THE ISSUE IN FOCUS

At least 20 million American adults, or about 8% of the adult population, self-identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), a number that is nearly double prior estimates.(1) Further estimates reveal that 5% of LGBT individuals identify with a sexual orientation other than lesbian, gay, or bisexual, such as queer, pansexual, or asexual.(2) Therefore, it is becoming more common for people to use expanded acronyms in order to encompass more orientations and identities; this article will use the term LGBTQ in alignment with guidance from Gay and Lesbian Alliance Against Defamation (GLAAD).(3)

LGBTQ identification is higher in younger generations: 19.7% of adult individuals in Generation Z identify as LGBTQ, compared to 11.2% of millennials and 3.3% or less among older generations.(2) A 2019 study by the Centers for Disease Control and Prevention (CDC) also reported that almost 2% of high school students identified as transgender or gender-diverse,(4) compared to more than 1% of the adult population.(1)

The acronym "LGBTQ," while implying homogeneity, is in reality a much more complex label. The terms "lesbian," "gay," "bisexual" and "queer" are different sexual orientations—a person's enduring emotional, romantic, or sexual attraction to another person—while the term "transgender" refers to a gender identity—a person's sense of themselves as male, female, both, or neither. However, there are additional terms that can describe a person's sexual orientation and gender identity.

Examples of additional terms for sexual orientations include(3):

• Asexual: a term to describe someone who does not experience sexual attraction to others.
• Pansexual: a term to describe someone who experiences emotional, romantic, or sexual attraction to people of any gender or gender identity.
• Questioning: a term used to describe someone who is exploring their sexual orientation.
• Same-gender loving: a term that some African Americans may prefer instead of lesbian, gay, or bisexual to express emotional, romantic, or sexual attraction to someone of the same gender.
• Two-Spirit: an umbrella term for someone who is not straight and/or cisgender that is used by some Indigenous and First Nations people. This term should only be used to describe an Indigenous person who uses it to describe themselves.

Examples of additional terms for gender identity include(3):

• Agender/gender-neutral: terms used to describe someone who does not have a gender, or who may identify as neither male nor female.
• Bigender: a term to describe someone who experiences two genders, either simultaneously or varying between the two.
• Demigirl/demiboy/demigender: terms to describe someone who partially identifies as a female or a male.
• Genderqueer/gender-expansive/nonbinary/gender-diverse: terms that can describe someone who rejects the static and binary categories of gender. People with these identities may see themselves as being both male and female, neither, or a different gender.
• Gender-fluid: a term to describe someone who does not have a fixed gender identity.
• Intersex: an umbrella term to describe a wide range of natural body variations that do not fit neatly into conventional definitions of male or female. Intersex variations may include, but are not limited to, variations in chromosome compositions, hormone concentrations, and external and internal characteristics.
• Multigender: a term that describes someone with more than one gender identity. It can be used as a gender identity in its own right, or as an umbrella term for other identities (e.g., bigender).
  

Neither of these are comprehensive lists, and sexual orientation and gender identity are by nature personal and can be fluid. There is also an ever-growing lexicon of microlabels available for individuals to further understand themselves and find community.

For members of the LGBTQ community, accessing healthcare that respects their unique needs and identities is a critical aspect of their overall well-being. While significant strides have been made in recognizing and addressing the specific healthcare challenges faced by the LGBTQ population, improvements can still be made to ensure that healthcare settings are truly welcoming and understanding of diverse orientations and identities.

For its annual Healthcare Equality Index (HEI) Report for 2022, the Human Rights Campaign noted improvements that participating healthcare organizations have made over the 15 years that the foundation has been issuing the survey. Of the 906 facilities that completed the survey for 2022—including hospitals, academic medical centers, and federally qualified health centers—496 (55%) organizations were designated as "LGBTQ+ Healthcare Equality Leaders," meaning they earned the top score of 100. An additional 251 organizations (28%) were designated as HEI "Top Performers," meaning they scored 80 to 95 points.(5)

To earn the HEI Leader designation, organizations must meet four core criteria: Non-Discrimination and Staff Training, Patient Services and Support, Employee Benefits and Policies, and Patient and Community Engagement. The first criterion includes the following sections(5):

1. Patient nondiscrimination policies with specific references to sexual orientation and gender identity
2. Equal visitation policies
3. Employment nondiscrimination policies with specific references to sexual orientation and gender identity
4. Staff training in LGBTQ patient-centered care
   

In addition, HEI Leader organizations must demonstrate that they offer transgender-inclusive benefits to their employees.(5)

The report also highlights areas that can still be improved upon. For example, most of the designated Leaders were located in the northeastern and western US states. Further, many states, including West Virginia, South Carolina, Mississippi, Wyoming, and Alaska, had no Leader organizations.(5)

The report highlighted additional gaps to be addressed, noting that only 54% had policies aimed at eliminating bias toward transgender patients, 47% had an LGBTQ-focused patient advocate, 44% captured a patient's pronouns and prominently displayed them in a banner or pop-up so all staff could see this information, and 26% had a patient navigation or advocacy program specifically for transgender patients.(5)

Laws, Regulations, and Standards

Patient Nondiscrimination

Section 1557 of the Affordable Care Act (ACA), also known as the "nondiscrimination section," prohibits discrimination against patients on the basis of race, color, national origin, age, disability, or sex in any healthcare organization or program that receives federal financial assistance.(6)

Shortly after the US Department of Health and Human Services (HHS) issued its Final Rule in 2016 that stated that discrimination "on the basis of sex" includes sex stereotyping, gender identity, and pregnancy termination, eight states along with a group of religious organizations filed a lawsuit claiming that these protections violated providers' religious beliefs. A federal judge ruled in favor of this group and issued an injunction preventing HHS from enforcing gender identity and pregnancy termination in this rule.(7)

In 2020, HHS issued revisions to Section 1557, adopting a religious exemption and removing prohibitions of discrimination based on gender identity, gender expression, sex stereotyping, and pregnancy. However, three days later, the US Supreme Court ruled that Title VII of the Civil Rights Act of 1964's prohibition of employment discrimination based on sex encompasses discrimination based on sexual orientation and gender identity.(8) After this decision, additional litigation challenged the 2020 Final Rule of Section 1557.

Citing the Bostock decision, HHS announced it would interpret and enforce Section 1557's prohibition on discrimination "on the basis of sex" to include sexual orientation and gender identity. In 2022, HHS issued a Notice of Proposed Rulemaking (NPRM) to revise Section 1557 to strengthen and solidify these protections and clarify that sex discrimination includes discrimination based on sex stereotypes; sex characteristics, including intersex traits; and pregnancy or pregnancy termination. The proposed rule also clarifies and expands the definition of covered entities. The NPRM does not include a religious exemption.(9)

Risk managers and organizational leaders should consult with legal counsel and the organization's ethics committee to remain up to date on evolving federal legislation and ongoing lawsuits, as the NPRM is still pending as of this publication.

The Centers for Medicare and Medicaid Service's (CMS) Conditions of Participation (CoP) requires organizations that participate in the Medicare or Medicaid programs to comply with all applicable federal, state, and local laws, including ACA. Further, CMS's CoP emphasize a patient's rights to(10):

• Personal privacy
• Receive care in a safe setting
• Be free from all forms of abuse or harassment
• Confidentiality of their medical records
  

Organizations should also comply with regulations and standards established by their applicable accreditation agency. Joint Commission, for example, prohibits accredited organizations to discriminate "based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity and expression."(11) Other accrediting groups have not addressed LGBTQ patient care as extensively as Joint Commission.

Despite the strengthening of Section 1557 and CMS and Joint Commission requirements, LGBTQ patients still report elevated levels of discrimination in healthcare, including harassment, abuse, and denial of services.(12) This discrimination leads to adverse health outcomes and further exacerbates the disparities in care this population experiences. For more information on LGBTQ discrimination, see the discussion Combat Discrimination with Inclusive Policies and Procedures.

Advance Directives and Power of Attorney

Advance directives and power of attorney legally document a patient's medical care preferences and appoint a surrogate decision-maker to make medical decisions on a patient's behalf if the patient loses decisional capacity. Organizations must provide information to patients on how to create advance directives and appoint a surrogate decision-maker of their choice. This decision-maker should be a person that the patient trusts, which may be a same-sex partner or spouse. Organizations cannot deny the patient this right based on their sexual orientation or gender identity. For more information, see Overview of Advance Directives: Acute Care.

In recent years, the United States has witnessed a concerning trend of legislative actions targeting healthcare for transgender individuals. As of September 2023, 22 states have passed legislation banning gender-affirming treatments, such as hormone therapy and gender confirmation surgeries, for individuals up to age 18.(13) In addition, currently five states (Idaho, North Dakota, Oklahoma, Alabama, and Florida) have laws making it a felony crime for providers to deliver such care to minors.(14)

Critics argue that these legislative measures represent a violation of patient autonomy, as they interfere with the patient's ability to make informed decisions about their healthcare. Many healthcare professionals assert that healthcare decisions should be based on the expertise and judgment of healthcare providers, considering the unique circumstances and needs of each patient.(15)

These bans have also faced opposition from professional organizations, many of which have released opinions and position statements emphasizing the importance of allowing patients and their providers to make healthcare decisions based on individual medical needs, rather than being dictated by legislative mandates. Examples of such statements include the following:

• American Academy of Pediatrics
• American College of Emergency Physicians
• American College of Obstetricians and Gynecologists
• American Public Health Association
• American Psychiatric Association
  

Access to gender-affirming care is widely recognized as a crucial asp​ect of supporting transgender individuals' mental health. Restricting these services can contribute to increased rates of depression, anxiety, and suicidal ideation, exacerbating the existing disparities in mental health outcomes in the transgender population (see the discussion Consider the Unique Needs of Transgender Patients).

As a response to these bans, some states are enacting "shield" laws to protect transgender patients and access to transgender healthcare. As of March 2024, 11 states and the District of Columbia have enacted such laws, with an additional three having an executive order in place protecting access to transgender healthcare.(16)

Organizations must consult with local counsel for the most up-to-date information regarding these laws as this is an ever-evolving landscape, with multiple lawsuits being filed on behalf of individuals who were denied gender-affirming healthcare.

Compared to their heterosexual and cisgender peers, LGBTQ individuals are more likely to experience higher rates of(17,18):

• Violence (e.g., bullying, harassment, intimate partner violence)
• Family or societal rejection
• Use or misuse of alcohol, tobacco, marijuana, and illicit drugs
• Engagement in high-risk sexual behaviors leading to a higher incidence of sexually transmitted infections (STIs) (e.g., HIV, syphilis, hepatitis)
• Mental health concerns (e.g., depression, suicidal ideation, eating disorders)
• Cancer diagnoses
  

In an effort to reduce these disparities, HHS created a goal to improve the health, safety, and well-being of LGBTQ individuals as part of their Healthy People 2030 initiative.(19)

LGBTQ Staff

A healthcare organization's LGBTQ-inclusive environment must extend to its workforce, as staff members may also identify as LGBTQ.

Although beyond the scope of this guidance article, risk managers and other organizational leaders should examine their hiring and firing practices, benefits packages, and employee nondiscrimination policies, as well as policies for transgender or transitioning employees, to ensure all staff members are treated equitably.

ACTION PLAN

Secure L​​eadership Support for LGBTQ Initiatives

Action Recomme​ndation: Secure leadership support for establishing an advisory committee tasked with creating a welcoming environment and guiding policy and organizational initiatives.

Organizational leaders set the tone for a culture that is inclusive and welcoming for all patients, including LGBTQ patients. With leadership's support, the organization can articulate its commitment to LGBTQ patient and staff needs in its policies and structure.

Organizations should consider designating a member of senior management as a "champion" who can discuss with staff the goals and rationale for creating a more welcoming environment for LGBTQ patients. The champion would also assemble and lead the organization's LGBTQ advisory committee, which should be tasked with planning, implementing, and monitoring strategies that promote inclusivity. Members of the committee should include organizational leaders, risk managers, patient safety officers, nurses, physicians, health information staff, human resources staff, and information technology (IT) personnel.

• Creating a welcoming environment for LGBTQ individuals begins when a patient walks in the door or looks at the organization's website. Strategies that LGBTQ advisory committees can implement include:
• Creating or revising the organization's patient and employee nondiscrimination policies with specific references to sexual orientation, gender identity, and gender expression. For more information, see the discussion Combat Discrimination with Inclusive Policies and Procedures.
  
• Providing gender-neutral restrooms. Organizations should consider additional options instead of only the traditional male and female segregated bathrooms, such as(20):
• A designated gender-neutral single occupancy bathroom that can be used by any employee
• A designated multi-occupant gender-neutral restroom that has lockable stalls
• Organizations should refrain from limiting transgender patients to gender-neutral restrooms and instead allow any patient to use a restroom that matches their gender identity.
• Developing rooming policies that allow patients to be assigned to a room in accordance with their self-identified gender unless the patient requests otherwise. If the patient requests a private room, the organization should try to accommodate the patient's wishes, if possible.
• Using inclusive patient intake forms. Admission, registration, and other patient forms should provide LGBTQ-inclusive options and allow patients to voluntarily self-report sexual orientation and gender identity. The forms should provide options to identify a relationship status other than husband or wife (e.g., spouse, partner) and to ask about a child's parents or guardians in a way that is inclusive of same-sex parents.
• Asking for and using a patient's preferred name and pronouns.
• Avoiding assumptions about a person's sexual orientation or gender identity. A patient wearing a wedding band may have a same-sex spouse, so staff should avoid asking male-presenting patients about their "wife." Further, male-presenting patients may be pregnant or request mammograms and Papanicolaou tests, whereas female-presenting patients may request prostate exams.
• Identifying LGBTQ-welcoming providers on the organization's website. The Gay and Lesbian Medical Association also maintains the LGBTQ+ Healthcare Directory for listing LGBTQ-friendly physicians and other healthcare professionals.
• Ensuring that the organization's website and materials in waiting rooms and other areas reflect LGBTQ patients and families.
• Posting the organization's Human Rights Campaign HEI Leader or Top Performer designation and other recognitions of diversity leadership on the organization's website.
• Displaying LGBTQ-friendly symbols, such as the LGBTQ (rainbow) flag or the transgender (blue, pink, and white stripes) flag, and a safe zone sign on placards and staff badges.

Combat Discrimination with Inclusive Policies and Procedures

Action Recommendation: Develop and enforce nondiscrimination policies that explicitly include sexual orientation and gender identity.

Action Recommendation: Ensure that visitation policies grant equal visitation rights.

For decades, non-heterosexual orientation and transgender status were classified as a mental disorder. Until 1973, the term "homosexuality" was classified as a "sexual deviation" within the larger category of "sociopathic personality disturbance" classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current version, DSM-5, does not include any diagnostic category that can be applied to people based on their sexual orientation.(21)

Transgender status was listed in the DSM as "gender identity disorder" until the DSM-5 was published in 2013 and it was replaced with "gender dysphoria." Gender dysphoria refers to clinically significant distress experienced by individuals whose gender identity does not correspond with their assigned sex at birth. Not all transgender individuals experience gender dysphoria, and the current diagnosis focuses on the dysphoria and distress as the clinical problem and not the identity.(21)

Because of these statuses, thousands of LGBTQ individuals were subjected to reparative therapies (i.e., conversion therapies) at the hands of healthcare professionals and others. Such procedures included hypnosis, electroshocks, medications, and forced sterilization. Conversion therapy has since been formally disavowed by medical and professional societies (see Human Rights Campaign's The Lies and Dangers of Efforts to Change Sexual Orientation or Gender Identity) and has been banned in many, but not all, states.

Healthcare discrimination persists to this day and can include verbal or physical harassment or outright denial of service, which can endanger a patient's life, as demonstrated in the following cases:

• A 39-year-old woman was taken to a medical center with a suspected brain aneurysm, but care was delayed after medical professionals discovered she was a lesbian. As a result, the patient fell into a coma and later died.(22)
• A patient with HIV claimed that after he disclosed that he had sex with men, hospital staff ignored him, refused to allow his family to visit, and withheld his HIV medication.(23)
• A transgender man experienced verbal and physical abuse after presenting to an emergency department (ED) for severe pain. One doctor was rough and hostile during an exam, allegedly jabbing at the patient's genitals and asking in an aggressive manner, "Who are you having sex with?"(24)
• An infant was turned away from a pediatrician's office because she had same-sex parents.(25)
  

However, discrimination is not always so obvious. A microaggression is "a comment or action that subtly and often unconsciously or unintentionally expresses a prejudiced attitude toward a member of a marginalized group."(26) For example, in the aforementioned case involving a transgender patient, the admissions clerk gave the patient an identification band with an "F" on it because his previous medical records identified him as female.(24)

Other instances of discrimination can include forcing the patient to answer unrelated questions or undergo unnecessary examinations. In one case, a patient who was being seen for a broken hand was "grilled about [their] sexuality for ten minutes by the emergency room doctor," while in another case, a transgender patient who was seeking treatment for a sore throat was "forced to have a pelvic exam."(27)

These cases are not isolated incidents, as shown in Figure 1. P​ercentage of LGBQ and Transgender Patients Who Experienced Abuse and Discrimination from a Healthcare Provider, 2022.

   
Harassment, humiliation, and denial of care can discourage LGBTQ individuals from seeking needed emergency care and preventive health services. According to a survey by the Center for American Progress, 23% of all LGBTQ respondents reported that they delayed or avoided receiving needed medical care due to prior discrimination from a healthcare professional, and 21% postponed or did not try to get preventive screenings for that same reason. Gender-diverse (i.e., transgender, nonbinary, gender-nonconforming, genderqueer, and agender) and intersex respondents reported avoidance at even higher rates—37% and 50%, respectively, reported avoiding needed medical care, and 41% and 42%, respectively, avoided preventive care.(12)

Finding another hospital or provider is not always possible; 22% of all LGBTQ respondents and 39% of transgender respondents said it would be "very difficult" or "not possible" to find the same type of healthcare service if they were denied care.(12)

Organizations must therefore develop and enforce policies that seek to eliminate discrimination, microaggressions, abuse, and denial of treatment for LGBTQ patients. To accomplish this, the organization's LGBTQ advisory committee should be involved in developing or revising organizational policies to ensure that patients' rights are not being violated.

The organization's nondiscrimination policy should include specific references to sexual orientation, gender identity, and gender expression. The policy should outline procedures for patients and staff to report instances of discrimination, as well as procedures that the organization will follow if they receive such a report.

The policy should be posted in high-profile locations, such as in the waiting room, in employee break rooms, and on the facility's website. Organizations can also provide copies of the policy to patients during admission or check-in. HHS's Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements can be adapted and used.

The LGBTQ advisory committee should also collaborate with risk management and legal counsel to develop a policy that details the appropriate organizational response if a provider or other staff member refuses to treat a patient based on their sexual orientation or gender identity. This policy should align with Section 1557 of the ACA and any state laws (see Laws, Regulations, and Standards).

The LGBTQ advisory committee should also ensure that the organization's visitation policy meets CMS and Joint Commission or other accreditation requirements for granting equal visitation rights for patients.(10,11) The written policy should include every patient's right to designate visitors, regardless of their legal or biological relationship. Visitors could include, but are not limited to, spouses and domestic partners, including same-sex partners, and children, including those that may not be biologically related to the patient. Policy should mandate that visitors cannot be discriminated against based on their or the patient's sexual orientation or gender identity. Joint Commission requires accredited organizations to inform each patient and their family of their rights prior to providing care.(11)

Documenting patient nondiscrimination policies with specific references to sexual orientation and gender identity and implementing equal visitation policies are both core requirements of the HEI Leader designation. In 2022, 98% of respondents indicated that their patient nondiscrimination policy included both sexual orientation and gender identity, and 99% of applicable respondents said they have equal visitation policies.(5)

Provide Staff Training, Education, and Support

Action Recommendation: Train staff on how to collect information about sexual orientation, gender identity, and sexual history and to ensure the confidentiality of this information.

Action Recommendation: Provide cultural competency and sensitivity training for all staff members to foster an understanding of diverse sexual orientations and gender identities.

Action Recommendation: Educate healthcare providers about LGBTQ-specific health concerns, such as HIV/AIDS prevention, hormone therapy, intimate partner violence, and mental health.

Healthcare organizations should prioritize staff training on collecting information about sexual orientation, gender identity, and sexual history; cultural competency; sensitivity; and LGBTQ-specific healthcare issues.(28)

Ongoing training in these areas contributes to healthcare workers' overall professional development. In an ever-evolving healthcare landscape, staying abreast of diverse cultural norms, evolving societal attitudes, and the latest research on LGBTQ health disparities and concerns is crucial. By investing in continuous education and training, healthcare organizations empower their staff to adapt to changing patient demographics and emerging healthcare issues, ultimately enhancing the overall quality of care provided to their patients.

Collecting Information on Sexual Orientation, Gender Identity, and Sexual History

Collecting information on a patient's sexual orientation, gender identity, and sexual history is crucial for identifying and addressing appropriate preventive screenings, assessment of STIs, behavioral health concerns, and other healthcare disparities.(28) However, healthcare staff must collect this information in a way that is structured, sensitive, and confidential.(29)

Organizations should ask the following questions and provide the following answer options, as recommended by the National Academy of Medicine and Joint Commission based on research conducted by the Center of Excellence for Transgender Health(29):

1. Do you think of yourself as:
1. Straight or heterosexual
2. Lesbian or gay
3. Bisexual
4. Queer, pansexual, and/or questioning
5. Something else; please specify
6. Don't know
7. Decline to answer
2. Do you think of yourself as:
1. Male
2. Female
3. Transgender man/trans man
4. Transgender woman/trans woman
5. Genderqueer/gender nonconforming/neither exclusively male nor female
6. Additional gender category (or other); please specify
7. Decline to answer
3. What sex was originally listed on your birth certificate?
1. Male
2. Female
3. Decline to answer
   

In addition, it is recommended that healthcare staff ask patients to include the name they want their providers to use and the correct pronouns.

For information on how to leverage technology to collect this information, see the discussion Use Technology to Improve LGBTQ Patient Care.

Intake or registration staff should receive targeted training on how to obtain this information and how to address negative patient responses. For example, staff can tell patients that the organization collects this information for all patients and assure them that the questions are important for their medical care and will be kept confidential.

Training should also include how to collect and record this information in the electronic health record (EHR), emphasizing that sexual orientation and gender identity are confidential patient information that should be kept in accordance with the Health Insurance Portability and Accountability Act. Training in confidentiality has been identified as an area that needs improvement in the Human Rights Campaign's HEI survey; only 66% of HEI respondents provide employees with training explicitly reminding them that LGBTQ status is confidential patient information.(5)

Cultural Competency Training

Fostering cultural competency among healthcare professionals ensures that they are equipped to provide inclusive and patient-centered care. Patients come from diverse backgrounds, each with unique cultural values, beliefs, and practices. By participating in cultural competency training, healthcare staff can better understand and respect these differences, leading to improved communication, trust, and overall healthcare outcomes.

For more information, see Culturally and Linguistically Competent Care.

Sensitivity Training

As part of sensitivity training, all staff members—including receptionists, medical assistants, nurses, and physicians—should be trained on how to interact respectfully with LGBTQ patients (e.g., using patients' preferred names and pronouns, using current and preferred terminology). For example, healthcare professionals may be used to describing certain patients as "men who have sex with men" or "women who have sex with women," but these clinical terms are outdated and can be offensive to many in the LGBTQ community.

During sensitivity training, staff should be cautioned that definitions and terms can vary across communities and that not all patients may agree with a term or definition; therefore, healthcare professionals should use the same words that the patient uses to describe themselves (e.g., if a female-presenting patient describes themselves as "queer," the healthcare professional should use that term instead of listing their sexual orientation as "lesbian").(30)

LGBT-Specific Healthcare Training

Addressing LGBTQ-specific healthcare issues through training is essential for creating an inclusive and welcoming healthcare environment, especially since formal education on LGBTQ health is limited in medical schools.(31)

LGBTQ individuals often face disparities in healthcare, including higher rates of STIs, cancer, anxiety, depression, and suicide (see LGBTQ Health Disparities).

Furthermore, higher rates of intimate partner violence have been observed in the LGBTQ community, especially among Black, transgender, and bisexual individuals. For more information, seeIntimate Partner Violence: Special Issues in LGBTQ Populations.

Training staff on how to address and mitigate these disparities promotes a more compassionate and understanding approach, in turn reducing the stigma and barriers that LGBTQ individuals may encounter when seeking healthcare services.

Providers should also receive additional training on LGBTQ-specific health concerns, such as STI screening recommendations (see the CDC's Sexually Transmitted Infections Treatment Guidelines, 2021) and hormone therapy.

Staff training in LGBTQ patient-centered care is a core component of being designated as an HEI Leader. In 2022, 93% of respondents reported providing training in LGBT patient-centered care.(5)

Foster Connections with LGBTQ-Friendly Providers and Organizations

Action Recommendation: Establish networks of LGBTQ-friendly healthcare providers and specialists for referrals.

Action Recommendation: Collaborate with local LGBTQ organizations to improve access to healthcare services.

Creating a network of LGBTQ-friendly healthcare providers and specialists is a crucial step for healthcare organizations to ensure inclusive and equitable care across the healthcare continuum.

To establish such networks, organizations should prioritize building relationships with external healthcare professionals who are not only competent in their respective fields, but also sensitive to the unique healthcare needs of LGBTQ individuals.

Establishing a centralized referral system is a key component of building a network of LGBTQ-friendly healthcare providers. This system should be easily accessible to both internal staff members and patients, streamlining the process of connecting individuals with specialists who can meet their specific needs. Clear communication channels and collaboration among healthcare providers within the network are essential to ensuring a seamless and coordinated approach to patient care.

Another effective strategy is to collaborate with local LGBTQ community organizations, advocacy groups, and support networks. These partnerships can also help healthcare organizations identify potential providers who have a positive history of delivering LGBTQ-affirming care.(28)

Open and transparent communication with local LGBTQ community groups can also help healthcare organizations gain insights into the specific needs and challenges of their local LGBTQ community.(28)

Such partnerships can extend beyond dialogue, with healthcare organizations actively participating in events and initiatives organized by LGBTQ advocacy groups. By demonstrating a commitment to supporting and attending events such as health fairs, educational workshops, or Pride parades, healthcare organizations can establish a visible presence within their local LGBTQ community. This presence not only builds trust but also provides opportunities for healthcare professionals to engage directly with potential patients.(28)

Healthcare organizations can also collaborate with advocacy groups to develop and distribute educational materials addressing healthcare concerns for community members, such as pamphlets on HIV prevention, substance use, and mental health concerns.

Patient and community engagement is an area of focus in the Human Rights Campaign's HEI survey. The report noted that(5):

• 85% of respondents took part in or support one or more LGBTQ-related events in their service area
• 56% engaged in marketing or advertising to the LGBTQ community
• 34% publicly supported LGBTQ equality by speaking out on local, state, or federal legislation

Use Technology to Improve LGBT Patient Care

Action Recommendation: Ensure that the EHR system collects and displays information about a patient's sexual orientation, gender identity, pronouns, and preferred name.

Action Recommendation: Promote telehealth services to enable LGBTQ patients to access care remotely.

Risk managers should work with IT personnel to implement technological strategies that can improve LGBTQ patient care.

Organizations should work with IT to establish a structured approach to collecting information on sexual orientation and gender identity, such as through the patient portal. IT personnel should also ensure this information is captured and displayed in the EHR, which should be modified if needed to highlight relevant patient information (e.g., add a color-coded flag in the record to specify how a patient prefers to be addressed; make their chosen name more visible than their legal name; prominently display their correct pronouns).

In the 2022 HEI survey, the Human Rights Campaign identified capturing and displaying patients' pronouns as an area that needs improvement in many participating organizations. Only 44% of respondents captured a patient's pronouns and prominently displayed them in a banner or pop-up so all staff could see this information.(5)

Providers can also promote telehealth visits with LGBTQ patients so they can access healthcare services remotely. These visits can help reduce barriers related to geography or discomfort in traditional healthcare settings.

Consider the Unique Needs of Transgender Patients

Action Recommendation: Implement guidance on caring for transgender patients.

Transgender individuals face unique healthcare needs that require sensitive and inclusive approaches from healthcare providers. The LGBTQ advisory committee should provide targeted guidance for healthcare staff related to caring for this population, as the Human Rights Campaign noted several areas of improvement regarding transgender healthcare in their 2022 HEI Report, including the following findings(5):

• 54% had policies aimed at eliminating bias toward transgender patients
• 44% capture a patient's pronouns and prominently display them in a banner or pop-up so that all staff can see this information
• 30% have a dedicated multidisciplinary gender clinic
• 26% provide patient navigation or advocacy services to transgender patients

Transgender Health Disparities

Transgender individuals often experience significant disparities in access to healthcare, quality of care, and health outcomes compared to their cisgender counterparts and even compared to other members of the LGBTQ community.

According to the American Heart Association, transgender and gender-diverse individuals are more likely to experience higher levels of heart disease, blood clots, and obesity.(32) This increased risk can be attributed to a variety of factors, including hormone use and higher rates of cigarette smoking, both of which can also lead to increased risk of strokes, higher blood pressure, lung cancer, and diabetes. Because transgender women may fear that their provider will make them stop estrogen therapy if they develop cardiac issues, they may not report symptoms such as chest pain or trouble breathing.

Transgender individuals also experience higher rates of negative mental health outcomes due to higher rates of discrimination (see Combat Discrimination with Inclusive Policies and Procedures), social stigma, and recent legislation banning gender-affirming treatments (see Transgender Care).(33) For more information, see Figure 2. Percentage of Transgender Youth Reporting Mental Health Concerns Compared to Cisgendered Youth, 2020.​

​​​Transgender individuals may also experience gender dysphoria (see Combat Discrimination with Inclusive Policies and Procedures) and higher rates of eating disorders.

Culturally competent mental health professionals can play a crucial role in helping transgender patients navigate these challenges by fostering a safe and accepting environment for them to express their concerns and emotions.

Gender-Affirming Healthcare

Transgender individuals may seek gender-affirming interventions such as hormone therapy, facial hair removal, speech modification therapy, or surgery to remove or add reproductive organs (e.g., vaginoplasty, phalloplasty, breast removal) in order to align their physical appearance with their gender identity.

Access to these services is vital for transgender individuals and has been shown to decrease negative mental health outcomes.(34) Healthcare providers should be knowledgeable about the latest guidelines, laws, regulations, and best practices in gender-affirming healthcare to offer informed and supportive services to their patients. Providers should also be aware of any barriers regarding health insurance, as many insurance carriers consider some surgical interventions to be cosmetic.

Moreover, all healthcare staff need to use respectful and affirming communication. Using correct gender pronouns and names is a basic yet vital aspect of respectful care (see the discussion Provide Staff Training, Education, and Support).