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Published in final edited form as: Nurs Outlook. 2022 Apr 13;70(3):513–524. doi: 10.1016/j.outlook.2022.02.005

How can the nursing profession help reduce sexual and gender minority related health disparities: Recommendations from the national nursing LGBTQ health summit

Tonda L Hughes a,b,*, Kasey Jackman a,c, Caroline Dorsen d, Cynthia Arslanian-Engoren e, Lauren Ghazal e, Thomas Christenberry-deceased f, Chris Coleman g, Melissa Mackin h, Scott Emory Moore i, Ronica Mukerjee j, Athena Sherman k, Sheila Smith l, Rachel Walker m
PMCID: PMC9393898  NIHMSID: NIHMS1828900  PMID: 35430056

Abstract

Background:

Lesbian, gay, bisexual, transgender and queer (LGBTQ) people, also commonly referred to as sexual and gender minorities (SGMs), live in every part of the United States and encompass all races and/or ethnicities, religions, and social classes. Major reports from various sources document higher rates of health issues (e.g., substance abuse, depression, suicidality, cardiovascular disease) among SGMs than heterosexuals. Chronic stress related to marginalization and discrimination is a key contributor to these disparities. The nursing profession has paid relatively little attention to SGM health issues.

Purpose and Methods:

To address these gaps, the first National Nursing LGBTQ Health Summit brought together nursing deans, leaders of national nursing organizations, and other participants from across the United States.

Discussion:

Participants agreed that increasing SGM-specific content in nursing curricula, practice guidelines, faculty development, and research is necessary to improve the health of SGM people.

Conclusion:

The Summit ended with a call to action for the nursing profession to prioritize SGM health through innovations in education, research, and practice.

Keywords: Nursing, LGBTQ, Sexual and gender minority, Health summit, SGM

Introduction

Health disparities are defined by the Centers for Disease Control and Prevention (CDC) as “preventable differences in the burden of disease, injury, violence, or opportunities to reach your best health” that are experienced by socially disadvantaged populations (Centers for Disease Control and Prevention, 2008). Sexual and gender minorities (SGMs) are recognized by the National Institutes of Health (NIH) as a health disparities population. Research reviewed in consensus study reports from the Institute of Medicine (now, the National Academies of Sciences, Engineering, and Medicine (Institute of Medicine, 2011; National Academies of Sciences, 2020) show that compared with heterosexuals, sexual minorities report higher rates of physical and mental health problems, such as substance use disorders, depression, suicidality, and cardiovascular disease. Transgender people also report poorer health than cisgender people (those whose gender identity matches their assigned sex at birth) and have particularly high rates of psychological distress and suicidality. Reduction of health disparities is a fundamental goal of public health research and practice. Although there is evidence that educational interventions are effective in improving care for SGM people (Sekoni et al., 2017) and for the clear need for tailored evidence-based care, prevention, and treatment, this is lacking in most health care settings—in large part due to the lack of attention to SGM health in health professions education (Institute of Medicine, 2011).

Faculty and administrative leaders in nursing schools have been slow to incorporate SGM health content into nursing curricula despite national recommendations (Bonvicini, 2017; McCann & Brown, 2018). The NIH, National Academy of Medicine, American Academy of Nursing, and National Student Nurses Association have each released statements endorsing efforts to increase education and research relative to SGM health (American Academy of Nursing, 2019; Institute of Medicine, 2011; National Academies of Sciences, 2020; National Student Nurses’ Association, 2017).

The First National Nursing LGBTQ Health Summit

The idea for a national nursing health summit to address these recommendations grew out of an informal conversation between Drs. Tonda Hughes (Associate Dean, Columbia University School of Nursing) and Ann Kurth (Dean, Yale University School of Nursing) at a meeting in San Francisco in 2016 and in subsequent conversations with Dean Eileen Sullivan-Marx (New York University) and Dean Bobbie Berkowitz (Columbia University). On November 9, 2017, an initial conference call with a small group of nursing deans and/or their designees furthered the discussion about a future nursing summit focused on issues related to SGM health. There was consensus that work is urgently needed to move the nursing profession forward regarding SGM health in all three aspects of the tripartite mission of schools/colleges of nursing (i.e., education, research, and practice). An in-person meeting to plan the Summit was held at Columbia University in March 2017, and included nursing deans from Columbia University, Johns Hopkins University, Long Island University, New York University, Rutgers University and Yale University. Students or other representatives from Columbia University, Duke University, New York University and the University of Pennsylvania also attended.

Subsequently, the National Nursing LGBTQ Health Summit, held November 21 to 22, 2019, brought together nursing leaders in education, research and practice, and experts or stakeholders in SGM education, research, clinical care and policy to take the first steps toward creating a national action plan and unified nursing agenda to improve SGM health.

Use of Sexual and Gender Minority Terms

Although we used the acronym LGBTQ (i.e., lesbian, gay, bisexual, transgender, queer) in the name of the Summit—and in the title of this report—we use the terms sexual and gender minority and the acronym SGM throughout the rest of the report. SGM has been increasingly used over the past 5 to 10 years, especially following the establishment of the Office of Sexual and Gender Minority Health in 2015 at the NIH, and the official designation of SGM people as a health disparity population for NIH research in 2016. As noted in the announcement of this designation, “The term SGM encompasses lesbian, gay, bisexual, and transgender populations, as well as those whose sexual orientation, gender identity and expressions, or reproductive development varies from traditional, societal, cultural, or physiological norms.” Thus, SGM is more encompassing and inclusive than LGBTQ, or LGBTQIA+, acronyms that are continuing to evolve and change.

Below we provide an overview of the literature focused on nursing education, research and practice related to SGM health, recommendations for the nursing profession, and a summary of the Summit and its outcomes.

Nursing Education

Nursing faculty consistently report insufficient knowledge and competency to instruct nursing students about how to effectively care for SGM people (Cornelius et al., 2017; Lim et al., 2015; McCann & Brown, 2018; McNiel & Elertson, 2018; Mitchell et al., 2016; Stewart & O’Reilly, 2017). In the absence of knowledge and pedagogical and/or andragogical expertise regarding SGM health, nurses entering practice will continue to be inadequately prepared to care for SGM people. This is troubling given that the proportion of individuals in the United States who identify as SGM is growing (Gallup, 2021), as are reports of discrimination against SGM people in health care settings (Cornelius et al., 2017; Lim et al., 2015; McCann & Brown, 2018; Mitchell et al., 2016; Stewart & O’Reilly, 2017).

Given the lack of knowledge about SGM health among nursing faculty, it is not surprising that graduating nursing students lack knowledge about SGM people and their health concerns, and thus are often not competent to provide SGM-sensitive care (Lim & Hsu, 2016; McCann & Brown, 2018; Strong & Folse, 2015). In a systematic review of SGM content in undergraduate and professional health education programs, issues were found regarding the development of SGM cultural competence; significant limitations and lack of variability in SGM-specific health topics (e.g., cancer, reproductive health, gender-affirming care, assessment of sexual orientation and gender); and lack of formal SGM curricular evaluation and integration of research evidence (McCann & Brown, 2018).

Most studies examining nursing students’ perceptions of SGM people have found that students hold neutral or negative attitudes towards these population groups (Lim & Hsu, 2016), are poorly prepared in the unique health needs of the SGM community and lack confidence in providing care to SGM patients (McCann & Brown, 2018). One study found that approximately one-third to one-half of nursing students surveyed reported that they would be uncomfortable working with SGM clients (Eliason & Raheim, 2000). Although most research on SGM content in nursing education has focused on baccalaureate-level prelicensure education, a review of graduate-level textbooks found insufficient content on about SGM health (De Guzman et al., 2018). Health assessment content on awareness, knowledge, and caretaking skills was limited and lacked exemplars and application to the SGM population. Barriers to incorporating appropriate content in nursing programs include negative attitudes of students, faculty, and staff; preconceptions and biases about SGM people, stereotypical beliefs, cisgenderism, and acceptance of prevailing heteronormative practices and policies (Carabez et al., 2015; Cheng & Yang, 2015; Daley & MacDonnell, 2015; Fredriksen-Goldsen et al., 2011.).

Arguably, such curricular shortcomings can lead to insensitive interactions and weakened patient-provider relationships, reducing ability to address the health needs of SGM individuals. This conclusion is corroborated by multiple studies reporting SGM people’s negative health care experiences, indicating persistent hetero- and cis-normativity as well as less common, but more damaging, overt discrimination and abuse (Cicero et al., 2019). Although curricular guidelines require that nursing education programs at all levels prepare nurses who demonstrate competency in the delivery of culturally sensitive care to diverse populations, such guidelines often fail to explicitly identify SGM people as groups for which such competencies must be demonstrated (American Nurses Association, 2010). Baccalaureate pre-licensure nursing programs across the United States report an average of only 2.12 hours spent on SGM-specific health topics (Lim et al., 2015). The absence of appropriate academic preparation is particularly notable with regard to the health needs of transgender and gender diverse people, 25% of whom report having to educate health care providers about their health needs (James et al., 2016).

In light of these shortcomings, nursing faculty and practitioners are beginning to develop specific approaches and strategies to enhance and support student learning experiences and to improve their competence in caring for SGM people (Bidell, 2017; Carabez et al., 2015; Gendron et al., 2013; Vance et al., 2017). Presentations, scripted interview sessions, group-work, SGM patient panels, case studies, simulations and e-learning technologies are being used to highlight particular health and social issues faced by SGM people (De Guzman et al., 2018; Vance et al., 2017). In one intervention study, 74% of students reported greater awareness of SGM issues and unconscious biases after completing an assigned SGM-related educational task (Carabez et al., 2015).

Some schools are also working to integrate theories and frameworks such as social determinants of health (Solar & Irwin, 2010; Tilden et al., 2018), critical social theory (Mooney & Nolan, 2006), intersectionality (Ruiz et al., 2021) and social justice (Perry et al., 2017) into curricula to better address health disparities and inequities in health and health care. Although these are more often used to teach students about racial/ethnic- and socioeconomic-related health disparities, they are also well suited to teaching about SGM-related health disparities. For example, the World Health Organization (WHO) social determinants of health con ceptual framework describes how social, economic, and political factors such as income, education, occupation, gender, race, and ethnicity influence a person’s socioeconomic position which, in turn, helps to determine health outcomes. Similarly, critical social theory explicates how the divisions between social groups or classes contribute to health problems or vulnerabilities to health problems among specific groups. Critical social theory can be used to help nursing students understand that health vulnerabilities are not the result of individual characteristics of a specific group, such as race/ethnicity or sexual orientation, but rather are linked to external social factors. It can also be used to address oppressive sociopolitical conditions that influence health care (Mooney & Nolan, 2006).

Continuing Education

Practicing nurses and other health care providers have knowledge gaps with regard to SGM cultural and clinical competencies, and little is known about SGM-specific continuing education for these providers (Cicero et al., 2019; Enson, 2015; Fredriksen-Goldsen et al., 2013.; James et al., 2016; White Hughto et al., 2015). Few SGM-specific clinically based educational interventions have been conducted with practicing nurses (Felsenstein, 2018; Klotzbaugh & Spencer, 2015). Horner and colleagues (Horner et al., 2012) found that SGM-specific continuing education opportunities for providers were not available at 83 elder care facilities in Western Australia. In addition, literature showing the efficacy of current continuing educational strategies in improving attitudes and knowledge of practicing nurses is sparse (Englund et al., 2020). This is concerning because nursing is the largest health care profession and thus has the capacity to significantly impact health care outcomes for SGM people, to influence the curricula and practices of other health care professions, and to impact policy.

Nurses are central to closing the health care disparity gap that SGM people face by fostering culturally appropriate and sensitive care (Lim & Hsu, 2016). Regulatory and authoritative bodies mandate that nursing leaders provide state-of-the-science culturally competent continuing education for frontline health care providers. Education focused on SGM health should be offered as part of orientation, diversity and inclusivity training, and as part of in-service education and re-certification requirements (Gay & Lesbian Medical, 2021, n.d.; Human Rights Campaign, 2020; The Joint Commission, 2011). Existing research and policy statements regarding education for nursing students, faculty, and practicing nurses support the need for a national strategy that addresses SGM health disparities. Structurally, national standards are needed to guide the integration of SGM content in nursing curricula in both didactic and clinical courses. Individually, education regarding the SGM population is needed for nursing students, faculty, and practicing nurses. Systematically creating standards for the integration of SGM content in nursing curricula and continuing education will support best practices for teaching SGM health.

Nursing Research

Theoretically grounded nursing science is the foundation of evidence-based nursing practice. However, with a few exceptions (e.g., research related to HIV/AIDS) nurse researchers have made relatively small contributions to the body of knowledge related to SGM health and health care. This has resulted in critical gaps in understanding the health experiences of large segments of the SGM population and how historical and contemporary sociopolitical realities impact SGM health. Without this knowledge base, nurses lack the capacity to lead care of these diverse and understudied population groups.

The dearth of research to support nursing practice in the care of SGM individuals stands in stark contrast to nursing’s covenant with society outlined in two key documents that guide professional nursing practice. Nursing’s Social Policy Statement (American Nurses Association, 2010) calls for “the incorporation of research and evidence into practice” (p. 4) and “the advancement of professional nursing knowledge through scholarly inquiry” (p. 9). Similarly, ethical standards outlined in the Code of Ethics for Nurses (American Nurses Association, 2015) that guide professional nursing practice compel “nurse researchers and scholars to contribute to the body of knowledge” (p. 28) and call for all nurses “to commit to advancing health, welfare and safety” (p. 31) and to be “formidable instruments for social justice” (p. 31).

Nursing has paid relatively little attention to research to improving care for SGM people, especially those who do not identify as lesbian, gay or bisexual, are not white and English-speaking, and who are not cisgender. A recent literature review of the top 20 nursing journals (based on impact factor) found that only 0.19% of articles focused on SGM health (Jackman, Bosse, Eliason, & Hughes, 2019). Less than one-half (44%) of empirical studies reported the racial/ethnic composition and gender identity of their samples; these samples were predominately white and cisgender. This article updated an earlier review with a similar methodology that found only 0.16% of articles in the top 10 nursing journals spanning the years 2005 to 2009 addressed SGM health (Eliason et al., 2010). Jackman et al. (2019) concluded that the slight increase in empirical articles—in addition to several editorials, literature reviews, and theoretical articles about this topic—suggest that the nursing profession is slowly recognizing the importance of SGM health. However, in light of substantial health disparities affecting SGM people, more research, including intervention studies, is urgently needed to address these disparities.

Reasons for the dearth of SGM nursing research are multifactorial, including limited federally funded support for this research. For nurse scientists, the National Institute of Nursing Research (NINR) is a major source of research funding; NINR’s research priorities provide a guidepost for much of nursing research. However, in a recent review of NINR-funded research Bosse and colleagues found that in the past 20 years, apart from predoctoral fellowships, only 13 research grants addressed SGM population (Bosse et al., 2020). From 1998 to 2017 less than 1% of R01-level funding awarded by NINR was for SGM related research. Overall, the portfolio of NINR research for SGM health was quite narrow, with more than 50% of funded grants focusing on HIV/AIDS and the remainder addressing specific disparities, health care experiences, or substance abuse (Bosse et al., 2020).

There are numerous gaps in knowledge about SGM health. The current polarized political climate in the United States and the Black Lives Matter movement should reinforce the nursing profession’s commitment to social justice. Nursing research must address intersectional identities (Crenshaw, 1991) among SGM people who are also Black, indigenous, Latinx, and people of color (BILPOC), areas broadly missing from nursing science. Additional nursing knowledge is needed to care for SGM people across the lifespan. Comparatively few nursing research studies have examined the health and care needs of older SGM adults (Cloyes, 2015). The nursing profession must also pay attention to SGM people who experience even greater marginalization and risk, such as those with disabilities, immigrants, refugees and asylum seekers, as well as other SGM people who are socially disadvantaged, including those who experience housing and/or food insecurity.

A landmark report from the National Academies of Medicine published a decade ago recommended several frameworks to guide research on SGM health, including life course perspective, social-ecological framework, intersectionality, and minority stress (Institute of Medicine, 2011). Of these, the minority stress model (Meyer, 1995, 2003; Pearlin, 2000) is the most commonly used. Notably, this model contains the word “minority” in its title. While this labeling is consistent with the model’s postulates that the SGM population faces greater stress due to experiences of stigma, oppression and violence from dominating cultures and institutional structures that marginalize them, it also positions research participants within a “deficit” model of health that tends to focus more on understanding pathology than well-being, resilience, or collective strength. In this sense, the minority stress model, although perhaps useful for framing certain mechanisms underlying the biopsychosocial health outcomes of SGM individuals, moves us no closer to dismantling structures of oppression that create disease or to creating emancipatory futures.

Critical theory, a possible alternative to deficit-based health frameworks, focuses expressly on the root causes of structural oppression and inequity (Felluga, 2015). Scholars of Black feminist theory, such as Dr. Patricia Hill Collins, have described the “matrix of domination” (Anderson, 2020; Collins, 1990; Schultz, 2019): structures of oppression that create the stigma and violence described in the minority stress model. Wesp et al., (2019) draw on theories of intersectionality and structural injustice in their conceptual framework for research with transgender populations (Wesp et al., 2019). The framework, Intersectionality Research for Transgender Health Justice (IRTHJ), provides guidance to researchers who wish to transform the design, implementation, and interpretation of transgender health research. Tenets of this framework are that “social inequities and the distribution of societal determinants of health are not random or accidental, but rather are structural injustices that have been systematically produced over time through actively maintained structures of power” (p. 290). The authors state that the main tenet of IRTHJ is that social and health inequities experienced by transgender people result from power relations produced within and between oppressive structures, institutional systems, and socio-structural processes.

Nursing Practice

Little is known about the quality of nursing care for SGM people, how nursing care of SGM individuals compares to that provided to heterosexual and/or cisgender patients, and how knowledge deficits and/or negative attitudes towards SGM people impact health care outcomes. As noted in the section on education above, historically there has been a lack of focus on teaching nursing students or practicing nurses about the health needs of SGM people. A small but growing body of literature has documented nurses’ attitudes towards SGM people and nurses’ attempts to create culturally sensitive health care climates for SGM people within nursing practice (Dorsen, 2012; Dorsen & Van Devanter, 2016; Radix & Maingi, 2018). Some research suggests that nurses may harbor more bias than other health care professionals towards SGM people (Sabin et al., 2015). Other studies have shown that nurses often do not understand how sexual orientation and gender identity impact access to and outcomes of care, and thus, in an attempt to be unbiased, choose to “treat all patients the same” rather than provide person-centered care that is culturally sensitive and responsive to the unique needs of SGM people (Beagan et al., 2012; Dorsen & Van Devanter, 2016).

Description of the Summit

Participants

The first National Nursing LGBTQ Health Summit was designed to bring together key nursing leaders and allies to discuss how to develop a national nursing agenda to meet the health needs of SGM people. The planning committee was intentional in its selection of Summit invitees. Because space and resources were limited careful consideration was given to ensure that those invited be committed to advancing SGM health within nursing; willing to engage in open and candid conversations about SGM health; and be able to influence education, research and/or practice relevant to SGM health within their institutions or organizations. As shown below, the approximately 80 Summit attendees included deans of schools/colleges of nursing, leaders of nursing organizations, and experts in SGM health representing 33 organizations, schools or colleges. The advisory board envisioned follow-up summits that would occur in subsequent years and would include a larger number of active participants and broader representation of nursing and SGM communities.

American Academy of Nursing
American Association of Colleges of Nursing
Columbia University School of Nursing
Drexel University College of Nursing & Health Professions
Duke University School of Nursing
Frances Payne Bolton School of Nursing, Case Western Reserve University
Indiana University School of Nursing-Fort Wayne
Johns Hopkins School of Nursing
Loyola University Marcella Niehoff School of Nursing
National Black Nurses Association
NIH, National Institute for Nursing Research
NIH, Sexual and Gender Minority Research Office
National Student Nurses Association
National Organization of Nurse Practitioners
Nell Hodgson Woodruff School of Nursing, Emory University
New York University, Langone Medical Center
New York University, Rory Meyers College of Nursing
Oncology Nursing Society
Rutgers University School of Nursing
Rutgers University School of Public Health
The George Washington University School of Nursing
University of Massachusetts-Amherst College of Nursing
University of California, San Francisco School of Nursing
University of California, Los Angeles School of Nursing
University of Illinois at Chicago, College of Nursing
University of Iowa College of Nursing
University of Miami School of Nursing and Health Studies
University of Michigan School of Nursing
University of Minnesota School of Nursing
University of Pennsylvania School of Nursing
University of Wisconsin-Madison School of Nursing
Vanderbilt School of Nursing
Yale University School of Nursing
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Summit Goals

The overall goal of the Summit was to accelerate the nursing profession’s progress in addressing SGM health issues in education, research, and practice and to lay the groundwork for an actionable plan for the future. A secondary goal was to provide a forum for nursing leaders to network and plan for future collaborations. Groupworks Consulting, in collaboration with the advisory board, helped to plan and facilitate the Summit. The two-day Summit was held on November 21 to 22, 2019 at Columbia University School of Nursing in New York City. Each day included presentations on SGM health-related topics, structured small-group discussions, and facilitated debriefing. Small group discussions used World Café, a publicly available group facilitation framework (http://www.theworldcafe.com) that provides participants opportunities to meet and have conversations in a formalized, structured way. Before the Summit began, participants were sent selected readings and were assigned to specific groups to ensure a diversity of perspectives. Participants were given a “travel itinerary” so they knew which table sequence they would follow for the World Café activity.

Each day of the Summit included keynote presentations. Perry Halkitis (Dean of the Rutgers University School of Public Health) provided the opening keynote, introducing the group to SGM health and health disparities. Tonda Hughes (Professor and Associate Dean, Columba University School of Nursing) summarized the state of nursing education, practice, and research related to SGM health, and asked focused questions to guide the dialogue. Examples of questions provided to groups are included in Appendix A. Facilitators and notetakers were on-hand to capture key ideas, questions, and action items over the course of each day.

Several rounds of group discussions culminated in a variety of creative presentations to the larger group and included a musical skit, posters and other visual aids. Each group was also tasked with creating a vision statement that encapsulated the rich themes that emerged over the course of several rounds of the World Café. These vision statements were intended to synthesize and condense key findings related to future directions. As shown in the table below, each vision statement fell into one of the three focal areas of the summit: education, research, or practice.

Vision Statements
Education All nursing faculty have the knowledge, skills, compassion, and support to educate the next generation of nurses about SGM health and health care.
Nursing faculty with expertise in clinical practice, education and/or scholarship serve as champions of SGM health and health care.
Nursing faculty act as advocates and guardians in the promotion of human dignity and as leaders in the care of diverse SGM population groups. They educate nurses who are competent and inspired to care for SGM people, having learned about sexual orientation and gender identity through a humanistic approach. AACN essentials document and nursing curriculum incorporate affirming, inclusive and dynamic SGM content using an intersectional lens and frameworks that situate health disparities within the larger socio-cultural context rather than within individuals.
Nursing schools provide a culture in which all nursing students and faculty feel safe to be their authentic selves.
Research Nurses are leaders in the generation of new knowledge about SGM health and wellbeing and translate that knowledge to inform education, practice, and policy.
SGM health is a research priority, including at NIH/NINR; SGM measures are included in all nursing research, and SGM nursing research is a key component of interdisciplinary SGM research.
Nursing Practice All nurses provide affirming, equitable, safe, and quality care to SGM people and their families.
Nurses are leaders in interprofessional health care teams learning to provide high-quality person-centered care to diverse SGM population groups.
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There was resounding support for the Summit to be held annually or biannually, perhaps with regional events that would then feed into larger in-person meetings. Suggestions included expanding future Summits to include licensed practical nurses in addition to those prepared at the associate degree, baccalaureate, master’s and doctoral level. Participants also encouraged the inclusion of clinical leaders, as well as legal and other health professional colleagues. There was consensus that representatives from SGM communities be included as active participants in future Summits. Consideration was given to expanding the geographic diversity of participants by including virtual attendees through the use of video conferencing and webcasts. In summary, the first National Nursing LGBTQ Health Summit succeeded in serving as a collective call to action for the profession to become active in the reduction of health inequities among this historically underserved population. As the largest health professional workforce globally, nurses are uniquely positioned to have a profound impact in reducing SGM health disparities.

Recommendations

Important questions remain about the quality of nursing care delivered to SGM individuals and families and the role that nursing has played in perpetuating or lessening health inequities among SGM populations. Still, it seems clear that nurses can play a central role in to closing the health care disparity gap that SGM people face by fostering culturally appropriate and sensitive care (Lim & Hsu, 2016).

Content related to SGM health must be included in nursing curricula, including content related to the unique culture and history of SGM populations, SGM health disparities, and the impact of stigma, bias and marginalization on health care access and utilization. Individual, community and structural interventions to create an affirming and inclusive environment for SGM patients and their families are needed (Mukerjee et al., 2021). SGM-specific clinical guidelines are needed for nursing education and practice. National standards are needed to support the integration of SGM content in nursing curricula—both in didactic and clinical courses. Individually, education regarding the SGM population is needed for nursing students, faculty, and practicing nurses. Systematically creating standards for the integration of SGM content in nursing curricula and continuing education will ensure best practices for teaching SGM health.

Regulatory and authoritative bodies mandate that nursing leaders provide state-of-the-science culturally competent continuing education for frontline health care providers. Education focused on SGM health should be offered as part of orientation, diversity and inclusivity training, and as part of in-service education and re-certification requirements (Gay & Lesbian Medical Association, nd., n.d.; Human Rights Campaign, 2020; The Joint Commission, 2011). Existing research and policy statements regarding education for nursing students, faculty and practicing nurses support the need for a national strategy that addresses SGM health disparities.

Data regarding sexual orientation and gender identity should be collected widely in electronic health records and national and population-based surveys (Bosse et al., 2018). This will allow researchers to further identify and better understand health disparities, including more nuanced understanding of the unique health needs of SGM subgroups. Efforts should also be made to increase funding of SGM research by NINR and other funding sources (Bosse et al., 2020). Importantly, training programs related to SGM health for nurse researchers should be supported to increase workforce capacity, including the pool of experienced nurse researchers who can mentor students and new investigators to conduct SGM research (Jackman et al., 2019).

Although there are some promising signs that nurses’ interests in SGM health is increasing, much work remains. New ways of conceptualizing this work are urgently needed. Nursing education, research and practice needs to move beyond frameworks and perspectives that focus on deficits to those, such as social determinants of health (SDH), that situate SGM related health disparities within the larger socio-political and cultural contexts (National League for Nursing, 2019). The WHO (2019) identified SDH as one of six priority areas and clearly stated that educating the health care workforce to understand and implement strategies to address SDH is a fundamental requirement of health professions education (World Health Organization, 2019). In addition, critical intersectional approaches will lead to emancipatory efforts and support nurses in upholding their ethical responsibility to work toward health equity for all people. Efforts to work against the structural factors undergirding sexual orientation- and gender identity-based health inequities are essential to reframing SGM health research and health care and bringing about meaningful and lasting change in the health and well-being of SGM individuals, families, and communities.

Finally, SGM community members should be included in the research process. Community based participatory research is a collaborative methodology in which researchers and all stakeholders are equal partners in the identification of research questions, conceptualization of studies and analysis of data (Israel et al., 2005). This process ensures that research questions are based in the real world needs of the community and that issues related to power and privilege are acknowledged and addressed (Wallerstein & Duran, 2006). CBPR is an appropriate method for working with historically stigmatized and marginalized populations, including SGM people.

Outcomes of the Summit

Following the Summit, we formed three workgroups (education, research and practice) that include participants from the Summit as well as practicing nurses, nurse faculty, and nurse researchers who have joined since the Summit in November 2019. In addition to contributing to this report, the workgroups have produced other tangible products. Members of the research workgroup published an historical overview and critique of funding from the National Institute of Nursing Research for SGM health research (Bosse et al., 2020). Members of the education workgroup published a description of an innovative approach to improving nursing curricula (Sherman et al., 2021) and results of an evidence-based Transgender Curriculum Integration Project (TCIP; Sherman et al., 2021). The education workgroup has also conducted three systematic reviews—one of which is currently under review. A summary of results from the three reviews was presented at the International Council of Nurses meeting in November 2021. The practice workgroup has also been active. A major outcome is the creation of a national SGM health mentoring program for pre-licensure nursing students. Six students from six universities are currently enrolled in the year-long program which will culminate in individual poster presentations by the mentees on a topic related to SGM health and a summary presentation describing the program at the 2022 National Student Nurses annual convention.

Other major outcomes of the Summit include the creation of a new Center for Sexual and Gender Minority Health Research, and a three-semester certificate program for nurse practitioners that focuses on transgender and nonbinary health, both at Columbia University School of Nursing. Also, the University of Pennsylvania School of Nursing (whose representatives participated in the Summit) recently launched the Eidos LGBT+ Health Initiative to train students to think about creative solutions to improve SGM people’s health and to catalyze evidence-based strategies and programs focused on SGM health issues. We also hope to offer a two-week summer bootcamp at Columbia University School of Nursing to train postdoctoral fellows and early career researchers in conducting research with SGM population groups.

Conclusion

Significant challenges exist to developing a robust, multifocal body of literature on issues related to nursing and SGM health, and even more so on interventions designed to reduce SGM-related health disparities. Nurses lack knowledge about the unique culture and health needs of SGM people generally and about why specific SGM-related health inequities exist, as well as how to address them. This lack of knowledge is explained, at least in part, by negative attitudes among nurses towards caring for SGM patients. Research continues to show that nurses harbor significant implicit biases towards SGM people and that these biases may influence SGM people’s decisions to access care; their experiences of nursing care, and ultimately the incidence and prevalence of health concerns such as depression and anxiety, cardiovascular disease, and substance use. By calling attention to these challenges and setting forth visions for future educational, research, and practice-based innovations, Summit participants took important first steps toward creating a unified plan to supports SGM health.

Acknowledgments

Members of the Summit Advisory Board include Patricia Davidson, PhD, former Dean, Johns Hopkins School of Nursing; William L. Holzemer, PhD, Dean Emeritus, Rutgers University School of Nursing; Tonda L. Hughes, PhD, Associate Dean, Global Health, Columbia University School of Nursing (leader of the Summit); David Keepnews, PhD, JD Executive Director, Washington State Nurses Association; Ann Kurth, PhD, Dean, Yale School of Nursing; and Eileen M. Sullivan-Marx, PhD, Dean, New York University Rory Meyers College of Nursing.

The advisory board wishes to thank the Health Resources and Services Administration (HRSA), Josiah Macy Foundation, Mary Ann Liebert, Inc and the following nursing colleges/schools for their support: Columbia University, Duke University, Frances Payne Bolton School of Nursing at Case Western Reserve University, George Washington University, Johns Hopkins University, New York University Rory Meyers College of Nursing, Rutgers University, University of California, Los Angeles, University of California, San Francisco, University of Iowa, University of Miami, University of Michigan, University of Minnesota, University of Wisconsin-Madison, Vanderbilt University, and Yale School of Nursing.

A special thanks to Perry Halkitis (Dean, Rutgers University School of Public Health) for delivering the opening summit presentation and to the predoctoral and postdoctoral fellows and nursing faculty from Columbia University and New York University who served as facilitators for the Summit. We also wish to thank the staff of Columbia University School of Nursing Offices of Development and Alumni Relations, Marketing and Strategic Communications, and Finance and Administration for their multiple forms of support before, during, and after the Summit.

*Tom Christenbery died in Feb 2021, while the manuscript was being drafted. He was co-lead of the nursing education section of the white paper and made substantial contributions to that section.

Appendix A

Education

In 2014 the American Association of Medical Colleges (AAMC) issued curricular guidelines for medical schools to improve students’ knowledge, attitudes, and skills related to SGM health. These guidelines include 30 competencies that can be integrated into existing curricula. Nursing has yet to develop similar guidelines or competencies. Nurse educators use curriculum guidelines promulgated by AACN (2006, 2008, 2011) and the National League for Nursing (NLN, 2016). These guidelines assert that nurses at all levels must demonstrate competency in the delivery of culturally sensitive care to diverse populations. However, none of the guidelines specifically identifies LGBTQ people as a population for which nurses must develop such competencies.

Questions

In the discussions that follow please consider (a) whether or how we can best advocate for formal curricular guidelines related to LGBTQ health content in nursing educational programs. (b) What steps must be taken in the development of such guidelines?

Lack of faculty knowledge about LGBTQ health concerns is among the most commonly cited barrier to the inclusion of this content in nursing curricula. If faculty is unprepared to teach such content, students will continue to lack awareness of these health issues and skill in caring for LGBTQ people. (a) How can we address this gap in the near term? (b) How can we address this gap in the long term?

Research

One of the most powerful ways to improve nursing education content about LGBTQ health is through nursing research.

Questions

  1. What are the potential advantages and disadvantages to making LGBTQ health a research priority in your schools?

  2. How might nursing organizations support this initiative?

  3. The National Institute of Nursing Research is currently undergoing a change in leadership. How might we capitalize on this development to advocate for greater and more visible emphasis on LGBTQ health as a research priority at NINR?

Practice

Currently, there are no practice guidelines for the care of LGBTQ patients.

Questions

Are such guidelines needed? If so, what steps must be taken to develop these guidelines?

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