Kodiak Ray Sung Soled|Kristen D. Clark|Molly R. Altman|Jordon D. Bosse|Roy Thompson|Allison Squires|Athena D. F. Sherman
Changing language, changes lives: Learning the lexicon of LGBTQ+ health equity
Harvard Pilgrim Health Care|Harvard University|University of New Hampshire|University of Washington|Northeastern University|University of Missouri|New York University|Emory University
lesbian gay bisexual pansexual transgender nonbinary twospirit queer questioning sexual gender diverseidentified people ie lgbtq1 represent heterogeneous group communities communities gained significant social acceptance legal protections united states last decade although hardfought advancements remain tenuous complex multilevel stigma eg individual interpersonal structural continues impact health systems provide personcentered care lgbtq people negatively impacts health outcomes addition compulsory heterosexuality cisgenderism heterosexuality cisgenderism assumed enforced upon people heterocisnormative society rich 1980 nursing perpetuate stigma within health care setting chinn 2008 searle 2019 rendering lgbtq nurses invisible continue series learning language health equity paper seeks advance understanding culturally sensitive personcentered language support nurses midwives researchers advancing health equity among lgbtq communities nurses midwives researchers cognizant nuances sex gender sexuality sex gender sexuality multidimensional concepts often conflated misunderstood even politicized however everyone sex gender sexualityeven sex based cluster anatomical physiological traits external genitalia secondary sex characteristics gonads chromosomes hormones sex assigned birth female male intersexdifferences sex development gender encompasses identity expression socialcultural norms expectations associated specific sex traits gender identities include limited cisgender nonbinary gender fluid transgender twospirit sexuality also called sexual orientation encompasses components emotional romantic andor sexual attraction sexual identity sexual behavior sexual identities include limited bisexual gay heterosexual lesbian pansexual samegender loving twospirit queer questioning table 1 provides details regarding constructs identities female male intersexdifferences sex development man cisgenderb transgenderc woman cisgender transgender nonbinaryd gender fluid twospirite asexual bisexual gay heterosexual lesbian pansexual samegender loving twospirit queer questioning recent estimates suggest 68 us adult population identifies sexually diverse ie lgbq communities lgbtq umbrella jones 2022 0507 gender diverse ie communitieswhich 200 increase estimates decade earlier herman et al 2022 jones 2022 estimates theorized much lower actual population levels however due complications assessment disclosure deterrents eg stigma victimization growing lgbtq population may driven younger generations 208 generation z born 1997 2003 identify lgbtq jones 2022 increased community size may driven improved methodological approaches identify lgbtq individuals implemented last decade research advocacy 2011 institute medicine iom report entitled health lesbian gay bisexual transgender people provided state science unique health disparities lgbtq individuals experience institute medicine 2011 iom report prompted national institutes health create sexual gender minority research office sgmro 2015 formally designate sexual gender minority2 ie lgbtq people health disparity population 2016 perezstable 2016 subsequently funding lgbtq health research collection sexual orientation gender identity sogi data nationally representative samples substantially increased sgmro 2022a 2022b availability sogi fields electronic health records cahill et al 2016 yet continued efforts needed support researchers policymakers clinicians identifying disparities establishing policies promote equity providing highquality personcentered care lgbtq people lgbtq people existed globally throughout history first recordings going back 5000 years peralta 2011 schott 2016 centuries lgbtq people persecuted eg sanctioned death penalties incarceration guise antisodomy laws public indecency prohibitions dressing manner socially attributed opposite sex 20th century lgbtq person decriminalized united states antidiscrimination legislation based sexuality gender yet realized 50 states example equality act 2021 bill would amend civil rights act 1964 expand antidiscrimination protections lgbtq people public spaces currently awaiting vote us senate 50 lgbtq adults experience harassment discrimination public places gruberg et al 2020 legal protection paramount lgbtq peoples health wellbeing furthermore compulsory sterilization requirements recently outlawed european convention 2017 practice persists globally stack 2017 associated press 2019 fact remains punishable crime 15 countries crossdress 69 jurisdictions engage private consensual samesex sexual activity 11 jurisdictions death penalty legally possible afghanistan brunei mauritania pakistan qatar united arab emirates actively implemented iran northern nigeria saudia arabia somalia yemen human dignity trust 2022 sherman et al 2021a legal protections gained lgbtq people continue threat 2022 alone 300 antilgbtq bills introduced state legislatures united states 70 states signing introducing antilgbtq bills law human rights campaign 2022 example floridas dont say gay bill banned classroom instruction sogi topics parental rights education 2022 yet bills targeted transgender youth including banning access medically necessary evidencebased care endorsed major medical associations american psychological association 2020 korioth 2021 madara 2021 fueled scientific misinformation lepore et al 2022 similar antilgbtq legislation also introduced globally including united kingdom poland hungary singapore afghanistan united states national association pediatric nurse practitioners society pediatric nurses signed amicus brief support providing health care transgender youth brandt rutledge 2021 however exceptions american academy nursing 2015 american nurses association ana 2018 sedlak boyd 2016 professional nursing associations historically glaringly silent response antidiscriminatory lgbtq legislation health care systems complicit history exclusion discrimination towards lgbtq community since first diagnostic statistical manuel mental disorders dsm published 1952 sexually diverse people categorized pathological mental disorders category paraphilias pedophilia drescher 2015 pathologization justified harmful unsettling treatment options including conversion therapy eg electroshock castration lobotomies genderdiverse people received pathological diagnosis beginning 1975 gender sexual identities grouped together period schwend 2020 gender diversity still exists dsm today less stigmatizing label gender dysphoria however distinguish mental disorder persons identity instead focus discomfort distress genderdiverse individuals experience physical body reflect gender identity functionally term provides way receive diagnosisa prerequisite accessing genderaffirming care hormone therapy surgery psychotherapy many countries schwend 2020 despite removal homosexuality dsm 1973 efforts depathologize gender diversity history perpetuated stigmatizing attitudes towards lgbtq people cost lives eg delayed public health response hivaids epidemic mischaracterizations lgbtq populations persist today current framing monkeypox epidemic sexually transmitted infection bragazzi et al 2022 impacting health health care access safety lgbtq health inequities commonly explained minority stressthe additional stress eg discrimination victimization experienced lgbtq people related marginalization sexuality andor gender brooks 1981 hendricks testa 2012 meyer 2003 within health care systems discrimination mistreatment common experiences lgbtq people lgbtq people often refused care experience harsh abusive language unwanted physical contact physically rough abusive care ayhan et al 2019 cicero et al 2019 gruberg et al 2020 experiences heightened among genderdiverse people lgbtq people racial ethnic minoritized groups gruberg et al 2020 discrimination victimization stigmatization impede care delivery engender mistrust negatively impact lgbtq individuals mental physical health outcomes hatzenbuehler 2009 ramsey et al 2022 soled dimant et al 2022 tyerman et al 2021 white hughto et al 2015 even anticipation discrimination dangerous 15 lgbtq 30 genderdiverse adults postpone avoid medically necessary care fear discrimination gruberg et al 2020 jaffee et al 2016 seelman et al 2017 stigma toward lgbtq people may become evident health care setting microaggressions implicit bias sabin et al 2015 expressed discomfort care people identities differ carabez et al 2016 attitudes stop lgbtq patients experiences existing studies lgbtq nurses highlight workbased stress related sexual andor gender identities eliason et al 2018 including experiences homophobia discrimination harassment patients peers supervisors eliason et al 2011 lgbtq nurses may feel need hide identity avoid negative consequences eliason et al 2018 randall eliason 2012 time hide ones identity component minority stress negative impact mental health pachankis et al 2020 one study stress associated problematic substance use among lgb nurses averydesmarais et al 2020 microaggressions subtle forms discrimination include microassaults microinsults microinvalidation example verbal communication using insensitive language even unintentional microaggression microaggressions negative health consequences increasing symptoms traumatic stress depression contributing low selfesteem nadal et al 2016 using language centers heterocisnormativity assumption heterosexual cisgender people norm common microaggression perpetuate discrimination insidious ways example insurance companies use language policies restrict health care services specific gender eg cervical cancer screening restricted women excluding transgender men transmasculine individuals restrict assisted reproductive technology infertility diagnosisa diagnosis impossible many lgbtq people receive soled niles et al 2022 discrimination resulting poor health outcomes particularly heightened lgbtq people multiply marginalized identities intersectionality theory explains people multiply marginalized identities social positions eg disability class race gender nativity sexuality experience multiple overlapping sources discrimination eg ableism classism racism cisgenderism ethnocentrismxenophobia heterosexism adverse health outcomes bowleg 2012 collins 2000 crenshaw 1989 hooks 1981 combahee river collective 1977 example intersections gender race resultant cisgenderism racism likely culprits exorbitantly disparate poor health outcomes black transgender women femmes including 273 times likely die black transgender people 238 times likely black cisgender men 243 times likely black cisgender women hughes et al 2022 intersectional effects consistently observed among number physical mental health outcomes walubita et al 2022 zubizarreta et al 2022 within health care system compounded discrimination among individuals intersecting marginalized identities impact health negatively inequities health care access receipt lower quality treatment bosworth et al 2021 legacy criminalization pathologization stigma carried discriminatory language well historical trauma inflicted requires intentional repair systems power eg health care professionals researchers lgbtq community effective communication cornerstone patient safety improved outcomes disch 2012 personcentered care kwame petrucka 2021 moreover nurses midwives ethical obligation use language respectful identities promotes provision culturally congruent competent safe care ana 2018both require lgbtq language literacy therefore learning lexicon lgbtq health equity starting point rebuilding trust facilitating delivery highquality personcentered care promoting lgbtq health equity like new language learning lexicon lgbtq health equity requires intentional continuous engagement practice develop fluency squires thompson 2021 practice gained actively identifying ways one unconsciously unintentionally commits harm others may disrupt one pathway implicit biases stigma communicated perpetuate socially constructed power dynamics foster marginalization shattell 2009 becoming conscious ones positionality relationship systems power oppression gaining fluency lexicon lgbtq health equity powerful strategies mitigating impacts systemic discrimination altman et al 2021 several important broad considerations understanding communicating lgbtq identities first identities fluid meaning change time throughout life course identity fluidity means sexual gender identities repeatedly asked updated longitudinal surveys flentje et al 2020 relevant appropriate clinical contexts secondly identities singular meaning person multiple sexual gender identities simultaneously thirdly identities defined anything beyond selfreported identification example persons sexual behaviors attractions define sexual identity eg person samesex behaviors may identify heterosexual gender expression ie way individual communicates gender chosen name pronouns manner dressing hairstyles sex assigned birth define gender identity eg person uses sheher pronouns long hair may identify nonbinary additionally identities adjectives qualify noun eg queer person queer people queers queer examples outdated stigmatizing language avoid found table 2 areas impact everyone particularly lgbtq people pronouns names like sexual gender identities pronouns assumed based gender identity gender expression sex assigned birth legal name person multiple pronouns multiple pronouns indicated eg hethey zeshe using included pronouns appropriate using incorrect pronouns refer someone called misgendering harmful furthermore individuals legal name may differ name use genderdiverse people referred legal name longer used called deadnaming also harmful avoid misgendering deadnaming someone setting first introducing name pronouns requesting names pronouns individual may refer appropriate relevant conversation subsequently ask sexual gender identities including option decline answer prefacing assessment questions reason asking done information eg ask everyone questions want provide best care may help increase comfort disclosing sogi data name pronouns identities never qualified preferred one identifies preference affirming language fluency competency gained one add pronouns places email signatures video conferencing screen names presentations name badges door names may practice normalizes visibility lgbtq lives signals allyship lgbtq people although signs inclusion eg displaying rainbow flag may also cause significant harm performative still employing inappropriate outdated language interactions humility decentering oneself interaction actively resisting defensiveness mistake held accountable essential developing language fluency communication mistakes nonaffirming actions addressed promptly brief yet sincere apology safe space health equity training may helpful practice moment mistake made using affirming statement apology vitals im sorry vitals focus mistake corrected restatement part process coined deep practice facilitates production myelin brain supports stronger faster skill fluency coyle 2009 also accountability followthrough mistake made witnessed accountability includes identifying cause whether system individual level advocating update language used organizations electronic medical record system support best clinical practices accountability also include respectfully correcting language colleague interaction reference lgbtq person moreover lexicon lgbtq health equity continually evolving learn become precise language time thus anything written today may soon outdated necessitates ongoing training education visibility inclusion lgbtq populations data paramount evidencebased clinical guidelines curriculum standards policies eg organizational state federal resource allocation purported niles et al 2022 earlier editorial series data must disaggregated various lgbtq communities understand unique inequities needs heterogeneous subgroups although collection sogi data become commonplace still widespread need include sogi questions within population surveys public health surveillance efforts patterson et al 2017 health data eg electronic medical records insurance claims bosse et al 2018 research heck et al 2017 pedersen et al 2022 including within lgbtq research eg collect gender identity study lesbian couples research nurses efforts support knowledge development specifically underresearched health wellbeing areas eg coulter et al 2014 sgmro 2022a including elucidation strengths resilience positive attributes lgbtq identities eg riggle rostosky 2014 unique ethical implications considered however example data must robust privacy confidentiality standards entities collecting data must nondiscrimination policies place personnel collecting data must trained ethical conduct research lgbtq populations medina mahowald 2022 moseson et al 2020b national academies sciences engineering medicine nasem 2022 lgbtq language data collection best practices may soon outdated current guidance measuring sex gender identity sexuality includes using language accurately precisely identifies lgbtq people reduces conflation sex biological variable gender improves quality data lgbtq populations improves research experience lgbtq study participants nasem 2022 debate utility allowing multiple writein response options foster inclusion representation versus forcing single identity selection yield sufficient statistical power data analyses contribute understanding context guide appropriate implementation multiple versus singular identity response options included example language sogi data collection table 3 using evidencebased recommendations leading researchers clinicians lgbtq community members federal interagency working group improving measurement sogi federal surveys 2016 interact nd puckett et al 2020 reisner et al 2016 suen et al 2020 man transgender man cisgender man woman transgender woman cisgender woman nonbinary genderqueer gender fluid agender respondent american indian alaskan native aian twospirit feel identity fits one categories free text words use describe gender identity male female third sexxa prefer answer yes dont know prefer answer sexual identity following best represents think sexual identity please choose one asexual bisexual gay lesbian pansexual queer samegender loving straightheterosexual respondent aian twospirit use different term freetext dont know prefer answer sexual behaviorb lifetime past 12 months etc sexual contact select apply sexual contact includes touching intimate body parts person upon another eg kissing anal sex fingering cisgender women transgender women cisgender men transgender men twospirit person nobodyno sexual contact nonbinary person another gender freetext dont know prefer answer sexual attractionc lifetime past 12 months etc sexually attracted select apply cisgender women transgender women cisgender men transgender men twospirit person nobody nonbinary person another gender freetext dont know prefer answer interested researching lgbtq communities compilation publicly available population data lgbtq measures maintained updated sgmro webpage sgmro 2022b well multidimensional intersectional framework elucidate factors influence lgbtq health inequities sgmro 2021 importantly research conducted historically oppressed minoritized communities lgbtq people communitybased participatory research methods serve important tool center community members communitybased organizations leaders leverage skills strengths solutions research teams coinvestigators advisory board members coauthors specific subgroup identities study also reflected community engagement efforts eg study trans men include trans men transmasculine community members research process academic institutions funding agencies play important role supporting research methods allow investigators overcome structural challenges meaningful community engagement allowing community members coinvestigators equal compensation power determine research questions prioritized aguilargaxiola et al 2022 ricks et al 2022 researchers also play role influencing institutions agencies support equitable communityengaged research practices lett et al 2022 scott et al 2020 support resources communityengaged research found patientcentered outcomes research institute nd engage equality nd implicit bias embedded within insensitive language may hinder delivery personcentered care particularly multiply marginalized identities consequently contribute adverse health health care outcomes afulani et al 2021 altman et al 2022 thus conjunction earlier recommendations series working latinx hispanic populations practicing culturally respectful communication important provision delivery personcentered care nava et al 2022 accomplished centering persons needs goals considering holistic person instead focusing disease risk factor symptom nava et al 2022 personcentered traumainformed care necessary complementary approaches communities experienced marginalization trauma promote physical emotional safety autonomy repair distrust reduce structural heterocisnormativity improve health health care outcomes mckinnish et al 2019 mcnicholas et al 2021 park et al 2018 rubashkin et al 2018 one opportunity reduce structural heterocisnormativity include organ anatomical inventory deutsch et al 2013 sexual reproductive health inventory ragosta et al 2021 opposed assuming organs sexual behaviors based sex assigned birth presumptive heterosexuality asking providing list detailing organs person removed organ anatomical inventory serves three functions opens normalizes conversation around body parts allows assessment body part names individual comfortable promotes understanding preventative screenings health promotion guidance may appropriate recommend sexual reproductive health inventory collects information pertaining sexual practices reproductive goals examples information collect include asking person sex body parts interact sexual partners also important ask practices used prevent promote pregnancy sexually transmitted infections depending relevancy person sexual practices practicing clinical assessment affirming traumainformed scripts may useful developing fluency area eg hahn et al 2019 krempasky et al 2020 tillman nd areas language assessed included table 4 although diversity language options needs familiar best practice mirror language someone uses except language acceptable insiders use ask terms would like use highly recommend education training gain comprehensive understanding inclusive language considerations structural changes address intersectionality promote personcentered traumainformed care within clinical context eg bi et al 2021 human rights campaign nd moseson et al 2020a ragosta et al 2021 rioux et al 2022 also critical lgbtq content included levels nursing midwifery curricula health professions training programs well included part ongoing continuing education practicing professionals hughes et al 2022 sherman et al 2021b resources include bi et al 2020 2021 bosse et al 2015 eliason chinn 2015 lavender health nd mommother dadfather biological parent parents genetic gestational parent period breastfeeding biologically malefemale bleeding menstruation nursinglactatingchestfeeding assigned malefemale birth breast ovaries uterus vulva clitoris vagina labia lips penis testicles prostate chest internal organs external genitals pelvic area genitalfrontal openingfront hole outer folds outer parts internal gland maternity ward maternalwomens health labor delivery perinatalfamilyreproductive health new mothers room womensmens bathroom nursinglactation room gender neutral bathroom paper primer learning lexicon lgbtq health equity supports efforts promote nurses midwives understanding culturally sensitive personcentered language lgbtq people growing population inequitable health outcomes part caused discriminatory stigmatizing outdated language permeates policies curricula research clinical practice language immense power shape world lived realities including power signal respect safety inclusionor opposite although journey lgbtq language literacy requires humility continuous engagement intentional practice fluency develop moreover nurses midwives took oath harm thus everyone us plays critical role using language communicates respect safety inclusion take small step forward creating equitable future authors meet criteria authorship stated uniform requirements manuscripts submitted biomedical journals dr soled conceptualized developed editorial content authors drs clark altman bosse thompson squires sherman contributed content integrity critical revision final approval editorial dr soled supported national institute minority health health disparities national institutes health nih award r01md015256 dr sherman supported national institute nursing research nih award k23nr020208 content solely responsibility authors necessarily represent official views nih authors declare conflict interest data available 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