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Population Health for Nurses

27.3 The LGBTQIA+ Community

Population Health for Nurses27.3 The LGBTQIA+ Community

Learning Outcomes

By the end of this section, you should be able to:

  • 27.3.1 Discuss health barriers experienced by the LGBTQIA+ community.
  • 27.3.2 Identify the health needs of the LGBTQIA+ community.
  • 27.3.3 Describe the nurse’s role in caring for LGBTQIA+ individuals.

Lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) individuals live in every community, hail from all walks of life, and represent every racial, ethnic, socioeconomic, and geographic group (CDC, 2019c). Both LGBTQIA+ individuals and sexual minority youth (SMY)—young individuals who identify as lesbian, gay, or bisexual; who are not sure of their sexual identity; or who have had same-sex partners—experience many health disparities and challenges. In particular, LGBTQIA+ adolescents are at high risk of experiencing bullying, dying from suicide, and using illegal substances. Many Health People 2030 objectives relate to these three major concerns (ODPHP, 2022b). Sexual and gender minority groups are subjected to harassment, discrimination, and violence due to unjust practices, policies, and social conditions (CDC, 2022b). Individuals who identify as transgender experience higher rates of discrimination and higher rates of interpersonal violence (Medina-Martinez et al., 2021). See Table 27.3 for examples of the many terms commonly used to describe gender and sexual identity.

Healthy People 2030

LGBTQIA+

Many Healthy People 2030 objectives relate to improving the health, safety, and well-being of LGBTQIA+ individuals. These objectives highlight the importance of collecting population-level health data on LGBTQIA+ health issues and improving the health and safety of LGBTQIA+ individuals with an emphasis on the adolescent population.

What is LGBTQIA+?*
L – Lesbian A woman whose physical and romantic attraction is to other women. Some may prefer to identify as gay or as gay women.
G – Gay An individual whose physical and romantic attraction is to people of the same sex. Most often refers to men, but some women prefer to identify as gay.
B – Bisexual A person who forms physical and romantic attractions both to those of the same gender and to those of another gender. Bisexual people do not need to have had specific sexual experiences to be bisexual.
T – Transgender An umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. People under the transgender umbrella may describe themselves as transgender or nonbinary. Some transgender people undergo treatment to bring their bodies into alignment with their gender identity.
Q – Queer/Questioning An adjective used by some people whose sexual orientation is not exclusively heterosexual or straight. This umbrella term includes people who have nonbinary, gender-fluid, or gender-nonconforming identities. Once considered a pejorative term, some LGBTQIA+ people have reclaimed queer to describe themselves; however, it is not a universally accepted term even within the LGBTQIA+ community.
Sometimes, the Q in LGBTQ can also describe someone questioning their sexual orientation or gender identity.
I – Intersex An adjective used to describe a person with one or more innate sex characteristics, including genitals, internal reproductive organs, and chromosomes, that fall outside of traditional conceptions of male or female bodies. Having an intersex trait is different from being transgender. Medical providers and parents assign an intersex person a sex at birth, either male or female — and that assignation may not match the gender identity of the child. Not all intersex individuals identify as being part of the LGBTQIA+ community.
A – Asexual This adjective describes a person who does not experience sexual attraction.
+ – Plus The “plus” is used to signify all the gender identities and sexual orientations that letters and words do not yet fully describe.
Other Terms Commonly Used
Cisgender Used to describe a person whose gender identity aligns with the sex assigned at birth.
Gender identity One’s self-concept as male, female, a blend of both, or neither. How individuals perceive themselves and what they call themselves.
Gender non-conforming Individuals who do not behave in a way that conforms to traditional expectations of their gender or whose gender expression does not fit into a category.
Gender fluid A person who does not identify with a single fixed gender or who has a fluid or unfixed gender identity.
Nonbinary Describes an individual who does not identify exclusively as a man or a woman. Nonbinary individuals may identify as both a man and a woman, somewhere between, or outside of these categories.
Table 27.3 Terms Commonly Used to Describe Gender and Sexual Identity (See Human Rights Campaign, 2023; Lesbian & Gay Community Services Center, Inc., 2023.) *Note: Throughout this section, a variety of acronyms are used based on the source material where the information was retrieved.

Health Barriers Experienced by the LGBTQIA+ Population

Throughout U.S. history, many policies and practices have discriminated against and stigmatized the LGBTQIA+ population. Same-sex sexual activity only became legal in every state in 2003 with the Supreme Court’s ruling in Lawrence v. Texas (CDC, 2022b). LGBTQIA+ individuals have faced discrimination in finding housing and jobs and in family court (CDC, 2022b). Similarly, until the 2015 Supreme Court ruling in Obergefell v. Hodges, many states did not recognize same-sex marriages. This impacted health insurance coverage and job protections for family leave (CDC, 2022b). Same-sex marriage bans further stigmatized this population and made same-sex couples unequal in the eyes of the justice system.

LGBTQIA+ individuals also experience significant harm due to structural discrimination, threats, verbal abuse, or violence (CDC, 2022b). In 2022, 17 U.S. states lacked state laws against discrimination based on sexual orientation or gender identity in employment, housing, and public accommodations (Movement Advancement Project, 2023). The medical community and health care system have also discriminated against LGBTQIA+ populations. Until 1973, the American Psychiatric Association classified homosexuality as a mental disorder (CDC, 2022b). From 1923 to 1981, individuals in Oregon who participated in same-sex sexual activity were sterilized without their consent (CDC, 2022b). These historical injustices have impacted accessing and seeking care for LGBTQIA+ populations. In many studies, LGBTQIA+ individuals report avoiding necessary health care because they feel uncomfortable and unsafe due to discriminatory attitudes and behaviors in health care systems (Medina-Martinez et al., 2021).

In 2022, anti-LGBTQ legislation took effect across several U.S. states. In Florida, South Dakota, and Alabama, bills passed restricting classroom discussions of gender and sexuality (Rummler, 2022; USA Facts, 2023), creating a stigmatized atmosphere of constraint and silence around LGBTQIA+ individuals. As of the 2023 legislative session, the American Civil Liberties Union (ACLU) was tracking 492 anti-LGBTQ bills advancing through state legislatures. These bills were attempting to:

  • weaken nondiscrimination laws,
  • allow businesses and hospitals to turn away LGBTQ individuals,
  • limit access to books about LGBTQ individuals,
  • limit discussion and education on LGBTQ individuals and issues,
  • ban drag show performances,
  • ban affirming health care for transgender youth,
  • block funding to medical centers that offer gender-affirming care,
  • prevent transgender students from participating in sports, and
  • prevent transgender individuals from using public bathrooms and locker rooms (ACLU, 2023).

Both implicit and explicit discrimination result in the unfair treatment of individuals or groups based on certain characteristics such as sexual orientation or gender identity (ODPHP, 2020b). Implicit discrimination is considered unconscious, shaped by previous experiences and learned associations of certain qualities and social categories. This can result in inequitable care when professionals communicate bias or make biased clinical decisions (National LGBT Health Education Center, 2018). Physical or verbal expressions of bias may determine whether LGBTQIA+ clients follow prescribed health advice or return for care (National LGBT Health Education Center, 2018). Examples of biased communication include referring to same-sex partners as “friends” or excluding same-sex partners from health conversations. Heteronormativity, the belief that heterosexuality is the normal, better, or only sexual orientation (Ferrari et al., 2021), can result in heteronormative behaviors, such as discussing oral contraception with all women of childbearing age regardless of their sexual orientation, that reflect implicit bias.

Explicit bias is a consciously held negative attitude or belief about a specific individual or group based on certain characteristics, such as sexual orientation or gender identity. Explicit biases are easily identified and communicated and result in the inequitable treatment of individuals or groups (Vela et al., 2022). Examples of explicit bias include health professionals refusing treatment to LGBTQIA+ individuals on the basis of their sexual or gender orientation or displaying open hostility and rudeness toward these individuals, such as not respecting their preferred name or pronouns (Medina-Martinez et al., 2021).

Case Reflection

Addressing Implicit Bias

The National LGBTQIA+ Health Education Center offers a series of cases exploring scenarios clients encounter frequently in health care settings to provide strategies for nurses and other health care staff to move past bias and provide holistic, culturally congruent care.

Access the Case Studies and scroll to page 3; read through the 10 short case scenarios, and then respond to the following questions.

  1. In what ways did the scenarios challenge or confirm your ideas about bias toward LGBTQIA+ clients in the health care system? Did one scenario resonate with you more than others? Why?
  2. Have you ever experienced these types of situations in health care, either as a client, an observer, or in the role of health care staff? If you could revisit a past experience, what, if anything, would you do differently?
  3. The scenarios emphasize that no one is an expert, regardless of their personal experience, and that learning and training benefits all health care professionals. As a future nurse, how prepared do you feel to address such biases in health care? What are some ways you might learn more?

Health Needs of the LGBTQIA+ Population

LGBTQIA+ individuals have poorer overall physical and mental health than their cisgender, heterosexual counterparts. This population has higher rates of anxiety and depression, many types of substance use, and suicide (Medina-Martinez et al., 2021). Lesbian and bisexual women have higher rates of obesity, osteoporosis, and cancers of the colon, liver, breast, ovaries, and cervix (Medina-Martinez et al., 2021). Gay and bisexual men have higher rates of HIV, viral hepatitis, sexually transmitted infections (STI), and cancers of the anus, prostate, testicle, and colon. Transgender people have higher rates of self-harm and suicide (Medina-Martinez et al., 2021).

SMY experience significantly higher levels of violence, harassment, bullying, and sexual violence in school, resulting in a greater risk of suicide, depression, and substance use than in heterosexual youth (CDC, 2020h). LGBTQIA+ youth face social stigma, discrimination, and social rejection regarding their sexual choices or identities. Given these factors, LGBTQIA+ students are at much higher risk for adverse health outcomes related to sexual behaviors, experiences with violence, substance use, mental health, and poor academic performance (CDC, 2020h). The CDC’s 2017 Youth Risk Behavior Survey found that, compared with their heterosexual peers, SMY were more likely to have experienced the following (CDC, 2019d):

  • Been bullied at school (32 percent of LGB students vs. 17.1 percent of heterosexual students)
  • Seriously considered suicide (46.8 percent of LGB students vs. 14.5 percent of heterosexual students)
  • Felt sad or hopeless (66.3 percent of LGB students vs. 32.2 percent of heterosexual students)
  • Used select illicit drugs (27.8 percent of LGB students vs. 12.7 percent of heterosexual students)
  • Been forced to have sex (19.4 percent of LGB students vs. 5.5 percent of heterosexual students)
  • Misused prescription opioids (12 percent of LGB students vs. 6.4 percent of heterosexual students)

LGBTQIA+ youth are also at increased risk for many negative health outcomes. Adolescent gay and bisexual males have high rates of HIV, syphilis, and other STIs, and adolescent lesbian and bisexual females are more likely to have been pregnant than their heterosexual counterparts. Transgender youth are more likely to have attempted suicide than their heterosexual peers (CDC, 2019c).

How LGBTQIA+ Experiences Intersect with the Social Determinants of Health

The experiences of LGBTQIA+ individuals intersect with the SDOH at the individual and community levels related to income, education, social cohesion, and the structural factors of community characteristics and government policies. Minority stress—the stigma, prejudice, and discrimination experienced by individuals and groups due to marginalized or vulnerable identities—is a key SDOH for sexual minority individuals (Schuler et al., 2021). Health disparities are driven by unequal distribution of health determinants, and this remains true in the LGBTQIA+ population (Schuler et al., 2021). Research has documented key economic disparities among LGB individuals (Schuler et al., 2021). Gay and bisexual males earn anywhere from 11 to 27 percent less than heterosexual males with the same occupation, education, and experience, and bisexual women have significantly higher rates of poverty than their heterosexual counterparts, even after adjusting for demographic factors (Schuler et al., 2021).

Social connectedness is another SDOH that has an impact on LGBTQIA+ individuals. Social isolation is associated with elevated mortality risks, and LGB individuals experience lower social connectedness than their heterosexual counterparts, as LGB adults are significantly less likely to be married, and older gay and bisexual men are more likely than heterosexual men to live alone. As discussed in Social Determinants Affecting Health Outcomes, incarceration contributes to poor health in many ways. National data indicate that females who identify as a sexual minority are disproportionately overrepresented in correctional facilities, with 42 percent of women and 39 percent of girls who are incarcerated identifying as a sexual minority (Schuler et al., 2021). In addition to the health risks of incarceration, such as isolation, communicable diseases, and limited economic opportunities upon release, sexual minority status is the largest risk factor for victimization while incarcerated (Schuler et al., 2021).

The Nurse’s Role in Caring for the LGBTQIA+ Population

Achieving health equity for LGBTQIA+ clients requires nurses and other health professionals to view current health inequities through the lens of structural discrimination. Using that lens, community and public health nurses can look for ways to address and decrease this discrimination and its effects (Medina-Martinez et al., 2021).

Protective factors that promote sexual health and positive outcomes among LGBTQ youth include acceptance and support from caregivers and peers, particularly regarding sexual orientation and gender identity, and school-based gay–straight alliances (Figure 27.5). Gay–straight alliances are student-led clubs that provide a safe place for students to support each other on issues related to sexual orientation and gender identity (CDC, 2019e). Community and public health nurses can assist transgender and other gender-diverse youth by offering quality sexual health education, assisting youth in accessing quality health care services, and providing a safe and supportive environment for these at-risk individuals (CDC, 2019f).

The transgender population faces particular stigma, health disparities, and challenges. Adolescent transgender individuals are at increased risk for experiencing violence, poor mental health and suicide, substance use, and risky sexual behaviors (CDC, 2019f). Despite these risks, adolescents are often resilient, capable of withstanding or recovering quickly from adversity. This resilience acts as a protective factor against stigma and discrimination. By connecting transgender individuals with quality sexual health education, access to health services, and supportive environments, community health nurses can help these adolescents to overcome adversity and flourish (CDC, 2019f). Understanding the experiences of the transgender youth population enables community and public health nurses to create more supportive environments for them. Nurses and other health professionals should take part in transgender cultural competency trainings and participate in the establishment of clinic protocols regarding confidentiality, chosen name, and chosen pronoun (CDC, 2019f).

The community health nurse is well-positioned to impact the health and wellness of the LBGTQIA+ population, especially LBGTQIA+ youth. School nurses can foster a sense of support, safety, belonging, and inclusion for these students. These nurses can support and conduct programs on inclusive sexual education, gender and sexual diversity, and bullying and suicide prevention topics (Medina-Martinez et al., 2021). The school nurse can help administrators review policies and practices to ensure inclusivity and provide or refer students to comprehensive, affirming sexual health services (CDC, 2019f). In the community outside of school, the community health nurse can foster social bonds among peers, teachers, community groups, and organizations that support LGBTQIA+ issues. By creating a community that fosters this environment, community health nurses can collaborate with other community leaders to address health risk behaviors within the LGBTQIA+ population and to provide appropriate sexual health education and services (CDC, 2020h).

Two people walk down a street carrying a parade banner between them. The banner has the shape of Washington state on it, presented in rainbow colors. Inside the shape are the words “Relevancy, diversity, inclusion”.
Figure 27.5 LGBTQIA+ groups can advocate for equity and inclusion in the community and beyond. (credit: Kevin Bacher/NPS/Flickr, CC BY 2.0)

Nurses can also play a role in reducing health inequities in the LGBTQIA+ population by being aware of implicit biases and actively working against them. Nurses can take implicit association tests (IATs) to help identify implicit biases and then learn strategies to minimize their impact. Mindfulness meditation and individuation training that focuses on individual characteristics and traits rather than group membership have successfully reduced implicit bias (Morris et al., 2019). Nurses should also participate in training related to LGBTQIA+ cultural competence among health professionals (Medina-Martinez et al., 2021). By using appropriate pronouns, actively listening to clients, avoiding assumptions based on gender or appearance, and advocating for a culturally appropriate health care environment, nurses can help counteract health inequities. Nurses play a role in primary, secondary, and tertiary prevention for caring for the LGBTQIA+ population (Table 27.4).

Primary Prevention
  • The school nurse should emphasize bullying prevention with educational sessions and posters and encourage administrators to adopt a zero-tolerance policy for bullying behaviors.
  • The school nurse can develop and implement policies to promote a positive school environment of safety and belonging for all students.
  • The school nurse can promote acceptance of LGBTQIA+ individuals by educating students and school staff about gender identity and sexual orientation.
  • The school nurse can encourage teachers to include age-appropriate information about LGBTQIA+ individuals in their lesson plans. Examples include discussions on different kinds of families or studying the civil rights movements for sexual minority individuals.
  • The community and public health nurse can advocate for laws and policies that specifically protect the rights of LGBTQIA+ individuals, such as anti-bullying laws to protect all students.
Secondary Prevention
  • Screen students who are at risk for being bullied or at risk for academic or emotional problems.
  • Encourage support groups for sexual minority students such as gay–straight alliances as means for these students to talk about their experiences at school and in the community.
  • Screen LGBTQIA+ individuals for depression, anxiety, suicide risk, and victimization.
Tertiary Prevention
  • Refer individuals who are experiencing social and emotional challenges to appropriate community services.
Table 27.4 Nurses’ Role in Primary, Secondary, and Tertiary Prevention for the LGBTQIA+ Population
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