Effective Date: 2018
Status: Position Statement
Written by: ANA Center for Ethics and Human Rights
Adopted by: ANA Board of Directors

Purpose

The purpose of this position statement is to reinforce the American Nurses Association’s (ANA) recognition that nurses must deliver culturally congruent care and advocate for lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) populations. The “+” designation in this position statement is used for inclusivity, to encompass other sexual and gender minorities not captured within the acronym LGBTQ. ANA is committed to the elimination of health disparities and discrimination based on sexual orientation, gender identity, and/or expression within healthcare. LGBTQ+ populations face significant obstacles accessing care such as stigma, discrimination, inequity in health insurance, and denial of care because of an individual’s sexual orientation or gender identity (Kates, Ranji, Beamesderfer, Salganicoff & Dawson, 2018).

In the United States, adults who identify as lesbian, gay, bisexual, transgender, questioning, or queer make up about 4.1% of the general population, which is an estimated 10 million adults (Gates, 2017). The Centers for Disease Control and Prevention estimated that there are 1.7 million youth of high school age who identify as LGBTQ+ (Kann et al., 2016). Because many individuals within LGBTQ+ populations have confronted intolerance from providers, many avoid treatment or delay care due to experiences of bias and/or bigotry. The lack of knowledge and understanding of the unique needs of this population contributes to ongoing health disparities and discrimination. The nursing profession must consider the needs of LGBTQ+ populations in the areas of policy, practice, education, and research (Keepnews, 2011).

Statement of ANA Position

ANA condemns discrimination based on sexual orientation, gender identity, and/or expression in healthcare and recognizes that it continues to be an issue despite the increasing recognition and acceptance of LGBTQ+ populations. Many LGBTQ+ individuals have reported experiencing some form of discrimination or bias when accessing healthcare services. Persistent societal stigma, ongoing discrimination, and denial of civil and human rights impede individuals’ self-determination and access to needed healthcare services, leading to negative health outcomes including increased morbidity and mortality. Nurses must deliver culturally congruent, safe care and advocate for LGBTQ+ populations.

Code of Ethics for Nurses with Interpretive Statements
Provision 1 of the Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a) asserts: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (p. 1). The interpretive statements that accompany this provision affirm that “the need for and right to healthcare is universal, transcending all individual differences” (p. 1) and that “nurses consider the needs and respect the values of each person in every professional relationship and setting” (p. 1). Nurses are expected to lead in the development, dissemination, and implementation of changes in public and health policies that support protection against discrimination due to sexual orientation, gender identity, and/or expression. The relationship that nurses create with their patients should be one of trust and compassion. Nurses should first identify and then set aside any bias or prejudice in the provision of nursing care. Interpretive Statement 1.2 instructs nurses to consider “factors such as culture, value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation, or gender expression, and primary language when planning individual [patient], family and population-centered care” (ANA, 2015a, p. 1). However, these factors must not be used to discriminate or prohibit access to compassionate and high-quality care.

The nurse-patient relationship is at the core of healthcare. Nurses practice with compassion and respect for the human rights of all individuals regardless of sexual orientation, gender identity, and/or expression. As expressed in Nursing: Scope and Standards of Practice (ANA, 2015b), nurses are expected to provide culturally congruent, competent, safe, and ethical care to all patients across all settings. Culturally congruent practice is the application of evidence-informed nursing that is in agreement with the cultural values, beliefs, worldview, and practices of patients and other stakeholders (ANA, 2015b). To demonstrate cultural congruence and safe practice, nurses must advocate for patient centered treatment, equal access, equal services, and equal resources for all populations that may be adversely affected by bias or prejudice. Nurses have an ethical duty to honor and respect the identities, beliefs, values, and decisions of all patients (ANA, 2015a).

Background

The Vision of Healthy People 2030 is “a society in which all people achieve their full potential for health and well-being across the lifespan” (Office of Disease Prevention and Health Promotion, 2017, p. 3). This includes the goal of eradicating health disparities and achieving health equity. To reduce the health disparities experienced by LGBTQ+ individuals, there is a need for research on the specific healthcare needs of unique groups within LGBTQ+ populations. Nurses have investigated best practices in the care of LGBTQ+ elders and created guidelines and policies for chief nursing officers, which supports appropriate culturally congruent care in maternity transgender clients, and knowledge levels of best practices care and curricular inclusion of LGBTQ+ populations in nursing faculty and nursing curricula (Echezona-Johnson, 2017; Lim, Brown & Kim, 2014; Lim, Johnson & Eliason, 2015; Klotzbaugh & Spencer, 2015; Strong & Folse, 2015; Zelle & Arms, 2015).

The U.S. National Library of Medicine (2018) defines healthcare disparities as the differences in access to or availability of facilities and services. Researchers have demonstrated that healthcare disparities are prevalent for those in LGBTQ+ populations: lack of knowledge on the part of providers in delivering care to this population, marginalization isolation, and stigma are some of the reasons that access remains an issue for many LGBTQ+ clients (Lim et al., 2014). Health status disparities refer to the variation in rates of disease occurrence and disabilities between defined population groups. Numerous disparities within LGBTQ+ populations exist in relation to disease patterns and behaviors affecting health (Schenck-Gustafsson, DeCola, Pfaff & Pisetsky, 2012). For example, LGBTQ+ youth are two to three times more likely to attempt suicide and are more likely to be homeless than their heterosexual peers (National LGBT Health Education Center, n.d.). They are also at higher risk for acquiring HIV and other sexually transmitted diseases (STDs) and are more likely to be bullied (National LGBT Health Education Center, n.d.). Gay men and other men who have sex with men (MSM) are at higher risk of contracting HIV and STDs, especially among communities of color (National LGBT Health Education Center, n.d.). LGBTQ+ individuals are more likely to smoke; they also have higher rates of alcohol or other substance use, depression, and anxiety (National LGBT Health Education Center, n.d.). Elderly LGBTQ+ individuals face additional barriers to healthcare because of isolation, diminished family support, and reduced availability of social services (National LGBT Health Education Center, n.d.). Of approximately 8% of LGBTQ+ individuals surveyed, nearly 27% of transgender and gender-nonconforming individuals, and almost 20% of HIV-positive individuals, reported being denied necessary healthcare (National Women’s Law Center, 2014). Thus, disparities are not caused by one’s sexual identity; rather, sexual orientation-related health discrimination and disadvantages create health disparities (Cochran, Björkenstam, & Mays, 2016). The Institute of Medicine has found these health disparities to be one of the main gaps in health disparities research (Institute of Medicine of the National Academies, 2011).

The National Academy of Medicine (NAM) (formerly Institute of Medicine) convened a committee of experts to assess current knowledge of the health status, experiences, and unique needs of members of LGBTQ+ populations, to identify research gaps and opportunities, and to prepare an agenda for National Institutes of Health-sponsored research (Institute of Medicine of the National Academies, 2011). The resulting NAM report recognized the lack of data needed to build a base of evidence about the needs and health concerns of LGBTQ+ populations. One of the goals of the Healthy People 2020 plan is to “Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals” (Healthy People 2020, 2014). In 2016, the National Institute of Minority Health and Health Disparities officially designated lesbian, gay, bisexual, and transgender populations as populations of focus for health disparity research (Department of Health and Human Services, 2016). The Fenway Institute’s National LGBT Health Education Center, the research, training, and health policy division of Fenway Health, has identified health disparities such as the prevalence of HIV/STDs; the high prevalence of tobacco, alcohol, and other substance use; and barriers to health, resulting from isolation and lack of social services and culturally competent providers (The Fenway Institute, n.d.). The Joint Commission, in its Field Guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the LGBT Community (2011), identified practices and strategies to help build trust among healthcare providers and hospitals and LGBTQ+ patients and families. It provides additional guidance for making a safe, welcoming, and inclusive healthcare environment (The Joint Commission, 2011).

In 2011, the Centers for Medicare & Medicaid Services finalized federal regulations protecting hospital patients’ rights to choose their visitors and prohibiting discrimination in visitation based on sexual orientation and gender identity. The guidance supports the rights of patients to designate the person of their choice to make medical decisions on their behalf in cases of incapacity, regardless of sexual orientation, gender identity, and/or expression (Centers for Medicare & Medicaid Services, 2011).

History/Previous Position Statements
ANA first took an official stance against anti-LGBT discrimination in 1978, when its House of Delegates (HOD) adopted a resolution supporting legislation to bar discrimination based on sexual orientation (ANA Convention ’78, 1978). In 1980, the HOD reiterated this position (ANA Convention ’80, 1980).

With the emergence of the HIV/AIDS epidemic in the 1980s, nurses and nursing organizations responded to provide and support evidence-informed approaches to combating the epidemic and opposing discrimination against people with HIV/AIDS (ANA, 1988; 1992a). Addressing the epidemic—particularly in its early days—required confronting antigay bias in the general population and within the nursing profession.

In 1992, the ANA House of Delegates voted to oppose policies barring gay and lesbian individuals from serving in the U.S. military (ANA, 1992b). After the military’s ban on gay and lesbian service members was modified into a “don’t ask, don’t tell” policy, ANA supported efforts to repeal that policy (ANA, 2010). This ban ended in 2016. In 2017, executive attempts to create a ban on transgender individuals serving in the military were unsuccessful. ANA again advocated in support of equality and human rights for LGBTQ+ populations serving in the military (ANA, 2017).

The American Academy of Nursing (AAN) initiated an Expert Panel on LGBTQ Health in 2011 (AAN, n.d.). Since that time, the Academy has adopted several position statements on LGBTQ health, including Position statement: Employment discrimination based on sexual orientation and gender identity (Expert Panel on LGBTQ Health, 2015a), American Academy of Nursing position statement on reparative therapy (Expert Panel on LGBTQ Health, 2015b), and Same-sex partnership rights: Health care decisiomaking and hospital visitation (Expert Panel on LGBTQ Health, 2015c). Other nursing organizations have adopted positions addressing concerns among LGBTQ+ populations, including the International Society for Psychiatric-Mental Health Nurses (2010), the National Association of School Nurses (2017), and the National Student Nurses Association (Burke et al., 2016).

Recommendations

1. ANA supports efforts to defend and protect the human and civil rights of all members of LGBTQ+ populations.
2. ANA advocates for the rights of all members of LGBTQ+ populations to live, work, study, or serve in the armed services without discrimination or negative activities, such as bullying, violence, incivility, harassment, or bias.
3. ANA affirms the need for nurses in all roles and settings to provide culturally congruent, competent, sensitive, safe, inclusive, and ethical care to members of LGBTQ+ populations, as well as to be informed and educated about the provision of culturally competent care.
4. ANA condemns any discrimination based on sexual orientation, gender identity, and/or gender expression in access to or provision of healthcare.
5. ANA advocates for:
   • Patients and families in LGBTQ+ populations to have equal rights for surrogate decision-making, visiting privileges, and access to loved ones when undergoing care or when hospitalized.
   • Patient information assessment, forms, and other ways of collecting patient demographics (e.g., electronic health records) that use best practice means of collecting sexual orientation and gender identity patient data so that appropriate clinical and culturally sensitive care is provided and preferred pronouns are used. It is understood that sexual orientation and gender identity patient information should be considered private patient information shared on a need-to-know basis.
   • Policies and legislation that support equal access to high-quality, culturally congruent healthcare for LGBTQ+ populations.
   • Research and interventions aimed at improving the health, wellness, and needs of LGBTQ+ populations, including collection of sexual orientation, gender identity, and/or expression in research studies.
   • Nurse educators that will help fill the void in knowledge by incorporating the issues of the LGBTQ+ populations as part of nursing curriculum.
   • Efforts to promote and advocate for public policy that is aimed at improved access to culturally sensitive, high-quality care and treatment of members of LGBTQ+ populations.
   • Federal funding to continue appropriate research of LGBTQ+ populations.
   • Making behavioral health services available that specifically address LGBTQ+ health.
   • The application of ANA’s Code of Ethics for Nurses with Interpretive Statements to ensure unwavering, culturally sensitive, inclusive, unbiased, and nondiscriminatory care of members of LGBTQ+ populations.
   • Strategies to educate nurses about the potential impact of personal bias, whether conscious or unconscious, particularly involving the care of LGBTQ+ populations.
   • Identification of strategies to raise nurses’ competency in addressing the needs of LGBTQ+ populations.
   • Support for nurses and other healthcare providers who are bullied or witness others being bullied or discriminated against.
   • Nursing education that includes population health education about systemic inequality, barriers, patient-specific care, and interventions for LGBTQ+ populations.
   • Nursing program accreditors and state boards of nursing that approve nursing program curricula to require inclusion of content on LGBTQ+ populations, including standardized gender-neutral terminology and documentation.

Acknowledgment: ANA acknowledges Ethics Advisory Board members Elizabeth Swanson, DNP, MPH, APRN-BC and Linda Olson, PhD, MBA, MSN, RN, NEA-BC, FAAN; and American Academy of Nursing Fellow David Keepnews, PhD, JD, RN, NEA-BC, FAAN, who contributed to the drafting of this document on behalf of the ANA Ethics Advisory Board.

Column Editor

Liz Stokes, JD, MA, RN
Email: liz.stokes@ana.org

Liz Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights and demonstrates expertise in writing public policy on ethical issues including medical marijuana, assisted death, intellectual disabilities, and women's reproductive health. She is an international speaker on the Code of Ethics for Nurses is published in the Journal of Nursing Regulation and the Journal for Nurse Practitioners. Liz also serves as an Associate Editor for the Journal of Bioethical Inquiry. Liz's sphere of influence as a nurse-attorney combined with her education in bioethics enables a unique contribution to nursing, ethics, law, and policy.