Of all U.S. adults, 5.6%–or over 18 million people–identify as part of the LGBTQIA+ community.¹ This has increased from 4.6% in 2017 reports. A total of 0.6% of U.S. adults consider themselves transgender, based on the 2020 Gallup survey.¹ Because the U.S. Census does not ask about gender identity, these numbers are an estimate based on surveys and interviews. Additionally, the number of nonbinary LGBTQIA+ adults in the U.S. is currently estimated to be 1.2 million people from the recently released Williams Institute survey.²

It is well documented that members of the LGBTQIA+ community and particularly transgender individuals routinely experience hostility in the health care setting and have worse health outcomes. For example, gender expansive cancer survivors are twice as likely not to disclose their LGBTQIA+ identity to cancer health care providers compared with cisgender survivors.³ Gender expansive survivors who did disclose their LGBTQIA+ identity were 3 times as likely to report their care as less welcoming afterward. Additionally, gender expansive people are less likely to receive recommended cancer screenings–possibly due to barriers to accessing culturally competent health care providers.³

The urological community is known to be the pioneers in science, research, technology and innovation. Our urological community also has the ability and responsibility to address the disparity in the care received by our LGBTQIA+ patients. We can address this by building inclusive practices in our own communities. The following are first steps to making your practice an inclusive and safe place.

Do not assume one’s gender or sexual orientation. Ask. Utilize Sexual Orientation Gender Identity forms if available. Have your electronic medical records reflect patients’ preferences.

Get training. Start by educating yourselves as well as your office and hospital staff in terminology, preferred pronouns and cultural sensitivity. Online resources include An Ally’s Guide to Terminology⁴ and the Cultural Competence webinar series,⁵ which provide easy-to-implement, user-friendly resources for the clinical setting.

Be inclusive in your office atmosphere by including LGBT- and transgender-friendly signage and brochures, making all-gender bathrooms accessible and reviewing your office intake forms to look for areas to broaden the categories from binary (male and female) to include other options. Additionally, changing demographic questions from “husband/wife” to “spouse/partner” and “mother/father” to “parents” will make the patients who are part of the LGBTQ community feel welcomed, included and seen.

Since 2015, we have seen a steady increase and growth in gender-affirming surgeries offered across the country. The most common complications after genital-affirming surgeries are urological and relate to lower urinary tract and sexual function. As urologists, some of us may feel that transgender care is complex and prefer to refer to centers of excellence. Although complications and consequences of post-gender-affirming reconstructive surgery may be complicated and intricate, the basic evaluation can be performed by any competent and willing urologist. Additionally, our LGBTQIA+ patients suffer from common urological conditions, like lower urinary tract symptoms, voiding dysfunction, nephrolithiasis, hematuria and genitourinary cancers, to name a few, that we are well equipped to evaluate and treat.

Based on the transgender survey from 2017, transgender patients delay their medical care due to poor prior experience with the medical system.⁶ According to our patients, one of the most disheartening comments to hear is, “I was not taught to treat this in training.” Recent graduates are more likely to have exposure to gender-affirming surgery training because we are seeing the expansion of transgender-specific curricula among urology training programs across the country. Additionally, a vast array of resources have been carefully curated by the AUA to support this area of urological training and education. We strongly encourage our urological community to use these resources to enhance and broaden their knowledge. Please refer to the recently updated section on Care of Transgender and Gender Non-Conforming Patients resources at https://auau.auanet.org/core as well as courses from the AUAUniversity and live courses at the upcoming AUA2022.

Given this area’s relatively recent emergence into academic urology, our current literature on outcomes and complications is relatively limited and heavily based on retrospective reviews of individual experiences. As a community of urological gender surgeons and scientists, it is time for us to combine our efforts for a more robust, prospective and longitudinal look into our surgical results. Even more important is patient-reported outcomes reporting. Given the functional and personal nature of these surgeries, patient-reported outcomes are invaluable and key to further advancement of our work.

In summary, it is our responsibility to provide our LGBTQIA+ patients with the full scope of culturally competent urological care. Caring for this patient population with skill and knowledge will help us reduce gaps and delays in screening, diagnosis and treatment of all urological conditions. Expanding our knowledge in gender-affirming surgery will help our patients access care safely and expeditiously.