Sexuality and sexual medicine

Safe and fulfilling sexual activity can be an important part of a healthy lifestyle. Safer sex requires education and awareness of the risks involved in sexual activity as well as taking precautions to mitigate these. Risks include infection (e.g., HIV, HPV, gonorrhea, syphilis), which is best prevented with barrier protection (e.g., condoms or dental dams); injury (from unsafe practices such as asphyxiation or from accidents resulting from potentially hazardous practices, e.g., bondage play), which is best prevented through prior education about the practices engaged in; and unintended pregnancy, which is best prevented with oral, barrier, or other forms of contraception. As a category of biological classification, “sex” refers to the binary division of most living beings into “male” and “female” based on their chromosomal, phenotypical, and reproductive traits; the category of “intersex” comprises various types of ambiguous chromosomal and phenotypical sex, generally, due to a disorder of sex development (DSD). In contrast to “sex,” the term “gender” refers to one's identity as male, female, or a variety of nonbinary configurations based on social, cultural, behavioral, and environmental factors rather than biological ones. Sexual orientation is the prevalent pattern of an individual’s sexual and emotional attraction to other individuals. People worldwide continue to experience discrimination, persecution, and marginalization based on their sex, gender, and sexual orientation. The ongoing struggle of women's rights, LGBT+, and other movements has raised awareness of the underlying injustices and advanced changes in culture and legislation promoting sexual/gender equality and empowering communities to openly live and advocate for their lifestyle. This has had a great impact on health care not only in terms of clinically addressing the needs of minority groups but also in terms of providing a safe and nonstigmatizing setting for all individuals to seek and receive reaffirming and medically appropriate health care. Accordingly, sexual medicine involves not only the treatment of gender- and sexuality-related disorders and sexually transmitted infections, but, moreover, includes the provision of counsel and support regarding topics of sexual development, sexual activity, gender identity, and sexual orientation.

Physiological aspects of sexuality, such as sexual development and the sexual response cycle are also discussed in this article. For disorders, see the articles on “Gender-and sexuality-related disorders” and “Differences (disorders) of sex development”.

Sex and gender are concepts that have always been subject to flux and negotiation but have diversified immensely in the past decades with the increasing recognition of LGBT+ rights worldwide. For the sake of clarity and consistency with the consensus in medical literature, “sex” will be defined in terms of physiology, whereas “gender” will be defined in terms of identity, representation, society, and culture. However, the glossary below and definitions should not be considered exclusive, exhaustive, or definitive in encompassing the entire spectrum of sexual/gender identity and expression.

The distinction between male and female based on an individual’s sexual phenotype and/or genotype. While sex most commonly aligns with the corresponding gender and heterosexuality, the categories of sex, gender, and sexual orientation are not inherently contingent on one another.

• Chromosomal sex: sex based on the XX (female) and XY (male) genotype
• Phenotypical sex (morphological sex; somatic sex): the physical manifestations of sex comprising the genital organs and secondary sexual characteristics as determined by an individual’s chromosomal and, subsequently, hormonal constitution.
• Sex assigned at birth
  • The male (assigned male at birth, AMAB) or female (assigned female at birth, AFAB) sex is generally assigned to an individual at birth by a physician, midwife, nurse, and/or relative on inspection of the infant’s genitals.
  • Children with ambiguous genitalia are typically assigned the sex most consistent with their external genitalia. With cffDNA testing more widely available, sex may also be assigned at birth based on chromosomal makeup as well as the external genitalia.
• Intersex
  • The congenital presence of chromosomal, gonadal, and/or phenotypical patterns that do not fit binary notions of male or female sex.
  • Individuals with intersex traits may identify as “intersex,” but gender identity is not inherently contingent on phenotype or genotype and individuals may also identify as otherwise nonbinary, male, or female.
  • The term "intersex" is the historical term for a group of conditions referred to today as "Differences (disorders) of sex development" (DSD).
  • While often still used synonymously in the literature and sometimes preferred by patients and advocacy groups, the term “intersex” can be distinguished from “DSD” and should not be confused with “transgender” (see below).
    • Depending on the DSD, intersex traits may be evident at birth (ambiguous genitalia), only become apparent with puberty, or never develop at all; accordingly, intersex may be considered a feature of some DSD, but not every DSD can be considered intersex.
    • Independently of the presence of intersex traits, some DSD pose a considerable health risk if left untreated (e.g., increased risk of breast and testicular cancer in Klinefelter syndrome), while others (e.g., double Y syndrome) may not require treatment.
  • Medically unnecessary surgery should not be offered before an age at which the patient can give informed consent.
• Transsexual
  • The historical term for “transgender” or “intersex” is generally considered stigmatizing today.
  • Although sometimes still used in literature when referring to transgender individuals who are undergoing or have undergone gender transition, the term should be avoided unless preferred by the patient.

Traditionally, an individual’s self-identification and self-expression according to the binary categories of male or female as informed by social, cultural, behavioral, and environmental factors associated with sex, the term today furthermore recognizes the relationship between masculinity and femininity as a spectrum that includes a wide range of gender-diverse identities. While gender identity typically corresponds to sex assigned at birth, it is also a social construct that may develop independently of sex.

• Gender identity
  • An individual’s personal and internal sense of being male, female, any combination of the two, or neither
  • Typically, formed by three years of age
  • Either described as cisgender or gender diverse (see below)
• Gender expression
  • The external representation of gender through culturally informed attitudes and behaviors, e.g., external appearance, mannerisms, gender roles
  • Typically reflects gender identity, though this is not necessarily the case

Cisgender

“Cisgender” describes a binary gender identity in alignment with sex assigned at birth, i.e., male or female.

• Cismale: a male individual who identifies as definitely male
• Cisfemale: a female individual who identifies as definitely female

Gender diversity

Gender diversity is the fair and equitable representation and inclusion of individuals of all genders in society and recognizes and addresses the fact that gender is a spectrum that goes beyond the binary framework.

• Gender diverse (gender nonconforming, gender nonbinary, gender variant, genderqueer)
  • Not aligned with the traditional understanding of gender as a binary construct
  • While often used as an umbrella term for gender identities that do not align with sex assigned at birth (e.g., transgender), the term “gender diverse” should be understood to encompass the entire spectrum of gender
• Transgender
  • The identification with a gender that does not correspond with the sex assigned at birth
  • Often used synonymously with “gender diverse” or “gender nonbinary,” but this is imprecise and should be avoided as transgender individuals may identify as nonbinary gender diverse or as binary male or female.
    • Transmasculine (transgender man; female-to-male or female-to-nonbinary individual, FTM/FTX): male-leaning or diverse gender identity in an individual assigned the female sex at birth
    • Transfeminine: (transgender woman; male-to-female or male-to-nonbinary individual, MTF/MTX): female-leaning or diverse gender identity in an individual assigned the male sex at birth
• Bigender (pangender, androgyne): identity that comprises both male and female gender
• Gender neutral (agender): identity that does not align with the notion of having a gender
• Genderfluid: identity in flux between genders
• Third gender: identity of a gender besides male and female as defined by oneself and/or society (e.g., Hijras in the Indian subcontinent, Khanith in Oman, and two-spirit identities in the United States)

Gender identity, gender expression, sex, and sexual orientation may not align with binary cisgender heterosexuality.

Gender diversity is not a disorder, but it may cause clinically significant distress leading up to, e.g., gender dysphoria.

Gender transition and affirmation

• Gender transition: the process of recognizing, accepting, embracing, and expressing a gender identity that is not in alignment with the sex assigned at birth
• Gender affirmation: the process of undergoing the social, legal, and/or physical changes necessary to complete gender transition; may involve gender-affirming hormone therapy and/or surgery
• Gender-affirming hormone therapy
  • Administration of hormones to induce the development of secondary sexual characteristics matching an individual’s transgender identity
  • See “Principles of transgender health care.”
• Gender-affirming surgery (formerly “gender-confirming surgery” or “sexual reassignment surgery”)
  • Surgery to modify an individual’s physical appearance to match their transgender identity
  • See “Principles of transgender health care.”

The prevalent pattern of an individual’s sexual and emotional attraction to other individuals. Like gender, sexual orientation is regarded today as a spectrum rather than a rigid classification of identities. Accordingly, while gender-conforming heterosexuality represents the dominant pattern of sexual orientation and behavior, an individual’s gender, sex, and sexual orientation as well as the sexual practices in which they engage may be in flux and are not necessarily contingently aligned. .

• Heterosexuality (straight)
  • Sexual attraction to individuals of the opposite sex
  • May also be defined as attraction to the opposite gender independent of sex assigned at birth (e.g., a transgender man who is attracted to women may identify as heterosexual)
• Homosexuality
  • Sexual attraction to individuals of the same sex
    • Gay: male homosexuality
    • Lesbian: female homosexuality
  • May also be defined as attraction to the same gender independent of sex assigned at birth (e.g., a transgender man who is attracted to men may identify as gay)
• Bisexuality
  • Sexual attraction to individuals of the same as well as the opposite sex, often in varying and/or fluctuating degrees
  • For many, bisexuality also encompasses having sexual attraction to gender diverse individuals
  • Bi-curious: interest in and/or openness to homosexual experiences despite currently identifying as neither homosexual nor bisexual
• Pansexuality: sexual attraction to people independent of sex, gender, or sexual orientation
• Polysexuality: attraction to individuals of various but not every sex, gender, or sexual orientation.
• Asexuality
  • Absence of sexual attraction to other people
  • Does not imply an inability to emotionally or romantically connect with other people

• LGBT+ culture
  • An umbrella term for the culture shared by lesbian, gay, bisexual, transgender, and queer individuals
  • Communities affiliated with LGBT culture may or may not define themselves based on gender or sexual activities.
• Sexuality-based cultures: cultures based on a shared interest, engagement, and pride in specific sexual activities (e.g., BDSM culture)
• Gender-based cultures: cultures based on a shared gender identity and pride in that identity (e.g., genderqueer culture)

Principles of healthy sexual activity

• Safe and fulfilling sexual activity can be an important part of a healthy lifestyle.
• Sexual activity between two or more individuals is legally contingent on mutual freely given consent and all participants having reached the age of consent, with any individual being having the right to revoke consent and stop the activity at any time.
• While the development of a sex-positive attitude is an important aspect of human health, awareness of potential risks involved in sexual activity (e.g., infection, injury, unintended pregnancy) is no less important.
• It is important for physicians to address issues of sexuality and sexual health openly and without prejudice.
• The glossary below serves to aid clinicians in communicating topics of sexual health openly with patients and can by no means cover the entire spectrum of human sexual activity.

Sexual intercourse (sex)

Sex comprises any form of physical sexual contact between two or more individuals, frequently but not always to the point of orgasm. The term “sex” is sometimes used more restrictively for penetrative intercourse only.

• Nonpenetrative: sexual intercourse not involving penetration
  • Mutual oral and manual nongenital stimulation
  • Foreplay: the engagement in acts aimed at mutual sexual stimulation in preparation for further sexual activity; may involve kissing, tactile stimulation, or oral sex
• Penetrative: sexual intercourse involving the penetration of the vagina, anus, or mouth with any part of the body or object
• Anal: sexual intercourse involving the erotic stimulation of another individual’s anus; may or may not be penetrative
• Vaginal: sexual intercourse involving the erotic stimulation of another individual’s vagina; may or may not be penetrative
• Oral: erotic stimulation of another individual using the mouth
  • Anilingus (analingus, colloquially referred to as “rimjob”): oral stimulation of another individual’s anus
  • Cunnilingus: oral stimulation of another individual’s vagina, vulva, and/or clitoris
  • Fellatio (colloquially referred to as “blowjob”): oral stimulation of another individual’s penis
• Manual: erotic stimulation of another individual using the hands
  • Handjob: manual stimulation of another individual’s penis
  • Fingering: manual stimulation of another individual’s vagina, vulva, and/or clitoris

Masturbation ^[1]

Masturbation is the practice of sexual self-stimulation, usually to the point of orgasm.

• Normal activity in individuals of all ages, usually beginning during adolescence
• Only considered excessive if associated with significant distress and impaired social or occupational function e.g., skipping school/work to masturbate
• Excessive and/or compulsive masturbation is not classified as a separate mental disorder in DSM-5. However, depending on manifestations, it can be diagnosed as an other sexual dysfunction, an impulse control disorder, or an obsessive-compulsive disorder.

Abstinence

The term abstinence describes the conscious and deliberate refraining from masturbation and/or sexual intercourse.

• Virginity: an individual’s state before their first penetrative intercourse
• Celibacy: the state of abstinence from marriage and/or sexual intercourse; in the narrow sense, applied to persons who have taken a religious vow
• Incel (involuntary celibate): an online community based on the shared inability to find a sexual partner despite the desire for sexual partnership

Varieties of sexual practices

• Polyamory: the practice of intimate relationships with multiple mutually consenting partners
• Monoamory: the practice of an intimate relationship with a single partner
• Men who have sex with men (MSM): practice of a male sex individual regardless of sexual orientation having sexual intercourse with another male sex individual
• Women who have sex with women (WSW): Practice of a female sex individual having sexual intercourse with another female sex individual
• Roleplay: the assuming and acting out of roles in an erotic context
• Cross-dressing (transvestism): the practice of wearing clothes traditionally associated with another sex
  • Individuals may engage in transvestism for a variety of reasons and purposes, not all of which are of a sexual nature.
  • Transvestism is often, but not necessarily, associated with LGBT+ culture and should not be confused with homosexuality or transgender identity.
  • As a performative art (drag), transvestism typically involves the exaggerated representation of another sex for comedic, often satirical, effect.
  • Cross-dressing ; for artistic purposes and in settings where it causes no distress and/or functional impairment to the individual is not a paraphillic condition and should not be diagnosed as transvestic disorder.
  • The cross-dressing and transvestic disorder must furthermore be distinguished from the normal practice of transgender individuals dressing according to their gender identity.
• Body modification: the modification of one’s body, e.g., through piercings or elective surgery
• BDSM: an umbrella term for a variety of practices and roleplay involving bondage and discipline (BD), dominance and submission (DS), and/or sadism and masochism (SM)
• Fetishism
  • Intense sexual arousal focused on an inanimate object or nonsexual part of the human body e.g., feet
  • Often more broadly defined as intense sexual arousal from a specific object, activity, (sexual or nonsexual) part of the body
  • Fetishism is only considered a disorder if the practice is associated with persistent fetishistic urges that cause significant distress and/or impairment of function, in which case it is considered a paraphilic disorder.
• Sex work (prostitution)
  • Engagement in sexual practices for money
  • May but does not necessarily involve sexual contact (includes, e.g., erotic dancing, performing sexual acts via webcam)

Sex-associated risks

• Sexually transmitted infections (STI)
• Unintended pregnancy
• Trauma and injury
• Potentially risky sexual activities
  • Multiple sexual partners → ↑ risk of STI
  • Rough sex (e.g., bondage, (auto)sadism/masochism, asphyxiation/choking) → ↑ risk of injury or death
  • Sex work (involving sexual intercourse)
    • ↑ Risk of STI
    • Exposure to maltreatment/violence

Sex-associated practices

• Contraception
  • Oral contraceptives
  • Barrier contraceptives
    • Condom
    • Diaphragm (contraceptive)
  • Coitus interruptus
  • Basal body temperature method
• Safer sex: the practice of engaging in sexual activities in a way that prevents disease and/or injury
  • Condom
  • Dental dam

Sexual violence

• Any sexual act involving the use of physical or mental force by an individual upon another individual.
• Violent sexual practices between consenting individuals do not automatically constitute abuse, rape, or sexual assault.
• See “Sexual violence” for more information.

Sexual development

• For embryological development of reproductive organs
  • See “Female reproductive organs.”
  • See “Male reproductive organs.”
• Puberty
  • See “Physical changes during puberty.”
  • See “Stages of adolescence.”

Sexuality and aging

The reproductive capacity of women ends at the beginning of menopause (45–55 years), while male reproductive capability is maintained throughout life. Aging has an effect on sexuality and sexual function in both men and women.

Female sexuality

• ↓ Sensitivity to nipple, vulvar, and clitoral stimulation
• Physical and psychological changes that affect sexuality (e.g., ↓ estrogen → vaginal dryness and atrophy → dyspareunia)
• ↓ Sexual activity
• For more information, see “Menopause.”

Male sexuality

• ↓ Amount and quality of sperm
• ↓ Sexual activity
• ↓ Sexual response
• Functional changes become more common in men > 50 years (see “Erection and ejaculation disorders”).

References:^[2]

The sexual response cycle describes the physiological response to sexual stimulation. In women, individual phases usually last longer than in men and are more susceptible to interference. ^[3]

The 4 phases of the Whipple and Brash-McGreer sexual response cycle

1. Desire phase
   • Interest in sexual activity
   • Manifests as sexual fantasies
2. Arousal phase
   • Excitement phase: initiation of physiological changes
     • ↑ Heart rate, blood pressure, respiratory rate
     • Nipples become erect
     • ♂: penis becomes erect, testes become congested and elevated, scrotum tightens (see also “Physiological erection”)
     • ♀: swelling of the clitoris, labia, and vagina; the vagina produces transudate; uterus becomes elevated within the pelvis
   • Plateau phase: enhanced physiological changes with persistent sexual excitement
     • ♂: Increased blood flow from the prostate and seminal vesicle leads to increased secretion of the bulbourethral gland and urethral glands; pre ejaculate (watery, viscous discharge at the external urethral orifice).
     • ♀: Increased secretion from the Bartholin glands leads to the increased production of vaginal transudate (lubrication), increased blood flow to the vagina, and expansion of the labia majora.
3. Orgasm phase
   • Climatic phase of physical arousal
   • Involuntary muscle contractions in the genital and anal regions
   • ♂: ejaculation
   • ♀: contractions of the proximal labia minora, distal vagina, and uterus
4. Resolution phase: The body returns to its physiological baseline.

The 5 Ps of sexual health assessment

Follow the 5 Ps in taking a patient’s sexual history. ^[4]

• Partners: Inquire about the number of sexual partners and sexual orientation.
• Pregnancy: Inquire whether the patient wants to avoid pregnancy or is planning a pregnancy.
• Practices: Inquire about sexual practices (e.g., oral, vaginal, anal)
• Protection against STIs: Inquire about the protective measures against STIs currently used by the patient and their partner(s).
• Past history of STIs: Inquire about history of STIs.

Counseling on safer sex practices

• Risks of unprotected sexual activity
  • STIs (e.g., HIV infection, chlamydia) and and risk factors (e.g., not using condoms, multiple sex partners)
  • Unintended pregnancy and abortion
• Importance of safe, pleasurable sexual experiences that are free from coercion and violence

Counseling on contraceptive options

• Contraceptive methods
  • Discuss the patient's priorities regarding whether and when to have children.
  • If the patient wishes education on contraceptive options, discuss their effectiveness, benefits, and potential adverse effects.
  • Hormonal contraceptive options (reversible)
    • Most effective: contraceptive implants and intrauterine devices with progestin
    • Injectable progestrin, oral contraceptives, and contraceptive patches
  • Nonhormonal contraceptive options
    • Most effective: vasectomy (potentially irreversible), female sterilization (irreversible), and copper intrauterine devices (reversible)
    • Less effective, reversible options include diaphragms (contraceptive) and condoms.
  • For more information on contraceptive methods, see “Hormonal contraceptives” and “Nonhormonal contraceptives.”

Sexuality- and gender-related conditions that may require specific counseling and treatment

• Urogenital malignancies (includes screening and prevention e.g., HPV vaccination, cervical smear)
  • Ovarian cancer
  • Endometrial cancer
  • Vulvar and vaginal cancer
  • Cervical cancer
  • Penile cancer
  • Testicular cancer
  • Prostate cancer
• Infertility
• Sexually transmitted infections
  • HIV infection
  • Syphilis
  • Gonorrhea
  • Chlamydia
  • HPV
• Differences (disorders) of sexual development
• Anomalies of the female genital tract
• Menstrual cycle and menstrual cycle abnormalities
• Puberty
  • Precocious puberty
  • Delayed onset of puberty
• Sexual disorders
  • Sexual dysfunction
  • Paraphilic disorders
• Gender dysphoria

Principles ^[5]

Affirmative care is a model of health care that takes a respectful, validating, and supportive approach to topics of gender identity, sexuality, and sexual relationships. The foundation of affirmative care is awareness for the special needs of and respect for patients with identities beyond the cisgender, heterosexual spectrum. This involves creating an inclusive clinical environment in which patients feel welcome and safe to discuss their health. A respectful and identity-affirming doctor-patient relationship is key to ensuring that all patients, but especially individuals belonging to potentially marginalized minorities who have often experienced discrimination, receive the health care they require.

Inclusive environments

• Try to ensure that registration systems and intake forms allow for including information on “gender identity,” “sex assigned at birth,” “preferred name,” “preferred pronouns,” and “preferred form of address” (e.g., Mr., Mrs., Ms, first name only, other)
• Provide separate all-gender bathrooms, if possible.
• Familiarize yourself with the preferred terminology used in the LGBT+ community.
• Provide training for staff to ensure behavior and language that promotes inclusivity.

Communication ^[5]

• Use gender-neutral language (a style of language that avoids attribution of individuals to binary gender categories) until a setting can be established to ask the patient what name and pronoun they prefer.
• Consider that individuals may be nonbinary, bigender, not identify with any gender, or be uncertain of their gender identity.
• Avoid making assumptions regarding gender identity and sexual orientation and refer to the information provided in the intake form when addressing questions of gender and sexuality.
• Only address questions of gender identity and sexual orientation if it is relevant to the patient's visit.
• Offer open communication about gender identity; Expressing empathy and acknowledging an individual's nonbinary or transgender identity establishes trust with positive effects for an individual's self-affirmation and quality of life.
• Be honest about mistakes made in gendered language and show a willingness to learn and improve.
• Provide information and resources about transgender care and facilitate access to health care services (e.g., gender-affirming therapy) if the patient expresses interest.
• Offer counseling and referral to mental health services if patients show signs of gender dysphoria, major depressive disorder, anxiety, social isolation, and suicidal ideation.
• Reiterate that a nonbinary or transgender identity is not a disorder and that medical attention is unnecessary unless the identity causes physical or mental health issues.
• Reassure patients of confidentiality.
• Only discuss a patient's gender identity with team members or colleagues involved in the patient's care if it is relevant, i.e., the information is needed to address the patient respectfully.

Reporting

• Summarize information provided by the patient to ensure it has been understood correctly.
• Report the patient's gender identity, chosen name, and pronouns used in order to ensure that this information is accessible to all health care professionals involved in the care of the patient.
• If the chosen name does not match the name on medical records or insurance, these documents may be updated to avoid confusion and clerical errors.

Special considerations in youth ^[6]

• Adolescents > 12 years of age should be interviewed alone and confidentiality should be ensured.
• Establish a setting that offers the opportunity to openly communicate about gender identity and sexuality.
• Provide the opportunity for children and adolescents to speak openly about gender and sexuality and do not assume gender binarity.
• Provide information and resources to educate parents, family members, school teachers about transgender and nonbinary identities, transition options, and creating a safe, inclusive environment at home and in one's social surroundings.
• Social transition measures (e.g., changes in clothing, hairstyles, names, and pronoun use) are an option for young individuals to reduce identity-related distress.
• Provide information and resources about medical interventions
  • See puberty suppression
  • See gender-affirming hormone therapy
  • See gender-affirming surgery
• For safety reasons, do not disclose a child’s gender identity to their parents without receiving consent/permission.

Gender-inclusive language in clinical practice ^[5][7]

• Use the patient's preferred name.
• Use the patient's preferred pronoun (e.g., “they,” “ze,” “xe,” “hir,” “per,” “ve,” “he,” “she”) or, if preferences are unknown, the gender-neutral singular “they.”
• Use gender-neutral language and avoid language that implies that gender is binary. For example:
  • Avoid “a physician should care for his patients” and rather say “physicians should care for their patients.”
  • Avoid gendered terms such as “mankind,” “chairman,” and “policeman” and use “humankind”, “chairperson”, “police officer” instead.
  • Avoid phrases such as “he or she,” “male or female,” or “opposite sex” and use open or inclusive terms such as the singular “they,” “gender,” and “another sex”/“other sex.”
• Use gender-neutral age-specific nouns (e.g., infant, child, adolescent, adult) and/or nouns corresponding with the patient's identity (e.g., boy, girl, woman, man, transgender woman, transgender man) instead of “male” or “female” in the noun sense (e.g., “the patient is a 23-year-old woman” rather than “the patient is a 23-year-old female”). “Male” and “female” may, however, be used in the adjectival sense to specify gender-neutral terms (e.g., “male infant”).
• Do not confuse the terms “sex” and “gender” or the concepts underlying them.
• Avoid assumptions about the patient's environment or lifestyle relating to gender identification and sexual orientation (e.g., “do you live in a partnership” rather than “are you married?” or “do you have a husband?”).

International human rights laws pertaining to sex and sexuality ^[8]

• United Nations Charter (Art. 1.3, 3.2, 55.3, 76.3), the Universal Declaration of Human Rights (Art. 2), and the Universal Declaration of Human Rights (Art. 2, 4, 24, and 26), and other international treaties declare and affirm that all human beings have the right to equality and non-discrimination, regardless of nationality, ethnic origin, color, age, sex, gender identity, sexual orientation, health status, disability, or religion.
• Countries that have signed these treaties undertake to promote and protect human rights and fundamental freedoms.

US Federal level discrimination laws ^[9]

• Employment
  • In 2020, the supreme court ruled that employment discrimination based on gender identity or sexual orientation is in violation of Title VII of the 1964 Civil Rights Act, which prohibits discrimination on the basis of national origin, race, color, sex, and religion. ^[10]
  • States and counties may have additional employment nondiscrimination laws.
• Education
  • Title IX of the Education Amendments of 1972, which bans public schools from discrimination based on sex, also encompasses discrimination based on gender identity and sexual orientation. ^[11]
  • States and counties may have additional education nondiscrimination laws.
• Housing
  • The Fair Housing Act prohibits most landlords from discrimination based on gender.
  • The Department of Housing and Urban Development (HUD) bans discrimination based on gender identity and sexual orientation in housing connected to the Department of Housing and Urban Development (HUD) or the Federal Housing Administration (FHA)
• Public accommodations (e.g., restaurants, theaters, hotels, retail stores)
  • Federal nondiscrimination laws protect against discrimination in public accommodations based on race, color, religion, national origin, and disability, but not sex, gender identity, or sexual orientation.
  • The majority of states prohibit discrimination based on sex in public accommodations and in many state courts, these laws are interpreted to include gender identity and sexual orientation.
• Access to healthcare ^[12][13]
  • Federal and state laws prohibit discrimination in health care and insurance coverage based on sex, gender identity, and sexual orientation.
  • Health care plans may not include provisions that exclude certain health care services (e.g., gender-affirming surgery).
  • Insurances must cover appropriate preventive care regardless of sex assigned at birth and gender identity (e.g., breast cancer screening in transgender men with residual breast tissue).

Laws concerning gender marker changes ^[14][15]

• Laws and policies regarding changing the name and/or sex on birth certificates vary from state to state.
• Some states require proof of gender-affirming surgery or a physician's letter confirming gender transition.
• Transgender individuals have the right to obtain passports that reflect their current gender (a physician certificate confirming gender transition is required; surgery is not a prerequisite)
• Social Security records can be updated to reflect the current gender (a government-issued document or physician certificate confirming gender transition is required)
• Several states (e.g., California, Colorado, Oregon) recognize nonbinary genders on drivers' licenses (denoted as gender X).

Organizations & networks

Advocacy groups

• National LGBTQ Task Force ^[16]
• Human Rights Campaign ^[17]
• Equality Federation ^[18]
• Victory fund ^[19]

Youth organizations

• LGBTQ+ Student Resources & Support ^[20]
• Gay–Straight/Gender–Sexuality Alliance (GSA) network ^[21]
• Gay Lesbian Straight Education Network (GLSEN) ^[22]
• Point foundation ^[23]

Legal help

• American Civil Liberties Union (ACLU) ^[24]
• Lambda Legal ^[25]
• LGBTBar ^[26]
• National Center for Lesbian Rights ^[27]

Transgender organizations

• Gender Spectrum ^[28]
• Gender Diversity ^[29]
• National Center for Transgender Equality (NCTE) ^[30]
• Transgender Law Center ^[31]

Military organizations

• Modern Military Association of America (MMAA) ^[32]
• American Veterans for Equal Rights ^[33]

Medical literature and guidelines

Clinical management

• Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 ^[34]
• Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals ^[35]
• Maternal Health in the Transgender Population ^[36]
• Acute Clinical Care for Transgender Patients ^[37]
• Care of Transgender Persons ^[38]
• UCSF Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People ^[39]

Gender confirmation surgery

• Demographic and temporal trends in transgender identities and gender-confirming surgery ^[40]
• Gender Confirmation Surgery: An Update for the Primary Care Provider ^[41]
• Gender Confirmation Surgery: Guiding Principles ^[42]

Hormone therapy

• Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons ^[43]
• Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline ^[44]
• Impact of Hormone Therapy on Laboratory Values in Transgender Patients ^[45]
• Hormone therapy for transgender patients ^[46]

Contraception

• Contraception choices for transgender males ^[47]
• Contraception across transgender ^[48]

Further reading

• Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians ^[49]

Media

• Reading materials
  • Equality Literacy 101 ^[50]
  • Guide to being a trans ally* ^[51]
  • 10 Things You Can Do to Be Trans Ally ^[52]
  • Our Trans Loved Ones ^[53]
  • Pronouns: Why They Matter ^[54]
  • Breaking Binaries ^[55]
• Documentaries
  • The Trans List ^[56]
  • This is me ^[57]
  • We've been around ^[58]