American College of Physicians statement

In April 2015, the American College of Physicians (ACP) publicly recognized that there are disparities in health care experienced by the LGBT community and made a series of recommendations to achieve equity for LGBT patients in the healthcare system.163 The 9-point position paper recommended that medical schools, hospitals, and all medical facilities adopt gender identity as part of nondiscrimination policies. It urged comprehensive transgender healthcare inclusion in public and private health insurance plans. They advocated that the definition of family should be inclusive of all those of the patient’s choice, regardless of biological relationship. The ACP also announced its support for civil marriages of same-sex couples, more research into health disorders of LGBT patients, and recruitment of LGBT medical students, residents, and practicing physicians. In addition, the ACP announced its opposition to the conversion, reorientation, or reparative therapy of individuals with LGBT identity.


A pervasive heterosexual bias exists in healthcare delivery in the United States. LGBT individuals have unique health problems and make up a sexual minority that is underserved. Taking a detailed sexual history is important in order to assess risk of health problems for LGBT patients. Questions should be specific in order to identify the anatomic sites from which to collect specimens for STD testing and cancer screening. Clinicians need to be sensitive that patients may not be comfortable talking about their sexual history, sex partners, or sexual practices until trust is developed.

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Specific issues should be taken into consideration for MSM, WSW, and transgender persons. MSM are at particularly high risk for many STDs, HIV infection, and anal cancer. It is important to dispel the commonly held belief that the transmission of STDs in WSW is negligible. Women are infrequently advised about how to engage in safe sexual activity with other women. Also, WSW erroneously believe they do not need cervical cancer screening and Pap tests. Transgender individuals have a higher rate of STDs and HIV, compared with the general population. For transsexual individuals, clinicians need to be aware of the specific types of surgical procedures that have been performed. It is important to screen transsexual individuals according to their unchanged anatomy as well as their reconfigured anatomy. Within the whole LGBT community, mental health issues are common, often due to the prejudice these individuals face at the hands of others.

Alexandra Gillespie is an honors student at Villanova University, and Theresa Capriotti, DO, MSN, CRNP, RN, is a clinical associate professor at the Villanova University College of Nursing in Pennsylvania.


  1. Morrison S, Dinkel S. Heterosexism and health care: a concept analysis. Nurs Forum. 2012;47(2):123-130.
  2. Irwin L. Homophobia and heterosexism: implications for nursing and nursing practice. Australian J Advanced Nursing. 2007;25(1):70-76.
  3. Neville S, Henrickson M. Perceptions of lesbian, gay, and bisexual people of primary healthcare services. J Adv Nurs. 2006;55(4):407-415.
  4. Westerståhl A, Björkelund C. Challenging heteronormativity in the consultation: a focus group study among general practitioners. Scandinavian Journal of Primary Health Care. 2003;21(4):205.
  5. Fish J, Bewley S. Using human-rights-based approaches to conceptualize lesbian and bisexual women’s health inequalities. Health Soc Care Community. 2010;18(4):355-362.
  6. Röndahl G, Bruhner E, Lindhe J. Heteronormative communication with lesbian families in antenatal care, childbirth, and postnatal care. J Adv Nurs. 2009;65(11):2337-2344.
  7. Saulnier CF. Deciding who to see: lesbians discuss their preferences in health and mental health care providers. Soc Work. 2002;47(4):355-365.
  8. Lesbian, gay, bisexual, and transgender health. Centers for Disease Control and Prevention website.
  9. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.
  10. Jenner CO. Transsexual primary care. J Am Acad Nurse Pract. 2010;22(8):403-408.
  11. Lesbian, gay, bisexual, transgender. American Psychological Association website.
  12. Quinn GP, Sanchez JA, Sutton SK, et al. Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. CA Cancer J Clin. 2015;65(5):384-400.
  13. What is intersex? Intersex Society of North America website.
  14. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
  15. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2011;13(4):165-232.
  16. Ward BW, Dahlhamer JM, Galinsky AM, Joestl SS. Sexual orientation and health among US adults: national health interview survey, 2013. Natl Health Stat Report. 2014;(77):1-10.
  17. Chandra A, Mosher WD, Copen C, Sionean C. Sexual behavior, sexual attraction, and sexual identity in the United States: data from the 2006-2008 National Survey of Family Growth. Natl Health Stat Report. 2011;(36):1-36.
  18. Fredriksen-Goldsen KI, Kim HJ, Barkan SE, et al. Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. Am J Public Health. 2013;103(10):1802-1809.
  19. Dilley JA, Simmons KW, Boysun MJ, et al. Demonstrating the importance and feasibility of including sexual orientation in public health surveys: health disparities in the Pacific Northwest. Am J Public Health. 2010;100(3):460-467.
  20. Strutz KL, Herring AH, Halpern CT. Health disparities among young adult sexual minorities in the US. Am J Prev Med. 2015;48(1):76-88.
  21. Duvivier RJ, Wiley E. WHO and the health of LGBT individuals. Lancet. 2015;385(9973):1070-1071.
  22. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. 2008;8:70.
  23. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex. 2011;58(1):10-51.
  24. Rubin R. Trans health care in the USA: a long way to go. Lancet. 2015;386(9995):727-728.
  25. O’Malley Olsen E, Kann L, Vivolo-Kantor A, et al. School violence and bullying among sexual minority high school students, 2009-2011. J Adolesc Health. 2014;55(3):432-438.
  26. A guide to taking a sexual history. Centers for Disease Control and Prevention website.
  27. Jin F, Crawford J, Prestage GP, et al. Unprotected anal intercourse, risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men. AIDS. 2009;23(2):243-252.
  28. HIV among gay and bisexual men. Centers for Disease Control and Prevention website.
  29. Key health concerns for MSM (men who have sex with men).Vanderbilt University School of Medicine website.
  30. Wilkin T. Clinical practice. Primary care for men who have sex with men. N Engl J Med. 2015;373(9):854-862.
  31. Lim FA, Brown DV Jr, Justin Kim SM. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: a review of best practices. Am J Nurs. 2014;114(6):24-34.
  32. Lu B, Wu Y, Nielson CM, et al. Factors associated with acquisition and clearance of human papillomavirus infection in a cohort of US men: a prospective study. J Infect Dis. 2009;199(3):362-371.
  33. Sadlier C, Rowley D, Morley D, et al. Prevalence of human papillomavirus in men who have sex with men in the era of an effective vaccine; a call to act. HIV Med. 2014;15(8):499-504.
  34. Goldstone S, Palefsky JM, Giuliano AR, et al. Prevalence of and risk factors for human papillomavirus (HPV) infection among HIV-seronegative men who have sex with men. J Infect Dis. 2011;203(1):66-74.
  35. Palefsky JM, Holly EA, Ralston ML, et al. Effect of highly active antiretroviral therapy on the natural history of anal squamous intraepithelial lesions and anal human papillomavirus infection. J Acquir Immune Defic Syndr. 2001;28(5):422-428.
  36. Nyitray A, Nielson CM, Harris RB, et al. Prevalence of and risk factors for anal human papillomavirus infection in heterosexual men. J Infect Dis. 2008;197(12):1676-1684.
  37. Schwartz LM, Castle PE, Follansbee S, et al. Risk factors for anal HPV infection and anal precancer in HIV-infected men who have sex with men. J Infect Dis. 2013;208(11):1768-1775.
  38. Human papillomavirus (HPV) infection. Centers for Disease Control and Prevention website.
  39. HPV and men—fact sheet. Centers for Disease Control and Prevention website.
  40. Klevens RM, Liu S, Roberts H, et al. Estimating acute viral hepatitis infections from nationally reported cases. Am J Public Health. 2014;104(3):482-487.
  41. Dan C, Moses-Eisenstein M, Valdiserri RO. CE: Viral hepatitis: new US screening recommendations, assessment tools, and treatments. Am J Nurs. 2015;115(7):26-35.
  42. Weinbaum CM, Williams I, Mast EE; Centers for Disease Control and Prevention. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008;57(RR-8):1-20.
  43. Mast EE, Weinbaum CM, Fiore AE, et al; Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the advisory committee on immunization practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep. 2006;55(RR-16):1-33.
  44. Sexual transmission and viral hepatitis. Centers for Disease Control and Prevention website.
  45. Hepatitis C FAQs for the public. Centers for Disease Control and Prevention website.
  46. Wilkins T, Akhtar M, Gititu E, et al. Diagnosis and management of hepatitis C. Am Fam Physician. 2015;91(12):835-842.
  47. World health statistics 2012. World Health Organization website.
  48. Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol. 2014;61(1 suppl):S58-S68.
  49. Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. N Engl J Med. 2013;368(20):1859-1861.
  50. Bansal S, Singal AK, McGuire BM, Anand BS. Impact of all oral anti-hepatits C virus therapy: a meta-analysis. World J Hepatol. 2015;7(5): 806-813.
  51. Foschi C, Filippini A, D’Antuono A, et al. Lymphogranuloma venereum in an Italian MSM: concurrent pharyngeal and rectal infection. New Microbiol. 2014;37(3):399-402.
  52. Kent CK, Chaw JK, Wong W, et al. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis. 2005;41(1):67-74.
  53. Cooper F, Barber T. ‘Gay bowel syndrome’: relic or real (and returning) phenomenon? Curr Opin Infect Dis. 2014;27(1):84-89.
  54. Daskalakis DC, Blaser MJ. Another perfect storm: shigella, men who have sex with men, and HIV. Clin Infect Dis. 2007;44(3):335-337.
  55. Valcanis M, Brown JD, Hazelton B, et al. Outbreak of locally acquired azithromycin-resistant Shigella flexneri infection in men who have sex with men. Pathology. 2015;47(1):87-88.
  56. Hoffmann C, Sahly H, Jessen A, et al. High rates of quinolone-resistant strains of Shigella sonnei in HIV-infected MSM. Infection. 2013;41(5):999-1003.
  57. Schmink S, Watson JT, Coulson GB, et al. Molecular epidemiology of Neisseria meningitidis isolates from an outbreak of meningococcal disease among men who have sex with men, Chicago, Illinois, 2003. J Clin Microbiol. 2007;45(11):3768-3770.
  58. Simon MS, Weiss D, Gulick RM. Invasive meningococcal disease in men who have sex with men. Ann Intern Med. 2013;159(4):300-301.
  59. Kratz MM, Weiss D, Ridpath A, et al. Community-based outbreak of Neisseria meningitidis serogroup C infection in men who have sex with men, New York City, New York, USA, 2010-2013. Emerg Infect Dis. 2015;21(8):1379-1386.
  60. Bostwick WB, Boyd CJ, Hughes TL, McCabe SE. Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. Am J Public Health. 2010;100(3):468-475.
  61. Stults CB, Javdani S, Greenbaum CA, et al. Intimate partner violence and substance use risk among young men who have sex with men: the P18 cohort study. Drug Alcohol Depend. 2015;154:54-62.
  62. Wang Z, Li D, Lau JT, et al. Prevalence and associated factors of inhaled nitrites use among men who have sex with men in Beijing, China. Drug Alcohol Depend. 2015;149:93-99.
  63. Buller AM, Devries KM, Howard LM, Bacchus LJ. Associations between intimate partner violence and health among men who have sex with men: a systematic review and meta-analysis. PLoS Med. 2014;11(3):e1001609.
  64. Moleiro C, Pinto N. Sexual orientation and gender identity: review of concepts, controversies and their relation to psychopathology classification systems. Front Psychol. 2015;6:1511.
  65. Solarz A. Lesbian health care issues. AWHONN Lifelines. 1999;3(5):13-14.
  66. Boehmer U, Case P. Physicians don’t ask, sometimes patients tell: disclosure of sexual orientation among women with breast carcinoma. Cancer. 2004;101(8):1882-1889.
  67. Mravcak SA. Primary care for lesbians and bisexual women. Am Fam Physician. 2006;74(2):279-286.
  68. Dean L, Meyer IH, Robinson K, et al. Lesbian, gay, bisexual, and transgender health: findings and concerns. J Gay Lesbian Med Assoc. 2000;4(3):102-151.
  69. Friedman MR, Dodge B, Schick V, et al. From bias to bisexual health disparities: attitudes toward bisexual men and women in the United States. LGBT Health. 2014;1(4):309-318.
  70. Bauer GR, Welles SL. Beyond assumptions of negligible risk: sexually transmitted diseases and women who have sex with women. Am J Public Health. 2001;91(8):1282-1286.
  71. Marrazzo JM, Koutsky LA, Kiviat NB, et al. Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women. Am J Public Health. 2001;91(6):947-952.
  72. Fishman SJ, Anderson EH. Perception of HIV and safer sexual behaviors among lesbians. J Assoc Nurses AIDS Care. 2003;14(6):48-55.
  73. Diamant AL, Schuster MA, Lever J. Receipt of preventive health care services by lesbians. Am J Prev Med. 2000;19(3):141-148.
  74. Rankow EJ, Tessaro I. Cervical cancer risk and papanicolaou screening in a sample of lesbian and bisexual women. J Fam Pract. 1998;47(2):139-143.
  75. Johnson SR, Smith EM, Guenther SM. Comparison of gynecologic health care problems between lesbians and bisexual women. A survey of 2,345 women. J Reprod Med. 1987;32(11):805-811.
  76. Roberts SJ, Sorensen L. Health-related behaviors and cancer screening of lesbians: results from the Boston Lesbian Health Project. Women Health. 1999;28(4):1-12.
  77. Massad LS, Xie X, Minkoff H, et al. Abnormal pap tests and human papillomavirus infections among HIV-infected and uninfected women who have sex with women. J Low Genit Tract Dis. 2014;18(1):50-56.
  78. Xu F, Sternberg MR, Markowitz LE. Women who have sex with women in the United States: prevalence, sexual behavior and prevalence of herpes simplex virus type 2 infection-results from national health and nutrition examination survey 2001-2006. Sex Transm Dis. 2010;37(7):407-413.
  79. Evans AL, Scally AJ, Wellard SJ, Wilson JD. Prevalence of bacterial vaginosis in lesbians and heterosexual women in a community setting. Sex Transm Infect. 2007;83(6):470-475.
  80. Marrazzo JM, Thomas KK, Agnew K, Ringwood K. Prevalence and risks for bacterial vaginosis in women who have sex with women. Sex Transm Dis. 2010;37(5):335-339.
  81. Bailey JV, Farquhar C, Owen C. Bacterial vaginosis in lesbians and bisexual women. Sex Transm Dis. 2004;31(11):691-694.
  82. Fethers KA, Fairley CK, Hocking JS, et al. Sexual risk factors and bacterial vaginosis: a systematic review and meta-analysis. Clin Infect Dis. 2008;47(11):1426-1435.
  83. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.
  84. Muzny CA, Kapil R, Austin EL, et al. Lower sexually transmissible infection prevalence among lifetime exclusive women who have sex with women compared with women who have sex with women and men. Sex Health. 2014;11(6):592-593.
  85. Muzny CA, Kapil R, Austin EL, et al. Chlamydia trachomatis infection in African American women who exclusively have sex with women. Int J STD AIDS. Sept. 18, 2015. [Epub ahead of print].
  86. Tao G. Sexual orientation and related viral sexually transmitted disease rates among US women aged 15 to 44 years. Am J Public Health. 2008;98(6):1007-1009.
  87. Van der Pol B. Clinical and laboratory testing for Trichomonas vaginalis infection. J Clin Microbiol. 2016;54(1):7-12.
  88. Singh D, Fine DN, Marrazzo JM. Chlamydia trachomatis infection among women reporting sexual activity with women screened in family planning clinics in the Pacific Northwest, 1997 to 2005. Am J Public Health. 2011;101(7):1284-1290.
  89. Muzny CA, Sunesara IR, Martin DH, Mena LA. Sexually transmitted infections and risk behaviors among African American women who have sex with women: does sex with men make a difference? Sex Transm Dis. 2011;38(12):1118-1125.
  90. Chan SK, Thornton LR, Chronister KJ, et al; Centers for Disease Control and Prevention (CDC). Likely female-to-female sexual transmission of HIV—Texas, 2012. MMWR Morb Mortal Wkly Rep. 2014;63(10):209-212.
  91. Pinto VM, Tancredi MV, Tancredi Neto A, Buchalla CM. Sexually transmitted disease/HIV risk behaviour among women who have sex with women. AIDS. 2005;19(suppl 4):S64-S69.
  92. Koh AS, Gómez CA, Shade S, Rowley E. Sexual risk factors among self-identified lesbians, bisexual women, and heterosexual women accessing primary care settings. Sex Transm Dis. 2005;32(9):563-569.
  93. Ard KK, Makadon HJ. Improving the Health Care of Lesbian, Gay, Bisexual, and Transgender People: Understanding and Eliminating Health Disparities. Boston, MA: The Fenway Institute; 2012.
  94. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women. Washington, DC: US Department of Justice; 2000.
  95. Lhomond B, Saurel-Cubizolles MJ. Violence against women and suicide risk: the neglected impact of same-sex sexual behaviour. Soc Sci Med. 2006;62(8):2002-2013.
  96. Kulkin HS, Williams J, Borne HF, et al. A review of research on violence in same-gender couples: a resource for clinicians. J Homosex. 2007;53(4):71-87.
  97. Reisner SL, Perkovich B, Mimiaga MJ. A mixed methods study of the sexual health needs of New England transmen who have sex with nontransgender men. AIDS Patient Care STDS. 2010;24(8):501-513.
  98. Ayala J, Coleman H. Predictors of depression among lesbian women. J Lesbian Studies. 2008;4(3):71-86.
  99. Bostwick WB, Hughes TL, Johnson T. The co-occurrence of depression and alcohol dependence symptoms in a community sample of lesbians. J Lesbian Studies. 2005;9(3):7-18.
  100. Burgess D, Tran A, Lee R, van Ryn M. Effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual, and transgender persons. J LGBT Health Res. 2007;3(4):1-14.
  101. Case P, Austin SB, Hunter DJ, et al. Sexual orientation, health risk factors, and physical functioning in the nurses’ health study II. J Womens Health (Larchmt). 2004;13(9):1033-1047.
  102. Cochran SD, Mays VM, Sullivan JG. Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. J Consult Clin Psychol. 2003;71(1):53-61.
  103. Cochran SD, Mays VM. Mortality risks among persons reporting same-sex sexual partners: evidence from the 2008 General Social Survey-National Death Index Data Set. Am J Public Health. 2015;105(2):358-364.
  104. Silenzio VM, Pena JB, Duberstein PR, et al. Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults. Am J Public Health. 2007;97(11):2017-2019.
  105. Koh AS, Ross LK. Mental health issues: a comparison of lesbian, bisexual, and heterosexual women. J Homosex. 2006;51(1):33-57.
  106. 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.
  107. Mayer KH, Bradford JB, Makadon HJ, et al. Sexual and gender minority health: what we know and what needs to be done. Am J Public Health. 2008;98(6):989-995.
  108. Levine DA; Committee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013;132(1):e297-e313.
  109. Skegg K, Nada-Raja S, Dickson N, et al. Sexual orientation and self-harm in men and women. Am J Psychiatry. 2003;160(3):541-546.
  110. Fergusson DM, Horwood LJ, Beautrais AL. Is sexual orientation related to mental health problems and suicidality in young people? Arch Gen Psychiatry. 1999;56(10):876-880.
  111. Oetjen H, Rothblum ED. When lesbians aren’t gay: factors affecting depression among lesbians. J Homosex. 2000;39(1):49-73.
  112. Kerker BD, Mostashari F, Thorpe L. Health care access and utilization among women who have sex with women: sexual behavior and identity. J Urban Health. 2006;83(5):970-979.
  113. National Center for Health Statistics. Health, United States, 2015: With special feature on racial and ethnic health disparities [Table 71]. Centers for Disease Control and Prevention website.
  114. Bradford J, Ryan C. The National Lesbian Health Care Survey Final Report. Washington, DC: National Lesbian and Gay Health Foundation; 1987.
  115. Matthews AK, Brandenburg DL, Johnson TP, Hughes TL. Correlates of underutilization of gynecological cancer screening among lesbian and heterosexual women. Prev Med. 2004;38(1):105-113.
  116. New national survey shows financial concerns and lack of adequate health insurance are top causes for delay by lesbians in obtaining health care. PR Newswire website. March 11, 2005.
  117. Diamant AL, Wold C, Spritzer K, Gelberg L. Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women. Arch Fam Med. 2000;9(10):1043-1051.
  118. Rankow EJ. Lesbian health issues for the primary care provider. J Fam Pract. 1995;40(5):486-496.
  119. Price JH, Easton AN, Telljohann SK, Wallace PB. Perceptions of cervical cancer and pap smear screening behavior by women’s sexual orientation. J Community Health. 1996;21(2):89-105.
  120. Roberts SJ. Health care recommendations for lesbian women. J Obstet Gynecol Neonatal Nurs. 2006;35(5):583-591.
  121. Ryan H, Wortley PM, Easton A, et al. Smoking among lesbians, gays, and bisexuals: a review of the literature. Am J Prev Med. 2001;21(2):142-149.
  122. Tang H, Greenwood GL, Cowling DW, et al. Cigarette smoking among lesbians, gays, and bisexuals: how serious a problem? (United States). Cancer Causes Control. 2004;15(8):797-803.
  123. Burgard SA, Cochran SD, Mays VM. Alcohol and tobacco use patterns among heterosexually and homosexually experienced California women. Drug Alcohol Depend. 2005;77(1):61-70.
  124. Cochran SD, Mays VM, Bowen D, et al. Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. Am J Public Health. 2001;91(4):591-597.
  125. Drabble L, Trocki KF, Hughes TL, et al. Sexual orientation differences in the relationship between victimization and hazardous drinking among women in the national alcohol survey. Psychol Addict Behav. 2013;27(3):639-648.
  126. Boehmer U, Bowen DJ. Examining factors linked to overweight and obesity in women of different sexual orientations. Prev Med. 2009;48(4):357-361.
  127. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? The Williams Institute website.
  128. Halloran L. Caring for transgender patients. J Nurse Pract. 2015;11(9):915-916.
  129. Primary care protocol for transgender patient care. Center of Excellence for Transgender Health website.
  130. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al; Endocrine Society. Endocrine treatment of transsexual persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132-3154.
  131. Urban RR, Teng NN, Kapp DS. Gynecologic malignancies in female-to-male transgender patients: the need of original gender surveillance. Am J Obstet Gynecol. 2011;204(5):e9-e12.
  132. Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist’s and urologist’s perspective. Acta Obstet Gynecol Scand. 2015;94(6):563-567.
  133. Perovic S, Djinovic R. Genitoplasty in male-to-female transsexuals. Curr Opin Urol. 2009;19(6):571-576.
  134. Toorians AW, Thomassen MC, Zweegman S, et al. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people. J Clin Endocrinol Metab. 2003;88(12):5723-5729.
  135. Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med. 2011;364(13):1251-1257.
  136. Sobralske M. Primary care needs of patients who have undergone gender reassignment. J Am Acad Nurse Pract. 2005;17(4):133-138.
  137. Elbers JM, Giltay EJ, Teerlink T, et al. Effects of sex steroids on components of the insulin resistance syndrome in transsexual subjects. Clin Endocrinol (Oxf). 2003;58(5):562-571.
  138. Hakimian P, Blute M Jr, Kashanian J, et al. Metabolic and cardiovascular effects of androgen deprivation therapy. BJU Int. 2008;102(11):1509-1514.
  139. Elamin MB, Garcia MZ, Murad MH, et al. Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses. Clin Endocrinol (Oxf). 2010;72(1):1-10.
  140. Asscheman H, Giltay EJ, Megens JA, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2011;164(4):635-642.
  141. Burcombe RJ, Makris A, Pittam M, Finer N. Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. Breast. 2003;12(4):290-293.
  142. Grynberg M, Fanchin R, Dubost G, et al. Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population. Reprod Biomed Online. 2010;20(4):553-558.
  143. Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract function. Eur Urol. 2005;47(3):398-402.
  144. Lumen N, Monstrey S, Goessaert AS, et al. Urethroplasty for strictures after phallic reconstruction: a single-institution experience. Eur Urol. 2011;60(1):150-158.
  145. Gooren LJ, Giltay EJ, Bunck MC. Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab. 2008;93(1):19-25.
  146. van Kesteren P, Lips P, Gooren LJ, et al. Long-term follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex hormones. Clin Endocrinol (Oxf). 1998;48(3):347-354.
  147. Mueller A, Gooren L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2008;159(3):197-202.
  148. 2015 sexually transmitted diseases treatment guidelines. Centers for Disease Control and Prevention website.
  149. Giami A, Le Bail J. HIV infection and STI in the trans population: a critical review. Rev Epidemiol Sante Publique. 2011;59(4):259-268.
  150. Herbst JH, Jacobs ED, Finlayson TJ, et al; HIV/AIDS Prevention Research Synthesis Team. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2008;12(1):1-17.
  151. Edwards JW, Fisher DG, Reynolds GL. Male-to-female transgender and transsexual clients of HIV service programs in Los Angeles County, California. Am J Public Health. 2007;97(6):1030-1033.
  152. Grant JM, Mottet LA, Tanis J. National Transgender Discrimination Survey Report on Health and Health Care. Washington, DC: National Center for Transgender Equality; National Gay and Lesbian Task Force; 2010.
  153. California tobacco control update 2006. California Department of Health Services website.
  154. Lindley LL, Nicholson TJ, Kerby MB, Lu N. HIV/STI-associated risk behaviors among self-identified lesbian, gay, bisexual, and transgender college students in the United States. AIDS Educ Prev. 2003;15(5):413-429.
  155. Carobene M, Bolcic F, Farías MS, et al. HIV, HBV, and HCV molecular epidemiology among trans (transvestites, transsexuals, and transgender) sex workers in Argentina. J Med Virol. 2014;86(1):64-70.
  156. Dos Ramos Farías MS, Garcia MN, Reynaga E, et al. First report on sexually transmitted infections among trans (male-to-female transvestites, transsexuals, or transgender) and male sex workers in Argentina: high HIV, HPV, HBV, and syphilis prevalence. Int J Infect Dis. 2011;15(9):e635-e640.
  157. Loverro G, Di Naro E, Caringella AM, et al. Prevalence of human papillomavirus infection in a clinic sample of transsexuals in Italy. Sex Transm Infect. 2016;92(1):67-69.
  158. Fernandes FR, Zanini PB, Rezende GR, et al. Syphilis infection, sexual practices, and bisexual behaviour among men who have sex with men and transgender women: a cross-sectional study. Sex Transm Infect. 2015;91(2):142-149.
  159. Dutton L, Koenig K, Fennie K. Gynecologic care of the female-to-male transgender man. J Midwifery Womens Health. 2008;53(4):331-337.
  160. Scourfield J, Roen K, McDermott L. Lesbian, gay, bisexual, and transgender young people’s experiences of distress: resilience, ambivalence and self-destructive behaviour. Health Soc Care Community. 2008;16(3):329-336.
  161. Lee R. Health care problems of lesbian, gay, bisexual, and transgender patients. West J Med. 2000;172(6):403-408.
  162. Roller CG, Sedlak C, Draucker CB. Navigating the system: how transgender individuals engage in health care services. J Nurs Scholarsh. 2015;47(5):417-424.
  163. Daniel H, Butkus R; Health and Public Policy Committee of American College of Physicians. Lesbian, gay, bisexual, and transgender health disparities: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;163(2):135-137.
All electronic documents accessed June 29, 2016.

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