The health care needs of people who are lesbian, gay, bisexual, or transgender (LGBT) have received significant attention from policymakers, legislators, educators, health care providers, and community leaders during the last several years. Indeed, recent reports from the Institute of Medicine (IOM), Healthy People 2020, and the Agency for Healthcare Research and Quality have highlighted the need for such long-overdue attention.1-3 The health care disparities that affect this population are closely tied to sexual and social stigma that linger to this day.2
Herek and colleagues have defined sexual stigma as the “society's shared belief system through which homosexuality is denigrated, discredited, and constructed as invalid relative to heterosexuality.”4 This construct has resulted in social determinants that affect the health of LGBT people, such as legal discrimination regarding access to health insurance, a lack of appropriate social programs, and a shortage of providers who are culturally competent in and knowledgeable about LGBT health.3
In a 2012 literature review of 17 studies of nurses’ attitudes toward the LGBT population, Dorsen noted that although eight studies were “positively leaning,” every study found evidence of negative attitudes.5 Because of various study limitations and a lack of outcomes research, the author cautioned care in generalizing the findings, and called for more rigorous research. But a 2011 IOM report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, offers further support.2 While this report acknowledged a need for further research, it found that “from the available literature, it appears that many providers are uncomfortable with providing services to LGBT patients.” It raised concerns about how provider attitudes toward LGBT patients may affect care, citing factors such as internalized sexual stigma (also called homophobia and transphobia), and noting that medical schools continue to teach “little or nothing about the unique aspects of lesbian, gay, and bisexual health” and even less about transgender health. For these reasons, LGBT people are collectively considered to be a “priority population” in discussions of health care disparities.1 This article explores such disparities and offers recommendations for best practices based on current evidence and standards of care.
GAPS IN THE CURRICULUM
The degree to which LGBT health concerns are included in nursing curricula is unknown. But experts generally agree that essential content appears to be limited or lacking.6, 7 A literature review of 16 studies exploring the attitudes of nursing students toward people with HIV infection or AIDS found that many students have negative attitudes about these populations, have some degree of homophobia, and harbor a fear of contagion.8 A Swedish study found that only 10% of nursing students had a “passing level” of care knowledge about LGBT people.9 Another study among undergraduates enrolled in a nursing prerequisite course found that more than one-third indicated they would have “considerable difficulty” working with LGBT people and people with AIDS.10 Similar findings have been reported among social work students.11 It's interesting that attitudes in the general population appear to be more positive, with 59% of people surveyed by Gallup in 2013 indicating that they find lesbian and gay relationships to be morally acceptable.12
The negative attitudes of nursing students toward LGBT people may be attributed in part to a lack of experience with this population and to the limited coverage of LGBT health issues in nursing education.6, 10 It stands to reason that a broader education that includes evidence-based knowledge about LGBT health issues and instruction in cultural competence could help dispel such attitudes.
It's unknown how much time nursing programs currently allot to LGBT-related topics. A recent survey of 132 American and Canadian medical schools found that on average, just seven hours during the entire preclinical and clinical curricula were dedicated to such topics.13 While there are no established formulas for determining how much time would be optimal, this seems far too little. Nursing programs need to assess the current range of LGBT health issues covered and the amount of time spent on instruction in order to identify gaps in the curricula. To address known gaps and meet LGBT-specific curricular objectives, Lim and colleagues have proposed various strategies, including developing relevant courses, encouraging independent and elective study, and using simulation and clinical case studies.14 They also suggest establishing clinical partnerships with agencies that serve the LGBT community, thereby giving students the opportunity to interact with people from sexually diverse groups. Similarly, Eliason and colleagues have stated that “the first task of nursing education is to infuse the curriculum with LGBT content,” and they encourage nursing faculty to forge ahead and begin doing so whenever possible.7 For example, they suggest including relevant materials (such as film) from other disciplines in classroom activities, and supporting student and faculty research into LGBT topics. The Association of American Medical Colleges has explicitly recommended that medical school curricula “ensure that students master the knowledge, skills, and attitudes necessary to provide excellent, comprehensive care” for LGBT patients.15 To our knowledge, no similarly explicit policy or position statement has come from nursing. If similar resolutions were to be issued by nursing education governance organizations, the inclusion of LGBT health concerns in the nursing curricula might be expedited.
LGBT HEALTH ISSUES
It's been estimated that, overall, between 5% and 10% of the U.S. population identifies as lesbian, gay, or bisexual, or transgender.16 (Estimates for the various subgroups vary further; for example, one estimate puts the percentage of transgender people at less than 1%.17) Although it's often simpler to refer to “the LGBT population,” providers must recognize that LGBT people aren't all alike. This population includes individuals “of every race, ethnicity, religion, mental capacity, physical ability/disability, age, and socioeconomic group.”17 And specific health concerns and needs vary considerably among lesbians, gay men, bisexuals, and transgender people. As Haas and colleagues have stated, the LGBT acronym “[does] not adequately reflect the heterogeneity of self-identifications or behaviors within these populations.”18 Indeed, the term “men who have sex with men” (MSM) was coined to acknowledge that self-identity and behavior don't always “match”; it includes gay men, bisexual men, and men who identify as primarily but not exclusively heterosexual.
Furthermore, the literature has often considered LGBT topics mainly in relation to disease and abnormality, while neglecting aspects such as patient-centered health promotion and individualized care following diagnosis. An IOM committee convened in 2010, tasked with identifying research gaps, found that “the existing body of research is sparse and that substantial research is needed.”2 In its final report the committee also noted that most studies had been conducted among lesbians and gay men, and very few among bisexual and transgender people.2 Addressing the needs of LGBT subgroups such as the elderly, adolescents, and racial or ethnic minorities is also essential to the implementation of outcomes-based patient care.
Certain LGBT health issues and health care disparities have been well documented, however, and efforts to address these must take this evidence into consideration.
Lesbians. A study analyzing national population-based data found that lesbians were significantly more likely to be overweight or obese than were women of any other sexual orientation.19 The finding held even after adjusting for demographic characteristics and parity. Given this higher risk of overweight and obesity, lesbians are also at higher risk for secondary outcomes of these conditions, such as type 2 diabetes, coronary heart disease, stroke, osteoarthritis, and breast and colon cancer.19 Regarding cancer, Cochran and Mays demonstrated that women in relationships with women were at significantly greater risk for fatal breast cancer than were women in relationships with men, although the researchers found no difference in the overall increased risk of death.20 Furthermore, according to the IOM, lesbians and bisexual women may use preventive health care services less frequently than heterosexual women.2
MSM. HIV infection rates are disproportionately higher among MSM; African American and Hispanic men appear to be at particularly high risk.21 It's worth noting that although MSM account for just 2% of the population, 61% of all new HIV infections in 2009 were among MSM.21 And thanks to advances in treatment, more people with HIV infection or AIDS are living longer. Both HIV infection and long-term antiretroviral therapy have been associated with increased risk of cardiovascular disease, including coronary artery disease, myocardial infarction, peripheral arterial disease, and chronic heart failure.22 There's evidence that MSM with HIV infection or AIDS are at higher risk for hepatitis B and hepatitis C coinfection.23 And some experts have urged comprehensive screening for sexually transmitted infections, including gonorrhea, syphilis, and chlamydia, among MSM and transgender people.24
The rates of human papillomavirus (HPV) infection and HPV-related anal cancer also appear to be much higher among MSM than among heterosexuals.25 One study identified smoking, having receptive anal intercourse, having had 15 or more sexual partners, and using corticosteroids as strong risk factors for anal cancer in this population.25 But there's currently no consensus on how to screen for anal cancer among MSM.26 Routine vaccination with quadrivalent HPV vaccine for males ages 11 through 26 years who have never been vaccinated or have not completed the three-dose series is recommended.27
Bisexuals. There's a dearth of information regarding the particular health issues faced by people who identify primarily as bisexual. That said, it's likely that bisexuals have distinct issues, and more research is needed to fully understand the needs of this subgroup. A comprehensive report on LGBT health by the New Mexico Department of Health found that along with gay men and lesbians, bisexuals reported higher rates of suicidal ideation and suicide attempts, depression, intimate partner violence, obesity, asthma, and life dissatisfaction than did their heterosexual counterparts.28 And a study among heterosexual, bisexual, and lesbian women found that bisexual women were more likely to ever have had an eating disorder.29
Transgender people are less likely than lesbians, gay men, bisexuals, and heterosexuals to have health insurance,3 and that may influence this group's usage of health care services. Furthermore, research indicates that, for transgender or gender-nonconforming people, discrimination by health care providers is a major deterrent to accessing those services, with “catastrophic consequences.”30 This was among the most important findings of a transgender health survey conducted jointly by the National Center for Transgender Equality and the National Gay and Lesbian Task Force.30 Nineteen percent of all respondents reported being denied care because of their transgender status. Transgender people of color reported even higher percentages. This study also highlights the dearth of primary care providers who are knowledgeable about transgender health issues. Fifty percent of those surveyed reported having to teach their providers about transgender medical care. The authors call for measures to address antitransgender bias in the medical profession and in the U.S. health care system, and urge providers to seek the knowledge they need regarding this population.
The same study found that AIDS is a major health threat for transgender people, who reported an HIV infection rate four times that of the general population.30 This highlights the importance of HIV prevention programs tailored to this group. Other health burdens that disproportionately affect transgender people include victimization, mental health issues, and suicide,3 further underscoring the need to develop outreach and community health programs for this largely underserved group.
Older LGBT people. It's been estimated that by 2050, LGBT people ages 65 years and older will account for one of every 13 elders in this country.31 Since a majority of health issues appear later in life, the burden of disease faced by older LGBT people will be considerably worse if they are also subjected to ageism and sexual stigmatization when they access the health care system. And regardless of one's age, negative experiences with health care providers are likely to affect follow-up care and patient care satisfaction.
It's estimated that nearly one-third of all people currently living with HIV infection or AIDS are 50 years of age or older.32 Among older adults, the confluence of HIV infection or AIDS, polypharmacy, and common comorbidities such as hypertension, coronary artery disease, and diabetes has marked implications, such as heightened risk for drug–drug interactions. And LGBT elders are less likely to have had children than their heterosexual peers; those who do are less likely to receive care from their adult children.2 This may create challenges such as having to rely more heavily on “nontraditional” caregivers (such as friends) “in an environment in which such support is frequently not recognized.”2
LGBT youth. There has been very little research conducted among lesbian, gay, and bisexual youth, and almost none among transgender youth; experts agree that much more is needed.2 That said, compared with their heterosexual counterparts, LGBT youth are at higher risk for depression, suicidal ideation, and suicide attempts2, 18, 33; and they may have higher rates of smoking, alcohol consumption, and substance use.2 They are also disproportionately likely to be homeless, and once homeless, to experience more negative outcomes.2, 34 The IOM proposes further research into how social structures such as families and schools affect LGBT health.2 Associations between health issues and potential stressors such as being bullied or belonging to a racial or ethnic minority also warrant investigation.
Tobacco, alcohol, and other substance use. The prevalence of smoking is reportedly 27% to 71% higher among gay and bisexual men, and 70% to 350% higher among lesbians and bisexual women, than it is in the general population.35 In a systematic review, Lee and colleagues found “an elevated prevalence of smoking among sexual minorities with odds ratios between 1.5 and 2.5 when comparing against heterosexual counterparts.”36 And the American Lung Association has reported that, of all sexual minorities, bisexual adults appear to have the highest rate of smoking.37 Such data require careful interpretation in order not to further stigmatize LGBT people. Experts have noted that sexual orientation is an indicator of health risk that must be interpreted in the context of various social and environmental factors.36 Higher rates of alcohol and drug use among LGBT people must be similarly interpreted.3, 38 Eliason and colleagues, who tested one LGBT-specific antismoking intervention and found it effective, have called for more research into such interventions.38
As more research findings emerge, the unique health issues of and care disparities among various LGBT subgroups may be better understood. For example, as the National Coalition for LGBT Health has stated, racial and ethnic minorities within the LGBT population are “left vulnerable to cumulative negative health outcomes by a combination of persistent racism and the stigma attached to their sexual orientation and/or gender identity.”39 It's crucial that all health care workers be aware that each distinct group has its own particular needs.
HEALTH PROMOTION AMONG LGBT PEOPLE
Reducing and ideally eliminating LGBT health care disparities is essential to ensuring the improved health, safety, and well-being of LGBT individuals.3 As health care providers, we need to widen our clinical “lens” so that it focuses not only on the diagnosis and treatment of illness but also on health promotion. As patient advocates, we can help empower LGBT clients to become self-advocates with regard to their health. Table 1 lists the top issues that LGBT people should discuss with their health care providers, according to GLMA: Health Professionals Advancing LGBT Equality (formerly the Gay and Lesbian Medical Association).40 Although these lists were developed for patients and their families, providers can use them both to explore these issues with their patients and to learn more themselves.
Adelson offers a guideline for working with children and adolescents who are gay, lesbian, bisexual, or “gender nonconforming” or “gender discordant.”41 The discussion on interventions aimed at altering sexual orientation (so-called “reparative” therapies) is particularly relevant. The guideline asserts unequivocally that there's no evidence that such therapies are effective, beneficial, or necessary; indeed, they have been shown to cause considerable harm to self-esteem. Their use is therefore contraindicated. The guideline is available free online from the National Guideline Clearinghouse (www.guideline.gov/content.aspx?id=38417#).
There is currently no guideline specific to older LGBT adults. That said, the American Society on Aging devotes a section of its Web site to the subject of aging in the LGBTQ (the Q stands for “questioning”) population (www.asaging.org/blog/content-source/5). Another useful resource for practice-oriented information is the nurse-authored e-book LGBTQ Cultures: What Health Care Professionals Need to Know About Sexual and Gender Diversity by Michele J. Eliason and colleagues, which can be purchased online.
The Center of Excellence for Transgender Health at the University of California, San Francisco, provides primary care protocols for transgender patient care. The protocols, which include various essential prevention and screening guidelines, as well as harm reduction strategies, are available free online (http://transhealth.ucsf.edu/trans?page=protocol-00-00). Another useful resource is the book Transgender Primary Medical Care: Suggested Guidelines for Clinicians in British Columbia by Jamie L. Feldman and Joshua Goldberg, which offers evidence-based guidelines for many transgender health concerns (http://bit.ly/QI7ZB8).
As in any clinical practice, and in accordance with their specialty, providers should make every effort to stay informed about the latest research and trends in LGBT health care.
PROMOTING CULTURAL COMPETENCE: A PRACTICE GUIDE
Various LGBT health interest groups have issued recommendations to guide providers in best practices for cultural competence. The Human Rights Campaign, the largest civil rights organization working to achieve equality for LGBT Americans, has developed a tool called the Healthcare Equality Index.42 This instrument has been used by health care facilities across the United States (participation is voluntary); it assesses how well a facility meets the four core policies considered essential for equitable and inclusive LGBT care: patient nondiscrimination, equal visitation rights, employment nondiscrimination, and staff training in LGBT patient-centered care. To check whether your facility has participated in the survey and whether it meets the “core four,” visit www.hrc.org/hei.
LGBT health: laws and regulations. As the Joint Commission has stated, in the United States “federal statutes prohibit discrimination on the basis of race, color, national origin, age, disability, and sex in virtually all hospitals nationwide.”17 And although “sexual orientation” or “gender identity” aren't yet explicitly included, advocates have been able to use the existing laws to file discrimination complaints against hospitals on behalf of LGBT clients. In 2011, the Department of Health and Human Services announced that all hospitals participating in Medicare and Medicaid were now required to “protect hospital patients’ right to choose their own visitors during a hospital stay, including a visitor who is a same-sex domestic partner.”43 The new rule also meant that hospitals were now obligated to protect patients’ right “to designate the person of their choice, including a same-sex partner, to make medical decisions on their behalf should they become incapacitated.”43 The rules were subsequently finalized by the Centers for Medicare and Medicaid Services.
The New York City Health and Hospitals Corporation (NYCHHC), the largest municipal health care organization in the country, is the first health care organization to require a mandatory LGBT cultural competency training for all its employees.44 The training curriculum includes a 10-minute video, To Treat Me, You Have to Know Who I Am: Welcoming Lesbian, Gay, Bisexual and Transgender (LGBT) Patients into Healthcare, with testimonials from health care providers and patients. (For links to videos, practice guidelines, and other resources, see LGBT Health Care Resources.)
Since each state has its own laws and regulations, it's recommended that all health care workers become informed about state and local regulations and initiatives regarding LGBT health.
Leading the change. In August 2010, the Joint Commission published a monograph aimed at hospitals, titled Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender Community: A Field Guide.17 In July of the following year, the Joint Commission began requiring that accredited hospitals “prohibit discrimination based on many factors, including sexual orientation and gender identity or expression.”17 Additional patient-centered communication standards were added to evaluations in July 2012.
The monograph, often referred to as the Field Guide, is evidence based and comprehensive.17 It covers five domains, including health care leadership; provision of care, treatment, and services; the workforce; data collection and use; and patient, family, and community engagement. It also offers core principles and a blueprint on how hospitals can provide care that is culturally competent and inclusive of LGBT patients, families, and staff members in any health care setting. In order to implement practice changes successfully, leadership efforts and support are critical. The Joint Commission recommends that health care leaders17
* develop or adopt a nondiscrimination policy that protects patients from discrimination based on personal characteristics, including sexual orientation and gender identity or expression.
* develop or adopt a policy ensuring equal visitation.
* develop or adopt a policy identifying patients’ right to identify support people of their choice.
* incorporate a broad definition of family into new and existing policies.
* develop clear mechanisms for reporting discrimination or disrespectful treatment.
* develop disciplinary processes that address intimidating, disrespectful, or discriminatory behavior toward LGBT patients or staff.
* monitor organizational efforts to provide more culturally competent and patient- and family-centered care to LGBT patients, families, and communities.
* identify an individual directly accountable to leadership for overseeing such organizational efforts.
* appoint a high-level advisory group to assess the climate for LGBT patients and make recommendations for improvement.
* identify and support staff or physician champions who have special expertise or experience with LGBT issues.
Promoting inclusive patient care. As the NYCHHC has stated, it's essential for health care providers “to show openness, use inclusive language, welcome and normalize individuals’ disclosure of their sexual orientation and gender identity, and use the knowledge they gain from each and every patient” in their practice.44 An awareness of one's possible biases and knowledge deficits and the willingness to be educated are vital first steps in developing cultural competence. Specific strategies to promote inclusive patient- and family-centered care, based on the Joint Commission's standards, are offered in Table 2.17
Implementing best practices guidelines will be an ongoing challenge. Embracing habits of lifelong learning and interprofessional collaboration will help ensure that health care workers continue to benefit from the expertise of those in both the health and social sciences. Besides nurses, other professionals such as physicians, social workers, physical therapists, pharmacists, and hospital chaplains also stand to gain from education in LGBT cultural competency.
As the largest group of direct patient care providers in this country, nurses are in an excellent position to “bridge health [care] disparities and provide culturally sensitive care across the lifespan.”31 Habits of self-awareness and reflection, ongoing professional development, and implementation of best practices are all essential to providing culturally competent care for LGBT people. An understanding of how social determinants of health—including race and ethnicity, literacy level, educational level, legal status, economic status, and geographic location—further affect health, and of their role in creating or exacerbating health care disparities in this population, is also essential.
As research yields more information regarding specific LGBT health issues and health care disparities, we hope to see more evidence-based practice guidelines that can inform providers, educators, and researchers. In the meantime, nurses and other providers are encouraged to practice open-mindedness and to welcome new opportunities to be educated on emerging best practices in LGBT health.
LGBT Health Care Resources
Child Welfare League of America
CWLA Best Practice Guidelines: Serving LGBT Youth in Out-of-Home Care (www.cwla.org/pubs/pubdetails.asp?PUBID=0951) is available for a small fee.
GLMA: Health Professionals Advancing LGBT Equality
Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients (http://bit.ly/1cxwDt5) is aimed at helping providers understand the health care disparities affecting LGBT populations and create welcoming clinical environments for LGBT patients and is available free online.
This online resource center offers “reliable LGBTQ health information and resources for health care professionals, educators, policy-makers and consumers.”
National Gay and Lesbian Task Force
Outing Age 2010: Public Policy Issues Affecting Lesbian, Gay, Bisexual and Transgender Elders (www.thetaskforce.org/downloads/reports/reports/outingage_final.pdf) provides useful information regarding LGBT people ages 65 and older.
Parents, Families and Friends of Lesbians and Gays
Straight for Equality in Healthcare (http://community.pflag.org/document.doc?id=297) is a guide for health care workers.
The Center of Excellence for Transgender Health
Primary Care Protocol for Transgender Patient Care (http://transhealth.ucsf.edu/tcoe?page=protocol-00-00), created within the Department of Family and Community Medicine at the University of California, San Francisco, aims to provide “accurate, peer-reviewed medical guidance” and to serve as a resource for health care professionals.
The Fenway Institute
This organization offers various resources, including this sample handout, “Self-Reflection or Group Discussion Exercises: Attitudes About Sexual Orientation and Gender Identity” (http://bit.ly/MasO5C).
To Treat Me, You Have to Know Who I Am: Welcoming Lesbian, Gay, Bisexual and Transgender (LGBT) Patients into Healthcare
This 10-minute video, from the New York City Health and Hospitals Corporation, is part of a landmark training program in cultural competency.
Gen Silent (trailer)
In the critically acclaimed documentary film Gen Silent, filmmaker Stu Maddux follows six LGBT elders who must decide whether to hide their sexuality in order to survive the health care system.
Patient Sexual Health History: What You Need to Know to Help
Although this short video from the American Medical Association is aimed at educating physicians, its strategies will be useful to nurses as well.
2. Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, Board on the Health of Select Populations, Institute of Medicine of the National Academies. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding
. Washington, DC: National Academies Press; 2011. https://www.ncbi.nlm.nih.gov/books/NBK64806
4. Herek GM, et al. Sexual stigma: putting sexual minority health issues in context. In: Meyer IH, Northridge ME, eds. The health of sexual minorities: public health perspectives on lesbian, gay, bisexual, and transgender populations
. New York: Springer Science and Business Media; 2007. p. 171-208
5. Dorsen C. An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients Can J Nurs Res. 2012;44(3):18–43
6. Brennan AM, et al. Lesbian, gay, bisexual, transgendered, or intersexed content for nursing curricula J Prof Nurs. 2012;28(2):96–104
7. Eliason MJ, et al. Nursing's silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts ANS Adv Nurs Sci. 2010;33(3):206–18
8. Pickles D, et al. Attitudes of nursing students towards caring for people with HIV/AIDS: thematic literature review J Adv Nurs. 2009;65(11):2262–73
9. Rondahl G. Students inadequate knowledge about lesbian, gay, bisexual and transgender persons Int J Nurs Educ Scholarsh. 2009;6:Article11
10. Eliason MJ, Raheim S. Experiences and comfort with culturally diverse groups in undergraduate pre-nursing students J Nurs Educ. 2000;39(4):161–5
11. Logie C, et al. Evaluating the phobias, attitudes, and cultural competence of master of social work students toward the LGBT populations J Homosex. 2007;53(4):201–21
13. Obedin-Maliver J, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education JAMA. 2011;306(9):971–7
14. Lim FA, et al. Lesbian, gay, bisexual, and transgender health: fundamentals for nursing education J Nurs Educ. 2013;52(4):198–203
18. Haas AP, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations J Homosex. 2011;58(1):10–51
19. Boehmer U, et al. Overweight and obesity in sexual-minority women: evidence from population-based data Am J Public Health. 2007;97(6):1134–40
20. Cochran SD, Mays VM. Risk of breast cancer mortality among women cohabiting with same sex partners: findings from the National Health Interview Survey, 1997-2003 J Womens Health (Larchmt). 2012;21(5):528–33
22. Esser S, et al. Prevalence of cardiovascular diseases in HIV-infected outpatients: results from a prospective, multicenter cohort study Clin Res Cardiol. 2013;102(3):203–13
23. Sanchez MA, et al. Epidemiology of the viral hepatitis-HIV syndemic in San Francisco: a collaborative surveillance approach Public Health Rep. 2014;129(Suppl 1):95–101
24. Cohen J, et al. WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and practice Sex Transm Infect. 2013;89(7):536–8
25. Daling JR, et al. Human papillomavirus, smoking, and sexual practices in the etiology of anal cancer Cancer. 2004;101(2):270–80
26. Machalek DA, et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis Lancet Oncol. 2012;13(5):487–500
27. Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep
28. VanKim NA, Padilla JL New Mexico's progress in collecting lesbian, gay, bisexual, and transgender health data and its implications for addressing health disparities
. Albuquerque, NM: New Mexico Department of Health, Chronic Disease Prevention and Control Bureau; 2010 Apr. http://hsc.unm.edu/programs/diversity/2010_LGBT_Report.pdf
29. Koh AS, Ross LK. Mental health issues: a comparison of lesbian, bisexual and heterosexual women J Homosex. 2006;51(1):33–57
30. Grant JM, et al. National transgender discrimination survey report on health and health care. Findings of a study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force
. Washington, DC: National Center for Transgender Equality; National Gay and Lesbian Task Force; 2010 Oct. http://transequality.org/PDFs/NTDSReportonHealth_final.pdf
31. Lim FA, Bernstein I. Promoting awareness of LGBT issues in aging in a baccalaureate nursing program Nurs Educ Perspect. 2012;33(3):170–5
33. King M, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people BMC Psychiatry. 2008;8:70
34. Rosario M, et al. Risk factors for homelessness among lesbian, gay, and bisexual youths: a developmental milestone approach Child Youth Serv Rev. 2012;34(1):186–93
35. Burkhalter JE, et al. Intention to quit smoking among lesbian, gay, bisexual, and transgender smokers Nicotine Tob Res. 2009;11(11):1312–20
36. Lee JG, et al. Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review Tob Control. 2009;18(4):275–82
38. Eliason MJ, et al. The last drag: an evaluation of an LGBT-specific smoking intervention J Homosex. 2012;59(6):864–78
41. Adelson SL. American Academy of Child and Adolescent Psychiatry, Committee on Quality Issues. Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents J Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74
For 33 additional continuing nursing education activities on cultural competence, go to www.nursingcenter.com/ce.