All patients, including SGM patients, have unique identities, histories, and healthcare needs. The National Academy of Medicine recognizes that while often grouped as LGBTQ, these patients represent incredibly diverse populations3 with different health concerns.1; 2 Broadly speaking, sexuality is the biological, psychological, social, and cultural factors that contribute to pair or romantic bonding, and/or reproduction.3 This includes sexual orientation, which is the emotional and/or sexual attraction individuals have toward others.4; 5 Sex refers to a labeled designation—typically male or female—that reduces complex genetic, hormonal, and developmental factors into a binary grouping. Individuals are assigned a sex designation at birth based on the appearance of their external genitalia. However, it is essential to recognize that this practice does not always accurately identify one’s sex or sexual development. Gender refers to social and cultural factors expected to align with sex designated at birth, including gender identity and gender expression. Gender is often assumed to be binary, relying on the idea that men and women are opposite sides of a continuum. However, gender is significantly more complex. Gender identity is an individual’s internal sense of gender, including the binary genders of female/woman or man/male, or genders outside of binary designations (non-binary), or perhaps another internally felt gender. Sex designated at birth and gender identity may align (e.g., cisgender) for some people but not for others (e.g., transgender).6 Finally, how individuals present their gender to the external world is referred to as gender expression (e.g., hairstyle, clothing, voice).7 Some individuals may experience gender and sexuality as unchanging, identifying with the same categories throughout their lives, while others will experience fluidity, occupying different types during their lifetimes.8
To illuminate the complexity associated with these ideas, the Gender Unicorn (see Figure 4.1) visually shows how sex designated at birth, gender identity, gender expression, and patterns of romantic attraction are separate but interrelated concepts.6 The Gender Unicorn helps represent these concepts, illustrating how their unique and particular combinations contribute to the rich diversity among people.
Figure 4.1. The Gender Unicorn