Discrimination and difficulty accessing healthcare persist. Here’s what some nurses are doing to bridge the gap in LGBTQ+ health disparities.
As a queer nurse and lesbian, gay, bisexual, transgender, and queer (LGBTQ+) nurse educator, Clare Madrigal, BSN, RN, knows the disparities and barriers that LGBTQ+ patients face in accessing health care. Although many healthcare organizations have increased their focus on the needs of LGBTQ+ patients, stigma and discrimination still exist. A 2022 study conducted by the Center for American Progress (CAP), found that over 30% of LGBTQ+ respondents reported at least one negative experience or form of mistreatment by healthcare providers over the past year.
“The lack of cultural competence within the healthcare system contributes to the many health disparities the LGBTQ+ community faces,” said Madrigal, who works as an LGBTQ+ nurse educator at Sibley Memorial Hospital in Washington, D.C., and as an ER nurse at Frederick Health Hospital in Frederick, Maryland. “Although some nursing schools are beginning to teach how to provide culturally competent care to LGBTQ+ patients, this hasn’t always been the case.”
In fact, a 2021 study found that 2.12 hours is the average time spent on LGBTQ+ healthcare content in the nursing school curriculum. In her role as an LGBTQ+ resource nurse, Madrigal serves both as a resource and advocate for LGBTQ+ patients and staff and provides training to employees through ongoing workshops.
Realizing many other providers, healthcare organizations, and private practices also needed guidance in creating an inclusive environment for their LGBTQ+ patients, Madrigal founded REACH: Rainbow Education and Consulting for Health in 2019. She offers both in-person and virtual workshops that address the differences between sexual orientation and gender identity, how to use inclusive language, and health issues faced by the LGBTQ+ community.
At work, Madrigal wears a rainbow pin with her pronouns and introduces herself to patients by saying, “I’m Clare, and I use she/her pronouns. How would you like to be addressed?” She also recommended avoiding assumptions by asking patients, “Who do we have here in the room with you?” so patients can introduce their family member or partner. She then asks if it’s OK to discuss medical issues in front of them. “Sometimes nurses and other medical staff are afraid they will offend or say the wrong thing, and they allow their fear to prevent them from saying anything at all,” Madrigal said.
As more hospitals and practices begin collecting Sexual Orientation and Gender Identity (SOGI) data on electronic health records or intake forms, Madrigal said this can help nurses to better offer inclusive care while also making LGBTQ+ patients feel validated. SOGI information typically consists of a patient’s legal name, preferred name, preferred pronouns, legal sex, and sex assigned at birth.
Making inclusive care a priority
Josiane Hickson, EdD, RN, NE-BC, Senior System Nursing Education Manager for Orientation and Onboarding at Mount Sinai Health System in New York City, said implementing policies, practices, and programs that best serve LGBTQ+ patients and their families is a priority at Mount Sinai.
Last year, the health system received a top score of 100 and the designation of “LGBTQ+ Healthcare Equality Leader” in the Human Rights Campaign Foundation’s 15th anniversary edition of the Healthcare Equality Index (HEI). The HEI is the national LGBTQ+ benchmarking tool that evaluates healthcare facilities’ policies and practices related to LGBTQ+ patients, visitors, and their employees.
Hickson oversees employee orientations offered twice a month at Mount Sinai’s eight campuses that include training on providing affirming and inclusive care to LGBTQ+ patients.
“We also offer additional training throughout the year, as well as online learning modules and virtual training sessions on topics such as Unconscious Bias, Using Patient Preferred Names and Pronouns, and Eliminating Health Disparities and Improving Outcomes,” Hickson said. “After the trainings, nurses report an increased understanding of how to provide culturally competent care to LGBTQ+ patients.”
In addition, staff are encouraged to use the AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) Communication Framework that was introduced in the mid-1990s and enables healthcare professionals to engage patients in a way that demonstrates empathy, improves clinical outcomes, and reduces burnout.
“It’s designed to keep patients informed and make them feel heard,” Hickson said. “I wish I’d had AIDET when I started my nursing career.”
Hickson said Mount Sinai also works to ensure that all patients across the gender and sexuality spectrum have access to affirming care. Its Center for Transgender Medicine and Surgery was one of the first in the nation and is one of the highest volume gender-affirmation centers in the country.
A patient population with a new set of challenges
As a gay man, John (Rob) Phoenix, MSN, APRN, FNP-C, founder and owner of the Huntridge Family Clinic in Las Vegas, Nevada, has observed how current legislation that directly impacts the LGBTQ+ community has resulted in increased anxiety and depression with many of his patients.
“As of early June, the American Civil Liberties Union (ACLU) is tracking 491 anti-LGBTQ+ bills, and we’ve seen how what happens at a policy level affects the health of our LGBTQ+ patients,” Phoenix said.
The need for affirming healthcare spaces was emphasized in The Trevor Project’s 2023 U.S. National Survey on Mental Health of LGBTQ+ Young People. The survey found that 86% of transgender and nonbinary youth reported that recent discussions around anti-LGBTQ+ legislation has harmed their mental health, and 72% of transgender and nonbinary youth polled said that policies that could ban healthcare professionals from providing gender-affirming care make them feel angry.
In addition to increasing anxiety and depression, Phoenix said these types of bills can dissuade many LGBTQ+ patients from seeking medical care and missing important screenings. He added that transgender patients need screening tests and treatments based on the sex they were assigned at birth rather than their current gender identity. For example, individuals between ages 21–65 who have a cervix need to get regular Pap smears. This includes transgender men and nonbinary patients with cervixes.
The value of training
While transgender health care is beginning to be taught in some nursing programs, nurses already working in the field may need increased training. “Nursing care models such as Rivera’s Gender Affirming Nursing Care Model offer nurses the opportunity to identify personal implicit and explicit bias and guide transgender nursing care,” Phoenix said.
He added that it’s important for nurses to help LGBTQ+ patients make better health decisions and to identify how they can engage in their care. A literature review of LGBTQ+ patients conducted by the American Cancer Society found that LGBTQ+ patients are disproportionately affected by seven types of cancer: breast, cervical, colorectal, lung, prostate, and uterine.
As the largest LGBTQ+ practice in southern Nevada, Phoenix said he and his colleagues use inclusive patient-first language with all their patients and avoid words, expressions, or assumptions that stereotype, demean, or exclude people.
As an example of patient-first language relating to the LGBTQ+ community, Phoenix said that, rather than asking about “preferred pronouns” that imply a choice about one’s gender, nurses should use the term “pronouns” or “identified pronouns” instead.
“I believe that as a nurse, it’s important to provide high-quality, compassionate care to all patients, regardless of their gender [identity], gender expression, sexual orientation, sexual identity, race, ethnicity, or religion,” he said.
Take these courses to learn more about caring for LGBTQ+ patients:
Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+): An Introduction
(1.5 contact hours)
Sexuality and gender identity have received significant attention in the last few decades across the spectrum of health and human services. This module presents a brief overview of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community and its history within society and healthcare systems.
Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+): Health Disparities
(2 contact hours)
The Health and Medicine Division’s (HMD) Healthy People 2030 and the Agency for Healthcare Research and Quality have highlighted the health disparities affecting LGBTQ+ populations. As evidence of health-illness patterns continues to be reported in the literature, this module presents the complex social determinants of health unique among the LGBTQ+ community.
Implicit Bias in Healthcare
(1.5 contact hours)
Recent movement toward diversity, equity, and inclusion (DEI) is encouraging for historically overlooked individuals. Diversity and inclusivity bring a variety of frequently ignored perspectives and experiences, but it has also uncovered the depth of implicit biases.