Lack of standardized education perpetuates healthcare disparities
- Gaps in nurse knowledge regarding LGBTQ+ patients can impact the care they receive in healthcare settings.
- A refresher on terminology, specific care concerns, and social determinates of health can help nurses provide respectful care.
Jordan (they/them), a 29-year-old nonbinary person, arrives for elective laparoscopic cholecystectomy. During the pre-operative intake, the nurse refers to Jordan as “she” and addresses them by their legal first name, despite Jordan introducing themself and noting their pronouns on the intake form. Jordan appears uncomfortable but doesn’t correct the nurse.
Later, in the recovery unit, Jordan refuses pain medication and limits communication with staff. A nurse practitioner overhears Jordan’s partner express concern: “They’re shutting down again. This always happens when people don’t see them for who they are.”
The American Nurses Association’s Nursing: Scope and Standards of Practice calls for cultural humility, stating that it “requires a commitment of lifelong learning and exposure, starting from providing dignity, respect, and grace to people regardless of origin, race, sexual [orientation], background, or socioeconomic status.” In addition, the 2025 Code of Ethics for Nurses now explicitly refers to gender identity and sexual orientation: “Attributes such as the patient’s culture, value systems, religious and/or spiritual beliefs, lifestyle, social support system, preferred language, and sexual identity are to be considered when planning individual, family, and population-centered care.”
Most nurses are familiar with the needs of our LGBTQ+ patients and consistently provide compassionate care. However, a reminder of the challenges LGBTQ+ patients face when attempting to access healthcare, a refresher on the terminology and concepts related to gender and sexuality, and a consideration of the education nurses require to provide competent care can help all of us better advocate for our patients.
Lack of standardized education
Although organizations such as the American Nurses Association, the American Association of Colleges of Nursing (AACN), and the Oncology Nursing Society emphasize the importance of diversity, equity, and inclusion in nursing education (including cultural competency in LGBTQ+ care), this education isn’t standardized or widely implemented. This lack of standardized education and training leaves some nurses feeling that they lack the knowledge to deliver the best possible healthcare to LGBTQ+ patients. (See Setting standards.)
Setting standards
In addition to the American Association of Colleges of Nursing, the following organizations have taken steps to determine and establish competency standards:
- The American Nurses Association position statement affirms nurses must provide culturally competent, nondiscriminatory care and advocate to eliminate health inequities for LGBTQ+ populations.
nursingworld.org/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/nursing-advocacy-for-lgbtq-populations—final_bodapproved.pdf - The Human Rights Campaign’s Healthcare Equality Index assesses healthcare institutions on their LGBTQ+ inclusiveness and provides a framework for improving care for LGBTQ+ patients. bit.ly/4h00FMA
- GLMA: Health Professionals Advancing LGBTQ Equality offers education and training for healthcare professionals on LGBTQ+ health. glma.org
- The Institute of Medicine (now the National Academy of Medicine), in its 2011 report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, called for better training for healthcare professionals to address the needs of LGBTQ+ individuals. ncbi.nlm.nih.gov/books/NBK64806/
- The National League for Nursing provides recommendations and resources for integrating culturally sensitive care, including LGBTQ+ care, into nursing curricula. bit.ly/3QvJlnI
According to a 2024 Gallup poll, 9.3% of U.S. adults identify as LGBTQ+ (up from 7% in 2022). This number will likely grow in the coming years. With an estimated 32 million LGBTQ+ adults in the United States, almost all nurses will care for these patients during their careers.
Across all healthcare specialties, health outcomes of patients within the LGBTQ+ population depend on culturally sensitive and inclusive care. Historically, however, these patients have faced disparities in healthcare access and treatment as a result of stigma and discrimination in healthcare settings and beyond. The nursing profession must take steps to increase nurses’ knowledge about the healthcare and societal issues relevant to their LGBTQ+ patients.
Continuing healthcare disparities
The stigma and discrimination experienced by LGBTQ+ individuals make sexuality and gender identity social determinants of health (nonmedical influences that play a role in a person’s health and well-being). Due primarily to a long history of discrimination and stigma, LGBTQ+ patients experience a higher incidence of alcohol, tobacco, and illegal substance use, as well as a higher prevalence of depression and suicidal ideation than those who identify as heterosexual or cisgender.
According to the Williams Institute, these disparities are even more prevalent in LGBTQ+ youth and LGBTQ+ people of color. As nurses, we must keep in mind that these disparities usually result, directly or indirectly, from stigma, discrimination, and mistreatment in healthcare spaces. These experiences can lead to patient disengagement, distrust of healthcare providers, and an expectation that their specific needs won’t be addressed.
Many LGBTQ+ patients feel reluctant to divulge their sexual orientation or gender identity, especially to new healthcare providers. This wait-and-see approach may allow the patient to gauge the safety and inclusion of the facility and the provider or may stem from a past negative disclosure experience.
In certain healthcare scenarios, sexual orientation or gender identity may not seem immediately relevant to patient assessment and treatment; however, both play a critical role. If a patient is willing to share this information, it could prove invaluable to nursing care, physician assessment, and differential diagnosis.
LGBTQ+ patients will more likely seek healthcare and attend follow-up appointments if they receive dignified and respectful treatment, which every person deserves. However, if they have a negative first experience (for example, staff members consistently misgender the patient or the provider makes assumptions without an assessment), they may not return or will seek healthcare elsewhere.
Without a set competency, no consistent baseline exists for us to follow when providing care. (See Taking the right approach.)
Taking the right approach
How we approach a given situation can make the difference between a patient feeling accepted or feeling stigmatized.
Scenario 1: Routine check-up
Situation: A transgender woman (assigned male at birth) arrives for a routine check-up.
Incorrect approach: “What was your name before you transitioned?”
Asking about a previous name (deadname) is intrusive and can feel invalidating or traumatic.
Correct approach: “How would you like to be addressed?” or “What name and pronouns do you use?”
Asking how the patient wants to be addressed shows respect, affirms identity, and centers the patient’s current lived experience.
Scenario 2: Sexual health discussion
Situation: A man arrives for a sexual health consultation.
Incorrect approach: “Do you have a wife or girlfriend?”
Assuming heterosexuality (asking about a wife or girlfriend) overlooks diverse relationships and alienates LGBTQ+ patients.
Correct approach: “Do you have a partner?” or “Are you sexually active? If so, what is the gender of your partner(s)?”
Asking about a partner or the gender(s) of partners normalizes all relationship types and fosters open, nonjudgmental communication.
Scenario 3: Family history
Situation: A lesbian couple is expecting a child and comes in for prenatal care.
Incorrect approach: “Who’s the real mother?”
This question undermines both parents’ roles and can feel dismissive or offensive.
Correct approach: “Who will be the primary contact for medical decisions?” or “How would you like us to document your family structure?”
Asking about primary contacts or preferred documentation recognizes both parents equally and respects the family’s structure without
judgment.
Scenario 4: Confidentiality concerns
Situation: A bisexual teenager expresses concern about confidentiality.
Incorrect approach: “Your parents will need to know about your sexual orientation.”
This response breaches trust, can deter honest disclosure, and may endanger LGBTQ+ youth.
Correct approach: “Your privacy is important to us. We’ll share information only with your consent.”
Emphasizing confidentiality protects patient autonomy, builds trust, and aligns with ethical and legal standards for adolescent care.
Scenario 5: Mental health support
Situation: A nonbinary patient is experiencing anxiety and depression.
Incorrect approach: “Maybe you’re just confused about your gender.”
Suggesting confusion on the part of the patient pathologizes their identity and worsens mental health stigma.
Correct approach: “How can we support you in your mental health journey?” or “What specific challenges are you facing that we can help with?”
Focusing on support and the patient’s specific challenges affirms their identity and promotes compassionate, effective mental healthcare.
Scenario 6: Intake forms
Situation: A new patient is completing intake forms.
Incorrect approach: Forms that offer only “Male” and “Female” options.
Offering only “Male” and “Female” options erases nonbinary and gender-diverse identities, which can result in distress and create barriers to care.
Correct approach: Forms that include options such as “Male,” “Female,” “Nonbinary,” and a space for preferred name and pronouns.
Including nonbinary options and preferred pronouns signals inclusivity and acceptance, which supports patient-centered care.
Scenario 7: Room assignments
Situation: A transgender man is admitted to the hospital.
Incorrect approach: “We’ll put you in a room with other men, is that okay?”
This response makes an assumption based solely on gender, and then asking if it’s “okay” centers hospital convenience over patient dignity and comfort.
Correct approach: “Do you have any preferences for room assignments to ensure your comfort and privacy?”
Asking about preferences empowers the patient, prioritizes safety and privacy, and acknowledges their identity respectfully.
Scenario 8: Partner involvement
Situation: A patient wants their same-sex partner involved in their care.
Incorrect approach: “Is this your friend?”
Referring to a same-sex partner as a “friend” minimizes the relationship and can prove deeply invalidating.
Correct approach: “Would you like your partner to be involved in your care discussions?”
Recognizing and affirming the partner’s role supports the patient’s wishes and strengthens patient-centered, inclusive care.
Preparation, competence, and empathy
According to Bass and Nagy, LGBTQ+ people experience preventable healthcare disparities and worse outcomes in all significant health categories—cardiovascular health, mental health, substance use, and sexual and reproductive health. Nurses on the frontlines of healthcare can play an instrumental role in decreasing and eradicating these disparities. We can begin by actively reducing stigma and discrimination in healthcare settings and helping to establish guidelines and policies regarding how to approach and correct our colleagues who (implicitly or explicitly) perpetuate these harms.
The American Nurses Association’s Nursing: Scope and Standards of Practice describes nurses’ attempts to bifurcate their feelings, views, and professional duties to the LGBTQ+ patient population as a flawed and unacceptable strategy. If a nurse harbors personal bias or disdain for LGBTQ+ patients, these feelings will likely reveal themselves in the care delivered.
All nursing programs should include sexuality and gender-related curricula. As described by Bass and Nagy, culturally sensitive care of LGBTQ+ patients could begin by focusing on these three areas: targeted care of the LGBTQ+ population, social and structural equality of care, and avoidance of discrimination and stigmatization.
This training need extends to programs for established professional nurses at all levels, including healthcare facility, organizational, community, and public health. Ideally, this training would occur as a regularly scheduled course (in-person or via the facility’s online learning management system for clinical education modules), complete with a proficiency exam or post-test and a required minimum grade for passing. Organizations such as the National LGBTQIA+ Health Education Center (lgbtqiahealtheducation.org) offer various educational and training resources for healthcare providers, many with continuing education credit.
Training might include definitions of sexuality, sexual orientation, gender, gender identity, and evidence-based healthcare considerations. Instruction also should cover expectations of professional behavior, such as respecting patient wishes for their preferred names and pronouns and sharing that information with the entire healthcare team. (See Understanding supports advocacy.)
Understanding supports advocacy
An understanding of sexuality and sexual expression, sexual orientation, biological sex (sex assigned at birth), and gender can help nurses engage effectively and compassionately with LGBTQ+ patients.
Sexuality and sexual expression
The World Health Organization defines sexuality as the way a person expresses themselves as a sexual being. Many researchers (including Kinsey in the 1960s, Diamond in 2009, and Savin-Williams in 2014) have identified sexuality as existing on a spectrum. It serves as an umbrella term that encompasses sexual identity, sexual expression, and sexual orientation.
We all use sexual identity to express our sexual orientation. For example, we may self-label as “queer,” “same-gender-loving,” or “polyamorous.” Sexual expression refers to how we outwardly express our sexual identity via behaviors, feelings, thoughts, and relationships, including sexual activity.
Sexual orientation
The Human Rights Campaign defines sexual orientation as an “immutable enduring emotional, romantic, or sexual attraction to other people.” Sexual orientation includes categories such as straight/heterosexual (attracted to people of a different sex than oneself), gay/ lesbian/homosexual (attracted to people of the same sex as oneself), bisexual (attracted to both males and females), pansexual (attracted to people of either sex or all genders), and asexual (not sexually attracted to anyone or having a weak attraction).
Sexual orientation isn’t always stagnant and doesn’t necessarily align with sexual behavior or expression. For this reason, we should never assume a consistent correlation between the two.
Biological sex
Biological sex (a fraught term as it’s been appropriated by anti-LGBTQ+ groups to deny the existence of transgender people) refers to the sexual organs, hormones, and chromosomes a person is born with. Technically, three categories of biological sex exist: male, female, and intersex (also referred to as “differences of sex differentiation”).
Intersex individuals typically have some combination of male and female organs and/or male and female chromosomes or hormones, but they don’t typically have complete sets of both male sex organs and female sex organs. According to the Cleveland Clinic, an estimated 1 in 100 Americans is intersex, and about 2% of people worldwide have intersex traits.
Gender
The Centers for Disease Control and Prevention (CDC) defines gender as “the cultural roles, behaviors, activities, and attributes expected of people based on their sex.” Gender serves as an umbrella beneath which gender expression and gender identity reside.
Gender expression refers to a person’s behavior and how they act; this is where the terms feminine and masculine come into play. Some of us present as more feminine (as defined by societal markers of appearance, dress, and behavior), some as more masculine, and some as a combination of feminine and masculine (or androgynous).
Gender identity refers to our internal feelings about our gender. Sometimes, this feeling matches our gender assigned at birth, in which case we’re cisgender (our sense of personal identity and gender corresponds with our sex assigned at birth).
Cisgender is the opposite of transgender. If we’re transgender, our internal sense of gender doesn’t align with our assigned birth sex. A transgender woman is someone assigned male at birth but who identifies as a woman. A transgender man is a person assigned female at birth but who identifies as a man. According to the Williams Institute, an estimated 0.6% of the U.S. population identifies as transgender (1.6 million people). Transgender people may or may not undergo hormonal treatments and may or may not have gender-affirming surgery to alter physical sex characteristics.
Gender nonconforming or nonbinary individuals, regardless of their gender assigned at birth, don’t identify as male or female and live outside of the gender binary. These individuals frequently use “they/them/theirs” as their pronouns.
Many electronic health record admission assessment questions now include patient pronoun preference. This question serves as a straightforward way for nurses to establish an early connection and trust with patients and reduce the chance of misgendering (using names or pronouns of a gender other than the one a person identifies with), whether or not they’re members of the LGBTQ+ community. Misgendering can cause a person to feel ignored, stigmatized, and unwelcomed in a healthcare setting
Social psychology teaches us that some people may have difficulty understanding and empathizing with individuals they perceive as different from themselves. Including LGBTQ+-identified guest presenters or keynote speakers in these training seminars helps to incorporate personal stories of the real-life consequences of mistreatment and implicit bias within healthcare. Inviting speakers who also work as healthcare professionals can help drive home the importance of this topic and reminds us that some of our colleagues are LGBTQ+. This personalization adds to the value of the training by helping nurses make direct connections between themselves and their LGBTQ+ patients.
In addition, various self-evaluation tools exist, such as a free online implicit bias self-assessment developed by Harvard University (implicit.harvard.edu/implicit). This resource allows clinicians to ask themselves survey questions designed to gauge their attitudes and feelings about caring for LGBTQ+ individuals. The Human Rights Campaign also offers detailed staff training suggestions and guidelines.
Culturally sensitive care
The nurse practitioner who overheard Jordan’s partner express concern speaks with the charge nurse, who initiates a quick huddle with the care team. She reminds staff to consistently use the patient’s affirmed name and pronouns and updates the whiteboard in the room to reflect this. She also advocates for documentation of gender identity, chosen name, and pronouns to be visible in the electronic health record in alignment with best practices.
Jordan’s assigned evening shift nurse introduces himself and says, “Hi Jordan, I see you use they/them pronouns. Thank you for sharing that with us. Let me know if there’s anything I can do to make you more comfortable tonight.” Jordan visibly relaxes and later accepts medication and assistance with ambulation.
Although many recognize the need for LGBTQ+-specific education in nursing, formalized and consistent curricula and training remain uneven across educational institutions and healthcare settings. As nurses, we must advocate for this vulnerable patient population and for the education needed to deliver culturally sensitive care.
Daphne Scott-Henderson is an informatics nurse, a doctoral candidate, and a leader in health equity.
Daphne Scott-Henderson’s story
I’ve been a registered nurse for 15 years. I began my career in critical care, where I witnessed firsthand how health systems can both help and harm patients, especially those from marginalized communities. In 2015, I earned my Master of Science in Healthcare Informatics, and since then, I’ve served in roles ranging from informatics nurse to informatics project manager and director. I’m passionate about advancing health equity through informatics and policy and using data to drive meaningful changes in patient care.
Currently, I’m a doctoral candidate, with my dissertation research focusing on the sexual and reproductive healthcare experiences of lesbian-identified Black women. As a Black lesbian myself, I’ve experienced discrimination in healthcare settings related to my intersecting identities. I remain deeply committed to building a healthcare system where all patients can receive equitable, affirming care.
American Nurse Journal. 2026; 21(3). Doi: 10.51256/ANJ032614
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Keywords: LGBTQ+, sexuality, gender, healthcare disparities
