LGBTQ: Culturally Competent Care Considerations Nursing CE Course

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This learning module aims to enable the learner to understand considerations in caring for individuals within the LGBTQ community. This includes understanding a brief history of past care, the continued evolution of healthcare concerns, and an understanding of personal and institutional interventions that will help develop personalized care plans for patients who identify as part of the LGBTQ community.  

By completing this learning module, the learner should be able to:  

• define terms used to describe individuals both within and outside the LGBTQ community 

• identify important early historical events that helped shape healthcare for the LGBTQ community 

• describe goals for improving the health of individuals in the LGBTQ community 

• describe the difference between sexual orientation and gender identity  

• explain healthcare professional (HCP) considerations for providing culturally competent care 

• identify barriers to healthcare for individuals who are part of the LBGTQ community  

Historically, the acronym LGBT was used to describe the community of individuals who describe themselves as lesbian, gay, bisexual, or transgender. At the turn of the 21st century, a "Q" was added to the acronym to include individuals identifying as queer or questioning. As the 21st century has progressed, more letters have been added to the acronym to be more inclusive to all individuals. Although there is debate on the most up-to-date acronym and the meaning for each letter, some organizations have accepted the expanded acronym of LGBTQIA+. The "I" stands for intersex, and the "A" stands for asexual or ally. The plus sign includes all individuals whose identity and/or sexual expression do(es) not fall under the other identified terms. There are many evolving definitions to help describe various groups and how they identify. However, the primary concern is how individuals identify themselves and relate to the descriptions provided (Gold, 2019; LGBTQIA Resource Center, 2020).  

The following is an abbreviated list of commonly used terms and their meanings (Gold, 2019; LGBTQIA Resource Center, 2020; Planned Parenthood, 2022): 

• Androgyne is an individual with a gender that is both masculine and feminine or somewhere between masculine and feminine.  

• Asexual, also known as ace, describes a broad spectrum of sexual orientations. Many individuals who identify as asexual do not feel sexual attraction to other people. This does not mean they are unable to experience romantic or emotional attraction. Asexuality is different from celibacy, which is the desire to engage in sexual activity but choosing to abstain from sex.  

• Bigender describes an individual who identifies as having two genders, exhibiting both masculine and feminine characteristics.  

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  Bisexual identifies an individual with sexual desire for any individual regardless of gender. Some people may use bisexual and pansexual interchangeably. Some people feel using the prefix "bi-" supports a male/female gender binary that is not inclusive enough.  

• Cisgender describes an individual who identifies with their sex assigned at birth.  

• Crossdresser (CD) is used to describe a person who dresses, at least occasionally, in clothing stereotypically worn by a person outside their assigned sex. This term replaces the word transvestite and does not reflect sexual orientation.  

• A drag king is a woman who appears like a man for an act or performance.  

• A drag queen is a man who appears as a woman for an act or performance.  

• Gay refers to an individual with a sexual or an emotional affection toward individuals of the same gender. Homosexual is an outdated term to describe these individuals.  

• Gender is used to classify an individual as a man, woman, or another identity. It is different than the sex a person is assigned at birth.  

• Gender expression is the external appearance of an individual's gender identity, often expressed through behaviors, clothing, appearance, and voice pitch. 

• Gender identity is an individual's innermost concept of being male, female, or neither. It encompasses how individuals perceive and refer to themselves. It can be the same or different than the sex an individual was assigned at birth.  

• Gender-nonconforming (GNC) describes an individual who expresses a gender outside of the traditional norms of masculinity and femininity. The term is often used to describe gender expression instead of gender identity.  

• Gender-fluid describes an individual whose gender identity or expression shifts or is fluid.  

• Gender-neutral describes individuals who prefer not to be described as either gender. These individuals often prefer to use the pronouns they/them.  

• Genderqueer is another term for individuals whose gender expression or identity falls outside the binary norm for their assigned sex.  

• Intersex is a general term used to describe an individual with a body variation that does not fit the conventional definitions of male and female. This includes variations in chromosome compositions, hormone levels, and external or internal sexual organ development.  

• Lesbian is often used to describe a woman who is sexually and emotionally attracted to an individual of the same gender. Some individuals who identify as nonbinary consider themselves lesbians.  

• Misgendering is attributing a specific gender to someone that does not align with their preferred gender identity.  

• Multisexual is a term used to describe being attracted to more than one gender. The term can encompass sexual attractions such as bisexual, polysexual, and omnisexual, to name a few.  

• Nonbinary, or enby, describes an individual who identifies as neither male nor female. These individuals embrace limitless forms of expression and create new ideas of themselves within society.  

• Omnigender is a term that describes someone that experiences all genders.  

• Pansexual or omnisexual describes a person attracted to individuals of all gender identities. The prefix "pan-"means "all," which can be more inclusive than the implied binary constraints accompanying the term bisexual.  

• Pronouns are used to refer to an individual in the third person. In some languages, pronouns are tied to gender identification and contribute to misgendering. Some examples of preferred pronouns include they/them/theirs, she/her/hers, he/him/his, and ze/hir/hirs.  

• Queer is defined as something abnormal or strange. Historically the term queer was used as a slur against individuals whose gender expression or sexuality did not conform with societal norms. Recently, the word queer has been reclaimed and used by individuals opposing assimilation. The term is still considered hateful and derogatory when used by individuals who do not identify as part of the LGBTQ community.  

• Questioning refers to individuals still exploring their gender identity, expression, and sexual orientation. Some individuals use this to represent the "Q" in LGBTQ.  

• Sex is a medically constructed categorization determined at birth, or via an ultrasound, based on the appearance of the external genitalia. Standard labels include male, female, or intersex.  

• Sexual orientation is the emotional, romantic, or sexual attraction or non-attraction to another individual. An individual's sexual orientation can be fluid and span various categories.  

• SOGIE is an acronym describing sexual orientation, gender identity, and expression.  

• Transgender is an umbrella term often shortened to "trans." The term describes individuals whose internal identification of gender differs from the expectations based on the sex they were assigned at birth. It can include a woman who was assigned male at birth, a man who was assigned female at birth, or an individual who identifies as another gender other than female or male (e.g., nonbinary, genderqueer, genderfluid).  

• Transitioning is an individual's process of moving toward living as their true gender. The method of transitioning is different for every individual and may or may not include medical interventions such as hormone replacement or surgery. A complete transition is not needed to validate the gender identification of an individual.  

• The symbol "+" has been added to include everything on the gender and sexuality spectrum that has not yet been described or labeled.  

Gay as a Disease  

LGBTQ is an umbrella term encompassing two distinct facets of identity: sexual orientation and gender identity. Everyone has a sexual orientation: lesbian and gay individuals are primarily attracted to people of the same sex, while heterosexuals are mainly attracted to individuals of the opposite sex. For much of history, being part of the LGBTQ community was viewed as having a disease. Initially, those interested in promoting the message that being gay could be healthy had a single primary goal: overturn the diagnosis of homosexuality as a mental disorder within the field of psychiatry. In 1973, following years of lobbying by gay activists, the American Psychiatric Association (APA) asked members attending their annual convention to vote on whether they believed homosexuality was an illness. If it were not considered an illness, the APA would have to remove the diagnosis of "homosexuality" from the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II). Ultimately, 5,854 voted to remove it, and 3,810 voted to retain it. On December 15, 1973, the APA released a statement stating that homosexuality was no longer considered a mental illness or sickness. The APA also noted support for civil rights legislation and pledged to advocate for the same fair treatment of and protections for homosexuals given to straight individuals. Although the APA removed homosexuality from the DSM-II, it was replaced with "sexual orientation disturbance" for people "in conflict with" their sexual orientation. Only in 1987 was homosexuality removed entirely from the DSM (Landers & Kapadia, 2019; Turner, 2017). 

Early Organization 

The concept of LGBTQ identity only began to emerge in the late 1970s through the formation of the National Lesbian and Gay Health Foundation in 1977, which later became the National Lesbian and Gay Health Association. A growing body of work addressed how homosexuality impacted society during this period. Still, the focus came less from medicine and more from political theory, psychology, social science, sociology, and education. In the early 1980s, concern grew about the lack of information available on the physical and mental health of lesbians. A few young researchers, public health professionals, and HCPs organized the first National Lesbian Health Care Survey. In the 1980s, acquired immunodeficiency syndrome (AIDS) was first identified. The gay community had to face the emergence of a deadly illness that was spreading quickly, with no treatment or cure, for which transmission vectors were only partly understood. Sexually transmitted infections (STIs) and AIDS prompted the LGBTQ community to focus their resources on encouraging the healthcare system to care for and attend to the needs of many gay men, bisexual men, and transgender women, with lesbians, bisexual women, and transgender men frequently at their side as caregivers (Landers & Kapadia, 2019). 

In the 1990s, there were successful attempts in some state and local jurisdictions to include questions about sexual orientation on health surveys such as the National Health and Nutrition Examination Survey (NHANES) and the National Survey of Family Growth (NSFG). For the first time, these questions provided scientifically valid data on LGB respondents (the terminology at the time included only lesbian, gay, and bisexual individuals), enabling public health workers to identify health disparities between LGB people and their heterosexual peers. At the end of the second Clinton administration, with a valid measure of health disparities available for the first time, the US Department of Health and Human Services (HHS) published its Healthy People 2010 document, which included 29 health disparities faced by LGB persons. In addition, they awarded funding to support the first-ever Companion Document for LGBT Health to Healthy People 2010 (which now also included transgender individuals). The Healthy People series is the federal framework for identifying and addressing objectives to improve national health metrics (Landers & Kapadia, 2019).    

Healthy People  

Individuals within the LGBTQ community encompass all races, ethnicities, religions, and social classes. Sexual orientation and gender identity questions are not asked on most national or state surveys, making it difficult to estimate the number of LGBTQ individuals and their health needs. Research suggests LGBTQ individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBTQ persons has been associated with higher rates of psychiatric disorders, substance abuse, and suicide than individuals identifying with socially normative sexual orientation and gender identification. Experiences of violence and victimization are more frequent for LGBTQ individuals and have long-lasting effects on individuals and their communities. Personal, familial, and social acceptance of sexual orientation and gender identity affects the mental health and safety of all LGBTQ individuals. The LGBTQ companion document to Healthy People 2010 highlighted the need for more research to document, understand, and address the environmental factors that contribute to health disparities in the LGBTQ community. Despite this work, there continues to be an ongoing need to increase the number of national, health-related surveys that collect information on sexual orientation and gender identity and expression (SOGIE). To address LGBTQ health issues effectively, HCPs need to collect this information in national surveys and health records securely and consistently. This will allow researchers and policymakers to accurately characterize LGBTQ health and disparities (Office of Disease Prevention and Health Promotion [ODPHP], 2022). 

Understanding LGBTQ health starts with knowing the history of oppression and discrimination these communities have faced. Social determinants affecting the health of LGBTQ individuals primarily relate to oppression and discrimination. One example includes a high rate of alcohol abuse within the LGBTQ community since bars and clubs were often the only safe places where LGBTQ individuals could gather. Another example includes legal discrimination limiting access to health insurance, employment, housing, marriage, adoption, and retirement benefits; a lack of laws regarding bullying in schools; a lack of social programs designed for LGBTQ youth, adults, and elders; and a shortage of healthcare providers who are knowledgeable and culturally competent in LGBTQ health (ODPHP, 2022). 

The newest version of Healthy People—Healthy People 2030—was released in 2020. This version has updated data and objectives based on current issues in health care and the results of the Healthy People 2020 survey. Healthy People 2030 focuses on the health disparities and challenges faced by members of the LGBTQ community. The first step to meeting the needs of the LGBTQ community is collecting population-level data; however, SOGIE is still not included consistently in many state and national surveys (ODPHP, n.d.). The Healthy People 2030 LGBTQ objectives include the following:  

• reduce bullying of LGBTQ high-school students  

• reduce the proportion of LGBTQ high-school students who have used illicit drugs 

• reduce suicidal thoughts in LGBTQ high-school students  

• increase the number of national surveys that collect data on LGBTQ populations 

• increase the number of states and territories that include sexual orientation and gender questions in the Behavioral Risk Factor Surveillance System (BRFSS)  

• reduce the syphilis rate in men who engage in sex with other men 

• reduce the number of new HIV infections and diagnoses  

• increase patient knowledge of HIV status 

• increase access to HIV care (ODPHP, n.d.)  

Several issues will need to continue to be evaluated and addressed over the coming decades, including nationally representative data on LGBTQ Americans; prevention of violence and homicide toward the LGBTQ community, especially the transgender population; resiliency in LGBTQ communities; LGBTQ parenting issues throughout the lifespan; elder health and wellbeing; exploration of sexual orientation and gender identity among youth; the need for an LGBTQ wellness model; and the recognition of transgender health needs as medically necessary (ODPHP, 2022). 

LGBTQ Issues in Healthcare 

As a group, members of the LGBTQ community often experience health disparities. This is caused by a combination of barriers to care, including decreased quality and timeliness of healthcare across the lifespan. One barrier is lower rates of health insurance coverage: members of the LGBTQ community are twice as likely to be uninsured compared to individuals outside of the LGBTQ community, despite advances made by the passing of the Affordable Care Act. In 2020 under the Trump administration, HHS removed the nondiscrimination protections in Section 1557 of the Affordable Care Act for individuals of the LGBTQ community regarding healthcare and insurance coverage. The original document stated that protections due to sex included those based on gender identity, including male, female, neither, or any combination. The latter version removed all references to gender identity, sexual orientation, and the LGBTQ community. Just four days before this change of the ACA, the US Supreme Court ruled to include discrimination based on sexual orientation and gender identity into Title VII of the Civil Rights Act of 1964. The legality of this change, according to HHS, despite the Supreme Court's ruling, was that health care is different than employment and is therefore exempt from the expansion of Title VII (Human Rights Watch [HRW], 2018; Malina et al., 2020; Margolies & Brown, 2019; National LGBT Health Education Center, n.d.; Simmons-Duffin, 2020).  

Another barrier to health for individuals in the LGBTQ community involves not having a primary HCP. Some states still permit HCPs to refuse care for LGBTQ members due to religious or moral beliefs. A national survey conducted by the Center for American Progress in 2017 reported that 8% of lesbian, gay, and bisexual and 29% of transgender respondents were refused care by an HCP due to their gender identity or sexual orientation in the previous year (HRW, 2018; Margolies & Brown, 2019; National LGBT Health Education Center, n.d.; Simmons-Duffin, 2020).  

A long history of bias has made members of the LGBTQ community cautious about the healthcare system, contributing to delayed treatment. Although research indicates explicit bias has decreased among HCPs, implicit bias persists within the healthcare system—even HCPs who are well-meaning lack proper education regarding LBGTQ issues. A national survey conducted in 2015 found the average time devoted to teaching nursing students about the LGBTQ community concerning healthcare delivery and considerations was only 2.12 hours. Another national study found that most practicing nurses have not received training on LGBTQ healthcare issues (HRW, 2018; Margolies & Brown, 2019; National LGBT Health Education Center, n.d.; Simmons-Duffin, 2020).  

Members of the LGBTQ have many of the same health concerns as the general population; however, specific disparities affect the LGBTQ community at higher rates than the public. This is compounded if the person identifying as part of the LGBTQ community is also a racial or ethnic minority (Daniel & Butkus, 2015). Several health-specific disparities affect the LGBTQ community, including the following (Daniel & Butkus, 2015; National LGBT Health Education Center, n.d.; ODPHP, 2022):  

• LGBTQ individuals are more likely to self-report being in poor health.  

• LGBTQ youth are 2-3 times more likely to commit suicide.  

• LGBTQ youth are more likely to experience homelessness.  

• Lesbians are less likely to receive preventative medical care related to cancer. 

• Gay men, and other men who have sex with men, are at an increased risk of contracting human immunodeficiency virus (HIV) and other STIs. These individuals account for over 50% of all HIV and acquired immunodeficiency disease (AIDs) patients in the US.  

• Lesbians and bisexual females have a higher rate of obesity. 

• Transgender individuals have an increased prevalence of HIV and other STIs, victimization, mental health disorders, suicide, and underinsurance.  

• Elderly LGBTQ individuals face barriers such as isolation and a lack of culturally competent care. 

• LGBTQ individuals have a higher rate of tobacco, alcohol, and illicit drug use.  

The minority stress model explains how LGBTQ individuals experience chronic stress living as a sexual or gender minority, impacting their overall wellbeing and resulting in poor health and decreased life expectancy. The stress can arise from concealing their true self or facing discrimination and stigma. Members of the LGBTQ community experience higher rates of depression, suicidal ideation, anxiety, alcohol abuse, smoking, cardiovascular disease, and interpersonal violence than individuals outside of the LGBTQ community (HRW, 2018; Margolies & Brown, 2019).    

Cultural Competence 

HCPs must recognize that sexual orientation is an identity label and may not correspond to the full range of a person's sexual behavior. Everyone also has a gender identity: transgender people identify as a sex other than the one they were assigned at birth, whereas cisgender people identify with the sex they were assigned at birth. The term transgender also includes those who may identify as nonbinary or genderqueer, meaning their gender identity is a combination of male, female, and/or neither. When obtaining a sexual history, HCPs should ask about sexual orientation and gender identity to identify and understand a patient's health risks (Human Rights Campaign [HRC], n.d.-b; Margolies & Brown, 2019). The Centers for Disease Control and Prevention (CDC, 2022) suggests that HCPs utilize the five "P"s to guide dialogue with patients about their sexual history: 

• partners 

• practices 

• protection from STIs 

• past history of STIs 

• pregnancy intention  

The goal of using the five "P"s is to improve patient health and outcomes. Although the information gained can be helpful to the HCP, it is essential not to use the five "P"s to obtain full disclosure from the patient, especially if they are not comfortable discussing this information (CDC, 2022).  

Healthcare professionals should not assume a person's gender, sex, or sexuality. While many healthcare organizations require sex to be documented, a culturally inclusive system will also refer to a person's gender and the name they wish to be called. Staff needs to be educated on capturing a patient's sexual orientation, gender identification, and preferred name and title during the registration process. Clinical terminology can be disrespectful when conversing with patients, so clinicians should use inclusive language and not make assumptions about sexuality. When discussions of historical events or information are necessary, clinicians should still use pronouns to match how a person now identifies (Margolies & Brown, 2019).  

A clinician can use non-gendered language that does not reflect unconscious bias or assumptions, even when asking questions about anatomy or biology. Healthcare professionals need to be aware that how they ask these questions can potentially create a barrier between themselves and the patient, leading to poor healthcare provision and poor health outcomes. All HCPs should undertake culturally competent training. Organizational policies and practices should be reviewed regularly to ensure they are inclusive and engage HCPs and consumers in their development (Margolies & Brown, 2019). 

When discussing a patient's relationships, HCPs should use non-gendered words, listen for how a person describes their partner(s), or privately ask how they identify. Avoid making assumptions by using terms such as boyfriend or girlfriend, husband or wife, or mother or father. How and whether a person chooses to label their relationship should be respected and will differ by individual. For example, a trans woman and her girlfriend may prefer to be described as a same-gender couple, not a straight couple. People in a relationship with someone of a nonbinary gender may choose to be characterized using gender-neutral language, such 

as partner instead of boyfriend or girlfriend and parent or caregiver instead of mother or father. If a patient is in a heterosexual marriage, do not assume their sexuality is heterosexual; ask appropriate questions regardless of marital or relationship status (Margolies & Brown, 2019).  

Transgender Special Considerations 

As defined above, transgender individuals choose to live, dress, and identify as a member of a gender different from the one they were assigned at birth. Individuals who identify as transgender often want to change their physical appearance to match their gender identity. The prevalence of male-to-female transgender individuals is estimated to be 1 in every 11,900 people. The prevalence of female-to-male transgender individuals is estimated to be 1 in every 30,400. Healthcare treatment for these individuals should focus on assisting the patient in achieving unity between their physical appearance and gender identity. The World Professional Association for Transgender Health (WPATH) has created the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender-Nonconforming People to provide clinical guidelines for HCPs treating these individuals. HCPs must accept patient preferences regarding gender identity without passing judgment and refer to individuals by their preferred pronouns and name (Schub & Kornusky, 2018). For more information, see the NursingCE course Transgender Care and Healthcare Considerations.  

Electronic Medical Record 

The barriers to comprehensive and appropriate healthcare for the LGBTQ community begin as soon as they enter a clinic, provider's office, or hospital. Often, patient questionnaires only allow the gender options of male and female, and there is no differentiation between which gender the patient identifies with and which sex was assigned at birth. Over 1 million individuals in the US identify as transgender and answering these questions can be challenging and leave the individual feeling ostracized (Backman, 2021).  

Most healthcare institutions have transitioned to using an electronic medical record (EMR). The EMR serves many purposes, including promoting continuity of care and ease of access to records by patients, their families, and HCPs. Unfortunately, even within the EMR, bias and discrimination are present. Within the EMR, the identification of birth sex has been used to help facilitate patient care needs. For example, when a person is assigned female at birth, the EMR alerts HCPs of preventative testing and assessments the patient should have, including a pap smear or mammogram. The EMR can also determine acceptable laboratory values and medication dosages based on an individual's assigned sex at birth. Including a gender identity area within an EMR can help ensure HCPs use correct pronouns and do not misgender a patient. A separate gender identity field in the EMR allows HCPs to address individuals as they identify but leaves assigned birth sex as initially determined so that preventative screening alerts, medication dosage changes, and laboratory value ranges will stay the same. Healthcare systems that do not have this option may be forced to change the patient's assigned birth sex to address the patient by their preferred pronouns; however, this removes all the gender-specific alerts for the HCP to provide certain health services (e.g., prostate exams and pap smears; Backman, 2021; Burgess et al., 2019).  

In response to this problem within various EMRs, the American Medical Informatics Association has endorsed a two-step self-identification approach to collecting data regarding a patient's SOGIE. This allows individuals to specify their preferred gender identity and the sex they were assigned at birth. This format is beneficial to the patient, as it validates their preferred identity, and to the HCP, as they can interpret testing results and provide preventative care based on each patient's assigned birth sex. For individuals or groups using healthcare data from the EMR to conduct research, this new identification approach will help place patients into the appropriate cohort if gender or sex is a factor. This would also allow for the collection of population-level data and facilitate the meeting of the Healthy People 2030 goals stated above of increasing the number of national surveys that collect data on LGBTQ populations and the number of states and territories that include sexual orientation and gender questions in the BRFSS (Backman, 2021; ODPHP, n.d.).  

Protected Health Information  

In 1996 the Health Insurance Portability and Accountability Act (HIPAA) was enacted into federal law. The purpose of HIPAA is to improve the continuity of health insurance coverage while establishing national privacy standards regarding patient medical information. The health data protected under HIPAA are referred to as protected health information (PHI). Some HCPs and institutions incorrectly use HIPAA to deny LGBTQ patients and families their right to visitation and information (HRC, n.d.-a).  

HIPAA contains several provisions recognizing the different roles family members or other individuals play in a patient's healthcare. HIPAA does not limit any information sharing based on the sexual orientation or gender identification of the patient or the recipient of the PHI. Privacy Rule 45 CFR 160.103 includes language that defines a family member, spouse, and marriage. Marriage consists of all lawful marriages. Same-sex marriage has been recognized since the Supreme Court ruled in the 2015 case of Obergefell v. Hodges that the Fourteenth Amendment requires any state to license a marriage between two same-sex individuals and recognize marriages from outside the state between same-sex individuals as lawful. The term spouse refers to all individuals in a legal marriage regardless of sex or gender. Family members include a person's spouse and dependents of a lawful marriage. These definitions are relevant since HCPs can disclose patient PHI—including location, condition, and death—to recognized family members under certain circumstances. These definitions also apply to the disclosure of genetic information for underwriting purposes. Insurance companies cannot use genetic information, diseases, or disorders of a family member to make underwriting decisions about an individual (Office for Civil Rights [OCR], 2017). The OCR (2017) explains that  

"under the HIPAA Privacy Rule, disclosures to a loved one who is not married to the patient or is not otherwise recognized as a relative of the patient under applicable law generally are permitted under the same circumstances and conditions as disclosures to a spouse or other person who is recognized as a relative under applicable law" (para. 7). 

This clarification occurred following the 2016 Orlando nightclub shooting, as hospitals did not know under what circumstances sharing PHI with a loved one was warranted or protected (OCR, 2017).  

Future Considerations 

Unfortunately, over the last five years, a reemergence of certain biases has affected the care of individuals belonging to the LGBTQ community. This is partly due to policy changes made by the previous presidential administration and specific states (e.g., Illinois, Mississippi, and Tennessee) allowing HCPs and insurance companies to deny care to members of the LGBTQ community based on moral and religious beliefs. This trend backward can be changed with increased education and acceptance. If society becomes less tolerant of the discrimination and bullying experienced by members of the LGBTQ community, those members may feel more safe and secure being themselves. This could increase social visibility and self-esteem and decrease depression, suicide, and substance abuse rates. Better acceptance by HCPs may increase healthcare visits for preventative care, STI treatment, and mental health referrals. This change includes the need for HCPs to be more educated on the LGBTQ community and their specific health risks. There has already been a positive change as more medical schools are incorporating diversity and cultural competence training into their curriculum (Dube Dwilson, 2018).  

The following are recommendations to state and federal entities to decrease the discrimination in healthcare faced by members of the LGBTQ community (HRW, 2018): 

• US Congress 

  • Enact legislation (e.g., the Equality Act) prohibiting discrimination based on SOGIE in all federally funded healthcare organizations, programs, and activities.  

  • Enact legislation (e.g., the Do No Harm Act) preventing individuals and groups from using the Religious Freedom Restoration Act to exempt themselves from federal laws regarding nondiscrimination and healthcare.  

• US Department of Justice 

  • Ensure existing protections are not misused to support or allow discrimination based on gender identity, sexual orientation, and other classifications.  

• US Department of Health and Human Services 

  • Preserve and enforce protections to prevent sexual orientation and gender identity discrimination.  

• State Legislatures 

  • As above, enact legislation prohibiting discrimination based on SOGIE in all state-funded healthcare programs.  

  • Repeal religious exemptions that allow insurance companies and HCPs to deny healthcare services to individuals based on their sexual orientation or gender identity.  

References  

Backman, I. (2021). Addressing gender identity biases in electronic health record systems. https://medicine.yale.edu/news-article/addressing-gender-identity-biases-in-electronic-health-record-systems/ 

Burgess, C., Kauth, M. R., Klemt, C., Shanawani, H., & Shipherd, J. C. (2019). Evolving sex and gender in electronic health records. Federal Practitioner, 36(6), 271-277. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590954/ 

Centers for Disease Control and Prevention. (2022). A guide to taking a sexual history. https://www.cdc.gov/std/treatment/SexualHistory.htm 

Daniel, H., & Butkus, R. (2015). Lesbian, gay, bisexual, and transgender health disparities: Executive summary of a policy position paper from the American College of Physicians. Annals of Internal Medicine, 163(2), 135-137. https://doi.org/10.7326/M14-2482 

Dube Dwilson, S. (2018). LGBTQ healthcare: A look at the present and future. https://www.dignityhealth.org/articles/lgbtq-health-care-a-look-at-the-present-and-future 

Gold, M. (2019). The ABCs of L.G.B.T.Q.I.A.+. https://www.nytimes.com/2018/06/21/style/lgbtq-gender-language.html 

Human Rights Campaign. (n.d.-a). HIPAA and LGBTQ healthcare equality. Retrieved April 27, 2022, from https://www.hrc.org/resources/hipaa-and-lgbt-healthcare-equality 

Human Rights Campaign. (n.d.-b). Sexual orientation and gender identity definitions. Retrieved April 26, 2022, from https://www.hrc.org/resources/sexual-orientation-and-gender-identity-terminology-and-definitions 

Human Rights Watch. (2018). You don’t want second best. https://www.hrw.org/report/2018/07/23/you-dont-want-second-best/anti-lgbt-discrimination-us-health-care 

Landers, S., & Kapadia, F. (2019). 50 years after stonewall, the LGBTQ health movement embodies empowerment, expertise, and energy. American Journal of Public Health, 109(6), 849-850. https://doi.org/10.2105/AJPH.2019.305087 

LGBTQIA Resource Center. (2020). Glossary. https://lgbtqia.ucdavis.edu/educated/glossary 

Malina, S., Warbelow, S., & Radix, A. E. (2020). Two steps back - rescinding transgender health protections in risky times. The New England Journal of Medicine, 383(21), e116. https://doi.org/10.1056/NEJMp2024745 

Margolies, L., & Brown, C. G. (2019). Increasing cultural competence with LGBTQ patients. Nursing, 49(6), 34-40. https://doi.org/10.1097/01.NURSE.0000558088.77604.24 

National LGBT Health Education Center. (n.d.). Providing inclusive services and care for LGBT people. Retrieved April 26, 2022, from https://www.lgbtqiahealtheducation.org/wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People.pdf 

Office for Civil Rights. (2017). Guidance on HIPAA, same-sex marriage, and sharing information with patients’ loved ones. US Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/special-topics/same-sex-marriage/index.html 

Office of Disease Prevention and Health Promotion. (n.d.). Healthy people 2030: LGBT. US Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt 

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Turner, A. (2017). #Flashbackfriday: Today, in 1973, the APA removed homosexuality from list of mental illnesses. https://www.hrc.org/news/flashbackfriday-today-in-1973-the-apa-removed-homosexuality-from-list-of-me