Changing language, changes lives: Learning the lexicon of LGBTQ+ health equity

Lesbian, gay, bisexual, pansexual, transgender, nonbinary, two-spirit, queer, questioning, and other sexual and gender diverse-identified people (i.e., LGBTQ+1) represent a heterogeneous group of communities. These communities have gained significant social acceptance and legal protections in the United States over the last decade, although those hard-fought advancements remain tenuous. Complex multilevel stigma (e.g., individual, interpersonal, and structural) continues to impact how health systems provide person-centered care to LGBTQ+ people, which negatively impacts their health outcomes. In addition, compulsory heterosexuality and cisgenderism, that is, heterosexuality and cisgenderism are assumed and enforced upon people by a heterocisnormative society (Rich, 1980), in nursing perpetuate stigma within the health care setting (Chinn, 2008; Searle, 2019), rendering LGBTQ+ nurses invisible. As we continue our series on learning the language of health equity, this paper seeks to advance our understanding of culturally sensitive and person-centered language to support nurses, midwives, and researchers in advancing health equity among LGBTQ+ communities. Nurses, midwives, and researchers should be cognizant of the nuances between sex, gender, and sexuality. Sex, gender, and sexuality are multidimensional concepts that are often conflated, misunderstood, and even politicized. However, everyone has a sex, gender, and sexuality—even you. Sex is based on a cluster of anatomical and physiological traits, that is, external genitalia, secondary sex characteristics, gonads, chromosomes, and hormones. Sex is assigned at birth as female, male, or intersex/differences of sex development. Gender encompasses identity, expression, and social-cultural norms or expectations associated with specific sex traits. Gender identities include, but are not limited to, cisgender, nonbinary, gender fluid, transgender, and two-spirit. Sexuality (also called sexual orientation) encompasses components such as emotional, romantic, and/or sexual attraction, sexual identity, and sexual behavior. Sexual identities include, but are not limited to, bisexual, gay, heterosexual, lesbian, pansexual, same-gender loving, two-spirit, queer, and questioning. Table 1 provides further details regarding these constructs and identities. Female Male Intersex/differences of sex development Man (cisgenderb or transgenderc) Woman (cisgender or transgender) Nonbinaryd Gender fluid Two-spirite Asexual Bisexual Gay Heterosexual Lesbian Pansexual Same-gender loving Two-spirit Queer Questioning Recent estimates suggest that 6.8% of the U.S. adult population identifies as sexually diverse (i.e., the LGBQ+ communities of the LGBTQ+ umbrella; Jones, 2022) and 0.5%–0.7% as gender diverse (i.e., the T communities)—which is more than a 200% increase from estimates a decade earlier (Herman et al., 2022; Jones, 2022). These estimates are theorized to be much lower than actual population levels, however, due to complications with assessment and disclosure deterrents (e.g., stigma and victimization). A growing LGBTQ+ population may be driven by younger generations, as 20.8% of Generation Z (born between 1997 and 2003) identify as LGBTQ+ (Jones, 2022). Increased community size may be further driven by improved methodological approaches to identify LGBTQ+ individuals implemented over the last decade through research and advocacy. A 2011 Institute of Medicine (IOM) report entitled The Health of Lesbian, Gay, Bisexual, and Transgender People provided a state of the science on the unique health disparities LGBTQ+ individuals experience (Institute of Medicine, 2011). The IOM report prompted the National Institutes of Health to create the Sexual and Gender Minority Research Office (SGMRO) in 2015 and to formally designate sexual and gender minority2 (i.e., LGBTQ+) people as a health disparity population in 2016 (Perez-Stable, 2016). Subsequently, funding for LGBTQ+ health research and collection of sexual orientation and gender identity (SOGI) data in nationally representative samples have substantially increased (SGMRO, 2022a, 2022b). So, too, has the availability of SOGI fields in electronic health records (Cahill et al., 2016). Yet, continued efforts are needed to support researchers, policymakers, and clinicians in identifying disparities, establishing policies that promote equity, and providing high-quality, person-centered care to LGBTQ+ people. LGBTQ+ people have existed globally throughout history, with the first recordings going back 5000 years (Peralta, 2011; Schott, 2016). For centuries, LGBTQ+ people have been persecuted (e.g., sanctioned death penalties, incarceration) under the guise of “anti-sodomy laws” and “public indecency” prohibitions for dressing in a manner that was socially attributed to the opposite sex. Not until the 20th century was being an LGBTQ+ person decriminalized in the United States, and antidiscrimination legislation based on sexuality and gender has yet to be realized in all 50 states. For example, The Equality Act (2021), a bill that would amend the Civil Rights Act (1964) to expand antidiscrimination protections to LGBTQ+ people in public spaces, is currently awaiting a vote in the U.S. Senate. As more than 50% of LGBTQ+ adults experience harassment or discrimination in public places (Gruberg et al., 2020), this legal protection is paramount to LGBTQ+ peoples' health and wellbeing. Furthermore, compulsory sterilization requirements were recently outlawed by the European Convention in 2017, but the practice persists globally (Stack, 2017; The Associated Press; 2019). In fact, it remains a punishable crime in 15 countries to cross-dress and in 69 jurisdictions to engage in private, consensual same-sex sexual activity; in 11 of those jurisdictions, the death penalty is legally possible (Afghanistan, Brunei, Mauritania, Pakistan, Qatar, and United Arab Emirates) or actively implemented (Iran, Northern Nigeria, Saudia Arabia, Somalia, and Yemen; Human Dignity Trust, 2022; Sherman et al., 2021a). The legal protections gained for LGBTQ+ people continue to be under threat. In 2022 alone, over 300 anti-LGBTQ+ bills have been introduced in state legislatures in the United States, with over 70% of the states signing or introducing anti-LGBTQ+ bills into law (Human Rights Campaign, 2022). For example, Florida's “Don't Say Gay” bill banned classroom instruction on SOGI topics (Parental Rights in Education, 2022). Yet, most bills have targeted transgender youth, including banning access to medically necessary and evidence-based care endorsed by major medical associations (American Psychological Association, 2020; Korioth, 2021; Madara, 2021) and fueled by scientific misinformation (Lepore et al., 2022). Similar anti-LGBTQ+ legislation has also been introduced globally, including in the United Kingdom, Poland, Hungary, Singapore, and Afghanistan. In the United States, the National Association of Pediatric Nurse Practitioners and Society for Pediatric Nurses signed an amicus brief in support of providing health care for transgender youth (Brandt & Rutledge, 2021). However, with few exceptions (American Academy of Nursing, 2015; American Nurses Association (ANA), 2018; Sedlak & Boyd, 2016), professional nursing associations have historically been glaringly silent in response to antidiscriminatory LGBTQ+ legislation. Health care systems have been complicit in this history of exclusion of and discrimination towards the LGBTQ+ community. Since the first Diagnostic and Statistical Manuel of Mental Disorders (DSM) was published in 1952, sexually diverse people have been categorized as having pathological mental disorders, in the same category as paraphilias, such as pedophilia (Drescher, 2015). Pathologization then justified the harmful and unsettling “treatment” options, including conversion therapy (e.g., electroshock), castration, and lobotomies. Gender-diverse people received a pathological diagnosis beginning in 1975, as gender and sexual identities were grouped together before this period (Schwend, 2020). Gender diversity still exists in the DSM today. It has a less stigmatizing label of “gender dysphoria,” however, to distinguish the mental disorder from a person's identity and instead focus on the discomfort or distress some gender-diverse individuals experience when their physical body does not reflect their gender identity. Functionally, this term provides a way to receive a diagnosis—a prerequisite to accessing gender-affirming care such as hormone therapy, surgery, or psychotherapy in many countries (Schwend, 2020). Further, despite the removal of “homosexuality” from the DSM in 1973 and efforts to de-pathologize gender diversity, this history has perpetuated stigmatizing attitudes towards LGBTQ+ people that have cost them their lives (e.g., a delayed public health response to the HIV/AIDS epidemic). These mischaracterizations of LGBTQ+ populations persist today, such as in the current framing of the monkeypox epidemic as a sexually transmitted infection (Bragazzi et al., 2022), impacting health, health care access, and safety. LGBTQ+ health inequities are most commonly explained by minority stress—the additional stress (e.g., discrimination, victimization) experienced by LGBTQ+ people related to the marginalization of their sexuality and/or gender (Brooks, 1981; Hendricks & Testa, 2012; Meyer, 2003). Within health care systems, discrimination and mistreatment are common experiences for LGBTQ+ people. LGBTQ+ people are often refused care and experience harsh or abusive language, unwanted physical contact, and physically rough or abusive care (Ayhan et al., 2019; Cicero et al., 2019; Gruberg et al., 2020). These experiences are heightened among both gender-diverse people and LGBTQ+ people from racial and ethnic minoritized groups (Gruberg et al., 2020). Discrimination, victimization, and stigmatization can impede care delivery, engender mistrust, and negatively impact LGBTQ+ individuals' mental and physical health outcomes (Hatzenbuehler, 2009; Ramsey et al., 2022; Soled, Dimant et al., 2022; Tyerman et al., 2021; White Hughto et al., 2015). Even the anticipation of discrimination is dangerous as about 15% of LGBTQ+ and 30% of gender-diverse adults will postpone or avoid medically necessary care out of fear of discrimination (Gruberg et al., 2020; Jaffee et al., 2016; Seelman et al., 2017). Stigma toward LGBTQ+ people may become evident in the health care setting through microaggressions, implicit bias (Sabin et al., 2015), and expressed discomfort in care for people with identities that differ from their own (Carabez et al., 2016). These attitudes do not stop at LGBTQ+ patients' experiences. The few existing studies of LGBTQ+ nurses highlight work-based stress related to their sexual and/or gender identities (Eliason et al., 2018), including experiences of homophobia, discrimination, and harassment from patients, peers, and supervisors (Eliason et al., 2011). As such, LGBTQ+ nurses may feel the need to hide their identity to avoid such negative consequences (Eliason et al., 2018; Randall & Eliason, 2012). Over time, having to hide one's identity, a component of minority stress, can have a negative impact on mental health (Pachankis et al., 2020). In one study, this stress was associated with problematic substance use among LGB nurses (Avery-Desmarais et al., 2020). Microaggressions are subtle forms of discrimination and include microassaults, microinsults, and microinvalidation. For example, verbal communication using insensitive language, even when unintentional, is a microaggression. Microaggressions have negative health consequences such as increasing symptoms of traumatic stress and depression and contributing to low self-esteem (Nadal et al., 2016). Using language that centers heterocisnormativity, that is, the assumption that heterosexual and cisgender people are the norm, is a common microaggression that can perpetuate discrimination in more insidious ways. For example, some insurance companies use language in policies that restrict health care services to a specific gender (e.g., cervical cancer screening restricted to women, excluding transgender men and transmasculine individuals) or restrict assisted reproductive technology to those with an infertility diagnosis—a diagnosis that is impossible for many LGBTQ+ people to receive (Soled, Niles et al., 2022). Discrimination and the resulting poor health outcomes are particularly heightened for LGBTQ+ people with multiply marginalized identities. Intersectionality theory explains why people with multiply marginalized identities and social positions (e.g., dis/ability, class, race, gender, nativity, sexuality) will experience multiple, overlapping sources of discrimination (e.g., ableism, classism, racism, cisgenderism, ethnocentrism/xenophobia, heterosexism) and adverse health outcomes (Bowleg, 2012; Collins, 2000; Crenshaw, 1989; hooks, 1981; The Combahee River Collective, 1977). For example, intersections between gender and race and the resultant cisgenderism and racism are likely culprits for the exorbitantly disparate poor health outcomes for Black transgender women and femmes, including being 2.73 times more likely to die than other Black transgender people, 2.38 times more likely than Black cisgender men, and 2.43 times more likely than Black cisgender women (Hughes et al., 2022). Intersectional effects are consistently observed among a number of physical and mental health outcomes (Walubita et al., 2022; Zubizarreta et al., 2022). Within the health care system, this compounded discrimination among individuals with intersecting marginalized identities can further impact health negatively through inequities in health care access and receipt of lower quality treatment (Bosworth et al., 2021). 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