Advocates for Health Equity: 

Background and Significance

School nurses are the cornerstone of school health, fostering a safe and healthy school environment so students may thrive academically. However, the responsibilities of a school nurse extend far beyond routine nursing care. School nurses provide critical health services, including care coordination, health screenings, immunizations, medication administration, emergency response, and behavioral health support. They also serve as educators, communicators, and advocate for students’ health needs and rights (“Chapter 1: Coordinated School Health Program,” 2023; Ramos et al., 2024; Daniel Shattuck et al., 2024; D. Shattuck et al., 2024). As one school nurse describes, “It’s more than Band-Aids and ice packs.” 

More than caregivers, school nurses are pivotal in advancing health equity. They serve as frontline providers for students from diverse backgrounds, including those who face disproportionate health risks due to systemic and structural barriers to healthcare. Among these populations are youth who identify as lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+), a group that has historically been overlooked in healthcare. The scope of health concerns for LGBTQ+ youth is poorly understood, in part because until recently, population-level data has not adequately captured their experiences, concerns, and needs.

The New Mexico Youth Risk and Resiliency Survey (NM-YRRS) has been instrumental in shedding light on the health needs of LGBTQ+ students. The NM-YRRS is the state-specific extension of the Center for Disease Control and Prevention’s Youth Risk Behaviors Surveillance

System, a collection of surveys that gather health and risk information about school-aged youth across the United States. Since 2013, the survey has included a question about sexual orientation in its high school questionnaire, and since 2017, it has included a gender identity question. In 2021, New Mexico became one of only four states to ask about sexual orientation in the middle school survey (along with Hawaii, North Dakota, and Vermont). These data help researchers and school health professionals, including school nurses, identify trends and risk factors affecting LGBTQ+ students, allowing for targeted interventions and more relevant training. 

According to the 2023 NM-YRRS, 6.5% of New Mexico high school students identified as transgender, nonbinary, or a gender other than (male/man/boy) and (female/woman/girl). In this same survey, 18.5% identified as lesbian, gay, or bisexual, and 3.4% described their sexuality in another way (e.g., demisexual, asexual, aromantic, pansexual), and 78.4% identified as straight (table 1). These numbers translate into thousands of students across the state – and present in every district – who identify as LGBTQ+. 

LGBTQ+ high school students in New Mexico report high rates of experiencing bullying, sexual assault, absenteeism due to safety concerns, homelessness, and suicidal ideation and attempts (table 2). Recent analyses of 2021 NM-YRRS data show that these risks begin as early as middle school, if not earlier (Kuhlemeier et al., 2024). 

The compounding effects of these experiences – combined with a potential lack of protective factors such as supportive adults, affirming peers, and engagement in school activities – can lead to serious consequences. In the short term, LGBTQ+ students may face increased risks of academic struggles, substance use, risky sexual health behaviors, and mental health crises. Over the long term, these students are at greater risk for chronic health issues, housing instability, social isolation, and diminished career opportunities (Blosnich & Andersen, 2015). 

2024 New Mexico School Nurse Survey

The web-based survey was implemented in the fall of 2024, recruiting participants through the NMDOH 2024 School Nurse Directory. The 2024 New Mexico School Nurse Survey gathered insights into various topics including their overall responsibilities, work environments, educational backgrounds, and training priorities. Participants included nurses working in public, charter, Bureau of Indian Education, Tribal, and private schools in the state. The web-based survey was implemented in the fall of 2024, recruiting participants through the New Mexico Department of Health (NMDOH) 2024 School Nurse Directory. The anonymous survey had an overall response rate of 67%, with 358 completed surveys representing 72 school districts across New Mexico. The survey was conducted by an independent evaluation firm (the Pacific Institute for Research and Evaluation) contracted by the NMDOH Office of Student and Adolescent Health. 

Results

Most of the school nurses who responded to the survey were registered nurses (95.9%) with more than half earning a bachelor’s degree (56.1%) and 14.4% having earned a master’s or doctoral degree. The survey included questions about training received and training desired. When asked about suicide risk screening, 61.1% of respondents stated that their school participates in such training, and 60% of respondents reported participating in suicide prevention training themselves. Nearly half (48.8%) had received supplementary training on lesbian, gay, and bisexual student health, while 36.8% expressed a need for further training on this topic. Notably, the percentage of school nurses who have received LGBTQ+ health training has not changed in recent years (50.8% in 2019), despite the ongoing relevance of these issues (Sebastian et al., 2021). 

In addition to this training gap, practical barriers limit school nurses’ ability to address students’ needs, including those that identify as LGBTQ+. Staffing shortages and high workloads prevent school nurses from fully taking on leadership roles in shaping broader school health policies. Without sufficient resources, school nurses often struggle to implement systemic changes that promote health equity (Daniel Shattuck et al., 2024) The full results of the 2024 New Mexico School Nurse Survey will be released later in 2025 through the NMDOH Office of Student and Adolescent Health.

Conclusion

Providing comprehensive health care for LGBTQ+ students in school-based settings is both an urgent necessity and a developing field of practice. While significant progress has been made in understanding the unique challenges LGBTQ+ students face, much remains to be learned and translated into evidence-based strategies. Data from the NM-YRRS and the New Mexico School Nurse Survey underscore the pressing need for increased training, resources, and systemic support to ensure that LGBTQ+ students receive the care they need.

The National Association of School Nurses (NASN) position statement is unequivocal in its support for LGBTQ+ youth, stating that school nurses are “…uniquely positioned to help LGBTQ youth by creating LGBTQ-affirming spaces, guiding youth towards resources, advocating for school-wide protections, and assuring youth that their identities and feelings are normal and appropriate. … NASN supports comprehensive care, guided by the principles of cultural humility, in safe, inclusive, and affirming school environments for LGBTQ youth… To reduce these health disparities and to provide comprehensive care, school nurses should collaborate with educational teams to create welcoming, healthier, and thus safer environments for all students, while addressing stigma, discrimination, and marginalization of LGBTQ students (LGBTQ Students [Position Statement], 2021).” 

As school health leaders, school nurses can make meaningful interventions – whether through direct care, advocacy, or the development of inclusive school policies. However, school nurses need adequate staffing, professional development, and institutional support to fully embrace this leadership role.

Recent federal Executive Orders will likely impact the types of information we have about the specific needs of LGBTQ+ populations in the future. This means that schools and school nurses will need to pay even closer attention to the needs of their communities without the assistance of many of their typical data sources. To move forward, school health systems must prioritize ongoing education on LGBTQ+ health, strengthen partnerships with community resources, and address systemic barriers that hinder inclusive care. By doing so, New Mexico school nurses can ensure that all students—regardless of gender identity or sexual orientation—can thrive in a safe and supportive school environment. n

References 

Blosnich, J. R., & Andersen, J. P. (2015). Thursday’s child: the role of adverse childhood experiences in explaining mental health disparities among lesbian, gay, and bisexual U.S. adults. Soc Psychiatry Psychiatr Epidemiol, 50(2), 335-338. https://doi.org/10.1007/s00127-014-0955-4 

Chapter 1: Coordinated School Health Program. (2023). In New Mexico School Health Manual. NM Department of Health. https://schoolhealthmanual.clickhelp.co/articles/#!new-mexico-school-health-manual-publication-1/chapter-one

Kuhlemeier, A., Shattuck, D. G., Willging, C. E., & Ramos, M. M. (2024). Comparing behavioral health of lesbian, gay, bisexual, questioning, and heterosexual middle school students. LGBT Health. https://doi.org/10.1089/lgbt.2023.0477 

LGBTQ Students [Position Statement]. (2021, January, 2021).  National Association of School Nurses. Retrieved February 15 from https://www.nasn.org/nasn-resources/professional-practice-documents/position-statements/ps-lgbtq#:~:text=NASN%20POSITION,%2Fquestioning%20(LGBTQ)%20youth.

Ramos, M. M., Sebastian, R., Shattuck, D., Acosta, S., & Zamarin, K. (2024). School nursing workforce differences between urban and non-urban areas: implications for school health services and equity. J Sch Nurs, 40(5), 482-490. https://doi.org/10.1177/10598405221119516 

Sebastian, R., Zamarin, K., Shattuck, D., & Ramos, M. (2021). 2019 New Mexico School Nurse Workforce Survey Report. N. M. D. o. Health. https://southwest.pire.org/wp-content/uploads/sites/10/2022/04/2019-NM-School-Nurse-Survey_Full-Report_FINAL-with-PIRE-citation.pdf

Shattuck, D., Ramos, M. M., Richard, B. O., Hall, J. L., Sparks, R., & Willging, C. E. (2024). School nurse leadership and the implementation of school-based support for lgbtq+ students. The Journal of School Nursing, 0(0), 10598405241265706. https://doi.org/10.1177/10598405241265706 

Shattuck, D., Sebastian, R., Zamarin, K., Acosta, S., & Ramos, M. M. (2024). School nurse management of behavioral health, violence, and trauma related emergencies: Findings from statewide survey. J Sch Nurs, 40(5), 536-546. https://doi.org/10.1177/10598405221120437