Considerations for the Treatment of Sexual and Gender Minority Individuals in Colon and Rectal Surgery

Abstract

Sexual and gender minorities (SGMs) experience critical barriers to health care access and have unique health care needs that are often overlooked. Given the rise in individuals identifying as lesbian, gay, bisexual, transgender, and queer, colorectal surgeons are likely to care for increasing numbers of such individuals. Here, we discuss key barriers to health care access and research among SGM populations and outline approaches to address these barriers in clinical practice. We also highlight two specific topics relevant to SGM populations that colorectal surgeons should be familiar with: current approaches to anal cancer screening among men who have sex with men, and transgender individuals, as well as the management of recto-neovaginal fistula in transfeminine individuals.

 

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Keywords

LGBT - rectovaginal fistula - vaginoplasty - anal cancer - gender-affirming care

The needs of sexual and gender minority (SGM) individuals are being increasingly recognized in conversations around health equity ([Table 1]). With the percentage of U.S. residents identifying as lesbian, gay, bisexual, transgender, and queer, a subset of SGM individuals, doubling in the past decade to 7.2%, colorectal surgeons can expect to care for an increasing number of SGM individuals in their clinical practices.[1] SGM individuals experience several disparities in health and health care access with respect to gastrointestinal health.[2] [3] In addition, they exhibit higher rates of certain cancers and demonstrate lower engagement with preventative screenings.[2] [3] [4] Recognizing and addressing these disparities is essential for promoting equitable health care for all individuals, irrespective of their sexual orientation or gender identity. Colorectal surgeons play a pivotal role in contributing to the overall well-being of SGM patients by fostering inclusive and culturally competent health care practices, ultimately working toward closing the existing health care gaps in this population.

Barriers to Clinical Care and Research

SGM individuals have a history of experiencing discrimination and stigma within the health care system, and this insecurity or lack of safety permeates all aspects of their health care experiences.[5] [6] [7] [8] [9] [10] [11] Consequently, many SGM individuals do not feel comfortable disclosing their sexual orientation or gender identity to their health care providers, which leads to significant consequences.[12] [13] This lack of disclosure may result in incomplete medical histories, leading to a lack of pertinent information and suboptimal treatment, exacerbating issues related to trust between providers and communities. In addition, within the health care system, failure to disclose can contribute to reduced engagement in preventive care, such as cancer screenings.[4] [8] [10] [11] Qualitative studies of SGM patients have highlighted a correlation between prior homophobic or transphobic encounters with health care providers and diminished participation in cancer screening programs.[8] [14] [15] [16] [17] [18]

 

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Improving Communication

Patient-provider communication can impact all aspects of an individual's care and it is important that clinicians are able to discuss patients' gender identity and sexual practices openly and without judgment. Gender identity and sexual practices can impact risk factors, screening recommendations, differential diagnoses, and shared decision making. Perceived or anticipated discomfort from providers while discussing sexual behaviors common in same-sex sexual encounters can prevent patients from receiving appropriate care. For example, discomfort with discussing anal sex with healthcare workers has been shown to predict reduced rates of anal health screenings.[4] Conversely, the use of inclusive language and provider familiarity with SGM communities' experiences facilitated increased patient comfort with cancer screenings.[8] Clinicians should become comfortable taking a thorough history regarding sexual practices and contextualize the reasons for asking particular questions.[2] Although it is important to identify specific risk factors when evaluating patients, clinicians should be mindful not to make assumptions about patients' sexual behavior based on their sexual orientation, as sexual practices can vary widely. Beyond a discussion of sexual behavior, ensuring that spaces are safe for SGM individuals to be open about their lives is vital to offering high-quality patient-centered care. It is well-established that for patients undergoing major surgeries, social support is critical to promoting optimal outcomes.[19] [20] [21] Therefore, ensuring that clinical environments promote the safe disclosure of SGM identity and nonheterosexual family relationships enable clinicians to better engage patient's support systems.

Transgender and gender-diverse (TGD) individuals have unique needs with regard to clinical communication. Many TGD individuals are fearful of discrimination when accessing health care and may not feel comfortable disclosing their gender identity with clinicians.[13] [22] In spite of this, patient anatomy may have important implications for their surgical care. It is recommended that clinicians perform an organ inventory, by asking which at-risk organs patients currently have, as part of the routine clinical intake. However, clinicians must recognize the sensitivity around asking patients about previous gender-affirming surgeries.[2] As discussed above, contextualizing the reason for asking these questions can help to address the potential sensitivity. Clinicians should also take care to correctly use patients' lived name and pronouns, as this will establish trust, demonstrate respect, and ensure patient dignity. When discussing anatomical terms, clinicians should ask patients if they have preferences around the terminology that is used to describe their body. Some patients may prefer that clinicians use alternative terms, for instance, “chest” instead of “breast.” Care should be taken when conducting patient exams to preserve patient modesty, such as pelvic or anorectal examinations. Patients may experience worsening gender dysphoria if ungowned for a long period of time or may be concerned about unwanted disclosure of their assigned sex during examinations. Treating variations in genital anatomy as routine, asking patients about their preferences regarding examinations, and clearly explaining the steps of examinations using gender-neutral language can help to alleviate some of these concerns.

 

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Issues in Research

The prevalence of health disparities among SGM patients likely remains underappreciated, as the collection of sexual orientation and gender identity (SOGI) data are not standardized nor routinely collected across different health care settings or data sets. As a result, inaccurate and inadequate SOGI data collection critically limits our understanding of health disparities in SGM populations.[11] [23] Although the methods of SOGI data collection in a clinical setting has been shown to be acceptable to most patients, barriers to implementation remain.[24] [25] [26] Some barriers include limited information technology infrastructure and lack of provider and staff knowledge and training.[26] In response, tools are increasingly being built within electronic health records for recording SOGI data. However, accurate data collection relies on adequate training, and implementation remains widely variable. Even where infrastructure for SOGI data collection is adequate, collection may be limited by a lack of patient trust, and as indicated above, the perceived safety of clinical encounters is known to impact a patient's willingness to disclose their sexual orientation or gender identity.[13] [27] [28] As such, it is important that providers establish trust and ensure comfort in discussing sexual health and gender identity sensitively to enable accurate SOGI data collection and facilitate quality clinical care.

 

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Special Topics in Colon and Rectal Surgery in Sexual and Gender Minority Populations

Beyond broad barriers to clinical care, some SGM populations are at risk for specific conditions that colorectal surgeons should be familiar with. Below we highlight two of these: anal cancer screening in SGM populations and the management of recto-neovaginal fistula (RNVF) in transfeminine individuals.

 

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Anal Cancer in the SGM Population

Prevalence/Risk

SGMs face an increased risk for certain cancers.[5] [6] [7] [29] [30] In particular, men who have sex with men (MSM) and transfeminine patients have been shown to have a higher risk for anal squamous cell carcinoma (aSCC).[30] [31] MSM who are living with human immunodeficiency virus (HIV) have the highest risk, with a reported incidence of 85 per 100,000 person-years.[30] While some of this risk is incurred from HIV status alone, MSM who are HIV negative continue to have an elevated risk of aSCC, with a reported incidence of 19 per 100,000, compared with the 1 to 2 cases per 100,000 person years at a general population level.[30] This increase in risk has been hypothesized to be attributable to increased human papillomavirus (HPV) prevalence in this population and a higher prevalence of receptive anal sexual intercourse; however, it should be noted that the risk for aSCC has still been demonstrated in MSM who do not engage in receptive anal sexual intercourse.[31]

Anal cancer is highly associated with HPV and is thought to follow similar steps to malignant transformation as cervical squamous cell carcinoma, progressing from HPV infection to high-grade squamous intraepithelial lesion (HSIL) lesions, and ultimately to aSCC.[32] Precancerous HSIL lesions have become a potential target for screening programs, in addition to aSCC itself. Recent data from the ANCHOR trial has demonstrated that appropriate treatment of anal HSIL (aHSIL) significantly reduces the risk of progression to anal cancer as compared with active surveillance.[33] However, conflicting data has arisen from the SPANC trial, a prospective cohort study examining the epidemiology of HPV and anal cancer, indicating that aHSIL has a high incidence and rate of clearance in MSM.[34] As a result, further work is needed to fully characterize the risks and benefits of identifying and treating aHSIL lesions.

 

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Recommended Screening Approaches

There are currently no national consensus guidelines on screening for anal cancer or precancerous anal lesions in SGM populations despite the well-documented elevated risk. For individuals with HIV, the HIV Medicine Association of the Infectious Disease Society of America recommends anal Pap tests at the time of HIV diagnosis for MSM who engage in receptive anal sexual intercourse.[35] Abnormal results should be further evaluated using high-resolution anoscopy (HRA), therefore they recommend screening only when this is feasible.[35] Additionally, they recommend annual screening with digital anal rectal exam and anal Pap testing for those living with HIV and having receptive anal sexual intercourse. Guidelines developed by the New York State Department of Health AIDS Institute recommend that MSM, transgender women, and transgender men aged 35 and older should receive annual digital anal rectal exam and anal Pap testing.[36] For patients receiving screening anal Pap testing, HRA is the gold standard diagnostic testing for anal cancer. Providers must perform approximately 200 HRAs to be proficient enough to reliably detect aSCCs.[31] This can lead to diagnostic delays or misdiagnoses for individuals who are not in proximity to a high-volume provider.

For MSM who are HIV negative there are no screening guidelines, national or otherwise. Proponents of screening cite cost analyses of anal cancer screening in MSM that are comparable to the cost and quality-adjusted life expectancy of cervical cancer screening, a nationally recommended preventive health screen.[37] Other proponents of routine screening note the comparable incidence of anal cancer in this population to other conditions we routinely screen for in the general population, such as breast, colon, and cervical cancer.[30] [38] Until clear guidelines are developed, shared decision making with a primary care or other subspecialty physician, such as infectious disease physicians or colorectal surgeons, should be used to guide decision making.[14] [32] [39]

 

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Considerations in Treatment and Survivorship

Unique considerations are warranted for SGM patients during cancer treatment and survivorship care given the health disparities and discrimination this patient population frequently faces. There has been increasing focus on SGM patients in oncology care on a local and national scale. In 2017, the American Society of Clinical Oncologists released a position statement on strategies for reducing cancer health disparities among SGM populations.[40] Recommendations include improving provider education for culturally competent care, creating safe spaces for SGM patients, and improving SOGI data collection.[40] In spite of growing interest in providing culturally competent care and addressing health disparities in SGM patients, there are significant barriers to be addressed. Similar to studying SGM populations in general, there continues to be a lack of accurate SOGI data in cancer care.[11] This impedes the ability to look at outcomes in the SGM patient population and leads to a significant survivorship bias in many studies. The National Cancer Institute (NCI) turned their attention to this issue in 2022 when they funded select NCI-Designated Cancer Centers to study the implementation of standardized SOGI data reporting.[41]

The issue of disclosure of sexual orientation or gender identity may be exacerbated in the setting of oncologic care, given the life-threatening implications of discrimination in this setting. In a recent survey of SGM cancer survivors by the American Cancer Society Cancer Action Network, 48% of respondents chose not to disclose their SOGI data to providers.[42] This may in part be driven by fear of discrimination, as over half of participants in the same survey reported concern about facing discrimination in the health care setting and over a third of patients have experienced some kind of discrimination.

SGM oncology patients also have demonstrable differences in their cancer care and outcomes than their cisgender and heterosexual counterparts. SGM patients report increased levels of emotional distress after a new cancer diagnosis, increased social isolation and decreased shared decision-making during treatment, and overall lower satisfaction with the oncology care they received.[6] [43] [44] While there is insufficient data to assess cancer-related mortality in SGM populations, small retrospective studies have suggested there may be increased cancer-related mortality in lesbian and transgender SGM.[5] [45] [46] Finally, there are few studies on colorectal cancer survivorship in SGM patients specifically. One small qualitative study demonstrated results aligned with the broader body of work on SGM oncology patients, and highlighted issues such as disclosing SOGI data to providers and a desire for communication with providers that is culturally sensitive and not based in assumption.[47] This qualitative study also brings to light the economic impact of a colorectal cancer diagnosis on SGM patients, including struggles with job loss and insurance status.[47]

Lack of provider education remains an identified barrier to care. In 2018, Banerjee et al surveyed oncology providers and only 5% of those surveyed were able to correctly answer seven questions assessing knowledge of SGM health care, despite over 80% of respondents reporting having friends or family in the SGM community.[48] Schabath et al similarly surveyed a subset of oncologists registered with the American Medical Association about SGM patients in 2019.[49] Less than half of providers felt confident in their knowledge of SGM health needs and only a third of providers identified knowing their patient's sexual orientation as important.[49] Barriers identified on qualitative analysis included lack of knowledge, lack of communication skills, and a fear of offending patients.[49] [50]

 

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Gender-Affirming Vaginoplasty and Recto-Neovaginal Fistula

Gender-Affirming Vaginoplasty

Gender-affirming vaginoplasty is a procedure pursued by transfeminine individuals with genital incongruence. Vaginoplasty techniques include penile inversion vaginoplasty, peritoneal flap vaginoplasty, and intestinal vaginoplasty. Penile inversion vaginoplasty is the most commonly performed type of vaginoplasty and includes orchiectomy, shortening of the urethra, creation of the neoclitoris from the glans of the penis, dissection of the neovaginal canal between Denonvillers' fascia and the prostate, and lining the neovagina with a skin graft harvested from the scrotum.[51] Peritoneal flap vaginoplasty involves creating the neovaginal canal from robotically harvested peritoneal flaps and securing these to penile skin, which creates the introitus and distal portion of the vagina.[51] Intestinal vaginoplasty is the least common form of vaginoplasty and involves utilizing either a portion of small or large bowel in creation of the neovaginal canal.[51] Complications following any approach include hematoma, wound dehiscence, issues with urine stream, vaginal stenosis, and rectovaginal fistula (RVF).[51]

 

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Recto-Neovaginal Fistula

RNVFs are an uncommon, but catastrophic complication of gender-affirming vaginoplasty. In a large case series of primary vaginoplasty, the prevalence of RNVF ranges from 0.53[52] to 1.81%,[53] with higher rates observed in smaller series.[54] [55] For secondary vaginoplasty, rates are thought to be significantly higher, nearing 6%.[56] The most common cause of RNVF fistula is rectal injury during vaginoplasty.[57] In the largest published series of RNVF to date, 17.4% of known rectal injuries progressed to RNVF.[56] It is likely that several cases are due to occult rectal injury or local ischemia, as the majority of cases present in the immediate postoperative period.[56] [57] [58] Other reported causes of RNVF include dilation injury, tissue necrosis, and cancer; however, these causes are significantly less common.[56] [59] [60]

 

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Diagnosis of Recto-Neovaginal Fistula

Cases of RNVF are frequently diagnosed clinically in the immediate postoperative period following index vaginoplasty. In many cases, fistula is identified on initial bolster (i.e., neovaginal packing) removal used in penile inversion and peritoneal vaginoplasties when feculent material is noted on the neovaginal bolster.[54] [56] [61] In other cases, fistula is first observed during postoperative neovaginal dilation[62] or is identified due to clinical symptoms such as feculent neovaginal drainage or passage of flatus from the neovagina. Rarely, RNVF can present many years following index vaginoplasty, due to injury during dilation or intercourse.[60] When diagnosis is not clear from clinical symptoms alone, imaging techniques can be considered. Previous approaches include cross-sectional imaging such as computed tomography or magnetic resonance imaging, endoscopic evaluation, and/or fistulography. However, specific clinical algorithms for the use of imaging in RNVF have yet to be developed.

The role of colorectal surgeons in the management of RNVF varies. In cases of known intraoperative rectal injury during vaginoplasty or recognition of fistula in the immediate postoperative period, colorectal surgeons may be consulted by the initial surgeon for assistance in management. Colorectal surgeons may also be called upon to treat delayed or refractory cases of RNVF. Additionally, cases may present to colorectal surgeons for primary management following previous failed attempts at repair.[61] [62] [63]

 

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Management of RVF in Cisgender Women

In cisgender women, the management of RVF is determined by the underlying cause. The most common cause of RVF in cisgender women is obstetric trauma.[64] In traumatic causes, fistulas generally involve well-vascularized tissue and are thus easier to treat. Other causes of RVF include inflammatory processes, such as Crohn's disease, as well as gynecologic or rectal malignancy and associated radiation treatment.[64] [65] [66] Nonobstetric causes generally require more extensive surgical approaches compared with traumatic obstetric causes.[64] [65] [66]

 

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Management of RNVF in Transfeminine Individuals

Repair of RNVF following gender-affirming vaginoplasty often differs from repair of RVFs in cisgender women. The tissue of the neovaginal vault following penile inversion vaginoplasty has different characteristics compared with the vaginal vault of cisgender women. The former is most commonly composed of keratinized squamous epithelium, derived from local flaps and skin grafts.[51] Additionally, scar tissue makes it more difficult to identify the correct planes, limits the tissue available for repair, and increases the overall friability of the tissue.

Management of RNVF in transgender women frequently requires different approaches from those used in cisgender women, although the overall principles of treatment are similar. Like in cisgender women, conservative approaches are attempted initially for smaller fistulas, but more extensive approaches can be required in more complicated cases. Similar to nonobstetric causes of RVF, RNVF often requires a more invasive surgical approach. Many of the same procedures used in cisgender women are also used in the repair of RNVF in transgender women,[60] [63] although some approaches are unique to transgender women.[58]

 

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Nonoperative Management

Conservative management is a common initial step in the management of RNVF. Conservative approaches include local wound care, antibiotics, hygiene measures, such as frequent water rinses and garment changes, and stool-bulking fiber supplements, which are administered in concert to reduce inflammation and promote spontaneous healing of the fistula. There are two reported cases of resolution of RNVF with conservative management alone.[56] [67] The first case, reported by Sarrau et al presented 2 years following initial vaginoplasty with neovaginal bleeding and passage of gas without stool, likely due to acute traumatic causes.[67] The patient was found to have a 1-cm low fistula and was placed on conservative management for symptomatic control while awaiting definitive surgical intervention.[67] On re-revaluation prior to surgery, the fistula had resolved.[67] The second case was reported in a series by van der Sluis et al.[56] Out of 13 cases of RVF reported in this series, 4 patients received conservative management as initial treatment.[56] Of these cases, one resolved with conservative management, while the others required additional surgical intervention.[56] All cases presented within 2 weeks of initial vaginoplasty.[56] Additional reports describe the use of conservative approaches, although in these cases it was either unsuccessful or outcomes were unreported.[54] [63] Conservative interventions are unlikely to resolve RNVF alone. However, these interventions are a useful adjunct to other therapeutic approaches and can be used while awaiting definitive management.

 

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Fecal Diversion

Fecal diversion with either a colostomy or ileostomy is an important part of the management of RNVF. The majority (52.2%) of reported cases of RNVF ultimately require fecal diversion.[52] [53] [54] [56] [58] [59] [60] [61] [62] [63] [67] [68] [69] [70] [71] In several reported cases, fecal diversion alone was sufficient to resolve the RNVF.[62] [68] In two of these cases, the fistula presented shortly following the initial vaginoplasty and diversion was performed immediately.[62] [68] In one case, the RNVF was resolved on follow-up at 4 months.[62] In the other, it spontaneously resolved while awaiting definitive management.[68] Additionally, van der Sluis et al report a case in which fecal diversion has been used following failed primary closure, where it has been sufficient to resolve RNVF without additional surgical repair.[56] In several other cases, diversion alone has been utilized, but outcomes are either not reported,[52] or remain unclear due to patient lost to follow-up or patient still undergoing treatment.[56] In several other reports, fecal diversion was unsuccessfully attempted prior to another intervention.[63] [71]

Even when diversion does not fully resolve the fistula, it may decrease active inflammation and aid in future repair.[62] As in cisgender women with refractory fistulas,[65] fecal diversion is frequently performed for refractory RNVFs. In certain cases of small uncomplicated fistulas in the immediate postoperative period, diversion may not be required.[56] Additionally, some have reported success in avoiding diversion by performing revision sigmoid vaginoplasty.[58] In the majority of more complicated cases, fecal diversion will ultimately be required.[60] [61] [62] [63] [70] [71]

 

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Local Repair

Local repair is commonly used as the initial approach in the management of RNVF and can result in fistula resolution. A variety of local approaches have been utilized. van der Sluis et al commonly employed fistulectomy with closure in layers as an initial approach.[56] Where closure in layers was not possible, local skin flaps or rectal V-Y advancement flaps were used.[56] Successful closure without fecal diversion was reported in 6 of 9 cases in which fistulectomy and local repair were performed as the initial step.[5] Guevara-Martínez et al report on two cases of successful closure using local rectal advancement flaps.[62] Dy et al report management with primary repair using a robotic approach, although they do not report the specific approach, resulting in a smaller, asymptomatic fistula.[69] Local transneovaginal repair was reported by Rossi Neto et al as the treatment of choice for RNVF, however, outcomes are not reported.[53] Additionally, local repair has been combined with dermal xenografts or autologous buccal mucosa and rectal grafts.[54] [60] [62] [71] Local repair is described in the initial step in reports of four cases, which ultimately required further repair.[60] [61] [62] The overall failure rate of local repair remains unclear likely due to reporting bias. Regardless, local repair approaches including fistula excision, direct closure, and endorectal advancement flaps are the preferred initial step in the management of RNVF in cases where tissue quality and availability are sufficient.

 

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Pedicled Flap-Based Approaches

In cases of refractory fistula, pedicled flap-based approaches are a common next step in management. Pedicled flaps have the advantage of bringing well-vascularized tissue to the site of the RNVF, which may itself be poorly vascularized due to scarring. Several pedicled flaps have been described for use in repair of RNVF, including the gracilis flap,[61] [63] the pudendal fasciocutaneous flap,[70] lotus petal fasciocutaneous flap, and the gluteal artery fasciocutaneous flap.[56] Depending on individual anatomy, muscle flaps such as the gracilis may be more technically challenging to perform in transgender women due to smaller pelvic outlet size and may restrict the size of the neovaginal canal. As a result, fasciocutaneous flaps may be preferred when feasible. In the majority of cases, flap-based approaches result in fistula resolution and should be considered as the next step if less invasive approaches are unsuccessful.

 

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Coloanal Anastomosis

Coloanal anastomosis is a common approach for repair of refractory RVF in cisgender women and has been reported in the repair of RNVF in transgender women. Bandi et al report resolution of RNVF following delayed colonic pull-through and coloanal anastomosis (i.e., Turnbull-Cutait) in two cases.[60] In one case, the patient had a fistula which had not resolved following several attempted gracilis flap repairs.[60] In the other, immediate ileostomy, local repair, and hyperbaric oxygen therapy were attempted without success, prior to ultimate resolution with coloanal anastomosis.[60] Coloanal anastomosis is a viable option to repair refractory fistulas, including those in which pedicled flap-based approaches have failed.

 

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Revision Vaginoplasty

Revision vaginoplasty is another approach described for the repair of RNVF. Pansritum et al describes the use of revision sigmoid vaginoplasty with a rectoprostatic fascia reinforcement flap in seven cases with no return of fistula at 1 year.[58] Advantages to the approach include the avoidance of fecal diversion. Drawbacks to this approach include the need for sigmoid resection, which may limit other reconstructive options such as coloanal anastomosis. In addition, this procedure is more invasive than other approaches and requires sigmoid vaginoplasty, which some patients may not prefer due to mucous drainage. Newer approaches to revision vaginoplasty, such as peritoneal pull-through have also been reported in the repair of RNVF and resulted in successful resolution of RNVF.[60]

 

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Conclusion

SGM individuals represent a growing population that is likely underappreciated in colon and rectal surgery. This may manifest in both the ways providers communicate with patients and how data are collected on SGM populations. The unique challenges in screening for specific cancers, treatment, and outcomes in SGM populations for many conditions of the gastrointestinal tract remain unexplored. Here, we provide guidance in communication with SGM individuals and discuss the role of the colorectal surgeon in the management of anal cancer screening and RNVF.

Table 1 Terminology and definitions

Terminology	Abbreviation	Definition
Sexual and gender minorities	SGM	Includes sexual minority individuals, such as lesbian, gay, and bisexual individuals, as well as those who hold other nonheterosexual identities, such as asexual or queer. Also includes gender minorities, such as transgender and nonbinary individuals[2]
Lesbian, gay, bisexual, transgender, queer	LGBTQ	A colloquial term used to describe a subset sexual and gender minority (SGM) individuals. In academic work, SGM is used to encompass a broader range of possible identities. Here, we primarily use SGM, but include LGBTQ for contextual purposes
Sexual orientation and gender identity	SOGI	Sexual orientation refers to the gender of a person's physical, emotional, and romantic attachments.[2] Gender identity is a person's internal sense of being male, female, or some other gender.[2] The term SOGI is generally used to describe data collected from patients to describe their sexual orientation and gender identity
Transgender and gender-diverse	TGD	Includes individuals who identify as transgender as well as individuals whose gender identity or expression differs in some way from their assigned sex at birth
Men who have sex with men	MSM	Used to describe individuals' sexual behavior, rather than sexual orientation. The term MSM can describe gay or bisexual identified men but can also include men with a heterosexual identity who engage in sexual relationships with men[72]
Transfeminine	–	Encompasses both transgender women as well as gender diverse or gender nonbinary individuals who are assigned male at birth who identify as partially or fully feminine[73]

 

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Conflict of Interest

None declared.

Acknowledgment

The authors would like to acknowledge William M. Kuzon, Jr., MD, PhD, for his critical evaluation and feedback of this manuscript.

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Publication History

Article published online:
25 April 2024