Sexual and Gender Minority Health:
Considerations for
Nursing Practice
Hillary J. Dutton, MPH, MS, RN, CNE (she/her/hers)
NURSE-UN 1248 Contemporary Issues in Healthcare
Class Objectives
1. Define SGM terminology
2. Discuss health inequities among SGM persons
3. Describe role of stigma and marginalization in SGM health
disparities
4. Explore literature on nurses’ attitudes towards SGM persons
5. Discuss how to support our patients and colleagues
Acknowledgements
Thank you to the following individuals for generously sharing their
slides and expertise:
• Gabby Bolaños, BSN, RN, MEDSURG-BC, GERO-BC
• Kelseanne Breder, PhD, PMHNP, RN
• Caroline Dorsen, PhD, RN
Framing the Discussion
• What are the moral concerns and ethical dilemmas involved in the
care of SGM individuals and communities?
• What are the applicable provisions from the code of ethics that guide
nursing care for SGM communities?
• How can the nursing process for clinical-ethical situations guide
nursing care for SGM communities?
What is the role of nursing in addressing SGM health
disparities?
Case 1
You hear some colleagues speaking in the lunchroom about a patient
on the floor, laughing and whispering about “what parts he, or she, or
it might have” and pretending to play “rock, paper, scissors” to decide
“who is going to go find out.” Your discomfort is made worse because
you know that one of the other nurses sitting in the room is
transgender himself. What do you do?
Case 2
You work in GYN oncology and get report that a new patient will be
coming to the floor who is having some adverse reactions to his chemo
regimen. He is a transgender man being treated for ovarian cancer. As
you are readying his room, the other patient politely expresses that she
“doesn’t want to be rude, but she just doesn’t feel comfortable having
a male roommate.” How do you handle this?
Case 3
A colleague announces at a team meeting that he will no longer care
for LGBTQ+ patients due a “religious exemption.” What is your
colleague talking about? Is this legal? How do you handle this?
Case 4
The new policy at your hospital is to ask everyone their sexual
orientation and gender identity. Your first patient is an older AfricanAmerican veteran.
You believe in the new policy but are worried about offending your
patient. What do you do?
Overview of Sexual and Gender
Minority Health
Sexual and Gender Diversity
LA County Department of Mental Health
Characterizing the SGM Community
• LGBTQIA2S+
• Sexual and Gender Diverse
• Sexual and Gender Minority
• Diversity of identity throughout
a spectrum, not across a binary
Establishing Relevant Terminology
• Sex assigned at birth – AFAB/AMAB
• These elements may not always align
• Concepts are fluid and evolving
A Brief History of SGM Rights and Health
For a more detailed
timeline, see this article
from CNN
The Stonewall Riots
How the Stonewall Riots Sparked a Movement
The AIDS Epidemic
• Originally called Gay-Related
Immune Deficiency (GRID)
• Concentrated in homosexual
men in major cities
• Stigma and marginalization
limited interventions to prevent
and treat HIV/AIDS
• Ethical concerns for medication
development
A Brief History of SGM Rights and Health
Marriage Equality
Federal Protection from Discrimination
SGM Health Disparities
SGM persons have disparities in most of the leading US health
indicators (Healthy People 2020 and 2030):
•
•
•
•
•
•
•
•
Access to healthcare
Clinical preventive services
Injury and violence
Mental health
Nutrition, physical activity and obesity
Reproductive and sexual health
Substance abuse
Tobacco
Our SGM Patients: Sobering Statistics
• Lesbian women have at least twice the risk of being overweight or
obese than heterosexual women
• Suicide attempts among SGM adolescents are at least 5 times that of
the general adolescent population
• Close to 50% of MTF transgender persons of color in NYC are HIV+
• SGM persons have among the highest rates of alcohol, tobacco and
drug use in the US
Causes of SGM Health Disparities
• Combination of:
• Individual risk behaviors
• Social and economic realities
• Stigma
• Health care provider/institution factors
Conceptualizing SGM Health Disparities
Stigma and Marginalization
Stigma
Marginalization
• Social process
• Stereotyping, discrimination,
rejection of human difference
• Peripheralization based on
identities, associations,
experiences, and environment
(Hall et al., 1994)
• Occurs across multiple levels of
influence
• Both a process and an
experience
• Produces health vulnerabilities
Intersectionality
• Multiple marginalized identities
• Intersecting experiences of
oppression
• Recognition of inherent power
dynamics
Minority Stress Theory (Meyer, 2003)
• SGM adults are subject to
ongoing psychological stress due
to their social experiences as
sexual and/or gender minorities
• Multiple chronic stressors over
the life course increase risk of
adverse health outcomes
Patient-Provider Relationship
• Lack of knowledge among healthcare providers
• Fear of mistreatment or discrimination
• Fear of refusal of treatment or services
An opportunity for providers to develop strong relationships with
SGM patients – how?
Barriers to Access and Utilization
SGM Equality by State: October 2022
SGM Equality by State: October 2023
SGM Equality by State: Sexual Orientation
SGM Equality by State: Gender Identity (10/22)
SGM Equality by State: Gender Identity (10/23)
SGM Equality by State: Bans on Medical Care
for Transgender Youth (10/22)
Movement Advancement Project. "Equality Maps: Healthcare
Laws and Policies." https://www.lgbtmap.org/equalitymaps/healthcare_laws_and_policies. Accessed 10/05/2022.
SGM Equality by State: Bans on Medical Care
for Transgender Youth (10/23)
SGM Equality by State: Transgender Healthcare
“Shield” Laws (10/23)
Considering the Role of Public Policy
Public Policy in New York
What does this mean for nursing
practice?
Codes of Ethics for Nurses
“Inherent in nursing is a respect for
human rights, including cultural
rights, the right to life and choice, to
dignity and to be treated with
respect. Nursing care is respectful of
and unrestricted by considerations of
age, colour, culture, disability or
illness, gender, sexual orientation,
nationality, politics, race, religious or
spiritual beliefs, legal, economic or
social status.”
ICN Code of Ethics, 2021
“The nurse practices with
compassion and respect for the
inherent dignity, worth and unique
attributes of every person… The
nurse promotes, advocates for, and
protects the rights, health, and
safety of the patient.”
ANA Code of Ethics, 2015
ANA Position Statement – 2018
“ANA condemns discrimination based on sexual orientation, gender
identity, and/or expression in healthcare and recognizes that it
continues to be an issue despite the increasing recognition and
acceptance of SGM populations. Many SGM individuals have reported
experiencing some form of discrimination or bias when accessing
healthcare services. Persistent societal stigma, ongoing discrimination,
and denial of civil and human rights impede individuals’ selfdetermination and access to needed healthcare services, leading to
negative health outcomes including increased morbidity and mortality.
Nurses must deliver culturally congruent, safe care and advocate for
SGM populations.”
ANA Position Statement: Nursing Advocacy for SGM Populations
Research: Nursing’s Silence on SGM Health
Nursing Students Attitudes
Clinical Practice: Nursing Literature
SGM Patient Experiences With Providers
SGM Content in Health Professions Education
Nursing
• Median of 2 hours devoted to teaching SGM health
Physicians
• Median of 5 hours of SGM focused content
• Implications for practice setting
Nursing Practice – What can you do?
Theory of Cultural “Compentimility”
Campinha-Bacote, J. (December, 2018). Cultural
competemility: A paradigm shift in the cultural competence
versus cultural humility debate – part I. OJIN: The Online
Journal of Issues in Nursing, 24(1).
Knowledge
• Learn about SGM culture and
experience
• Find out about your workplace’s
policies that may (or may not)
support your SGM patients and
colleagues
• Find out about state and
national policies that may or
may not protect your SGM
patients and colleagues
Gender Identity Research &
Education Society
Human Rights Campaign
Foundation
Movement Advancement Project
National Center for LGBTQIA+
Health Education Center
Attitudes
• Be conscious of potential explicit and implicit biases
• Practice compassion and empathy
• Don’t be afraid to admit what you don’t know (but don’t expect your
patients to be the ones to teach you)
• If you make a mistake, acknowledge it, apologize*, and move on
Skills
• Practice what to say when patients or other colleagues say something
potentially hurtful about SGM persons
• Remember the cumulative effect of that “microaggressions”
• Practice asking questions about sexual orientation and gender
identity (SOGI) in a thoughtful, straightforward, non-judgmental way
and think about WHAT information you need to know and WHY
Skills
• Share your preferred pronouns when introducing yourself to patients
and coworkers and ask others theirs
• Work on moving to an identity-based healthcare model
• Avoid assuming binary anatomy
• Utilize non-gendered language as much as possible
• Always ask open ended questions
What does
culturally
competent,
humble, and
affirming care
for SGM
communities
look like?
Saf et y
Trust w ort hiness and Transp arency
List en op enly and ow n m ist akes. Creat e
op p ort unit ies for client s t o share ab out
t heir id ent it y and aut hent ically affirm
t heir exp eriences.
Dem onst rat e a p roact ive affirm ing
st ance t o honor and celeb rat e sexual
and g end er d iversit y t hroug h affirm ing
form s, lang uag e, visual sig nals, and
LGBTQ+ com p et ent st aff.
LGBTQ+
Traum a-Inf orm ed Care
Peer Sup p ort
LGBTQ+ p eer g roup s nat urally
enab le m ut ual aid , as p rocessing
sim ilar exp eriences allow s for
ext ernal valid at ion and help s
challeng e neg at ive self-b eliefs.
Collab orat ion and Mut ualit y
SA MHSA ’s p rincip les of t raum a-inform ed care
g uid e p ract it ioners t o creat e safet y, t rust ,
t ransp arency, collab orat ion, and em p ow erm ent in
help ing relat ionship s, and t o ensure t hat services
have cult ural and g end er relevance.
Ind ivid ualized g oal p lanning resp ect s
t he ind ivid ual w hile coaching t he
client t o exp lore alt ernat ives, op t ions,
and d ecision-m aking st rat eg ies on t he
p at h t o self-accep t ance.
Researchers Jill S. Levenson, PhD, LCSW , Shelley
Craig PhD, RSW , LCSW , and A shley A ust in,
PhD, LCSW , have sug g est ed st rat eg ies for
t ranslat ing t hese p rincip les int o
affirm at ive p ract ice for LGBTQ+
client s.
Em p ow erm ent , Voice, and Choice
Creat e op p ort unit ies for LGBTQ+ client s
t o t ake t he lead in fram ing t heir ow n life
st ory & t reat m ent -relat ed need s
Levenson, J. S., Craig, S. L., & Austin, A. ( 20 21) . Traum a-inform ed and affirm at ive
m ent al healt h pract icesw it h LGBTQ+ client s. Psychological Services.
Cult ural, Hist orical, and Gend er Issues
Make services cult urally relevant and resp onsive
t o t he uniq ue feeling s and t reat m ent need s of
t ransg end er and g end er-d iverse client s.
Gender-Affirming Care
A Potential Clinical
Model for Meeting
the Health Needs of
SGM Clients
Goldhammer, H., Krinsky, L., & Keuroghlian, A.S. (2019).
Meeting the behavioral health needs of LGBT older adults.
Journal of the American Geriatric Society, 67, 15651570. https://doi.org/10.1111/jgs.15974
Advocacy and Allyship – What can you do?
• Make your allyship visible!
• Tell your patients and colleagues that you support and respect them
• Be the one who tells other people that a joke or comment is not
appropriate
• Make sure there is a safe place for your colleague to use the restroom
• Ask your employer about whether guidelines exist for transitioning
employees
Back to our guiding question…
what is the role of nursing in
addressing SGM health
disparities?
National Nursing LGBTQ Health Summit
• Meeting of nursing leaders to discuss role of nursing in addressing
SGM health disparities
• Tripartite focus: education, practice, research
• Recommendations for nursing profession
Hughes, T. L., Jackman, K., Dorsen, C., Arslanian-Engoren, C., Ghazal, L., Christenberry-Deceased, T., Lance
Coleman, C., Mackin, M., Moore, S. E., Mukerjee, R., Sherman, A., Smith, S., & Walker, R. (2022). How can the
nursing profession help reduce sexual and gender minority related health disparities: Recommendations from
the National Nursing LGBTQ Health Summit. Nursing outlook, 70(3), 513–524.
https://doi.org/10.1016/j.outlook.2022.02.005
Resources to Learn More
• Callen-Lorde
• Fenway Health/ The Fenway Institute
• GLMA: Health Professionals Advancing LGBTQ Equality
• Human Rights Campaign
• National Center for Transgender Equality
• UCSF Transgender Care
• World Professional Association for Transgender Health
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Nurse Education Today 53, 67-77.
“You do not have to
be me in order for
us to fight alongside
each other.”
- Audre Lorde