# LGBTQ+ Health in Primary Care

## Introduction

LGBTQ+ individuals face significant health disparities driven by minority stress, discrimination, barriers to culturally competent care, and historical medical mistrust. Family physicians are often the first and most consistent point of contact for LGBTQ+ patients and must be prepared to provide inclusive, affirming, and evidence-based care across the lifespan.

## Terminology and Concepts

Sexual orientation describes a person's enduring pattern of emotional, romantic, and sexual attraction and includes identities such as lesbian, gay, bisexual, pansexual, and asexual. Gender identity is a person's internal sense of their gender and may include identities such as man, woman, nonbinary, genderqueer, or agender. A transgender person is someone whose gender identity differs from the sex assigned at birth, while a cisgender person is someone whose gender identity aligns with their assigned sex. Gender dysphoria refers to clinically significant distress arising from incongruence between one's experienced gender and assigned sex. Clinicians should use patients' self-identified names and pronouns and document preferred name and pronouns in the EHR. It is important to avoid conflating sexual orientation with gender identity, as they are distinct dimensions of identity.

## Creating an Inclusive Clinical Environment

Creating an inclusive environment begins with visible signals such as Safe Zone stickers, nondiscrimination statements, and inclusive imagery. Intake forms should use gender-neutral language, asking questions such as "What is your gender identity?" and "What pronouns do you use?" Collecting sexual orientation and gender identity (SOGI) data in the EHR allows practices to identify and address disparities within their patient population. All staff, from the front desk through nursing and providers, should be trained on respectful and inclusive communication. Confidentiality is particularly important for adolescents and patients who may be in unsupportive environments. Clinicians should avoid making assumptions about sexual behavior, family structure, or anatomy based on appearance.

## Health Disparities in LGBTQ+ Populations

### Mental Health

LGBTQ+ individuals have higher rates of depression, anxiety, suicidality, and substance use disorders compared to their heterosexual and cisgender peers. The minority stress model explains these disparities as the result of chronic stress from stigma, discrimination, violence, and internalized prejudice. Transgender individuals face particularly high rates of suicidal ideation, with 40 to 50% lifetime prevalence. Family rejection is the strongest predictor of adverse mental health outcomes in LGBTQ+ youth, while access to gender-affirming care and supportive environments are protective factors.

### Substance Use

LGBTQ+ populations have higher rates of tobacco, alcohol, and substance use compared to heterosexual and cisgender peers. Social contexts historically central to LGBTQ+ community, such as bars and clubs, contribute to higher alcohol use. Methamphetamine and club drug use are elevated in some MSM subpopulations. Clinicians should screen proactively and approach substance use with nonjudgmental, harm-reduction principles.

### Sexual Health

MSM have a higher prevalence of HIV, syphilis, gonorrhea, and HPV-related anal cancer. Women who have sex with women are often underscreened for cervical cancer and STIs due to incorrect assumptions about risk. PrEP should be offered to patients at risk for HIV, and family physicians should be comfortable prescribing and monitoring it. HPV vaccination is recommended for all individuals through age 26, with shared decision-making through age 45. There are no universal guidelines for anal cancer screening, but heightened awareness is warranted for MSM and people living with HIV.

### Cancer Screening

Transgender men who retain a cervix require ongoing cervical cancer screening per standard guidelines. Transgender women on estrogen may develop breast tissue, and while screening recommendations are still evolving, mammography is generally recommended after 5 or more years of hormone therapy. Lesbian and bisexual women may have higher breast cancer risk due to factors including nulliparity and higher BMI.

![Infographic showing LGBTQ+ health disparities across mental health, substance use, sexual health, and cancer screening domains](images/lgbtq-health-disparities.jpg)

## Gender-Affirming Care

### Hormone Therapy

| Therapy | Medications | Expected Changes | Key Monitoring | Primary Risks |
|---------|------------|-----------------|----------------|---------------|
| Feminizing | Estradiol + anti-androgen (spironolactone) or GnRH agonist | Breast development, fat redistribution, reduced body hair | Estradiol, testosterone, K+, prolactin, lipids, LFTs | VTE (especially oral estradiol + age >40/smoking), CVD |
| Masculinizing | Testosterone (IM, subQ, or transdermal) | Voice deepening, facial hair, fat redistribution, menses cessation | Testosterone, hematocrit, lipids, LFTs | Polycythemia, acne, male-pattern baldness, CVD |

Feminizing hormone therapy for transfeminine patients consists of estradiol (available in oral, sublingual, transdermal, or injectable forms) plus an anti-androgen such as spironolactone or a GnRH agonist. Expected changes include breast development, body fat redistribution, softened skin, reduced body hair growth, and testicular atrophy. Monitoring includes estradiol and testosterone levels, potassium (when spironolactone is used), prolactin, liver function, and lipids. The primary risks are venous thromboembolism, particularly with oral estradiol in patients over 40 or those who smoke, and cardiovascular disease.

Masculinizing hormone therapy for transmasculine patients uses testosterone administered intramuscularly, subcutaneously, or transdermally. Expected changes include voice deepening, facial hair growth, body fat redistribution, clitoral growth, and cessation of menses. Monitoring includes testosterone levels, hematocrit (due to polycythemia risk), lipids, and liver function. Risks include polycythemia, acne, male-pattern baldness, and potential cardiovascular effects.

### Surgical Options

Chest (top) surgery includes mastectomy for transmasculine patients and breast augmentation for transfeminine patients. Genital (bottom) surgery options include vaginoplasty, phalloplasty, and metoidioplasty. Additional procedures include facial feminization surgery and tracheal shave. Surgical referrals typically require documentation of persistent gender dysphoria and letters of support from mental health providers per the WPATH Standards of Care.

### Care of Transgender Adolescents

Puberty blockers using GnRH agonists provide reversible suppression of pubertal development and allow time for continued assessment. Cross-sex hormones are typically initiated at age 16 or later, though some guidelines allow earlier initiation with appropriate evaluation. Mental health support should be integrated throughout the process. Family involvement and support are strongly associated with positive outcomes.

![Timeline showing the stages of gender-affirming medical care from social transition through hormone therapy and surgical options](images/gender-affirming-care-timeline.jpg)

## Preventive Care Considerations

Preventive care for transgender patients should be guided by organs present rather than gender identity. This means that all patients with a cervix need cervical cancer screening regardless of gender identity, and transgender women who still have a prostate should be considered for prostate cancer screening. Cardiovascular risk assessment should account for the effects of hormone therapy: testosterone may increase cardiovascular risk, and estrogen increases the risk of venous thromboembolism. Bone density monitoring should be considered in transgender patients, particularly those who had prolonged periods without sex hormones. Fertility counseling should be discussed before initiating hormone therapy or surgery, as both may affect reproductive capacity.

## Key Clinical Pearls

Collecting SOGI data in the EHR is essential for identifying health disparities and providing appropriate preventive care. Mental health concerns should be screened for proactively in LGBTQ+ patients, as minority stress is a significant driver of disparities that clinicians can address through affirming care. Gender-affirming hormone therapy can be safely initiated and managed in primary care, with the Endocrine Society and WPATH guidelines providing clear protocols. Preventive screening should be based on organs present, not gender identity: transgender men with a cervix need Pap smears, and transgender women may need prostate cancer screening.

![Flowchart showing organ-based preventive care screening recommendations for transgender patients](images/transgender-preventive-screening.jpg)

## References

1. Hembree WC, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline. *J Clin Endocrinol Metab*. 2017;102(11):3869-3903.
2. Coleman E, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (WPATH). *Int J Transgend Health*. 2022;23(Suppl 1):S1-S259.
3. Institute of Medicine. *The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding*. National Academies Press; 2011.
4. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. *Psychol Bull*. 2003;129(5):674-697.