In order to enhance gender health in professional case management practice, it is important to understand some key concepts in gender, sex and sexuality. This is particularly important when serving sexual and gender minority (SGM) clients in professional case management practice. The purpose of this article is to understand key terms in order to better assess the needs of all clients in developing and implementing case management plans of care that are responsive, respectful and impactful. This article will also address ways for professional case managers to enhance communication and trust while working with SGM clients.

GENDER, GENDER IDENTITY AND GENDER EXPRESSION

Gender is a social construct that refers to the cultural, behavioral and psychosocial characteristics that are typically associated with maleness and femaleness (Lehman, et al., 2020). Gender expression includes the types of clothing, hairstyle, mannerisms and other behaviors that a person displays in order to convey a particular gender. The concept of gender is influenced by the culture, region of the world and time period. For example, ancient Greek and Roman men essentially wore skirts that were considered masculine. Pink used to be associated with maleness, and now in many cultures pink is considered more female. The idea of what is male and female is not stagnant but rather changes as cultures and societies evolve.

Gender identity is based on how one thinks of their gender, and is not dependent on external genitalia. There are individuals who identify as gender non-binary, meaning the person does not identify exclusively as either male or female. A transgender person is one whose gender identity and expression are different from the cultural expectations imposed on them based on the sex they were assigned at birth. In contrast, a cisgender person is one whose gender identity matches the sex they were assigned at birth (Human Rights Campaign). Gender-affirming care is typically sought out by individuals who are transgender, and this can include a range of services, such as counseling, gender-affirming hormone therapy and surgical procedures. The professional case manager should avoid focusing solely on surgical procedures, and assess what the client needs to embrace their gender identity.

Gender expression includes the types of clothing, hairstyle, mannerisms and other behaviors that a person displays in order to convey a particular gender. It is the external appearance of one’s gender. An individual may be fluid with their gender expression, so that for a period of time they may take on the characteristics of what is considered male, and at other times they may take on the characteristics that are considered female.

SEX

It may seem like sex or natal sex is either male or female. Sex refers to the biological traits, including genotype (such as XX and XY chromosomes) and sex genotype (such as external genitalia) with which a person is born. These characteristics result in a newborn’s sex assigned at birth as either male or female.

Like gender identity and sexual orientation, sex is actually on a spectrum. Intersex is an umbrella term used to describe people born with sex traits that do not fit binary medical definitions of male or female sexual or reproductive anatomy (CAP, 2021). There are many variations that reflect naturally diverse human sexual development in genitalia, hormones, internal anatomy and/or chromosomes. There are many challenges faced by intersex clients, especially lack of knowledge by providers of these conditions as well as medically inappropriate procedures that are conducted without the consent of the client. The professional case manager needs to advocate for client consent for those procedures that are medically necessary based on clinical guidelines.

SEXUALITY

Sexual orientation is an inherent and immutable enduring characteristic regarding one’s sexual attraction to other people (Human Rights Campaign). A person’s sexual orientation is not the same as gender identity. Sexual orientation is about the sexual and/or romantic attraction to others. There are decades of evidence that sexual orientation is on a spectrum, and therefore is not binary. Sexual orientation may also evolve over time, so an individual may change their feelings about who they are attracted to.

TIPS FOR PROFESSIONAL CASE MANAGERS

There are a number of tips drawn from a variety of resources (Nurse.org staff, Fenway Institute and the American Psychological Association):

  • Use the name and pronoun used by the client
  • Honor the identified family regardless of whether it is the family of origin or family of choice
  • Respect the client’s choice to disclose or to not disclose their gender identity and/or sexual orientation
  • Use the language the client uses to identify themselves
  • Engage in on-going learning and development regarding the needs and preferences of sexual and gender minority clients as well as LGBTQ+ inclusive resources
  • Use gender neutral language when communicating with clients, such as using terms like spouse/partner, parent, etc.
  • Ask open-ended questions and acknowledge your appreciation to the client when they reveal personal information about themselves and/or their family and caregivers
  • Become aware of the physical, mental, societal and spiritual challenges faced by the members of the LGBTQ+ community
  • Advocate for timely and appropriate gender-affirming care for clients who are transgender and gender non-binary while consulting with legal experts on the impact of legislation and court rulings about gender-affirming care in affected jurisdictions
  • Assess and address behavioral health conditions, social determinants of health, literacy, health literacy, digital health literacy and health insurance literacy
  • Refer patients to LGBTQ+ providers by using available provider directories, such as GLMA: Health Professional Advancing LGBTQ+ Equality, United States Professional Association for Transgender Health (USPATH), FOLX Health, OutCare and InterAct: Advocates for Intersex Youth

SUMMARY COMMENTS

For sexual and gender minority clients, it is even more important to foster cultural safety (Mukerjee, et al., 2022), that includes the five main tenets.

The professional case manager should provide services that incorporate these tenets, advocacy and the other values (such as health equity) that meet the needs of LGBTQ+ clients. This requires an on-going journey of learning about the needs of the LGBTQ+ community and resources to improve the access to, experience of and outcomes from health and community services.

REFERENCES

American Psychological Association (APA) LGBTQ Resources and Publications, https://www.apa.org/pi/lgbt/resources.

CAP, Key Issues Facing People with Intersex Traits, https://www.americanprogress.org/article/key-issues-facing-people-intersex-traits/ Accessed 7/15/2025.

Fenway Institute; Organizational Strategies and Inclusive Language to Build Culturally Responsive Health Care Environments for Lesbian, Gay, Bisexual, Transgender, and Queer People, https://fenwayhealth.org/new-paper-provides-strategiesfor-making-health-care-environments-more-inclusive-for-sexual-andgender-minorities/ Accessed 7/15/2025.

FOLX Health Clinicians, https://www.apa.org/pi/lgbt/resources Accessed 7/15/2025.

GLMA: Health Professionals Advancing LGBTQ+ Equality, LGBTQ+ Healthcare Directory, https://www.apa.org/pi/lgbt/resources Accessed 7/15/2025.

Human Rights Campaign (HRC) Glossary of Terms: https://www.hrc.org/resources/glossary-of-terms Accessed 7/15/2025.

InterAct: Advocates for Intersex Youth, https://interactadvocates.org/intersexmedical-resources/ Accessed 7/15/2025.

Lehman, J.R., et al. (2022). The equal curriculum: The student and educator guide to LGBTQ health. Springer Publishing Company, LLC.

Mukerjee, R., et al. (2020). Clinician’s guide to LGBTQIA+ care: Cultural safety and social justice in primary, sexual, and reproductive care. Springer Publishing Company, LLC. Nurse.org; 10 Tips for Caring for LGBTQIA+ Patients, https://nurse.org/articles/culturallycompetent-healthcare-for-LGBTQ-patients/ Accessed 7/15/2025.

OutCare, The OutList LGBTQ+ Affirming Healthcare Directory, https://www.outcarehealth.org/outlist/ Accessed 7/15/2025.

United States Professional Association for Transgender Health (USPATH), Provider Directory, https://app.wpath.org/provider/search Accessed 7/15/2025.

Michael B. Garrett, MS, CCM, CVE, has more than 40 years of experience in case management, including government and private sector benefit programs (e.g., Medicare, Medicaid, and health plans). He has focused on improving health equity for historically underserved communities. He has served on the Commission for Case Manager Certification and URAC’s clinical accreditation committee. He currently serves on the editorial board of Professional Case Management, URAC’s health equity council, and CMSA’s DEIB committee. He holds a Bachelor of Arts in psychology, and a Master of Science in clinical psychology. He is board certified in case management and vocational evaluation.

Image credit: ANDREY_POPOV/SHUTTERSTOCK.COM