Spinal cord injury in sexual and gender minority individuals

Abstract

Sexual and gender minority (SGM) individuals face disparate access to and outcomes within healthcare, however little is known about spinal cord injury (SCI) in SGM populations. The term SGM is used in clinical and research settings to describe individuals who are minoritized based on their sexual orientation, gender identity and/or gender expression. This includes, but is not limited to, those who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ). Studies have shown that SGM individuals have particular disparities in health, including higher rates of disability and younger age at disability onset compared with heterosexual, cisgender (non-transgender) peers. Spinal cord injury is a significant source of morbidity and mortality worldwide, and the burden of SCI morbidity is experienced disproportionately in marginalized communities. Approximately 5.6% of the US population, or 18 million individuals, identify as LGBT, and this is likely an underestimate. If rates of SCI in SGM individuals mirror that of the general population, this estimate means that there are approximately 1000 new SGM individuals with SCI annually and over 16,000 SGM individuals living with SCI in the US alone. The SGM community is growing, with 1 in 6 adult members of Generation Z identifying as LGBT, however almost nothing is known about the experiences and needs of SGM individuals with SCI. In addition to new motor, sensory and autonomic impairment, SCI is associated with a broad range of symptoms, including chronic pain, cognitive impairment, depression, and changes in sexual function. These symptoms may differentially affect SGM individuals. Cognitive concerns after SCI, for example, may exacerbate existing disparities in rates of dementia and subjective cognitive impairment in SGM people. Disparities in mental health are well described in SGM populations, which may worsen after SCI. The SGM community also has higher rates of substance use, which could alter pain experiences after SCI as well as influence clinicians’ willingness to prescribe adequate pain control. Individuals who experience SCI may experience changes in sexual function that require dedicated counseling and management. If clinicians approach discussions assuming heterosexuality (heteronormativity) and cisgender identity (cisnormativity), they risk alienating their patients and losing an important opportunity to improve quality of life after SCI. Clinicians therefore need the skills to discuss sexuality in an inclusive and non-judgmental manner. Another aspect of SCI care in gender minority (GM) individuals that remains unexplored is the role of gender-affirming hormone therapy (GAHT). GM people may choose to use GAHT, including feminizing hormones (estrogens, antiandrogens, progestogens) or masculinizing hormones (testosterone). Research suggests that estrogen, progesterone, and testosterone may be neuroprotective in the setting of SCI. In animal models, estrogen helped to alleviate neuropathic pain after SCI. It remains unknown, however, if GAHT influences outcomes after SCI in GM individuals. Dedicated research in GM people using GAHT is needed as the formulations, dosing, and goals of hormones used for gender affirmation differ from hormones used in cisgender people for hormone replacement therapy. The consequences of SCI extend beyond the physical; SCI affects a broad range of socioeconomic factors that directly and indirectly influence health. For example,