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Introduction

Although LGBTQ+ (lesbian, gay, bisexual, transgender, queer, plus so much more!) individuals share many of the same health concerns as the rest of the population, they also have many unique and inadequately studied health concerns and experience numerous health disparities.^1-3 These disparities can be attributed in part to a history of experiencing significant stigma and discrimination because of their gender identity or their orientation. Despite increased visibility and acceptance by the general public, many of these health disparities are still ongoing, and in some areas of the country, it is actually legal to discriminate against LGBTQ+ patients.⁴ This creates a feeling of insecurity that negatively impacts LGBTQ+ communities and can influence how LGBTQ+ patients interact with and view the health care system.^1,5 Consequently, LGBTQ+ patients may be significantly more cautious, less trusting, and fearful of health care providers. They may also be hesitant to disclose their LGBTQ+ identity or to seek health care when needed. Moreover, in the current health care system, LGBTQ+ people are often in situations where they need to educate their health care providers on their LGBTQ+ identities.⁶

Pharmacists are integral members of the health care team. Therefore, it is imperative pharmacists are educated on these disparities and how to create a welcoming environment in their pharmacy that will serve to counteract the stigma that LGBTQ+ individuals have faced for years. This continuing education (CE) course is designed to provide the basics that will enable pharmacists to provide care in an informed and culturally sensitive manner. Admittedly, because the topics of LGBTQ+ health and the challenges LGBTQ+ people face in the health care system are complex, we will not be able to provide a comprehensive review. However, this CE will provide you with a summary of common health issues experienced by LGBTQ+ individuals, some basic information on understanding LGBTQ+ identities, tips for creating welcoming and inclusive pharmacies, and resources for more in depth information and recommendations.

The Need for LGBTQ+ Cultural Sensitivity in the Pharmacy

In the United States, LGBTQ+ individuals represent 4.5% of the total population.⁷ This means that 1 out of every 20 patients you treat and interact with will be LGBTQ+. However, due to the relatively small number of LGBTQ+-focused studies,⁸ we are still at the beginning stages of understanding the health care needs of LGBTQ+ populations. Additionally, there still is a lack of training on LGBTQ+ health among all health care providers⁹ and also specifically in pharmacy education.^10,11 The impact of this lack of training is reflected in the statistic that only 36% of pharmacy residents report that they feel confident in treating transgender patients.¹² Pharmacists and pharmacy educators have recognized this need¹³ and have begun to successfully incorporate LGBTQ+ content into the curriculum including integration in required courses,^14-16 standalone elective courses,¹⁷ panel discussions,¹⁸ and interprofessional health forums.⁹ In addition, the District of Columbia now requires training in LGBTQ+ cultural competency for all pharmacists^19,20 and HRC (the Human Rights Campaign) now offers pharmacy-specific LGBTQ+ resources.²¹

The National LGBT Health Education Center divides the barriers to care for LGBTQ+ people into the three separate categories of: 1. Limited access, 2. Lack of knowledge of providers, and 3. Negative experiences.²² It is important to note that lack of access to quality health care and health care inequities increases among specific LGBTQ+ subgroups, including transgender communities, low-income people, and communities of color.²³ Given their accessibility and specialized training, pharmacists are uniquely positioned to make a positive impact on the health care of their LGBTQ+ patients by addressing each of these barriers.

Limited Access – Research has shown that LGBTQ+ patients are less likely to have a source of ongoing care.² This is due in part to the fact that, for various reasons, it is very common in LGBTQ+ communities to be uninsured or underinsured. This lack of insurance is especially prevalent in transgender communities.^1,2 Pharmacists can help their uninsured and underinsured LGBTQ+ patients by referring them to prescription assistance programs, settling insurance claims,²⁴ and working with their providers to find alternative medications that are less expensive.

Lack of Knowledge of Providers – In addition to insurance issues, many LGBTQ+ people also lack access to providers who are knowledgeable about their unique health needs or who understand how to address them with cultural sensitivity.²⁵ Therefore, when seeking health care, many LGBTQ+ people find themselves in the position where they need to educate their health care providers about their identities and their health care needs. These deficiencies in providers’ education are due to a lack of availability of LGBTQ+ specific training.⁹ Given the risks associated with hormone therapy, the lack of knowledgeable providers can be especially problematic for transgender populations.²⁶ The specialized training on medication management that pharmacists receive coupled with the fact that pharmacists review prescriptions by both primary care physicians and specialists, gives pharmacists a unique opportunity to become role models in demonstrating knowledge and sensitivity regarding all the medication needs of LGBTQ+ people.

Negative Experiences – LGBTQ+ patients may consciously avoid all health care because of fear of discrimination including verbal abuse and refusal of treatment.⁹ It goes without saying that avoiding health care screenings and appropriate treatment will lead to poorer health outcomes for LGBTQ+ patients.¹⁶ Additionally, when LGBTQ+ patients do seek health care, many receive substandard care as a result of provider bias, discomfort, or the aforementioned lack of knowledge.⁹ In order to receive the appropriate diagnosis and preventative care, it is imperative that LGBTQ+ patients feel comfortable sharing their identity with their health care providers.²⁷ Pharmacists can attenuate the impact of some of those negative experiences in health care by providing unbiased, culturally sensitive, and gender-affirming care,²⁸ and by creating physical environments that are welcoming to their LGBTQ+ patients. The evidence that discrimination in public spaces predicts poorer health outcomes²⁹ reinforces the impact that can be made by creating welcoming spaces in the pharmacy. Additionally, given the accessibility of pharmacists and the long-term relationships that pharmacists tend to have with their patients, LGBTQ+ patients may feel safer sharing concerns with their pharmacist than with their physician.³⁰ Some best practices that pharmacists can use to create a LGBTQ+ welcoming and inclusive pharmacies will be discussed later.

Medical Concerns in the LGBTQ+ Communities

Most LGBTQ+ people live healthy, productive lives the same as people from the general population. They have the same basic health care needs and they obviously deserve the same respect. Even though we are about to share some areas where LGBTQ+ individuals are at an increased risk for certain health issues or where they may face special challenges due to bias and discrimination, it is important that health care professionals do not assume that LGBTQ+ patients are sicker or more challenging to treat.^5,27,31

Historically, bias and discrimination in the medical field against LGBTQ+ patients has made it difficult for this community of people to receive appropriate treatment.^5,18,32,33 As mentioned above, these biases, discriminatory practices, and the lack of cultural sensitivity have, and still do, prevent many LGBTQ+ patients from trusting health care professionals enough to even access care when it is needed. Financial concerns may have a greater influence on LGBTQ+ patients as well,⁸ and they may hinder health-seeking behaviors, especially among LGBTQ+ people of color.²³ There is also evidence that bias and discrimination against LGBTQ+ individuals may contribute to the development of certain health problems.³⁴ For example, LGB individuals who experienced prejudice were 3 times more likely to experience a physical health problem compared to those that have not.³⁵

In the past, LGBTQ+ health care education and community outreach has been primarily focused on awareness and treatment of HIV and sexually transmitted infections (STIs). Although vitally important, these infections are not the only health threats that disproportionately affect LGBTQ+ patients.^36-40 The narrow focus on HIV and STIs has left many people unaware of other critical health disparities among LGBTQ+ people. A few of these disparities are listed below.

LGBTQ+ youth have an increased risk of suicide^1,2 and LGB individuals have higher rates of depression, anxiety, and suicide attempts compared to heterosexual individuals.⁴¹ Most startlingly, 40% of transgender individuals have attempted suicide, compared to 4.6% in the general population.⁴² These increased rates of mental health challenges can be attributed in part to the persistent impact of stigma and discrimination.³⁶ Pharmacists can be a valuable resource for patients struggling with mental health issues by counseling on the importance of adherence, by informing patients of the potential for drug-drug interactions with mental health medications, and by making referrals to LGBTQ+ knowledgeable mental health services.

LGBTQ+ individuals also have higher rates of tobacco, alcohol, and substance use,^1,2,39 even though only a minority of LGBTQ+ patients are regular users of illicit substances.⁸ Pharmacists can inquire about the factors that lead to tobacco use, provide valuable counseling on the impact of smoking on health, and recommend the appropriate smoking cessation products.

TERMINOLOGY TIMEOUT! Cisgender: Relating to an individual whose gender identity matches the sex they were assigned at birth. It can also be defined as "not transgender." If you were born and the doctor or midwife stated, "It's a boy!" or "It's a girl!" and as you grew this identity fit for you, then you are cisgender. The majority of us are cisgender. Why did we need a term that meant "not transgender?" Because we were at risk for saying offensive things like, "I'm not transgender, I'm normal."

Cisgender lesbian and bisexual women are more likely than cisgender heterosexual women to be overweight or obese,^1,2 which will increase their risk of diabetes, heart disease, and hypertension. Cisgender lesbian and bisexual women also have an increased risk for certain cancers. For example, the lower pregnancy rate of cisgender lesbian and bisexual women may correspond to an increased risk of breast cancer.⁵ Cisgender lesbians and bisexual women also have a lower rate of HPV vaccination and Pap testing than cisgender heterosexual women, which can contribute to a higher prevalence of cervical cancer.^2,8,43-45

One final health care topic that is critical to mention is the continually increasing number of individuals seeking medical care for gender dysphoria,²⁹ and the important issues associated with gender incongruence.²⁸ Counseling transgender patients on drug-drug interactions, adverse drug reactions, and the reversible and irreversible long-term effects of medications may produce some unique challenges. Because hormonal products are not FDA-approved for transgender patients, dosing may need to be extrapolated from their use for other disease states.⁴⁶ Additionally, as pharmacists, it is important to be aware of the patient’s sex assigned at birth in order to appropriately counsel on the risks of teratogenic agents and to calculate doses on the appropriate creatinine clearance.²⁸ Finally, it is important to be aware of the fact that what is often referred to as “side effects” of hormonal therapies may actually be desired effects for transgender patients. A thorough analysis of transgender medication management is outside the scope of this article. For further information on transgender health care in the pharmacy, please see the articles by Redfern and Jann²⁸ and Bishop.²⁶

It is essential to always customize care based on an individual patient’s needs,⁸ but knowing the risk factors, challenges, and barriers to care associated with LGBTQ+ communities will help us to offer the best care possible.

Understanding the LGBTQ+ Initialism

In order to offer the best care possible to members of LGBTQ+ communities, it is important that we understand who LGBTQ+ people are. In this section and the one below, we will share information on the LGBTQ+ initialism and some of the many identities within LGBTQ+ communities.

You may see the LGBTQ+ initialism written as “LGBT,” “LGBTQQI,” “LGBTQQIAA2SPP,” as well as other variations. For this CE we have chosen to use the initialism “LGBTQ+,” in an effort to be both concise and inclusive. Below is a description of what these letters and the (+) symbol stand for.

The Components of Sex, Gender, and Sexuality

Now let’s move beyond the limited confines of the letters in the initialism and take a look at the wonderful variability that exists in humans regarding our bodies, our gender, our expression, and our attractions. For simplicity sake, people may take on identity labels like, “lesbian,” “male,” or “transgender,” but there is so much variability even within these categories. Below are the 4 components that make up our sex, gender, and sexuality. Think of each component as a vast continuum or spectrum of identities.

TERMINOLOGY TIMEOUT! Transman and Transwoman: Many people have difficulty remembering which term coincides with which person. The answer is these identities are the end point, if you will. So, a transman is an individual who was assigned "female" at birth, but whose gender identity is "man." And a transwoman is an individual who was assigned "male" at birth, but whose gender identity is "woman." An easy way to remember this is to keep in mind that these terms are identities that people embrace, not labels. People are unlikely to embrace an identity term that has the wrong gender in it. The actress Laverne Cox, for example, would not want the word "man" as a part of her identity. She is a transgender woman or a transwoman, or merely, a woman.

Who we are (i.e., the top 3 components) and who we are attracted to (i.e., orientation, the fourth component) are completely separate things. For example, if we meet a transman we have no way of knowing who he is attracted to unless we ask. He may be straight, gay, bisexual, asexual, etc, just as a person who is cisgender can be any of these orientations.

To help aid in our understanding of the variety that exists among humans and how each component is independent of the others, we have asked 6 individuals to help us out. These are real people and their real identities. The only thing that has been changed to protect their privacy is their name. Look carefully at the way they identify and the pronouns they use for themselves, and then see where they fall on each of the 4 spectrums.

TERMINOLOGY TIMEOUT! Pansexual: Relating to an individual who is sexually attracted to people regardless of their gender. This term was developed because some people felt that the term "bisexual" was too binary. In other words, "bisexual" can imply that the person is attracted to only men and women. If a person is attracted to someone who does not identify as a man or a woman then the term "bisexual" may feel too restrictive for them. People who are pansexual have the potential to be attracted to anyone.

TERMINOLOGY TIMEOUT! Non-binary: Relating to an individual whose gender identity is neither man nor woman. This can also be used as an umbrella term, which includes many identities, such as agender, gender-expansive, gender fluid, genderqueer, Two-Spirit, and others. Non-binary should not be confused with androgynous. Androgynous has to do with a person’s gender expression (i.e., how we express our gender through clothes, hairstyle, etc). Non-binary has to do with gender identity (i.e., who we know ourselves to be). It is the answer to the question, “Are you a man or a woman?” Jay, the non-binary individual in this CE, might answer this question with, “Um. Both.”

Best Practices for Pharmacists

Now let’s look at some actual best practices that we can engage in that will help to make pharmacies more safe, welcoming, and inclusive for LGBTQ+ patients and for LGBTQ+ employees. We have learned that LGBTQ+ patients may have heightened fears and anxieties when they enter a pharmacy, and they may be less likely to trust. Therefore, our goal is to implement actions with our language, our forms and records, our signs and literature, our policies, and our physical spaces, that will indicate our awareness and our acceptance.

Hopefully one of the big takeaways from the last section on the components of sex, gender, and sexuality, is that none of us can accurately guess someone’s identities simply by looking at them. So, where does that leave us when we are speaking with patients and coworkers? How do we know how someone identifies and how they want to be addressed? The answer, of course, is that we won’t necessarily know which of our patients and coworkers are LGBTQ+ and which are not. The best practice suggestions listed below are actions that should be implemented at all times and used with everyone to ensure respectful conversations and welcoming, safe spaces for all.

Best Practices for Respectful Interactions with Patients and Coworkers

• Ungender Language: Using ungendered language is a great way to indicate to a patient or coworker that you understand that not everyone is straight and cisgender, and that you are open to hearing about their authentic selves and their loved ones. Use “spouse” or “partner” instead of “husband” or “wife.” Use “they” instead of “he” or “she” if you are unsure of gender.

• Mirror terms. One of the simplest and most effective ways to be respectful with our language is to mirror the terms that people use for themselves and for their loved ones. If a woman tells you that her wife might be picking up her prescription, then you have just received valuable information for being respectful. You should now switch from your previous ungendered term of “partner” to “wife.” For example: “That won’t be a problem. Your wife can pick it up any time after 2:00 PM today.”

• Ask everyone how you may respectfully address them. Regardless of whether someone is a part of the LGBTQ+ communities or not, asking everyone how they would like to be addressed is a great way to make all people feel comfortable and respected. If patients are confused by your question, you can simply say, “Would you prefer I address you as Mr. Rodriguez, Daniel, or in some other way?”

• Be aware of language when counseling on pregnancy risks, infertility, teratogenic effects, impotence, hair growth, etc. For example, facial hair growth may be an unwanted side effect for a cisgender woman, but it is likely to be a desired effect for a transgender man. To be respectful, shift language from “side effect” to “possible effect” or “possible outcome.”

Best Practices for Creating Safe and Inclusive Spaces

• Because LGBTQ+ individuals can be invisible and are sometimes excluded from diversity and inclusion initiatives, seeing a sign that says, “We do not discriminate here,” may not be enough to convince an LGBTQ+ person that they will be welcome at your pharmacy. Consider wearing a rainbow lapel pin or posting a sign that says, “All families welcome here” with a rainbow on it. Request that your pharmacy’s brochures and informational posters include diverse images of people. Consider having two moms or two dads displayed on a poster in a high traffic area.

• Wear a pronoun pin or attach a ribbon to your name badge that states your pronoun. One of the best ways to create a space where someone will feel comfortable sharing their pronoun with you is to offer your pronoun first. For example, your name tag might read, “Jasmine Bell, Pharmacist,” with a ribbon underneath that says, “She,” or “she/her/hers.” Displaying your pronoun is also a great way of indicating to LGBTQ+ patients and coworkers that you welcome the opportunity to work with all people and that you are working toward creating more inclusive spaces.

• If you uncover good information on how a patient would like to be addressed or how they refer to their partner or loved ones, make a note in the chart for others. For example: “Please refer to this patient as Georgette, even though this is not her legal name, and use “she, her, and hers” for her pronouns.”

• Help to educate others on respectful language. Many people want to be respectful, but they don’t know how, are intimidated, or are afraid they will accidentally mess up and embarrass themselves or others. Share what you have learned with coworkers and friends and encourage them to connect, rather than shut down. Let them know that beginning a conversation with, “I mean to be respectful, please help educate me if I mess up or use the wrong term,” goes a long way toward creating safe and comfortable spaces for LGBTQ+ people.

Advocating for More LGBTQ+ Inclusive Pharmacies

• Transgender people are often put at risk in public-gendered restrooms. Educate others on the need for all-gender facilities. If you have “men’s” and “women’s” single-stall restrooms at your pharmacy, suggest replacing the old gendered signs for new “all-gender restroom” signs. If you are renovating your space, advocate for at least one single-stall, all-gender restroom.

• Medical forms and records can be extremely limiting and frustrating for LGBTQ+ patients. This is an area where you can help to educate others on the need for improvements. The “M” and “F” box is one area that is hugely problematic. Should someone indicate their biological sex or their gender? Which box should a transman check? Which box should an intersex person check? If the information that your pharmacy needs is the gender marker on the patient’s insurance card, then state that on the form. Then include another section where the patient can communicate to you how you should properly address them or a blank box that allows a patient to fill in their self-identified gender identity. Insurance card gender markers do not always reflect a person’s identity. Another problematic area on many forms is the name section. Ideally, “name” should be at the top of your form, so it is the name that is used to address the patient. “Legal name if different from above” should come later on the form, so staff does not mistakenly address the patient using the wrong name.

• Advocate for the development of a private consultation room or quiet corner where patients can share personal information without being overheard by other customers. Transgender individuals, especially transgender women of color, are at an extremely high risk for violence. “Outing” a transgender person to other patients may create a very unsafe situation.

• Cultural sensitivity training addressing LGBTQ+ health is important for all health care education programs.²⁸ Request that your pharmacy offer trainings for all staff on understanding LGBTQ+ identities, barriers to care, health risks, respectful communication pointers, and creating safer and more welcoming pharmacies.

For more information on how to be an ally, the importance of all-gender restrooms, best restroom signage to use, creating inclusive policies and forms, and much more, check references 49-52.

Conclusion

The World Health Organization states that, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.”⁵³ Quality, informed, and respectful health care is important for living a happy, healthy, and dignified life. In the past, in the health care system, members of LGBTQ+ communities have been at best overlooked, and at worst disgraced and denied services. It is time to actively repair the damage done and work toward increasing LGBTQ+ patients’ faith and trust in health care services. Becoming aware of the health care challenges and barriers to care that LGBTQ+ people face is a great start, but we must also take steps to ensure that our pharmacies are welcoming, safe, and inclusive places. These steps include training all staff on LGBTQ+ cultural sensitivity and awareness, updating and creating more inclusive records and forms, interacting with patients and coworkers in ways that do not assume orientation or gender, displaying visible images that show support of LGBTQ+ communities, providing all-gender facilities, and ensuring privacy for LGBTQ+ patients when they are sharing sensitive information. Creating environments where LGBTQ+ patients feel respected and safe is likely to lead to an increase in LGBTQ+ patients utilizing our services, as well as increasing our opportunities for counseling on critical LGBTQ+ health indicators such smoking, alcohol use, vaccinations, and mental health.⁵⁴ Thank you for your efforts toward creating more welcoming, safe, and inclusive pharmacies.

References

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52. National LGBT Health Education Center. Focus on Forms and Policy: Creating an Inclusive Environment for LGBT Patients. Available from: https://www.lgbthealtheducation.org/wp-content/uploads/2017/08/Forms-and-Policy-Brief.pdf. Accessed July 19, 2019.
53. World Health Organization. Health is a fundamental human right. Available from: https://www.who.int/mediacentre/news/statements/fundamental-human-right/en/. Accessed July 29, 2019.
54. Substance Abuse and Mental Health Services Administration. Top health issues for LGBT populations information and resource kit. HHS Publication No(SMA) 12-4684: Rockville, MD; 2012.

Appendix 1. LGBTQ+ Glossary of Terms

This glossary is from The Savvy Ally: A Guide for Becoming a Skilled LGBTQ+ Advocate by Jeannie Gainsburg, Expected publication Spring 2020.

Affectional Orientation: The part of an individual’s identity that describes to whom they are romantically attracted. It is also known as “romantic orientation.”

Ally: A person who is not a part of a particular marginalized group, but who stands up for and advocates for the rights of people in that group.

Androgynous: A gender expression that is neither feminine nor masculine. It is sometimes defined as a blending of both masculinity and femininity.

Agender: Relating to an individual who has no gender.

Aromantic: Relating to an individual with a low or absent romantic attraction.

Asexual: Relating to an individual with a low or absent sexual attraction.

Binary: Relating to two things or two options. Individuals who identify their gender as either “man” or “woman” fit into the gender binary.

Biological Sex: Relating to an individual’s reproductive system and secondary sex characteristics, including genitalia, chromosomes, hormones, etc.

Biphobia: Fear, intolerance, or hatred of people who are, or who are perceived to be, bisexual or pansexual.

Biromantic: Relating to an individual who is romantically attracted to men and women.

Bisexual: Relating to an individual who is romantically or sexually attracted to men and women.

Cisgender: Relating to an individual whose gender identity matches the sex they were assigned at birth; someone who is not transgender.

Cissexism: The assumption that everyone is cisgender or that being cisgender is the “right” way to be.

Crossdresser: An individual who, for comfort, enjoyment and/or self-expression, wears clothing that has been designated by society as inappropriate for their gender.

Drag King: An entertainer whose act features wearing men’s clothing, facial makeup, and facial hair in order to impersonate a man.

Drag Queen: An entertainer whose act features wearing women’s clothing and makeup in order to impersonate a woman.

Gay: Relating to an individual who is exclusively romantically or sexually attracted to people of the same gender as themselves. Traditionally a term used only by men, it is now embraced by some women as well.

Gender-Expansive: Relating to an individual whose gender expression and/or gender identity does not fit into society’s binary expectations. Some people prefer this term to “gender non-conforming.”

Gender Expression: The way an individual expresses their gender to the outside world, through clothing, hairstyles, interests, mannerisms, and movement. It is typically labeled as “masculine,” “feminine,” or “androgynous.”

Gender Identity: An individual’s sense of their own gender, typically labeled as “man,” “woman,” or “non-binary.”

Genderfluid: Relating to an individual whose gender identity regularly fluctuates.

Genderqueer: Relating to an individual whose gender identity is neither man nor woman.

Gender Non-Conforming: Relating to an individual whose gender expression and/or gender identity does not fit into society’s binary expectations. Some people prefer this term to “gender-expansive.”

Hermaphrodite: An outdated and derogatory term for a person born with atypical genitalia. The word “intersex,” which is broader in its definition, is a more respectful term.

Heteroromantic: Relating to a man who is exclusively romantically attracted to women, or a woman who is exclusively romantically attracted to men.

Heterosexism: The assumption that everyone is heterosexual or that being heterosexual is the right way to be.

Heterosexual: Relating to a man who is exclusively sexually attracted to women, or a woman who is exclusively sexually attracted to men; also known as “straight.”

Homophobia: Fear, intolerance, or hatred of people who are, or who are perceived to be, gay or lesbian.

Homoromantic: Relating to an individual who is exclusively romantically attracted to people of the same gender.

Homosexual: A dated term relating to an individual who is exclusively sexually attracted to people of the same gender. The words “gay” or “lesbian” are more respectful terms.

Intersex: Relating to an individual whose biological sex features (i.e., genitals, reproductive organs, chromosomes, hormones, etc) are not typical.

Intersectionality: The complex and overlapping ways that an individual’s many identities (eg, sexuality, gender, race, ethnicity, ability, socioeconomic status, immigration status, language, size, religion, spirituality, etc) come together and shape their experiences and interactions. Prejudice and discrimination related to these overlapping identities are unique and are different than prejudice and discrimination faced by people with each individual identity.

Intimate Behaviors: Sexual and/or romantic activities.

Lesbian: A woman who is exclusively romantically or sexually attracted to other women.

LGBTQ+: One of the many initialism created to express all sexual and gender minorities. It stands for: lesbian, gay, bisexual, transgender, queer, plus so much more!

Microaggression: A commonplace comment or behavior towards a marginalized group that is hurtful, insulting, or demeaning. The comment may be unintentionally or intentionally insulting.

Misgender: To refer to an individual by the incorrect gender.

MSM: An abbreviation for “men who have sex with men.” This term was created to acknowledge and offer appropriate health care to men who do not identify as “gay,” “bisexual,” or “pansexual,” but who are engaging in sexual activities with men.

Non-Binary: Relating to an individual whose gender identity is neither man nor woman. This can also be used as an umbrella term, which includes many identities, such as agender, gender-expansive, gender fluid, genderqueer, and Two-Spirit.

Pansexual: Relating to an individual who is sexually attracted to people regardless of their gender.

Panromantic: Relating to an individual who is romantically attracted to people regardless of their gender.

Polyamorous: Relating to an individual who engages in more than one sexual and/or romantic relationship at a time, with the knowledge and consent of all involved.

Queer: A reclaimed term that is liked by some and disliked by others. It can be used to define any orientation that is not straight or any gender that is not cisgender.

Questioning: Relating to an individual who is currently unsure of or exploring their orientation and/or gender identity.

Romantic Orientation: The part of an individual’s identity that describes to whom they are romantically attracted. It is also known as “affectional orientation.”

Same-Gender Loving: An identity term used within some communities of color relating to individuals who are attracted to people of the same gender.

Sexual Orientation: The part of an individual’s identity that describes to whom they are sexually attracted.

Straight: Relating to a man who is exclusively sexually attracted to women, or a woman who is exclusively sexually attracted to men; also known as “heterosexual.”

Transgender: Relating to an individual whose sex assigned at birth does not match their gender identity. This word can also be used as an umbrella term that includes many identities, such as genderqueer, non-binary, transman, and transwoman. Someone who is transgender may or may not transition in a variety of ways.

Transition: Changing from one state to another. Often used to refer to the process by which a transgender individual brings alignment to their body and their gender identity.

Transman: Relating to an individual who was assigned “female” at birth, but whose gender identity is “man.”

Transphobia: Fear, intolerance, or hatred of people who are, or who are perceived to be, transgender.

Transsexual: A dated term relating to an individual who uses hormonal and/or surgical treatments to help align their gender identity with the sex they were assigned at birth. The words “transgender” or “trans” are more respectful terms.

Transvestite: A dated term for an individual who enjoys wearing clothing that has been designated by society as inappropriate for their gender. The word “crossdresser” is a more respectful term.

Transwoman: Relating to an individual who was assigned “male” at birth, but whose gender identity is “woman.”

Two-Spirit: A modern term, created in 1990, that may be used by people indigenous to North America as an LGBTQ+ identity term or to describe people who have the spirit of both “man” and “woman,” and/or are a third gender. It is embraced by some indigenous North Americans and rejected by others. The term may be defined differently depending on the community or tribe.

Appendix 2.

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