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Transgender and gender diverse (TGD) individuals deserve high-quality health care in which they feel safe and empowered. Critical to achieving this aim is creating a clinical space where a comprehensive health history can be discussed, free of judgment or shame. No such history is complete without a respectful understanding of patients’ sexual experiences and behaviors; therefore, it is recommended that a sexual history be obtained from all patients. Because all patients need an open-minded and nonjudgmental approach to feel comfortable discussing their sensitive personal experiences, use of a gender- and sexuality-inclusive framework is of paramount importance. Studies suggest that many TGD people do not disclose their gender identity to a health care professional; as many as 60% of TGD patients do not disclose they are transgender or gender diverse to some of their health care professionals, and 30% do not disclose to any of them.1 Other patients may not yet be aware of being TGD when they first begin care with a health care professional. Therefore, it is not uncommon for many health care professionals to have TGD patients whom they inaccurately believe to be cisgender. Due to the spectrum of possibilities in clinical practice, it is important to maintain an open and neutral approach with all patients that fosters opportunities for disclosure instead of creating barriers. This chapter has been written particularly with primary health care professionals in mind; those in other specialties and disciplines, however, may also benefit from incorporating aspects of obtaining a gender-affirming sexual history into their practice.


Currently, few clinical training programs offer instruction on how to provide health care that is affirming for TGD people.2,3 Most education and practice models have been developed with cisgender people in mind and do not consider the different identities, experiences, bodies, and needs of TGD individuals. Given that at least 1 out of 200 people identify as TGD,4 such neglect means that a large population of people receives suboptimal health care, leading to delayed or missed diagnoses and worse health outcomes than their cisgender peers.

Additionally, although familiarity with gender diversity is increasing, the majority of Americans report that they do not personally know an openly transgender person.5,6 Clinicians likely mirror this statistic, though most see TGD patients throughout their careers whether they know it or not. Without personal familiarity or dedicated training, it is likely that even those health care professionals who have some working knowledge of trans health still do not have an understanding of the adverse impacts of gender non-affirmation, particularly when it occurs in a health care setting.

In this chapter, gender non-affirmation comprises behaviors and actions—either intentional or unintentional—that signal to a person that they are not being viewed as the gender that they identify as or know themselves to be. Such behaviors include using the incorrect ...

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