Sexual health for people who are not straight

Sexual health services have improved considerably and a great deal of general health advice still assumes heterosexual, cisgender patients, which produces gaps that are avoidable.

The principle

Clinical risk follows practice, anatomy and partner networks rather than identity.

Which means the useful clinical question is what someone does and with whom, not how they describe themselves — and it means that assumptions in either direction cause missed testing.

The most common failures: not testing extragenital sites; assuming women who have sex with women need no screening; assuming anyone in a long relationship is not at risk; and not asking at all.

Testing sites

The single most important practical point.

Chlamydia and gonorrhoea infect the throat and rectum, frequently without symptoms.

Urine testing alone misses a substantial proportion of these infections, which then persist and transmit.

Which means anyone who has receptive anal or oral sex should be offered throat and rectal swabs, and these are self-taken in most services.

If they are not offered, asking for them is entirely reasonable.

Men who have sex with men

Guidance in most countries recommends more frequent screening — commonly at least annually and more often with multiple partners.

Hepatitis A and B vaccination is recommended, and HPV vaccination is offered in many countries to men who have sex with men up to a specified age, since they do not benefit from herd effects of female vaccination programmes.

Pre-exposure prophylaxis for HIV is highly effective and is a standard part of prevention where available.

Anal HPV and its association with anal cancer is a recognised concern, with screening approaches varying by country and not universally implemented.

And syphilis has risen substantially in several countries, with early diagnosis mattering considerably.

Women who have sex with women

Where the largest gaps in care sit.

Transmission of HPV, herpes, trichomonas, bacterial vaginosis and syphilis occurs between women, and the assumption that it does not has produced substantially lower rates of screening in this group.

Cervical screening is required on the same basis as for any woman with a cervix, and evidence consistently shows lower attendance driven partly by incorrect advice from clinicians.

Barriers for shared toys, gloves and dams reduce transmission, and are used less than they might be partly because they are rarely mentioned.

And contraception may still be relevant depending on practices and partners, which is another assumption worth not making.

Trans and non-binary people

Where care is frequently poor and the requirements are straightforward.

Screening should be based on the organs present rather than on gender marker: anyone with a cervix needs cervical screening; anyone with a prostate retains prostate-related considerations; anyone with breast tissue has breast health considerations.

Systems that invite by gender marker routinely fail to invite trans men for cervical screening, which is a known and correctable administrative problem.

Gender-affirming hormone therapy affects tissue and sexual function: testosterone can cause vaginal atrophy and dryness, which is treatable with local oestrogen and which is frequently not raised; oestrogen affects erectile function and fertility.

Fertility preservation should be discussed before starting hormones.

Hormone therapy is not reliable contraception and does not prevent pregnancy.

And after genital surgery, care requirements are specific and specialist input matters.

Finding care that works

Practical steps.

Specialist sexual health services generally have more experience and better protocols than general practice for this.

Many areas have services specifically for LGBTQ patients.

Registering accurately with a service, including organs present, improves the automated invitations for screening.

Being direct about practices at the outset saves a great deal of time.

And a clinician who is uncomfortable or uninformed is a reason to see someone else rather than to conclude the care is unavailable.

Mental health alongside

Worth including because the evidence is unambiguous.

Rates of depression, anxiety, self-harm and substance use are higher in LGBTQ populations, and the evidence attributes this to minority stress — discrimination, rejection and concealment — rather than to identity.

Which means the clinical response is support and affirmation rather than investigation of the identity, and that services which get this wrong actively deter people from seeking care of any kind.

Family acceptance is one of the strongest protective factors identified, which is worth knowing for anyone reading this about someone else.

General information only, not medical advice. Consult a sexual health service or qualified clinician — screening should be based on the organs you have and the sex you have.