Discover the Rainbow

Portrait of K. Michael Rowley PhD ’18

Unpacking the LGBTQQIA+ acronym with a discussion about the intersection of identity and biology. 

November 2019

Understanding the unique challenges LGBTQQIA+ folks face as patients requires an understanding of the intersection of identity — a concept of self — and biology — a person’s physiology. An accessible route to grasping the complex interactions of identity and biology is to simply walk through the commonly used acronym. In mainstream sources, the shortest version I’ve seen is LGBT, and the longest is LGBTQQIAA+, with any variation in between. For this article’s purposes, I’ll use LGBTQQIA+. The “A” I’m leaving off stands for LGBT “allies.” While we appreciate and need their support, this article isn’t about them, so I’ll focus on LGBTQQIA+. This acronym includes terms describing sexual orientation, gender identity and at least one term describing biological sex. We’ll introduce the terms in these categories:


The Human Rights Campaign defines sexual orientation as “an inherent or immutable enduring emotional, romantic or sexual attraction to other people.” Some of these terms — lesbian, gay and bisexual — may be the most familiar to you. The modern concept of sexual orientation is often attributed to Alfred Kinsey, who wrote his famous Kinsey Reports in the early 1950s, describing how large portions of American men and women either fantasized about or engaged in same-sex relations. He and his colleagues developed the Kinsey Scale, which ranks sexual orientation on a scale from 0 (“exclusively heterosexual”, i.e. straight) to 6 (“exclusively homosexual”, i.e. gay or lesbian), with any value in between.

A person who experiences sexual or romantic attraction to both their own and other genders may identify as bisexual or pansexual. There is also a “null” category, of sorts, describing persons who do not have sociosexual contacts or reactions. In the Kinsey Scale, this is denoted with an “X,” and in our acronym this is described by the term asexual. One way to be inclusive of diverse sexual orientations in the clinic is to avoid assumptions and to use gender-neutral terms like “partner” or “person” instead of “husband,” “wife,” “boyfriend” or “girlfriend.”


Gender identity is someone’s innermost concept of themselves as a man, woman, some of both or neither and includes both how people perceive themselves and what they call themselves. We all have a gender identity, most often “man” or “woman.” For most of us, our innermost concept of our gender matches the biological sex we were assigned at birth. For example, I was assigned the sex of male at birth because I was born with a set of XY chromosomes, external genitalia and testosterone-producing gonads. I also identify my gender as a man, whatever that means to me and to the society/culture in which I live. Because these match, I am “cisgender” or “cis.”

For someone who was assigned a biological sex at birth that does not match their gender identity, they are “transgender” or “trans.” There are also many people who don’t identify as a man or a woman, but as some of both or neither. This is where you may hear terms like “genderqueer,” “gender non-binary” or “genderfluid.” Sometimes these individuals also identify as “transgender” since the sex they were assigned at birth does not match their gender identity.

It’s important to mention that gender identity is beginning to be characterized as a physiological feature of neural pathways, thus putting it at the cutting-edge of how biology and identity intersect. There is new and exciting neuroimaging research that shows important similarities between the brains of trans people and the brains of cis people of the same gender identity as opposed to cis people of the same sex assigned at birth. As we learn more about what gender is — neurologically, biologically, culturally, personally — our understanding of trans issues will continue to evolve.

A mention of pronouns is warranted here as well. If you run in progressive spaces, you may have been asked to introduce yourself with your name and your pronouns. This is a way of informing others about your gender identity and how you would like to be described. A man may say, “My pronouns are he/him/his.” A woman may say, “My pronouns are she/her/hers.” A person who identifies as genderqueer, gender non-binary or another gender may say, “My pronouns are they/them/theirs.”

In clinics, allowing patients to indicate their pronouns on intake forms and adding pronouns to staff name tags are two easy ways to be inclusive of trans or non-binary patients. Some documentation platforms are allowing for this as well, now that “non-binary” is an officially recognized gender on driver’s licenses and state IDs in California.

Importantly, there is a lot of variation in a trans person’s expression, preferences and goals. The now somewhat dated term — transsexual — technically describes someone who undergoes one or more interventions like hormone replacement therapy (HRT) or gender affirmation surgery to change their sex characteristics to match their gender identity, a process called “transitioning.” There are trans people who have transitioned, who are in the process of transitioning and who do not plan to transition.

It is generally considered impolite to ask a trans person about their transition process or plans. In a healthcare field, it may be necessary to know about surgical history, HRT or other interventions. My suggestion to clinicians who need to broach this topic with their patients is to make it clear why you need to know the information before asking.


The conventional narrative is that biological sex is binary and static throughout our lives. Is that true? To answer this question, we need to know what defines biological sex. Traditionally, sex is defined by our chromosomes, our genitals and gonads, our hormones and our secondary sex characteristics. All but one of these is changeable through HRT and surgical interventions. And not a single one is binary. Sex chromosomes can be found in at least six variations — the traditional XX and XY as well as X, XXY, XYY and XXX. Nonbinary variations in genitalia and gonads also exist, including vaginal agenesis, ovotestes, mixed or complete gonadal dysgenesis and hypospadias. Sex hormone variations include conditions such as androgen insensitivity syndrome and adrenal hyperplasia.

The American Journal of Human Biology in 2000 published a review of medical literature from 1955 to 1998 and reported that 1 in 100 births exhibited at least one of these variations. These individuals fit the definition of intersex, not conforming to a standard definition of male or female. Many activists are concerned about the incidence of cosmetic surgeries on infants to normalize the appearance of their genitalia, sometimes even without informing parents. This same study reported that 1-2 in 1,000 newborns received such surgery, equating to about 8,000 per year in the United States.


The term “queer” is often used as an umbrella identity for any sexual or gender minorities who are not heterosexual or cisgender. In the past, queer was a slur used against the LGBT community. In the late 1980s, queer scholars and activists began to reclaim the word to unify and distinguish the community. Today, people who seek a broader and perhaps deliberately ambiguous alternative to the traditional LGBT labels may describe themselves as queer. Because of the former negative connotation of the word, it is always a good idea to let someone identify themselves as queer before using the word to describe them.

Questioning is an important part of the acronym and may represent the largest group of individuals in any of the identities discussed so far. Understanding our own sexual orientation or gender identity is a process and may be fluid, especially in a society where the default assumption is heterosexual and cisgender. A study by Ott et. al. in Archives of Sexual Behavior (2010) followed 13,840 persons over 13 years and reported 2 percent described being “unsure” of their orientation at some time. Being unsure or questioning also doesn’t mean someone will necessarily identify as LGBTQ+. This same study reported two-thirds of those “unsure” individuals identified as heterosexual in future reports. Identities can change and evolve throughout life. It’s important, especially when working with patients, to remain non-judgmental and supportive if identities change over time, whether that is a sexual orientation identity or a gender identity as you may be seeing a patient during their transition.

Finally, the “+.” The plus sign symbolizes love, acceptance and embracing of all sexual and gender identities. It serves as an inclusive and intentional way of representing different identities and experiences. Though we categorize them into a few discrete options, in reality there are as many sexual and gender identities as there are humans on the planet. The identities we’ve discussed here may not fit for someone, and we welcome them into our community, regardless. We include this + as a reminder that however you identify is welcome.

Now that you have a deeper understanding of these terms, I’m proud to introduce myself to you with the words I use to describe my identities: I am Michael Rowley, a gay, cis, queer man. Thank you for devoting time to learning about how to better serve your LGBTQQIA+ patients and for being that additional and important “A” — an ally. For more resources, check out the Human Rights Campaign, GLAAD or ask a trusted friend or colleague about their experiences and identities.

inMotion Spring 2019 CoverThis story originally appeared in inMotion, the official publication for the USC Division of Biokinesiology and Physical Therapy. Read more stories like this in our Spring 2019 issue.

Posted May 2019