Sexual orientation and gender identity are core elements of the human experience. Historically, people identifying as sexual minorities have broadly experienced inequities in health care and employment. Changes in social norms and cultural climate have led to an increased awareness of these issues and advocacy work. There has recently been an increased wave of interest in diversity, equity and inclusion (DEI) in almost all facets of health care including our specialty of urology. This encompasses the full spectrum of medicine including direct patient care, research, education and workforce. Attention to LGBTQ+ population needs is a central part of DEI work in health care. The acronym stands for “lesbian, gay, bisexual, transgender, queer or questioning.” The “+” symbol represents other sexual orientations and gender identities including supportive straight allies.

There has been a general paucity of scholarly research and policy efforts related to urological issues in sexual minorities. We are starting to see some increased work in this field. I have selected a few recent studies and programmatic efforts to highlight.

Several years ago, a summit was organized by interdisciplinary faculty at Memorial Sloan Kettering Cancer Center in New York which sought to develop a national action plan for LGBTQ+ community needs regarding cancers.¹ This included genitourinary cancers, and urological issues following cancer care such as continence and sexual health. I was proud to be part of that research team, and it has been encouraging to see programmatic initiatives and other efforts that have stemmed from this work. Similarly, I have been honored to be part of the AUA DEI TaskForce that has been working over the past year. You will soon hear and read more about that ongoing work and future goals.

As experts in the field of sexual medicine, urologists are uniquely positioned to provide high quality health care for our LGBTQ+ patients. Every day we help people with extremely personal and private clinical issues. Creating a welcoming and supportive professional environment that fosters trust and rapport is crucial to success. Simon Rosser and colleagues have published favorable results on feasibility and acceptability of routinely collecting sexual orientation and gender identity data in urology and oncology clinics.² Many health systems have incorporated this into electronic medical records.

Epidemiological research has shown sexual minority men and women may experience sexual health problems at similar rates compared to heterosexual people, but that their needs and practices may differ.³ Additionally, it appears sexual minority men may experience higher overall rates of urinary incontinence. Recent studies have also shown differences in mental health parameters between older and younger LGBTQ+ veterans, and between LGBTQ+ veterans living in rural or small town communities versus suburban and urban settings.^4,5 Other work has shown older adult LGBTQ+ patients may have unique needs related to palliative and end-of-life care which can include specific urological or sexual health issues.⁶

Transgender health care has recently gained increased attention across the full spectrum of health care. It has also become a focal point for cultural debate at the state level, with multiple legislative bodies working to pass statutes that could limit access to needed health services, particularly for transgender youth. Multiple professional organizations including the AUA and other urological societies are taking an active role working to advocate for patients and their families, and help shape current and future health care policy.

More reconstructive urologists are starting to perform gender affirmation surgery, and it is now being included as part of the formal curriculum in many urological residency and fellowship training programs. We are seeing more continuing education offerings and professional meetings incorporating programming on transgender health care. Research is also expanding. Chen and colleagues recently published a study examining factors associated with fertility planning among transgender youth.⁷ This pilot survey with 18 transgender adolescents and young adults identified 5 key thematic areas including future parenthood desires, individual experiences with gender dysphoria, family values about biological parenthood, financial considerations and provision of fertility information. Other research has led to development of a validated patient self-report tool for postoperative aesthetic and urological outcomes of feminizing gender affirmation surgery in transwomen.⁸

Northwestern University has recently opened a clinical center dedicated to providing urological health care for gay and bisexual men.⁹ This includes patients who identify as men who are gender-nonconforming or gender-nonbinary. Urologist Channa Amarasekera, MD serves as the program director, and the group works in conjunction with the Northwestern Medicine Gender Pathways program which serves transgender patients. Hopefully, similar urology clinical programs will be developed and implemented at other centers across the country to address LGBTQ+ needs. This group has recently published results of a pilot survey study of sexual health outcomes in a cohort of 53 gay men treated for prostate cancer.¹⁰ In heteronormative research, questions about sexual function tend to focus only on erectile function. For gay and bisexual men, this excludes other domains of sexual function that may be important to them. These data showed 76.5% felt the standard questionnaire used to assess erectile function was applicable. However, it also identified 64.2% of gay men felt the prostate was an important source of sexual pleasure, and 52.8% felt it was important to assess sexual satisfaction associated with receptive anal intercourse. These results highlight a need for additional validated survey instruments specifically relevant to lived experiences of men who have sex with men.

Education is a crucial component of fostering better care for LGBTQ+ patients. From my own observation, we are starting to see more residency applicants and medical students expressing an interest in learning about urological health care issues specific to LGBTQ+ patient groups. For many years, our University of Kansas medical students have conducted free health care clinics for underserved patients in our metropolitan area. The highly regarded program has won several awards for excellence over the years. It provides hands-on early clinical experience for students training under supervision of experienced clinical faculty members. Recently, they have started holding regular monthly clinics focused specifically on care for transgender patients. This has several important implications. It provides an access point for quality care for patients who may need these types of services but who have challenges accessing more traditional established medical care systems. It also fosters a strong, positive educational environment for clinicians-in-training to develop core skills and attitudes necessary to provide high quality services in their future practices.

There is a great deal of work yet to be done regarding LGBTQ+ issues in urology. Expanded opportunities for research and clinical training are certainly needed. This would include developing and increasing targeted research funding to address health care gaps for the LGBTQ+ population. Other ongoing initiatives are examining urological workforce issues including efforts to expand and promote DEI. This includes urologists, other urological health care providers and researchers who themselves identify as members of the LGBTQ+ community. We need to continue to look for opportunities to come together and support each other on this journey.