Journal of Nursing Education

Major Article 

Lesbian, Gay, Bisexual, and Transgender Health: Fundamentals for Nursing Education

Fidelindo A. Lim, MA, RN, CCRN; Donald V. Brown, MA; Henrietta Jones, BA

Abstract

As the health care needs of the lesbian, gay, bisexual, and transgender (LGBT) population become increasingly important, health care professionals require appropriate academic and clinical training in preparation for the increased demand for culturally competent care. Nurses are of particular interest, as they are the core direct caregivers in many health care settings. This article explores the national climate around LGBT individuals and their related health needs. Educators and administrators who work with future nurses should strive to ensure they foster the development of knowledgeable practitioners who will be able to implement best practices in LGBT patient care. Attention should be paid to providing students with diverse clinical placements, access to LGBT interest groups, and clear expectations for LGBT-sensitive nursing care plans and course outcomes selection that promote cultural competence. Recommendations for nursing education and curricular reform are discussed. [J Nurs Educ. 2013;52(4):198–203.]

Mr. Lim is Clinical Faculty, Mr. Brown is Academic Advisor, Office of Academic Advising & Learning Development, and Ms. Jones is Administrative Aide, College of Nursing, New York University, New York, New York.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Fidelindo A. Lim, MA, RN, CCRN, Clinical Faculty, College of Nursing, New York University, 726 Broadway, 10th Floor, New York, NY 10003; e-mail: fl9@nyu.edu.

Received: July 31, 2012
Accepted: October 24, 2012
Posted Online: March 11, 2013

Abstract

As the health care needs of the lesbian, gay, bisexual, and transgender (LGBT) population become increasingly important, health care professionals require appropriate academic and clinical training in preparation for the increased demand for culturally competent care. Nurses are of particular interest, as they are the core direct caregivers in many health care settings. This article explores the national climate around LGBT individuals and their related health needs. Educators and administrators who work with future nurses should strive to ensure they foster the development of knowledgeable practitioners who will be able to implement best practices in LGBT patient care. Attention should be paid to providing students with diverse clinical placements, access to LGBT interest groups, and clear expectations for LGBT-sensitive nursing care plans and course outcomes selection that promote cultural competence. Recommendations for nursing education and curricular reform are discussed. [J Nurs Educ. 2013;52(4):198–203.]

Mr. Lim is Clinical Faculty, Mr. Brown is Academic Advisor, Office of Academic Advising & Learning Development, and Ms. Jones is Administrative Aide, College of Nursing, New York University, New York, New York.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Fidelindo A. Lim, MA, RN, CCRN, Clinical Faculty, College of Nursing, New York University, 726 Broadway, 10th Floor, New York, NY 10003; e-mail: fl9@nyu.edu.

Received: July 31, 2012
Accepted: October 24, 2012
Posted Online: March 11, 2013

I am talking about gay, lesbian, bisexual, and transgender people, human beings born free and given bestowed equality and dignity, who have a right to claim that, which is now one of the remaining human rights challenges of our time. ~Hillary Rodham-Clinton (2011)

The health and well-being of the lesbian, gay, bisexual, and transgender (LGBT) population is now considered a health priority, not only by interest groups but also by federal health care agencies. The Institute of Medicine’s (IOM, 2011) consensus report highlighted the lack of science-based knowledge on the health of LGBT individuals owing to the lack of research in LGBT health. Healthy People 2020 (2011) and the U.S. Department of Health and Human Services (HHS, 2011) further underscored the existence of health disparities and the lack of compassionate services for LGBT individuals.

Because the subject of LGBT health is closely linked with health care policies, the political arena has also become a platform for discussion. At the direction of President Obama, the HHS (2011) has taken action to ensure equal visitation rights for LGBT individuals to visit their partners in the hospital or in nursing homes. In December 2011, Secretary of State Hillary Rodham-Clinton addressed the United Nations in Geneva during the 60th anniversary of the Declaration of Human Rights and reminded world leaders that LGBT rights are human rights. Clinton admonished policy makers, health advocates, researchers, practitioners, and care recipients to engage in a more proactive role in bridging health disparity among the “invisible minority” (Rodham-Clinton, 2011, ¶ 7).

Starting in July 2012, The Joint Commission (2011) began evaluating compliance with standards for effective communication, cultural competence, and patient- and family-centered care for LGBT care recipients as part of the accreditation criteria. This evaluation provides greater impetus for health care facilities “to begin building trust and making the health care environment more welcoming, inclusive, and safe for LGBT patients and their families” (The Joint Commission, 2011, p. 2).

Health in Numbers: Counting the LGBT Population

Many surveys that are administered on national and state levels do not collect demographic data on sexual orientation or gender identity, thus making it difficult to acquire an accurate sense of how many individuals in the United States identify as LGBT (Healthy People 2020, 2011). According to current estimates, approximately 5% to 10% of the total population is LGBT (Grant, Koskovich, Frazer, Bjerk, & Lead Collaborator, Services & Advocacy for GLBT Elders, 2010).

The 2010 United States Census was the first to count both same-sex partners and same-sex spouses. According to the revised estimates, there are 131,729 same-sex, married-couple households and 514,735 same-sex, unmarried-partner households in the United States (U.S. Census Bureau, 2011). This is a significant increase from the 145,000 same-sex, unmarried households in 1990 (AVERT, 2011). Even at its best, taking census is an inexact science, and we will never fully know the precise number of LGBT individuals and associated subpopulations. What is certain is that during their careers, nurses will inevitably engage with gender minorities across the lifespan.

Historical Perspectives in LGBT Health

In presenting its landmark report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, the IOM (2011) stressed the importance of understanding the historical context that influenced the lives and health of LGBT individuals. Legal and social barriers have historical roots and have played major roles in the continued stigmatization of LGBT individuals.

Homosexuality has been criminalized and pathologized throughout history. Although homosexuality was declassified as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders in 1973 (American Psychiatric Association, 1974), repercussions are still felt today. The lingering effects have tainted discussion on the mental health of LGBT individuals due to the higher prevalence of mental disorders in LGBT individuals compared with their heterosexual counterparts (Meyer, 2003). Being classified as pathologic has shaped sexual minority patients’ interactions with the health care system, which has an impact on service utilization and follow-up care (IOM, 2011).

Lack of data on sexual orientation and gender identity in federally funded surveys administered by the HHS and in other relevant federally funded surveys constrains understanding of the context of health disparities in LGBT populations (Dean et al., 2000; IOM, 2011). The LGBT population is underrepresented in health care research even though the unique health disparities affecting this population have been known for decades (IOM, 2011). Minimizing the disparities provides the impetus to study the state of health of LGBT populations.

Social Determinants of Health in LGBT Individuals

The health effects of oppression and discrimination are more apparent in historically marginalized communities (Haile, Padilla, & Parker, 2011). Legal barriers to equal access to health insurance, employment, housing, marriage, adoption, and retirement benefits directly impact LGBT health (Healthy People 2020, 2011). The American Psychiatric Association’s position statement (2005) on same-sex civil marriage declares “same-sex couples…experience several kinds of state-sanctioned discrimination that can adversely affect the stability of their relationships and their mental health” (¶ 3). Laws prohibiting marriage between same-sex individuals often affect the access of lesbians, gay men, and bisexual people to employer-sponsored health insurance (IOM, 2011).

Lack of laws protecting against bullying in schools has recently attracted attention due to several suicides of young victims of bullying. Ironically, this comes at a time when 52% of Americans support the moral acceptability of gay and lesbian relations (Saad, 2010). Social stress exerts undue mental distress among LGBT individuals, putting them at risk for anxiety and mood disorders (Bostwick, Boyd, Hughes, & McCabe, 2010). Understanding this risk will help contextualize these mental health issues and aid in implementing effective interventions (Meyer, 2003). Nurse clinicians and those in academia can play an active role in exploring these issues among LGBT patients and students who may not exhibit obvious signs of victimization.

Shortage of health care providers who are knowledgeable and culturally competent in LGBT health (Healthy People 2020, 2011) means that implementation of best practices in culturally sensitive care, such as those advanced by the Joint Commission (2011), will remain largely unfulfilled.

Health Status of the LGBT Population

Governmental agencies and stakeholders now recognize LGBT health as a priority. Healthy People 2020 (2011) identified significant health disparities and seeks much needed collaboration from health care professionals and policy makers to address them. Among its findings are the following:

  • LGBT youth are 2 to 3 times more likely to attempt suicide.
  • LGBT youth are more likely to be homeless.
  • Lesbians are less likely to get preventive services for cancer.
  • Gay men are at higher risk of HIV and other sexually transmitted diseases, especially among communities of color.
  • Lesbians and bisexual females are more likely to be overweight or obese.
  • Transgender individuals have a high prevalence of HIV and sexually transmitted diseases, victimization, mental health issues, and suicide and are less likely to have health insurance than heterosexual or lesbian, gay, or bisexual individuals.
  • Elderly LGBT individuals face additional barriers to health due to isolation and a lack of social services and culturally competent providers.
  • LGBT populations have the highest rates of tobacco, alcohol, and other drug use.

These health issues are partly thought to be the effects of chronic stress resulting from stigmatization (IOM, 2011). Consequently, the health–illness burdens unique to the LGBT population might in turn pose as new stressors due to the inequity of access and available resources. It is beyond the scope of this article to provide a detailed outline on how to address these disparities; however, specific recommendations have been published by the HHS (2011).

Literature Review

A review by Eliason, Dibble, and DeJoseph (2010) of the 5-year impact score, from 2005 to 2009, of the top 10 nursing journals found only eight articles focusing on LGBT issues, for a rate of 0.16% of all articles published. Seven of the top 10 journals published no articles that focused on LGBT issues in that 5-year period (Eliason et al., 2010). This lack of scholarly discourse on LGBT issues in the nursing literature is representative of the lack of inclusion of such topics in nursing curricula. Although research on LGBT health has significantly increased, few studies were performed by nursing scholars (Randall & Eliason, 2012) and most were performed by nurse researchers outside of the United States (Eliason et al., 2010).

Various studies have noted the conspicuous absence of LGBT health content in the education of nursing faculty, nursing home administrators, nurses, and physicians (Bell, Bern-Klug, Kramer, & Saunders, 2010; Eliason et al., 2010; Eliason & Raheim, 2000; Gray et al., 1996; Rondahl, 2009; Smith, 1993). These findings are emblematic of the assertion that “nursing has lagged behind other fields in publishing research studies, theoretical frameworks, or practice guidelines about LGBT health” (Eliason et al., 2010, p. 206). Research shows that LGBT nurses and other health care workers may have internalized homophobia (Riordan, 2004) and as a result remained “in the closet” for fear of being discriminated against at work (Eliason, DeJoseph, Dibble, Deevey, & Chinn, 2011).

LGBT Nursing Workforce and Nursing Students: Straight Facts

In 2008, there were 3,063,163 licensed RNs in America (HHS, 2010). Extrapolating from these numbers, based on the estimate that 5% to 10% of the population is LGBT, it is projected that approximately 150,000 to 300,000 nurses are LGBT. These numbers matter, as one indicator of an individual’s support for LGBT rights or homophobia is based on whether one personally knows someone who is LGBT (Byrne & Murphy, 1993). Nurses who work with LGBT colleagues may be more likely to support initiatives that address LGBT issues (Byrne & Murphy, 1993). For fear of recrimination, some LGBT nurses may prefer to “stay in the closet” and not take part in advocacy that might benefit the profession collectively (Eliason et al., 2011).

A dearth of nursing research performed by nurses exists related to LGBT populations (Eliason et al., 2010). Over the years, various studies exploring the attitudes of nursing students toward LGBT individuals reveal the following:

Although most of those studies have small sample sizes, the findings need to be addressed given that today’s students will be tomorrow’s frontline care providers.

The study by Dinkel, Patzel, McGuire, Rolfs, and Purcell (2007) of undergraduate nursing students and faculty found that attitudes are slowly changing and are becoming less overtly tied to negative stereotypes (i.e., less prejudice), resulting in lower homophobia scores. However, in their analysis, those authors contend that the scores may reflect neutrality and heterosexism, a subtle form of discrimination that can perpetuate the invisibility of LGBT populations. Nurse researchers can look into the IOM report for guidance in conducting studies among the LGBT population and fill in the gaps in the science of LGBT health (American Academy of Nursing, 2011).

The Closeted Curriculum: Recommendations for an Inclusive Nursing Education

Historically, the education and training of health care workers has lacked LGBT-specific curricular content (IOM, 2011). The study by Obedin-Maliver et al. (2011), which assessed the inclusion of LGBT-related content in 150 undergraduate medical education programs in the United States and Canada, showed an average of only 5 hours of instruction. A similar study examining how much time is devoted to LGBT-related topics in the nursing curriculum has yet to be performed.

With the exceptions of the American Academy of Nursing’s endorsement of the IOM’s report and the National Association of Pediatric Nurse Practitioners’ position statement on the health risks and needs of LGBT and questioning adolescents, no other national professional nursing organization has issued a policy statement related to the care of LGBT individuals and the education of health care providers (Keepnews, 2011).

The American Nurses Association (2010) refers to promoting visitation rights of same-sex partners in its end-of-life position statement, but it otherwise remains silent on the broader issues of LGBT health. This omission is significant because policy statements can have tremendous influence on curricular design and faculty development programs, with the ultimate aim of aligning practice with the current evidence base.

Initiatives to integrate LGBT health into the nursing curriculum are not new. At the height of the AIDS epidemic, there was a call to encourage nursing schools to develop a nursing curriculum that incorporates social values that recognize diverse lifestyles and encourage clinical education, which allows nursing students to interface with the LGBT community (Bevis, 1989).

The nursing curriculum must be reviewed for gaps in LGBT-related topics in all levels. This review must include, but not be limited to, examining textbooks, course assignments, clinical affiliations, patient assignment, and simulation scenarios for deficiencies in LGBT-related content (Dinkel et al., 2007). A good starting point is to examine the school’s mission and core values to assess for inclusive language. A suggested template for curricular review of LGBT health inclusion in various courses comprises:

  • Course name.
  • LGBT-related learning outcomes.
  • Specific topics covered.
  • Time allotted.
  • Teaching strategies.

A similar template may be used to review clinical activities to obtain qualitative and quantitative data on the extent of inclusion of LGBT health content in the curriculum. In addition, a needs assessment survey among students, faculty, and staff about baseline knowledge of LGBT health disparity would be essential in developing programs that address site-specific needs and issues.

The American Association of Colleges of Nursing’s (AACN, 2008) Essentials of Baccalaureate Education for Professional Nursing Practice offers no specific language that directly addresses LGBT health inclusion into the curriculum. Likewise, no LGBT-inclusive language can be found in the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007), although its main aim is to implement patient-centered care. Because curriculum design aspires to implement the AACN’s and QSEN’s recommendations, lack of inclusive language might result in more gaps in future nurses’ knowledge of LGBT health.

Translating the Evidence Base into Practice

Specific educational and student support strategies that seek to promote LGBT health integration into the curriculum and overall student experience are described below. If LGBT health is taught under the broader lens of health optimism, health promotion, and the positive gains that would result from bridging health disparities, the curriculum would better prepare future nurses to provide science-based care to all historically marginalized groups.

Educational Strategies: Integrating LGBT Health into the Curriculum

Simulation. With the increasing popularity of high-fidelity simulation as one of the solutions for overcoming the limitations of traditional clinical education (Tanner, 2006), individuals designing simulation curricula should include LGBT identities when creating scenarios. Because manikins do not portray the facial nuances and tonal qualities of humans, specially trained people can portray standardized LGBT patients (Lim & Levitt, 2011), allowing students to cultivate culturally sensitive communication and motivational interviewing skills. Simulation using standardized patients can fill the practice gap and the lack of clinical interface between students and LGBT clients.

Case Studies. Case scenarios used in seminars, didactics, and testing, including the NCLEX®, may be infused with LGBT identities and may ask application-type questions that highlight best practices in cultural sensitivity. Any clinical scenario can be made to reflect LGBT health disparity by simply asking during debriefing: “What if the client described is gay, lesbian, or transgender?”

Nursing Care Plans. Students should be encouraged to move beyond assessment of physical manifestations or indicators of health, such as risk for skin breakdown or falls diagnoses, and consider identity-based needs as well. Faculty can inspire students to explore patient-centered needs that address identity, gender, and sexuality issues by using nursing language. Students’ patient assignment must be diversified to increase interaction between students and gender minorities.

Course Development. Nursing faculty should seek opportunities to develop courses that allow sustained exploration of topics related to LGBT health. In doing so, it removes pressure from students to seek out their own opportunities for LGBT-centered education, and it provides a structured, university-approved source of knowledge dissemination related to LGBT issues. Faculty should ensure that texts and resources used to enhance courses are comprehensive in scope and are adequate in meeting the intended learning outcomes. Web-based resources, such as Lavender Health ( http://www.LavenderHealth.org), in addition to journal articles and current textbooks can be used. An example of a text that could be used in designing a course (or integrating LGBT topics into existing courses as suggested above) is LGBTQ Cultures: What Health Care Professionals Need to Know About Sexual and Gender Diversity (Eliason, Dibble, DeJoseph, & Chinn, 2009). This online only text provides an introduction to LGBT health, as well as recommendations for creating safe environments for patients.

Independent Study and Elective Courses. In institutions where developing new courses may be challenging, encouraging independent study provides the opportunity for nursing students to engage in guided learning on topics that may be absent from the extant curriculum. Advisors and nursing faculty can encourage students to undertake projects designed to increase cultural competence, exposing them to current literature on LGBT health. In addition, diverse course options from neighboring departments that reflect LGBT content can be made available to students. Students should be encouraged to complete coursework that exposes them to the myriad sexual realities they will encounter in their practice. By increasing exposure to LGBT patients and their related issues in the academic setting, students can be more familiar with necessary interventions when in the clinical experience.

Clinical Affiliations and Assignment. Diverse clinical education is one of the hallmarks of a well-rounded clinical education. By establishing clinical partnership with LGBT-specific community health agencies, students would have the chance to interface with diverse and underserved populations, as well as to learn from expert clinicians in LGBT health.

Student Support Strategies: Acknowledging LGBT as a Necessary Component

Academic Advising. The relationship between nursing students and their advisors is one of few sustained, consistent connections between themselves and a representative of the university (Harrison, 2009). Advisors working with nursing students can use this relationship as a way to discuss and foster positive outlooks and advocacy relevant to the nursing curriculum for LGBT patient populations. Advisors and faculty who serve as advisors should encourage students to think critically about their value of diversity and the ways they can apply their education to diverse patient populations. Advisors can also seek out appropriate avenues to increase their own competencies in working with LGBT students to assist them in feeling more at ease in their identities. Advisors should consider becoming safe zone–certified through their institution (or complete a comparable ally training program) and display the certificate in a highly visible location to foster comfort. Minority populations persist and perform better in higher education when academic advising is both effective and supportive (Museus & Ravello, 2010).

Recruiting Diverse Nursing Faculty. Nursing schools can benefit from recruiting faculty members from diverse backgrounds, including ethnic minorities and those who are openly LGBT. The inclusive faculty recruitment policy would bring fresh perspectives in multicultural education to the classroom and clinical settings. In addition, the diverse faculty may also serve as role models for LGBT students and underrepresented groups (Lowe & Archibald, 2009).

Interprofessional Education. Interprofessional education and interprofessional collaboration are gaining greater recognition as priorities in the health professions for strategies to improve health care services (Reeves et al., 2011). By collaborating with LGBT experts from other professions, we can enhance the resource capacity of nurse educators, which subsequently serves to provide greater support to the nursing student population those educators serve.

LGBT Interest Groups. The university must provide students with the opportunity to organize or be a part of any interest group in which the students find a sense of community. Some universities and schools of nursing may already have an LGBT group in which nursing students can participate. Such groups are an excellent platform for students to cultivate leadership and advocacy skills. Nursing school administration must encourage and support the formation of diverse interest groups.

The above recommendations are by no means complete. As the state of science in LGBT health continues to evolve, efforts to integrate content into the curriculum must follow. Clinical practice remains the cornerstone of nursing education (AACN, 2008); therefore, program design of the nursing curriculum must facilitate the interface between LGBT individuals and nursing students in real-time and at all levels. Faculty must take seriously the challenges of teaching students skills in critical thinking and in examining some the most difficult issues facing society and nurses, such as heterosexism and the resulting homophobia (Neville & Henrickson, 2006).

Conclusion

A curriculum that promotes the “normalization of sexual diversity in nursing education will subsequently improve the health care of LGBT people” (Dinkel et al., 2007, p. 10). Being direct caregivers, nurses and nursing auxiliary staff can play a pivotal role in eliminating health disparities in the LGBT population. Education and training are the essential first steps in achieving this goal. The nursing school’s mission and goals must reflect the changing social norms with regard to the growing acceptance of gender diversity and sexual minorities.

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