A record number of bills targeting lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth have been introduced this year, including the criminalization of gender-affirming care and banning of affirming school environments and/or classroom discussions regarding sexual orientation or gender identity (SOGI), emphasizing the need for hospital-based clinician LGBTQ+ competencies. Healthcare systems are at the forefront for implementing system training to ensure clinicians are equipped to provide LGBTQ+ affirming care for youth. Clinicians are uniquely positioned to improve health care processes and outcomes for LGBTQ+ youth through education, advocacy, and clinical practice. This article discusses how pediatric clinical services can advocate, leverage, and enact change through higher system-level collaborations, clinical approaches, and interdisciplinary education. On the basis of our experience in efforts to increase inclusivity, visibility, and an affirming care approach across a hospital system, we propose a framework to inform and guide similar efforts and actionable items for clinicians in pediatric hospital settings.
Minority Stress and LGBTQ+ Youth Health Disparities
The minority stress model is the leading framework for understanding sexual and gender minority youth health risks.1 According to this framework, LGBTQ+ youth face unique distal and proximal stressors, which in turn increase their vulnerability to psychological distress and suffering. Stressors often include discrimination, peer or family rejection, identity concealment, and internalized homophobia/transphobia. Greater minority stress exposure has been associated with greater odds of attempted suicide among LGBTQ+ youth.2 Over the past year, 50% of LGBTQ+ youth seriously considered suicide, whereas 25% attempted suicide.3 LGBTQ+ youth are at significantly increased risk for adverse medical and psychological health outcomes, including depression, anxiety, trauma, and substance misuse compared with heterosexual cisgender peers.4–6 Additionally, LGBTQ+ youth experience victimization and discrimination at higher rates at home, in school, and healthcare settings. Oppressive environments, stigma related to SOGI, and laws restricting LGBTQ+ rights have negatively impacted LGBTQ+ youth mental health and well-being.3 Chronic experiences of interpersonal and societal discrimination and maltreatment often deter LGBTQ+ youth from accessing health care.
Historically, within healthcare, LGBTQ+ individuals have experienced pathologization. For example, “homosexuality” was considered a psychiatric diagnosis in the Diagnostic and Statistical Manual until 1973, gender dysphoria was referred to as an identity disorder until 2013, and despite denouncement by the American Psychiatric Association, SOGI change efforts (referred to as conversion “therapy”) are still practiced and legal in most states. Because of clinician implicit biases and insufficient training, LGBTQ+ youth experience significant health disparities when compared to heterosexual cisgender peers.7,8 Discriminatory health care experiences among LGBTQ+ patients can lead to increased medical distrust, lower health care utilization, delayed diagnosis, treatment, and less follow-up attendance.6,9–13 A recent study found a gap in clinicians’ awareness of ongoing discrimination and implicit bias affecting LGBTQ+ youth.14 Low awareness may lead clinicians to be negligent during the assessment and treatment of LGBTQ+ youth, thwarting disclosure of critical identity information and leading to negative health care experiences. Research has shown that a simple affirming technique such as affirmed name and pronoun use reduces suicidal behavior by 56% among transgender and nonbinary youth.15 LGBTQ+ youth are more inclined to self-disclose their SOGI to affirming clinicians.
Steps for Clinician Training and Inclusivity Efforts
Hospitals provide countless opportunities for education and training, making them ideal settings for the implementation of LGBTQ+ youth inclusive health care practices. We recommend collaboration at multiple levels (ie, clinician, system, community) to improve LGBTQ+ inclusivity within healthcare. At the clinician level, clinicians can deliver youth gender and sexual diversity trainings across medical specialties and psychosocial services (eg, psychiatry, family medicine, pediatrics, nursing, social work, child life). Training sessions should include awareness of clinician biases, inclusive SOGI vocabulary and terminology, an affirming approach to assess youth SOGI, the documentation of SOGI data in electronic health records, addressing health disparities among LGBTQ+ youth, visible affirming care culture, and current state policies impacting LGBTQ+ youth. LGBTQ+ affirming practices guided by resources, such as those from Fenway Health and the Human Rights Campaign, can assist in the development of youth gender and sexual diversity trainings.
Specific strategies involve clinicians introducing themselves with their own pronouns and displaying visual cues (sticker, lanyard, pin). It is critical that clinicians ensure confidentiality when speaking with youth about SOGI. A simple script may sound like this: “Some kids/teens aren’t out to family. I want to respect your privacy and ensure your safety. How would you like me to document this information in your medical chart? What name and pronouns would you like me to use when talking with your family or medical team?” When assessing SOGI, we highly recommend open-ended questions to ensure clinicians are not assuming SOGI on the basis of patient appearance. For example, clinicians can ask, “What’s your gender identity?” and “What’s your sexual orientation?” Patients may have their first SOGI assessment by hospital-based clinicians; therefore, preparedness to explain these concepts using developmentally appropriate language is essential. Clinicians can explain that “gender identity is who you are (eg, some people may feel like a boy, girl, both, neither, or something else), whereas sexual orientation is who you are attracted to.” Inclusive scripts enhance patient–clinician trust, instill hope, and create opportunities to educate and normalize discussions regarding sexual and gender diversity. Clinicians can then provide patients and families with affirming resources and referrals (eg, local PFLAG chapter, The Trevor Project, LGBT National Youth Talk Line).
Clinicians play a critical role in responding to anti-LGBTQ+ rhetoric, which is often a clinician-to-clinician discussion. A useful approach can be through Haslam’s Interrupting Bias: Calling Out versus Calling In, which is a framework that describes calling in as an invitation for discussion and exploration to find mutual understanding across differences. This may also include providing education to colleagues on the importance of LGBTQ+ inclusivity and affirming care. For example, if a clinician expresses confusion or ambivalence about patient-affirmed name and pronouns, we recommend a collegial discussion about the importance of respecting pronouns and the potential psychological harms of nonaffirming language. Most importantly, clinicians should continuously educate themselves on evolving linguistic trends related to SOGI. The American Psychological Association Inclusive Language Guidelines may be a starting point.16
Steps for System- and Community-Level Collaboration Efforts
At the system level, collaboration with hospital departments, such as human resources, learning and organizational development, and diversity, equity, inclusion, belongingness facilitates systemwide efforts for the application of LGBTQ+ inclusivity and training. The Human Rights Campaign Core 4 Criteria: nondiscrimination policies across business entities, equitable benefits for LGBTQ+ workers and their families, supporting an inclusive culture, and corporate social responsibility can guide systemwide efforts. For example, forms and documentation encompassing the spectrum of SOGI (eg, parent/caregiver contact information versus mother’s contact information and father’s contact information) promote an inclusive culture. Moreover, healthcare systems can increase awareness of LGBTQ+ health disparities through hospital town halls and forums composed of LGBTQ+ health experts within the system. We propose the development of learning modules focused on LGBTQ+ history, health disparities, and an affirming care approach that are available to all staff. An easily applicable system-level inclusive strategy is the inclusion of pronouns to employee e-mail signatures.
At the community level, the establishment of formal partnerships with LGBTQ+ nonprofit organizations or advocacy groups supplement and ensure informed inclusivity practices. Such partnerships enable training and education for healthcare employees (clinical and nonclinical) and connect patients with community healthcare resources. Community outreach strategies are an avenue for engaging LGBTQ+ community members with local hospital systems and resources, and play a critical role in empowering and creating a support system for LGBTQ+ individuals. Community outreach involvement may include hospital participation in local events and forums (eg, Pride). Community informational events focused on raising awareness of LGBTQ+ youth health care needs, affirming mental health resources, and local LGBTQ+ organizations can bridge the gap between hospital and community efforts.
Conclusions
LGBTQ+ youth experience significant health inequities and disparities compared to cisgender heterosexual peers.17,18 Recent quality improvement studies demonstrate increased clinician capacity to provide affirming care to LGBTQ+ patients, which ultimately reduces disparities.19,20 In multiple states across the United States, healthcare systems and LGBTQ+ youth and families have found themselves in the midst of political clashes between major medical and psychological association guidelines and governmental entities. Our efforts serve as a roadmap of how pediatric clinicians can reduce LGBTQ+ health care inequities at the clinician, system, and community level within the context of the current hostile sociopolitical climate. Clinicians with a stronger foundation of basic LGBTQ+ health knowledge and affirming care approaches are more likely to integrate this knowledge into daily clinical practice. Education and training at the system level can improve LGBTQ+ patient health outcomes and experiences, while also increasing clinician competency, knowledge, and comfort in working with gender and sexual minorities.19,20
More youth are self-identifying as sexual and gender minorities, at younger ages, making inclusive and affirming health care practices a necessity to improve health outcomes for LGBTQ+ youth.21 A top–down approach to evaluate and restructure systems of care focused on the improvement of LGBTQ+ youth should be a priority for healthcare systems to facilitate positive clinical interactions and improve health outcomes through patient-tailored screenings, referrals, and care.
Acknowledgments
We thank all LGBTQ+ youth who continue to demonstrate tremendous resilience.
Dr Darban conceptualized and designed the quality improvement efforts, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Poulopoulos conceptualized, designed, and supervised the quality improvement efforts, and critically reviewed and revised the manuscript; Dr Campuzano contributed to the design of the quality improvement efforts; Dr Oliva contributed to the design of the quality improvement initiative, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
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