormone therapy with agents Effect Onset ( months ) Softening of the skin Decreased libido Decreased spontaneous erections Decreased muscle mass Decreased testicular volume Decreased terminal hair growth Breast growth Fat redistribution Voice changes None

248 Introduction to Studies Because of the or effects of endocrine agents used in transitioning , the coming out process for someone who as transgender or gender nonconforming may be challenging and may differ from the coming out process of individuals . individuals may keep their sexual orientation concealed , but the effects of hormonal agents on the transgender person are noticeable to others . Transgender and individuals may have to come out during social interactions , unless they wish to relocate to a new area , where they may choose not to disclose their transgender identity , often referred to in the community as living stealth . The coming out process may seem daunting to endure and may encompass numerous challenges . Those lacking support or who have been mistreated , harassed , marginalized , by surgical status , or asked probing personal questions may . experience Additionally , the persistent and chronic nature of these aggressions have led some researchers to apply the minority stress model to transgender and Such experiences create a potential for increase in the rate of certain health care , such as clinical depression and anxiety and their somatization , or conversion to physical ' Transgender people , like all other people , need to learn how to become informed consumers of health care services and make informed choices about their physical and mental . The next section explains how to become such a knowledgeable patient . Watch A video from the Montgomery College , Maryland , nursing program ( provides a case study that focuses on culturally competent health care for trans and people . It many of the challenges that a trans patient might face during initial interactions with staff and providers at a health care clinic . What challenges does oe face in terms of accessing health care ?

What are some of the mistakes made by staff at the health care clinic ?

How does Nurse Rachel address those mistakes , both in that initial visit to the clinic and afterward ?

Health and Wellness 249 BEING A SMART PATIENT AND HEALTH CARE CONSUMER As noted throughout this chapter , individuals encounter more discrimination in health care compared with the heterosexual population . While some evidence shows that negative experiences for some persons are decreasing , discrimination continues . Lack of health care provider education in culturally inclusive communication and care is frequently noted as a contributing factor for health professionals discrimination . The shortage of educated practitioners and amount of practitioner bias have caused many persons to either delay or avoid seeking health care services . A primary reason attributed for this delay or avoidance is that individuals often feel invisible to their providers and have experienced discrimination in previous Other factors also contribute to the negative health care experiences of individuals . A provider whose value system , religious beliefs , and political party are hostile to people may have providing the respectful and care that persons are entitled to . For people to receive respectful and culturally inclusive , care from their providers , they must take it on themselves to be informed health care consumers , practice , and shop wisely for providers who are affirming . is essential to optimizing access to quality health services . HEALTH CARE PROVIDERS The teaching of medical and nursing students about health issues unique to the population is inconsistent among education programs for health care providers . An emerging body of research a need for more education to better meet the requirements of patients . In one study , for example , US . medical schools were found to provide only an average of hours of education throughout the curriculum . Baccalaureate nursing programs in another study spent only an average of a little over two hours teaching content about health topics . Less is known about the extent to which other health provider education grams cover this content . During a health care clinical experience , individuals often encounter health care providers who lack a basic standing of cultures , terminology , and culturally inclusive Locating a health care facility that affirms people can be but is not impossible . Some national organizations provide resources for persons and health care providers . For example , the Human Rights Campaign , the largest national civil rights organization

250 Introduction to Studies with over three million members , has a tool , the Healthcare Equality Index , to recognize the health care facilities with policies and procedures for equity and inclusion of patients , visitors , and employees . Health care facilities evaluated by the index are available in its directory . An agency must reapply every year to demonstrate that it meets the current standards outlined by the Human Rights ' Another organization , Gay and Lesbian Medical Association ) advances health care equality for people and has an extensive directory of health care providers across the United States that are affirming . The published guidelines that offer recommendations for practitioners to consider when caring for clients . The National Health Education Center , a program of the Institute , also has excellent resources to help educate Both organizations provide valuable resources and are worth mentioning to a provider who lacks sufficient knowledge to provide culturally inclusive care for persons . Organizations and that support health are listed in table . All provide free publications and resources for the person and health care providers . Table . education and advocacy organizations Health Professionals Advancing Equality Association of Lesbian , Gay , Bisexual , Transgender Addiction Professionals and Their Allies World Professional Association for Transgender Health Center of Excellence for Transgender Health National Cancer Network Trevor Project Community of Centers Health Howard Brown Health Los Angeles Center Center Health and Health Link

Health and Wellness 251 INFORMED HEALTH CARE CONSUMERS When navigating a system in which not all providers understand or practice care that includes people , individuals need to know what questions to ask when visiting their provider . Although it is important to be true to yourself and disclose your sexual identity to your provider so you can receive the most holistic care possible , not all persons feel comfortable disclosing this information , particularly to a new health care provider with whom they have not yet established a trusting relationship . The Institute of Medicine has recommended ing sexual orientation and gender identity data in electronic health records so that more health care facilities will ask patients for this Ultimately , however , persons must decide for themselves when and to whom to disclose their identity . Before visiting a provider , consider calling the office to ask if they provide inclusive care for patients . Bring a friend or partner to the visit for support if you are uncomfortable meeting with the health care provider . Health care providers must adhere to laws , policies , and ethical codes to keep your information private . Although a health care provider may ask about sexual orientation and gender identity , persons also have the right to request that the provider not enter their sexual orientation and gender identity into the medical record . PAYING ATTENTION TO SPECIAL HEALTH ISSUES Providers must understand health care issues common in the population and explore whether their patients have any of these risk factors . has created ten resource sheets for persons , each one addressing one of the top health concerns to discuss with a health care provider . Although not all these health issues apply to every person , it is essential to be aware that these health topics are more common among people . Several health topics are relevant to all groups , and others pertain more to one group . For example , research has that depression , tobacco and alcohol use , sexually transmitted diseases ( including human and ) and certain cancers are greater health risks in the population . Moreover , the risk of illicit use of injectable silicone is a more concern among transgender women . Other health issues are more common within certain groups , such as breast and gynecological cancers among lesbians and transgender persons . In addition to the risk of among men who have sex with men , they also have a higher incidence of and mortality from prostate , anal , and colon '

252 Introduction to Studies Minimizing risk factors for these acute and chronic illnesses is to maintaining health . The Health Link is a network for health equity and offers very practical advice for things that people can do to improve their wellness . Recommendations include how to search for insurance options , practice preventive care , seek mental health support , adopt a healthier lifestyle , and practice safer ' The resources provided in this section support individuals to advocate for themselves when seeking health care services , particularly from providers who are not well educated about health issues or who do not demonstrate culturally inclusive and behaviors . Although health care providers are responsible for establishing a trusting relationship with their patients , this does not consistently occur in every health care setting . When a health care provider demonstrates genuine concern and respect for an individual in a practice not restricted to a office visit , then there is greater opportunity for , holistic , care . Becoming a smarter health consumer requires being aware of the community complex history with medicine , understanding the unique health issues involved , and recognizing health risks and changes that occur over the course of life . KEY QUESTIONS How has Western medicine shaped the history of tive genders and in Europe and the United States ?

How has activism health care systems and medical practice ?

What connections do you see between people sexual or gender identities and their experiences in Western health care settings ?

Why would it be important for a health care professional to understand a patient identity from an intersectional ?

Why would some argue that Western medicine is a key social institution that has helped to define and enforce structures of inequality for people ?

Health and Wellness RESEARCH RESOURCES Compiled by Stephen Discuss Choose one or two resources listed in this chapter , and discuss them in relation to what you have learned about health and wellness . Present Choose a key topic or event found in this chapter . Then locate one or two resources from the Quick Dip and Deep Dive sections and develop a presentation for the class . Explain the of the topic , and provide additional details that support your explanation . Create What idea , person , or event from this chapter really moved you ?

Do more research on that idea , person , or event based on the resources in this chapter . Then , create your own artistic response . Consider writing a poem , drawing a picture , or editing a photograph in a way that demonstrates both what you have learned and how you feel about the issue or person . Debate Find a partner or split into groups , and choose a topic , idea , or controversy from this chapter . Have each ner or group present an opposing perspective on it . Use at least two of the resources in this chapter to support your argument . QUICK DIP ONLINE RESOURCES Accessing Sexual Health Information Online Use , Motivations , and Consequences for Youth with Different Sexual , by . Mitchell , Michele , and Nearly 80 percent of youth in an extensive 2014 survey in Health Education Research ( volume 29 ) said they seek sexual information online , compared with less than 20 percent for their heterosexual counterparts . Discussions about how youth use the information and accuracy of the information received add to the article value .

254 Introduction to Studies Agenda Health and , by the Global Forum on and HIV and OutRight Action International Agenda 2030 is the United Nations global effort on sustainability , ing health and preventive education . The Global Forum on and OutRight Action International wrote an excellent report in 2017 of how countries and governments can meet these 2030 goals through attention to people and their needs while addressing the they face based on sexual orientation , gender identity and expression , and sex characteristics . See . Health Care for Lesbians and Bisexual Women , by Committee on Health Care for Underserved Women This opinion from practitioners , written in 2012 and reaffirmed in 2021 , on gynecologic issues for women who have sex with women covers recommendations for the standards of care for women seeking care in physician offices , from mental health to social concerns . It is the standard all physicians need to adhere to for their sexual and gender minority patients . See . from World Health Organization The World Health Organization ( WHO ) is the United Nations tion concerned with public health issues worldwide and is both a health monitoring and data collection agency . Its web page ( provides HIV and AIDS information , and data sets , maps , reports , and charts available on the website highlight the work individual countries are doing to increase access to HIV medications and their prevention efforts . Improving the Health Care of Lesbian , Gay , Bisexual and Transgender ( People Understanding and Eliminating Health Disparities , by Kevin Ard and Harvey . This brief 2012 report covers the disparities in health services and comes seen in the community , as well as areas of concern in the population . It provides basic education for understanding communities and concerns within those populations , discusses

Health and Wellness 255 differences in health care among people of color , and lists steps for and health care providers to take to provide culturally care . The report is cited by numerous authors and used as a link from many governmental websites about health care . See . Lesbian , Gay , Bisexual , and Transgender ( Health Services in the United States Origins , Evolution , and Contemporary Landscape , by Alexander . Patrick Wilson , and Meyer Covering the history of health services within the community , this article provides insight into the future success or failure of such clinics , which have played a huge role in the of health . The 2017 article in One ( volume 12 , number ) was funded as part of a study from the National Institutes of Health , the US . primary biomedical and public health agency . Lesbian , Gay , Bisexual , and Transgender Health , from Centers for Disease Control and Prevention The Centers for Disease Control and Prevention provides a website lighting health issues among the populations ( It links to publications , statistics , data sets , and news from a wide variety of journals , government agencies , and other sources . The is the preeminent US . government agency on illness and health . Mental Health Syllabus , from Group for the Advancement of Psychiatry This educational website ( is for people training in psychology and psychiatry and a source of information for any mental health trainee or practitioner on issues surrounding service to individuals . It includes a history of treatment of people and primers on transgender and intersex patients . National Health Education Center , from Institute This website ( provides free access to numerous publications highlighting health care concerns and issues of the population for health care organizations and service

256 Introduction to Studies . Translations of their publications in Spanish and other languages are also available . The Institute is the world largest health care , research , and education organization . Sexual and Gender Minority Health What We Know and What Needs to Be Done , by Kenneth Mayer , Judith Bradford , Harvey . Ron Stall , Hilary Goldhammer , and Stewart Landers This 2008 article in the American of Public Health ( ume 98 , number A ) offers a strong summary of known disparities in health outcomes in the health , research into health topics , and a discussion of what directions health care needs to move in to meet the needs of clients . The authors , experts in health care , are among the authors of the Guide to Lesbian , Gay , Bisexual and Health . Homophobia , from International Lesbian , Gay , Bisexual , Trans and Intersex Association This annual report on the laws gender and sexuality around the world also has articles focusing on particular countries and regions . Data sets used to generate the report can be accessed at the reports website ( The national Lesbian , Gay , Bisexual , Trans and Intersex Association is the world foremost and holds special consultative status with the United Nations Economic and Social Council . DEEP DIVE BOOKS AND FILM And the Band Played on Politics , People , and the AIDS Epidemic , by Randy Told from a variety of viewpoints , this book on the AIDS epidemic is an expose of the failures of the medical establishment , public health , federal government , and research scientists that led to the AIDS crisis in the . Written by a journalist from San Francisco , it is a foundational text for the examination of how politics plays a role in disease outbreaks , and it exposes both society and government as partners in allowing the deaths of hundreds of thousands of people . The book won the American Library Association Stonewall Award ( New York Penguin Books , 1988 )

Health and Wellness 257 Black Health in the United States The Intersection , Gender , and Sexual Orientation , edited by Lourdes Dolores and Jonathan Lassiter This book for both health consumers and health workers looks at the intersections of being Black and a person . Chapters cover sexual identity , women , incarceration , HIV , and much more . Some authors use the cultural signifying term , rather than the standard term . The book is for anyone interested in intersections of sexual and gender identity with race in the United States and focuses on positive steps for individuals and communities , not on statistics and pathologies . The book received the 2017 Achievement Award from the Health Professionals for Equality ( Lexington Books , 2016 ) Guide to Lesbian , Gay , Bisexual , and Health , edited by Harvey , Kenneth Mayer , Jennifer Potter , and Hilary Goldhammer Written by public health professionals , researchers , and , this book ( second edition ) provides information on health concerns to populations such as health care across the life continuum , disease prevention , understanding health care needs , health motion , and gender identity . The Institute in Boston is a research , education , and care center . It works with and populations and is in the ( American College of Physicians , 2015 ) Gen Silent , directed by Stu This documentary is about older people who are going back into the closet as they age in order to survive societal discrimination . The discusses the aging process , depression and loneliness , and problems with assisted living facing older people . It includes the stories of a transgender senior and an interracial couple . The won jury and audience awards for best documentary at the Sacramento Film and Music Festival in 2010 and the audience award for best documentary at the Film Festival in 2011 ( United States Productions ) Gynecologic Issues for Lesbians , by Susan Johnson This chapter ( is part of an online encyclopedia ( Global Library of Women

258 Introduction to Studies Medicine ) of womens health issues containing over four hundred written by medical specialists in their respective . The chapter covers issues of special interest to all women who have sex with women , including more than simply gynecologic issues and a variety of life , not simply studies . Preventive Health Measures for Lesbian and Bisexual Women , by Robin and Shelly Kerr This solid discussion of the similarities and differences of preventive health care in women who have sex with women and minorities within that community also includes descriptions of possible outcomes from who treat patients with discrimination and stigmatization ( Milton Park , UK Taylor and Francis , 2007 ) Trans Bodies , Trans Selves A Resource the Community , edited by Laura Written in the style and tone of Our Bodies , Our Selves , this book is a resource for both professionals and on mental , and physical health and other topics . It places the trans individual in charge of their life and health . The book received the 2015 ment Award from the Health Professionals for Equality , and it was listed as one of the top ten transgender books of 2014 by Advocate magazine ( Oxford Oxford University Press , 2014 ) Unequal Health Disparities Gay and Bisexual Men in the United States , edited by Richard , Ron Stall , and Ronald . The health of men who have sex with men ( has numerous with health of the broader male population . The editors feature research and analysis that demonstrates not only general disparities but also those that affect older men , people of color , and others . A highly recommended book that can serve both researchers and general readers , it contains numerous ideas for health promotion and public health intervention ( New York Oxford University Press , 2008 ) GLOSSARY bisexual . Romantic attraction , sexual attraction , or sexual behavior toward both males and females or toward more than one sex or gender .

Health and Wellness 259 degeneracy . Also known as degeneration theory theory that homosexuality and bisexuality were akin to criminality , alcoholism , and drug addiction . hormone therapy . Hormone therapy in which sex and other hormonal medications are administered to gender or individuals to more closely align their secondary sexual characteristics with their gender identity . surgery . Also known as sex reassignment surgery surgical procedures by which a transgender person physical and function of their existing sexual characteristics are altered to resemble those socially associated with their gender . gender dysphoria . The distress a person can feel because of a mismatch between their gender identity and their sex assigned at birth . gender expression . A person behavior , mannerisms , interests , and appearance that are associated with gender in a particular cultural context , with the categories of femininity or masculinity . gender identity . The personal sense of one gender , which can correlate with assigned sex at birth or can differ from it . gender nonconformity . A behavior or gender expression by an individual that does not match masculine or feminine gender norms . hermaphrodite . Biologically , an organism that has complete or partial reproductive organs and produces normally associated with both male and female sexes . homosexual . A person with a romantic attraction to , sexual attraction to , or sexual behavior with others of the same sex or gender . incidence . A measure of the probability of occurrence of a given medical condition in a population within a period of time . Overlapping or intersecting social identities , such as race , class , and gender , and related systems of oppression , tion , or discrimination . intersex . People born with any of several variations in sex characteristics , including chromosomes , gonads , sex hormones , or genitals . minority stress model . A sociological model , as proposed by Meyer , explaining why sexual minority individuals , on average , experience higher rates of mental health problems relative to their straight peers . pansexual . The sexual , romantic , or emotional attraction toward people regardless of their sex or gender identity . prevalence . The proportion of a particular population affected by a ( typically a disease or a risk factor such as smoking or seat belt use ) sex reassignment surgery . Also known as surgery surgical procedures by which a transgender person physical

260 Introduction to Studies and function of their existing sexual characteristics are altered to resemble those socially associated with their identified gender . sexually transmitted infections . Pathogens that are commonly spread by sexual activity , especially vaginal intercourse , anal sex , and oral sex . third sex . A concept in which individuals are categorized , either by selves or by society , as neither man nor woman . NOTES . Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and gender People Building a Foundation for Better Understanding ( Washington , National Academies Press , 2011 ) The History of Sexuality , vol . An Introduction , trans . Hurley ( New York Vintage Books , 1978 ) 43 . and , Homosexual Studies and Politics in the Century Karl Maria , journal of Homosexuality 19 ( 2010 ) von , Psychopathia . Eine ( Germany Ferdinand , 1886 ) The Construction of Homosexuality ( Chicago University of Chicago Press , 1988 ) The Construction Homosexuality . and Martin , Sexual Behavior in the Human Male ( Philadelphia Saunders , 1948 ) 638 . AIDS Gay Health Politics in the 19705 ( Philadelphia University of Pennsylvania Press , 2018 ) Davis , The Making of Our Bodies , Ourselves How Feminism across Borders ( Duke University Press , 2007 ) 10 . Jay and A . Young , You Out Personal Experiences of Gay Men and Lesbian Women ( New York Links , 1975 ) 11 . A . Wilson , and Meyer , Lesbian , Gay , Bisexual , and Transgender ( Health Services in the United States Origins , Evolution , and Contemporary Landscape , One 12 , no . 2017 ) 12 . Victory Deferred How AIDS Changed Gay in ( Chicago University of Chicago Press , 1999 ) 13 . How Sex Changed A History of in the United States ( Cambridge , MA Harvard University Press , 2002 ) Transforming Sex Christine in the Postwar , Magazine of History 20 , no . 2006 ) 14 . Ford , Hopkins to Resume Surgeries after Nearly 40 Years , Think Progress , October 18 , 2016 , 15 . Study Suggests Surgeries Are on the Rise , Along with Insurance Coverage , Hub ( Hopkins University ) February 28 , 2018 ,

Health and Wellness 261 16 . Kim , and , Health Disparities among Lesbian , Gay , and Bisexual Older Adults Results from a Study , American journal of Public Health 103 , no . 10 ( 2013 ) Institute of Medicine , The Health Lesbian , Gay , Bisexual , and People , White , Bradford , and . Health Disparities Comparing Full Cohort and Nested Study Designs in a Community Health Center , Health , no . 2014 ) Russell and . Fish , Mental Health in bian , Gay , Bisexual , and ( Youth , Annual Review of Clinical Psychology 12 ( 2016 ) 17 . For childhood , see . Palmer , and , ing Resiliency Openness about Sexual Orientation Gender Identity and Its Relationship to and Educational Outcomes for Students , ican Community Psychology 55 , nos . 2015 ) for young adulthood , see Ryan , Russell , Diaz , and . Sanchez , ily Acceptance in Adolescence and the Health of Young Adults , journal of Child and Adolescent Psychiatric Nursing 23 , no . 2010 ) and . Watson , and , Disordered Eating among Transgender Youth Probability from Risk and Protective Factors , International journal of Eating Disorders 50 ( 2017 ) and for late adulthood , see , Promoting Health Equity among and Older Adults Revealing How and Older Adults Can Attain Their Full Health Potential , Generations 38 , no . 2014 ) 18 . Meyer , Prejudice , Social Stress , and Mental Health in Lesbian , Gay , and Bisexual Populations Conceptual Issues and Research Evidence , Bulletin 129 , no . 2003 ) 19 . Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and gender People . 20 . Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and gender People . 21 . Parent , and , Approaches to Research on Perspectives on Gender , and Identities , Sex Roles 68 , nos . 2013 ) 22 . Watson , and , Evidence of Diverse in a Large National Sample of Sexual and Gender Minority Adolescents , journal of Research on Adolescence 30 ( 2020 ) 23 . Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and gender People . 24 . See , Watson , Lewis , Fish , Sexual Minority Youth Continue to Smoke Cigarettes Earlier and More Often than Heterosexual Peers Findings from Data , Drug and Alcohol Dependence 183 ( 2018 ) 25 . For family and parent support , see , Watson , Russell , Diaz , and Ryan , Support Networks for Young Adults Low Cost Strategies for Positive Adjustment , Family Relations 64 , no . 2015 ) for clubs , see , Marx , and , Vary on Dimensions of Youth Socializing and Advocacy Factors Accounting

262 Introduction to Studies for Individual and Differences , American journal of Community Psychology 55 , nos . 2015 ) for supportive peers , see . son , and Russell , Sources of Social Support and tal Health among Youth , Youth and Society 51 ( 2019 ) and for supportive policies and laws , see , and , Policies and Psychiatric Morbidity in Lesbian , Gay , and Bisexual Populations , American nal Health 99 , no . 12 ( 2009 ) 26 . For African American men , see Mays , Cochran , and dio , HIV Prevention Research Are We Meeting the Needs of African American Men Who Have Sex with Men ?

journal Black Psychology 30 , no . 2004 ) for PrEP , see , and , From Efficacy to Effectiveness Facilitators and Barriers to PrEP Acceptability and Motivations for Adherence among and Transgender Women in New York City , AIDS Patient Care and 27 , no . 2013 ) for rates of HIV acquisition , see Kirby and , Uptake of PrEP for HIV Slow among , Lancet 383 , no . 9915 ( 2014 ) and for other factors , see . Parsons , Lassiter , Starks , and , Uptake of HIV Prophylaxis ( PrEP ) in a National Cohort of Gay and Bisexual Men in the United States The Motivational PrEP Cascade , journal of Acquired Immune Syndromes 74 , no . 2017 ) 27 . and Maness , der Patient Perceptions of Stigma in Health Care , Medical Care 46 ( 2013 ) German , and , Managing A Grounded Theory of Stigma in Transgender Health Encounters , Social Science and Medicine 84 ( 2013 ) Radix , and , Satisfaction and Healthcare Utilization of Transgender and Gender Individuals in A Participatory Study , Health 103 , no . 10 ( 2014 ) Roller , and , Navigating the System How Transgender Individuals Engage in Health Care Services , Scholarship 47 ( 2015 ) Sanchez , Sanchez , and , Health Care Utilization , Barriers to Care , and Hormone Usage among Transgender Persons in New York City , American journal of Public Health 99 ( 2009 ) and . Johnson , Barriers and Facilitators to Engagement and tion in Care among Transgender Women Living with Human Immunodeficiency Virus , Annals of Behavioral Medicine 47 , no . 2014 ) 28 . James , Herman , and Ana , The Report of the 2015 US Transgender Survey ( Washington , National Center for Transgender Equality , 2016 ) 29 . Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and gender People . and A . Lawrence , Epidemiology of Gender Identity Disorder Recommendations for the Standards of Care of the World Professional Association for Transgender Health , International journal 11 ( 2009 ) 30 . Flores , Herman , Gates , and Brown , How Many Adults as in the United States ?

Los Angeles , CA Williams Health and Wellness Institute , 2016 ) 31 . Coleman , et , Standards of Care for the Health of Transsexual , Transgender , and People , Version , International nal 13 , no . 2012 ) 32 . Coleman , and , Male Behavior in ( Burma ) A Description of the , Archives of Sexual Behavior 21 , no . 1992 ) Kessler and , Gender An methodological Approach ( New York Wiley , 1978 ) Wilson , How We Find Ourselves Identity Development and People , Harvard Educational Review 66 ( 1996 ) 33 . Psychiatric Misadventures , American Scholar 61 ( 1992 ) 34 . Coleman et , Standards of Care , 168 . 35 . Fisk , Gender Dysphoria Conceptualization That Indications for Total Gender Reorientation and Implies a Broadly Based Rehabilitative Regimen , Western journal of Medicine 120 ( 1974 ) American Psychological Association , Related to Sexual Orientation and Gender Diversity , 36 . Board of Directors , ment , released May 26 , 2010 , 37 . Coleman et , Standards of Care , 187 . 38 . Meyer , Webb , Stuart , Lawrence , and Walker , Physical and Hormonal Evaluation of Transsexual Patients A Longitudinal Study , Archives Sexual Behavior 15 , no . 1986 ) 39 . Meyer III , Webb , Stuart , Lawrence , and Walker , Physical and Hormonal Evaluation of Transsexual Patients A Longitudinal Study , Archives of Sexual Behavior 15 ( 1986 ) Barber , and , Treatment of Gender Identity Disorders , Endocrine Practice ( 2003 ) dickey , and Sharon , Mental Health with Transgender and Gender Nonconforming Clients , in Guidelines for the Primary and Care of and Gender People , ed . San Francisco , CA Center of Excellence for der Health , 2016 ) 41 . Hendricks and . Testa , A Conceptual Framework for Clinical Work with Transgender and Gender Nonconforming Clients An Adaptation of the Minority Stress Model , Psychology Research and Practice 43 ( 2012 ) Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and People . 42 . Miner , Hamilton , and Coleman , Stigma , Mental Health , and Resilience in an Online Sample of the US Transgender Population , American journal of Public Health 103 , no . 2013 ) 43 . For continuing discrimination , see , An Integrative Review of Nurse Attitudes towards Lesbian , Gay , Bisexual , and Transgender Patients ,

264 Introduction to Studies Canadian journal of Nursing Research 44 ( 2012 ) for lack of ally inclusive communication and care , see and . Lesbian , Gay , Bisexual , and Healthcare A Clinical Guide to Preventive , Primary , and Specialist Care ( New York Springer , 2016 ) and , Cultures What Health Care Professionals Need to Know about Sexual and Gender Diversity , ed . Philadelphia wer , 2018 ) Landry , Delivering Culturally Sensitive Care to Patients , journal for Nurse Practitioners 13 , no . 2017 ) Ard , and . Advancing Health Equity for Lesbian , Gay , Bisexual and Transgender ( People through Sexual Health Education and Healthcare Environments , Sexual Health 14 ( 2017 ) 119 Lim , Brown , and Kim , Addressing Health Care Disparities in the Lesbian , Gay , Bisexual , and Transgender Population A Review of Best Practices , American 114 ( 2014 ) NA and Joint Commission , Advancing , Cultural Competence , and and Care for the Lesbian , Gay , Bisexual and ( Community A Field Guide ( Oak Brook , IL oint Commission , 2011 ) and for being invisible and discrimination , see , and Scott , Never in All My Years . Nurses Education about Health , journal of Professional Nursing 31 ( 2015 ) and , Lesbian , Gay , Bisexual and Healthcare and and , Cultures . 44 . For the need for more education , see , Dibble , and . De , Nursing Silence on Lesbian , Gay , Bisexual , and Transgender Issues The Need for Emancipatory Efforts , Advances in Nursing Science 33 ( 2010 ) and Lim , son , and . A National Survey of Faculty Knowledge , Experience , and Readiness for Teaching Lesbian , Gay , Bisexual , and Transgender Health in Nursing Programs , Nursing Education Perspectives 36 , no . 2015 ) for the study of medical school hours on education , see . Goldsmith , Stewart , White , Tran , Wells , et , Lesbian , Gay , Bisexual , and Content in Undergraduate Medical Education , journal of the American Medical Association 306 ( 2011 ) for other health provider education programs , see Lim , Johnson , and , A National Survey of Faculty Knowledge and for lack of standing of inclusive care , see Landry , Delivering Culturally Sensitive Care to Patients . 45 . For the 2022 index , see Human Rights Campaign , Healthcare Equality Index 2020 , 46 . For the provider directory , see , For Patients , accessed April 26 , 2021 , practitioners can see , For Providers and Researchers , accessed April 26 , 2021 , and for the guidelines , see , Guidelines for Care of Lesbian , Gay , and Patients ( San Francisco , 2006 ) 202006 . See

Health and Wellness 265 also National Health Education Center , Ten Things Creating Inclusive Health Care Environments for People ( Boston , MA Institute , 2016 ) and of terms for Health Care Teams , published February 2020 , 47 . Institute of Medicine , The Health of Lesbian , Gay , Bisexual , and gender People . 48 . For health risks , including cancers , see Institute of Medicine , The Health an , Gay , Bisexual and People and Centers for Disease and Prevention , Health Considerations for Youth , updated ber 20 , 2019 , for silicone use , see , Abbas , et , Illicit Massive Silicone Injections Always Induce Chronic and Silicone Blood Diffusion with Complications , Cine 98 , no . 2019 ) and for prostate , anal , and colon cancer , see , and , An Ecological Analysis of Colorectal Cancer Incidence and Mortality Differences by Sexual Orientation , Cancer 11 ( 2011 ) 400 . 49 . Bare , Kamen , Ka , et , Best and Promising Practices out the Cancer Continuum , 2016 ,