Challenges and Opportunities for Advancing Research and Improving Care for Sexual and Gender Minorities With Inflammatory Bowel Disease

As of 2022, approximately 7.1% of individuals living in the United States identified as lesbian, gay, bisexual, transgender, queer, intersex, asexual, or another sexual or gender diverse minority (LGBTQIA+).¹ While there is a great diversity of identities encompassed within the LGBTQIA+ community, many of the challenges encountered in healthcare are shared. Inequities in access to care, disparities in health outcomes, and issues related to stigma are common among this patient population and span multiple areas of clinical care.²

Within the field of gastroenterology and inflammatory bowel disease (IBD) specifically, there has been little research exploring the healthcare experiences and perspectives of LGBTQIA+ individuals. Unique medical challenges may be prevalent for this group, particularly at the intersection of IBD and sexual health. Among patients with IBD, the gastrointestinal and extraintestinal manifestations of disease, as well as various medications and surgical procedures utilized in management, are a common cause of sexual dysfunction.³ Certain sexual and gender minority (SGM) groups are also disproportionately impacted by issues associated with sexual health, such as an increased prevalence of sexually transmitted infections (STIs) and gynecologic and anorectal cancers.⁴ These issues may be further complicated by factors known to influence patients’ disclosure of symptoms, including sexual stigma and fear of discrimination, both important determinants of health for LGBTQIA+ individuals.^5,6 Further research efforts that investigate the impact of IBD on the sexual health of LGBTQIA+ patients may serve as an important step toward inclusive and culturally sensitive care for this diverse patient population.

In a recent study published in Gut, Mansoor et al⁷ identified an increased prevalence of IBD in men who have sex with men (MSM) compared with men who have sex with women. They searched TriNetX, a large population-based database encompassing 58 U.S. healthcare organizations, to identify individuals with self-reported sexual orientation and examined International Classification of Diseases–Tenth Revision codes specific for high-risk heterosexual activity or high-risk homosexual activity. The authors examined demographic details, clinical characteristics, and medical management of 851 patients with ulcerative colitis or Crohn’s disease and compared those with high-risk homosexual behavior with those with high-risk heterosexual behavior. Their results showed that MSM with high-risk homosexual activity, compared with men who have sex with women with high-risk heterosexual activity, were more likely to have a diagnosis of Crohn’s disease (odds ratio, 1.64; 95% confidence interval, 1.29-2.09) and ulcerative colitis (odds ratio, 2.45, 95% confidence interval, 2.35-3.34). Mansoor et al hypothesized that the increased prevalence of IBD identified may be due in part to the specific microbiome features present among this population.⁷ Prior studies have shown that MSM may harbor a distinct gut microbiome with significantly richer and more diverse fecal microbiota in comparison with non-MSM individuals. The link between the gut microbiome and the pathogenesis of IBD is well known, with disease activity most prominent in intestinal regions that harbor the highest numbers and maximal diversity of bacteria.⁸ This study is groundbreaking in that it is the first of its kind to describe the epidemiology of IBD among SGMs on a large scale. One important limitation is that women identified as having high-risk homosexual activity were excluded from the study due to low number of patients with a diagnosis of Crohn’s disease or ulcerative colitis.

With evidence to suggest an increased prevalence of IBD among certain SGM groups, further investigation may be valuable in delineating the potential impact of IBD manifestations and management strategies on sexual health for this patient population. Specific features of IBD, including perianal fissures, fistulae, and proctitis, may contribute to unpleasurable or painful receptive anal intercourse (RAI), a sexual practice that is common but not exclusive to SGM individuals and MSM.⁹ Certain surgical interventions such as the ileal pouch–anal anastomosis (IPAA) may also impact postoperative RAI engagement. IPAA surgery involves removal of the colon and rectum with attachment of the J-pouch to the anal canal. Decreased elasticity of the ileum in comparison to the rectum may increase the risk of damage to delicate suture lines during intercourse.⁹ One study investigating the disease-related concerns of gay and lesbian patients with IBD found that patients often experience a sense of loss following operative IBD management, specifically citing IPAA-related restriction of preferred sexual activity as a contributing factor.¹⁰ For some patients the surgical creation of an ostomy, another procedure commonly used in the operative management of IBD, has been associated with a decrease in sense of sexual attractiveness and desirability and issues related to intimacy.¹¹ This surgical outcome may result in especially harmful effects for gay and bisexual men, a patient population shown to experience higher rates of body image disturbance.¹² Surgical intervention involving the bowel often serves as an essential step in certain gender-affirming procedures.¹³ For patients who undergo a sigmoid vaginoplasty, there may be additional considerations for those with IBD, as the long-term outcomes and potential postsurgical complications associated with chronic inflammation of the neovagina remains an area for much needed research.¹³

In the absence of reliable, published data regarding the sexual health risks and limitations associated with IBD surgery, patients often resort to patient-initiated blogs to obtain advice regarding the safety and feasibility of RAI and other issues related to sexual health.⁹ Further research is warranted to determine evidence-based recommendations for safe receptive intercourse in the setting of IBD flares and in the postsurgical setting.

Among select LGBTQIA+ groups, there is an increased risk of STIs as well as gynecologic and anorectal cancers; however, the impact and potential overlap of IBD with this risk remains largely uninvestigated.⁴ IBD with rectal involvement and/or perianal disease may compromise the integrity of anorectal tissue, potentially increasing the risk for traumatic abrasions and exposure to viral pathogens such as HPV during receptive intercourse.⁹ Among gay and bisexual men, an increased prevalence of HPV has led to higher rates of intra-anal HPV-related cancer, particularly for those over the age of 45 years.¹⁴ Unprotected RAI is an important risk factor for STIs including Neisseria gonorrhoeae and Chlamydia trachomatis; however clinical and histological findings associated with proctitis due to STIs may be difficult to differentiate from inflammation related to IBD, potentially resulting in misdiagnosis.¹⁵ While research is limited, there is also evidence to suggest a higher prevalence of cervical cancer among lesbians, bisexual women, and women who have sex with women, possibly due to lower rates of cervical cancer screening.^16,17 Similarly, women with IBD may experience increased rates of high-grade cervical dysplasia and cancer, particularly among those receiving immunosuppressive therapy.¹⁸ Whether this risk is compounding for SGM women with IBD is unknown. Future research may provide increased insight of STI and malignancy risk among SGM patients with IBD.

Effective patient–clinician communication is essential in determining appropriate screening, disease prevention interventions, and timely management recommendations for sexual health issues among both IBD patients and those who identify as LGBTQIA+.⁶ Many gastroenterologists report challenges associated with inquiring about sexual health for patients with IBD, citing reasons such as a lack of time, deficiency in knowledge on the matter, and personal discomfort with the topic.¹⁹ A reluctance to discuss the impact of disruptive bowel symptoms on sexual functioning has also been documented among patients with IBD.⁵ Concern for anti-LGBTQIA+ bias and internalized stigma may hinder disclosure of symptoms related to sexual dysfunction for SGM persons.^5,6 Additionally, is not uncommon for SGM adolescents and young adults to conceal their sexual orientation and/or gender identity from healthcare providers. For many patients, the timeline of initial sexual identity discovery and acceptance may align closely with that of IBD diagnosis, potentially complicating conversations regarding sexual functioning and IBD.^20,21

LGBTQIA+ inclusive practices implemented at the level of patient–clinician interactions, paired with strategies designed to create a safe and welcoming clinical care setting, may result in an increase in patient trust and an improvement in the overall healthcare experience for sexual and gender minorities with IBD. Using open-ended questioning and gender-neutral language, gastroenterologists may be empowered to carry out thorough gastrointestinal-related sexual health histories that inquire about sexual partners, symptoms of sexual dysfunction, and high-risk exposures. Patients identifying as LGBTQIA+ have a significantly increased lifetime risk of experiencing sexual and physical trauma; thus, implementing trauma-informed physical exam techniques, particularly as they relate to the rectal and IBD-specific perineal exam, may be of increased importance for SGM patients.²² Prioritizing the use of patients’ preferred names and pronouns, utilizing intake forms and documentation that include a range of sexual orientations and gender identities, and providing patients with educational information inclusive of SGM health topics, are general steps to aid in the establishment of an LGBTQIA-friendly clinical environment.⁴ Finally, ensuring opportunities for continued clinical training on topics relevant to LGBTQIA+ health may be useful in ensuring that trainees and healthcare providers are well equipped with the knowledge and skills to care for members of the SGM community.²³

Findings presented by Mansoor et al have demonstrated an increased prevalence of IBD among certain SGM groups, highlighting opportunities in research to identify and characterize the likely multidimensional overlap of IBD and sexual health issues among LGBTQIA+ individuals. Investigation of the safety of RAI in the presence of IBD flares and following certain surgical procedures is warranted. Additionally, research to determine precise estimates of STIs as well as anal and cervical cancer prevalence among SGM patients with IBD may be useful in the development of screening guidelines for those at highest risk. Last, supporting research that explores the overall perceptions and experiences of SGM patients as they seek and receive care for IBD is a critical step in advancing equitable IBD care for LGBTQIA+ patients.

Conflicts of Interest

None declared.

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