Abstract

In healthcare-oriented settings nationwide, there is widespread discrimination against lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) people and other individuals who identify with a sexual orientation or gender identity not described in this acronym. This paper discusses the discriminatory practices against this community that persist in medical schools, physicians’ offices, and hospitals throughout the United States. The mental health effects of discrimination on LGBTQIA+ individuals are considered. Lastly, this paper offers several specific recommendations for improvement that encompass reforms in legislation, education (including K-12, undergraduate, and medical school settings), and healthcare-related settings.

Background
 

Over 4.5% of U.S. adults– roughly 11 million people— – identify as members of the LGBTQIA+ community (American Heart Association News).[1] Members of this community are frequently discriminated against in healthcare settings and denied access to services. Hence, many LGBTQIA+ patients either refuse to seek medical care, or experience extreme discomfort when seeking treatment. These responses can result in prolonged illnesses and, in some cases, untimely deaths.

Biased attitudes against the LGBTQIA+ community in the healthcare arena result in provider mistreatment of these patients. Several studies that measured negative attitudes about LGBTQIA+ people among physicians nationwide found rates varying from 19%-58% (Chaimowitz et al.). A study of second- year medical students found that 25% believed that homosexuality is immoral and that 9% believed it is a mental illness (Klamen et al.). An additional study among medical students found that 23% agreed that same-sex relationships are always or almost always wrong and that only 29% would routinely discuss sexual orientation with adolescent patients (Klamen et al.). These mentalities can manifest into biased healthcare practices that can jeopardize the health of LGBTQIA+ patients. Moreover, such practices can lead to a variety of mental health problems in this community.

Medical School Discrimination
 

There is a preponderance of LGBTQIA+ discrimination in medical schools throughout the country. “In a national sample of U.S. medical students, 81% of heterosexual respondents held anti-gay/lesbian implicit bias” (Mateo et al.). [AM3] An additional study conducted among LGBTQIA+ medical students reinforces this finding: “Anti-LGBT discrimination had been witnessed by 14.6% and heterosexism by 31.1% of respondents. Anti-LGBT discrimination most often originated from fellow medical students” (Nama et al.). These medical students’ behaviors not only create a toxic learning environment, but can also spread to other peers. For example, peers who are friends commonly share their interests and practices. In turn, those who participate in homophobic or transphobic actions may share these practices with others.

These findings suggest that such biases may manifest when these medical students become physicians; doctors - may exhibit discriminatory practices against their patients in the LGBTQIA+ community. Consequently, LGBTQIA+ patients of these doctors may feel unwanted and not heard, which, in turn, can lower the number of LGBTQIA+ community members  seeking treatment.

 
Discrimination Against LGBTQIA+ Patients 
 

Many LGBTQIA+ patients have experienced discrimination by providers. An estimated seven out of 10 patients from this community have endured negative care based on their gender identities (Neira). One member of the LGBTQIA+ community said that some of her healthcare providers “provided no value” (Guertin-Anderson) because they spent more time asking questions about her sexual orientation than providing medical care. In turn, this patient actively sought providers specializinge in LGBTQIA+ healthcare issues to avoid having to "explain herself” (Guertin-Anderson). To this end, she has discovered an “underground network of referrals” for LGBTQIA+ providers who offer this population “a place that's safe" (Guertin-Anderson). Beyond experiencing negative interactions with healthcare providers, LGBTQIA+ community members are prevented, at times, from attaining care at all. Notably, “8% of lesbian, gay and bisexual adults and 29% of transgender adults reported that a health care provider refused to see them because of their sexual orientation or gender identity” (Monuiszko). This problem was illustrated during a routine visit between a homosexual patient and his doctor. The patient described his encounter:

[The doctor] was warm and fine before, and then things got very got cold and brusque,” he recalls. “As soon as I revealed myself as gay, she said, ‘You really have to get an HIV test.’ I wasn’t out to my parents at that time, but I was on their health insurance, so I couldn’t get one that way. I said, ‘What else can I do?’ She said, ‘I don’t know.’ She left the room and never came back. (Smith).

These issues result in numerous negative consequences for LGBTQIA+ individuals. Approximately 31% of LGBTQIA+ individuals have reported refusing to seek hospital-based care on at least one occasion “because of fear of discrimination”[AM6]  (Dennis 24). This delay can result in poor health outcomes because many medical issues have the highest chance of positive prognoses when addressed quickly. In turn, LGBTQIA+ populations suffer from “...greater rates of chronic disease (e.g., diabetes, coronary heart disease, and certain forms of cancer), social health problems (e.g., violence, discrimination, exclusion, and loneliness), and mental health symptoms and disorders (e.g., depression, anxiety, substance use, and suicide)”[AM7]  (Gorczynski). Furthermore, LGBTQIA+ populations have the highest rates of tobacco, alcohol, and other substance abuse issues (Smith). It has become increasingly clear that LGBTQIA+ people have poorer health outcomes than the general heterosexual population nationwide due to their aforementioned discomfort.

In addition, subsets of the LGBTQIA+ population face increased risks for specific health issues. For example, LGBTQIA+ youth are at an elevated risk for substance abuse disorders (Smith). Lesbians also face specific significant challenges; they are statistically less likely to obtain preventive services for cancer and are more likely to be overweight or obese. Moreover, transgender individuals have a higher prevalence of HIV /STDs than other LGBTQIA+ populations (Smith). Elderly LGBTQIA+ individuals face additional health-related concerns, primarily due to their relative isolation, lack of social services, and a dearth of culturally competent providers (Smith). Recent research has also revealed that transgender and gender-nonconforming individuals fare worse than most other members of the LGBTQIA+ community. Transgender and gender-nonconforming individuals “...experience the highest rates of discrimination and barriers to care” (Lambda Legal). Furthermore, a recent nationwide transgender survey… reported that “...a third of transgender people who saw a health care provider in the prior year had at least one negative experience, such as being verbally harassed or refused treatment” (James et al.)

Mental Health of LGBTQIA+ People Because of Discrimination

LGBTQIA+ members' mental health has been studied; but brarely discussed. As recently , as the 1970s, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders listed homosexuality as a “sociopathic personality disturbance” (Am. Psychiatr. Assoc. 1952). Individuals who experience (or have experienced)  discrimination or violence or both may be afraid to share their narratives and advocate for themselves. Members of the LGBTQIA+ community may experience discrimination in different ways, whereas some may not experience it at all.[AM8]  Patients who experience “discrimination… due to their gender orientation/sexual orientation can have diverse negative effects. For example, minority-specific psychological processes…include internalized homophobia expectations of rejection, and identity concealment” (Fredriksen-Goldsen).

The negative and harmful emotions experienced by those in the community can and often do result in suicidal behaviors and thoughts. In international and U.S. studies, consistently conclude that LGBTQIA+ youth report elevated rates of emotional distress, symptoms related to mood and anxiety disorders, self-harm, suicidal ideation, and suicidal behavior compared to heterosexual youth (Eskin et al. 2005, Fergusson et al. 2005, Fleming et al. 2007, Marshal et al. 2011)., Research indicates that compromised mental health is a fundamental predictor of multiple behavioral health disparities evident among LGBTQIA+ youth (e.g., substance use, abuse, and dependence; Marshal et al. 2008). Furthermore, in a recent meta-analysis, Marshal et al. (2011) reported that sexual minority youth were almost three times as likely to report suicidality; these investigators [AM9] also noted a statistically moderate difference in depressive symptoms compared to heterosexual youth. Furthermore, LGBTQIA+ youth score higher on many critical universal risk factors for compromised mental health, such as conflict with parents and substance use and abuse (Russell et al.). On a deeper level, conflict with parents can lead to a multitude of issues. In a homophobic or /discriminatory environment, D’Augelli and colleagues (1998) found that, compared to those who had not disclosed, youth who had told family members about their LGBTQIA+ identity often reported more verbal and physical harassment from family members and experiences of suicidal thoughts and behavior. (Russell et al.). Compared to those reporting low levels of family rejection, individuals who experienced high levels of rejection were significantly more likely to report suicidal ideation, attempt suicide, and score in the clinical range for depression. (Russell et al.).

These effects are often overlooked by those inside and outside the community. On a social and cultural level, the lack of support in the fabric of the many institutions that guide the lives of LGBTQIA+ youth (e.g., their schools, families, and faith communities) limits their rights and protections and leaves them more vulnerable to experiences that may compromise their mental health.

The discussions of mental health in LGBTQIA+ members is being talked about to a small extent, however they are not where they need to be. Often times, the discussion of mental health in even cisgender and hetero individuals is ignored, but the vast majority of LGBTQIA+ members go through things that are not talked about; things that should be discussed so that we can not only improve on ourselves and these issues, but to normalize that being part of the LGBTQIA+ community is nothing to be ashamed about.[AM10]  “[AM11] Minority stress theory  provides a foundational framework for understanding sexual minority mental health disparities. It posits that sexual minorities experience distinct, chronic stressors related to their stigmatized identities, including victimization, prejudice, and discrimination. These distinct experiences, in addition to everyday or universal stressors, disproportionately compromise the mental health and well-being of LGBTQIA+ people (Russell et al.)”. This quote explains that LGBTQIA+ members not only face issues privately, but also manage the stressors that surround everyday life.

LGBTQIA+ youth in schools with enumerated nondiscrimination or anti-bullying policies (policies that explicitly include actual or perceived sexual orientation and gender identity or expression) report fewer experiences of victimizations and harassment than those who attend schools without these protections (Russell et al.). Lesbian and gay youth living in counties with fewer sexual orientation and gender identity (SOGI)-specific anti-bullying policies are twice as likely to report past-year suicide attempts than youth living in areas where these policies are more common (Russell et al.). Further, studies indicate that youth who live in communities that are generally supportive of LGBTQIA+ rights (i.e., those with more protections for same-sex couples, greater number of registered Democrats, presence of gay-straight alliances [GSAs] in schools, and SOGI-specific nondiscrimination and anti-bullying policies) are less likely to attempt suicide even after controlling for other risk indicators, such as a history of physical abuse, depressive symptomatology, drinking behaviors, and peer victimization (Russell et al.).

Researchers have demonstrated that biased-based bullying (i.e., bullying or victimization due to one’s perceived or actual identities, including, race, ethnicity, religion, sexual orientation, gender identity or expression, and disability status) amplifies the effects of victimization on negative outcomes. When compared to non-biased-based victimization, youth who experience LGBTQIA+-based victimization report higher levels of depression, suicidal ideation, suicide attempts, substance use, and truancy (Poteat et al. 2011, Russell et al. 2012a), regardless of whether these experiences are in person or via the Internet (Russell et al.).

The inclusion of sexual attraction, behavior, and identity measures in population-based studies (e.g., the National Longitudinal Study of Adolescent to Adult Health and the CDC’s Youth Risk Behavior Surveillance System) has greatly improved knowledge of the prevalence of LGBTQIA+ mental health disparities and the mechanisms that contribute to these inequalities for both youth and adults; there remains, however, a critical need for the development and inclusion of measures to identify transgender people (Russell et al.).

Recommendations For Improvement  
To improve the quality of life for LGBTQIA+ individuals, multiple domains must be efficiently addressed. These areas include improvements in legislation, K-12, undergraduate, and medical school educational institutions, and employment settings.

Legislation
 

Both federal and state governments can help protect LGBTQIA+ community members who are vulnerable to persecution. To this end, lawmakers must “...ensure there are federal and state protections in place to prevent discrimination and harassment based on sexual orientation and gender identity” (Brown). It is critical that these requirements are implemented in all settings nationwide. These safeguards can not merely protect the physical well-being of LGBTQIA+  people; they must, also protect their socioemotional state as it is “understood that laws and policies provide the broad, societal-level contexts that shape minority stress and, consequently, mental health” (Russell et al.).[AM12] 

For students, legislation can help enforce anti-bullying laws that include SOGI in schools. This may help create an open and safe space in which all students can learn. Students “...living in states with enumerated anti-bullying laws that include sexual orientation and gender identity report less homophobic victimization and harassment than do students who attend schools in states without these protections” (Russell et al.). These laws can significantly impact the quality of life for LGTBQIA+ students and, therefore, allow them equal access to educational opportunities.

Furthermore, legislation can enhance the lives of other marginalized members of the LGTBQIA+ community. This legislation includes “...nondiscrimination laws in employment, housing and public accommodations, marriage equality, and legislation to support non-kin caregivers. Sexual and gender identity need to be added as protected classes in an expansion of the 1964 Civil Rights Act” (Fredriksen-Goldsen). Notably, most current policy advocacy efforts focus on the concerns of LGTBQIA+ persons in committed partnerships. These laws fail to meet the requirements of LGTBQIA+ individuals who are unattached, in non-traditional relationships, or in committed partnerships but do not wish to be married. Therefore, it is essential that families of choice and next-of-kin who are not partners, biological family members, or legal family members are also considered in attempts to advocate for legislation  (Fredriksen-Goldsen). Healthcare institutions should also advocate for laws that benefit the lives of all LGTBQIA+ people. To this end, regulations and accreditation standards must “...require all providers to deliver to LGBTQIA+ people the same level of high-quality care afforded others” (Lambda Legal). Any discriminatory practices that deny or limit coverage for LGTBQIA+ people who need care must be prohibited by law.

Educational Reform:
 

K-12
 

K-12 education is another critical domain in which advancements can be made for LGBTQIA+ people. Education that promotes the inclusion of this marginalized community should be universal and early— – for both children and their parents. LGBTQIA+-inclusive curricula that integrate historical figures, events, and information into student learning have been found to increase feelings of acceptance and safety among LGBTQIA+ youth. “Further, LGBT-specific training for teachers, staff, and administrators fosters understanding and empathy for LGBT students and is associated with more frequent adult intervention in biased-based bullying” (Russell et al.). [AM13]  To emphasize this point, creating school organizations, such as gay student alliance[AM14] s (GSAs), can also  foster inclusive and open environments in which LGBTQIA+ student members can feel heard and valued. GSAs are school-based, student-led clubs open to all youth who support LGBTQIA+ students; GSAs aim to reduce prejudice and harassment within school environments (Russell et al.). GSAs also teach cisgender and -heterosexual students about the LGBTQIA+ community, promoting awareness and education. Studies indicate that “LGBT students in schools with GSAs and SOGI resources often report feeling safer and are less likely to report depressive symptoms, substance use, and suicidal thoughts and behaviors in comparison with students in schools lacking such resources” (Russell et al.). With more resources and curricula, students feel less alone and isolated because of their identity. With more resources and curricula being provided early on can also help their development into adulthood, as “benefits of these programs are also seen at later developmental stages…youth who attended schools with GSAs, participated in a GSA, and perceived that their GSA encouraged safety also reported better psychological health during young adulthood” (Russell et al.).

Schools can also introduce historical events and persons, such as Marsha P. Johnson (a transgender activist, famous for her influential role in the Stonewall riots by fighting for equal rights), and information about the community. “LGBT-inclusive curriculums… have been shown to improve students’ sense of safety and feelings of acceptance and to reduce victimization in schools” (Russell et al.). Beyond school education and clubs, fostering inclusivity and acceptance is created through interpersonal relationships with others. For example, “...youth who engage in more LGBT-based discussions with peers and who have LGBT friends are more likely to participate in LGBT-affirming behavior and intervene when hearing homophobic remarks” (Russell et al.).

Undergraduate and Medical School
 

There are rules and laws in undergraduate and medical schools that attempt to prevent discrimination against LGBTQIA+ individuals; however, they are not enforced nor are these rules to help LGBTQIA+ members improved upon. One LGBTQIA+ member states that “Internships/field placements should include placements in service/healthcare organizations that serve marginalized populations,” which, in turn, would foster acceptance and inclusivity. More specifically, “medical schools, nursing programs, social work programs, [and] counseling programs should do more outreach and recruiting to/from the LGBTQ+ communities” (Brown). Outreach to more LGBTQIA+ members would create acceptance in the workspace. Additionally,, more LGBTQIA+ doctors would make patients feel comfortable seeking care from providers. More LGBTQIA+ representation = would create more comfort and acceptance in these settings, which. could affect thousands of individuals directly. In terms of physicians’ medical school education, they should “have a minimum level of LGBTQ needs…, it should be a required part of learning in med school…”you should not be a doctor or therapist if you haven't had this learning provided to you yet” (Guertin-Anderson). Furthermore, medical libraries should consider appointing and training a specialist in LGBTQIA+ health information (Lambda Legal). This way, education for students can be fact- checked by a specialist to ensure that the proper curriculum is  taught.  Without the proper curriculum, doctors cannot be true doctors. LGBTQIA+ curriculum must be provided as a basic necessity—not a luxury.

One way LGBTQIA+ people can do to help others in their community is to become a counselor. One A member, personally surveyed, explains the issues he encountered with patients as a counselor: “I started volunteering as what was called a “gay man’s peer Ccounselor” for Whitman Walker Clinic in DC.  The role was one that provided peer support to gay men presenting with problems of daily living – particularly relationship issues, coming out issues, self-esteem, etc. I really liked the work and had a knack (I think) for doing counseling” (Brown). Patients can benefit greatly from counseling from other community members with a first-hand understanding of the struggles they face.

Job-Based – Healthcare-Specific Settings
 

Job- based discriminiation has more coverage and more consequences, but there are things that we can do to improve it. Just as it is important to educate oneself and learn new things, [AM15] it is also “important for nurses and doctors alike to work with LGBTQ patients, and not on them” [AM16] (Margolies et al., 2019). By intentionally creating a collaborative patient-provider relationship, trust is formed, and there is both shared decision-making sand increased patient engagement (Dennis 17). Another key factor in reducing discrimination and increasing the comfort level of LGBTQIA+ patients lies in the provider’s role. A provider is a person or group of people who care for every patient encountered in their job; it is their responsibility to educate themselves and others (if needed) on how to care for their patients. Not knowing is acceptable; not learning is unacceptable. To address this, “Residents, nurses-in-training and other post-graduate healthcare professionals should have rotations that expose them to working with marginalized populations, including LGBTQ+ populations” because “nursing programs in the United States provide only a median of 2.13 hours of training content regarding LGBTQ health”[AM17]  (Kuzma et al.).

 Through exposure, more providers-in-training will better learn how to care for LGBTQIA+ patients - and others. Furthermore, in healthcare settings, “Many responses [AM18] also indicated the need for improvement of health intake forms, suggesting more inclusive language and the preference for intake forms to ask for both gender and sexual orientation” (Dennis 18). Intake forms can include “...having the option to list legal names alongside preferred names, and replacing the traditional husband/wife with spouse/domestic partner” (Dennis 20). ” “By taking the time to make these simple adjustments to paperwork that is required upon entry, a patient has the chance to share important information about themselves that they may not otherwise feel comfortable sharing. Creating this culture is what inspires change, brings more people into a healthcare setting ready to seek care and trust their providers, closing this health disparities gap” (Dennis 26).

“"It's really just trying to educate people that, when you ask questions, for example, about husbands or wives or partners, or if you need to ask about certain private body areas, that you don't make assumptions about what that person has, and you either leave it open-ended or give that person multiple options." - Dr. M. Brett Cooper, an assistant professor of pediatrics at UT Southwestern Medical Center in Dallas” (American Heart Association News).

Lastly, a unique way LGBTQIA+ people can do to help others in their community is to become a counselor. One A member, personally surveyed, explains the issues he encountered with patients as a counselor: “I started volunteering as what was called a “gay man’s peer Ccounselor” for Whitman Walker Clinic in DC.  The role was one that provided peer support to gay men presenting with problems of daily living – particularly relationship issues, coming out issues, self-esteem, etc. I really liked the work and had a knack (I think) for doing counseling” (Brown). Patients can benefit greatly from counseling from other community members with a first-hand understanding of the struggles they face.

As a whole, research studies must incorporate LGBTQIA+ individuals of varying social positions to examine the influence of the intersectionality of social positions on health. For example, the experiences of LGBTQIA+ people of color and those of varying socioeconomic statuses are largely absent in existing research. (Fredriksen-Goldsen). Longitudinal studies, currently sparse in LGBTQIA+ research, are necessary. Understanding individual trajectories and cohort variations in health in shifting structural and environmental contexts would help to articulate ways to promote health equity. (Fredriksen-Goldsen). More research on marginalized LGBTQIA+ groups (and others) will benefit all by creating mutual understanding and, respect, and educating people about other aspects of these communities. Research also needs to explore ways in which different forms of social exclusion and marginalization interact with behavioral, social and community, psychological, and biological factors at multiple levels to identify factors that foster or impede health equity. At this level, the improvements that can be done for all members is exponential. This work will potentially improve health outcomes for not only current members of the LGBTQ groups but also future generations.

 
Summary
Because of the issues described above, “faced with inadequate — and sometimes hostile — care, many LGBTQ patients are understandably reluctant to share their sexual orientation and gender identity” (Neira). LGBTQIA+ people’s safety, and their families’ safety can be risked when sharing this information with others. Nevertheless, people who share their experiences impart valuable information about rarely discussed topics.. With loose support systems provided by the government, and unequal opportunities for help, members are often left helpless. The government, which is supposed to protect and advocate for others, barely does. The healthcare system does not fulfill its duty to provide help to all who need it and has characterized “homosexuality as a “sociopathic personality disturbance” (Am. Psychiatr. Assoc. 1952).” These failures leaves LGBTQIA+ members at a significant disadvantage in securing the same rights and liberties as cisgender and /hetero individuals. Furthermore, some people refuse to accept LGBTQIA+ people as humans, compounding the problem. Further omission of LGBTQIA+ people, especially during the pandemic, contributes to the substantial deficit of health knowledge and health services.  (Gorczynski). The more that goes unspoken; the more that people suffer behind closed doors. As more people suffer in silence, and the more that people do not speak up about these issues, directly results in normalizing homophobia. However, structural change takes time, and in the interim, individual LGBT community members need support and care to thrive. (Russell et al.). We, as contributing members of society, can start helping those in need in the community by advocating for the necessary clinical, policy, and educational changes to empower the LGBTQIA+ community.

The fight to create equality for everyone a constant battle. The ideas that many carry about our community can only be disproved through research and education. Through this paper, and others, people can learn more about human complexities and the issues that we and other communities face daily basis.

Appendix A
: “Important Terms”
           

Sexual and gender identity are complex constructs and are highly contingent upon culture and social context, which can shift rapidly over time. Sexuality encompasses at least three key components: sexual identity, sexual attraction, and sexual behavior. Sexual identity is an individual’s own perception of his or her overall sexual self. For many people their sexual identity, such as lesbian, gay, bisexual, or heterosexual, is consistent with their sexual attraction and behaviors, but for some individual’s sexual identity may be inconsistent with attraction and/or behavior. (Fredriksen-Goldsen).

Cisgender: of, relating to, or being a person whose gender identity corresponds with the sex the person had or was identified as having at birth (Merriam Webster).

FtM: Female to male (Sachdej).

Gay bashing/Gay Bullying: An attack, abuse, or assault committed against a person who is perceived by the aggressor to be gay, lesbian, bisexual, or transgender. The attack may be physical or verbal. This can also include abuse, bullying or assaults perpetrated against a heterosexual person whom the attacker perceives to be LGBT.

Heterosexism: discrimination or prejudice against non-heterosexual people based on the belief that heterosexuality is the only normal and natural expression of sexuality (Merriam Webster).

Homophobia: irrational fear of, aversion to, or discrimination against homosexuality or gay people.

LGBTQ: Lesbian, gay, bisexual, transgender, and queer (Sachdej).

MSM: Men who have sex with men (Sachdej).

MtF: Male to Female (Sachdej).

Queer: of, relating to, or characterized by sexual or romantic attraction that is not limited to people of a particular gender identity or sexual orientation (Merriam Webster).

Two Spirited: a term used by North American indigenous LGBT people (Nama et al.)

WSW: Women who have sex with women.

Works Cited

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Eliason, Michele J., and Peggy L. Chinn. LGBTQ Cultures: What Health Care Professionals Need to Know about Sexual and Gender Diversity. 3 ed., Wolters Kluwer, 2017. Accessed 14 August 2022.

Fredriksen-Goldsen, Karen I., et al. “The Health Equity Promotion Model: Reconceptualization of Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Disparities.” American Journal of Orthopsychiatry, vol. 84, no. 6, 2014, p. 11, doi.org/10.1037/ort0000030.

Guertin-Anderson, Cindy. Personal Interview. 10 May 2022.

Kuzma, Elizabeth K., et al. “Improving Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning Health: Using a Standardized Patient Experience to Educate Advanced Practice Nursing Students.” National Library of Medicine, vol. 31, no. 12, 2019, pp. 714-722, pubmed.ncbi.nlm.nih.gov/31169783/.

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Merriam Webster. Heterosexism Definition and Meaning. Merriam-Webster.com, merriam-webster.com/dictionary/heterosexism.

Moniuszko, Sara M. “LGBTQ-Inclusive Healthcare is Still not 'Mainstream.' Here's why.” USA Today, 1 October 2021, usatoday.com/story/life/health-wellness/2021/10/01/lgbtq-inclusive-healthcare-still-not-mainstream-heres-why/5904801001/. Accessed 17 August 2022.

Nama, Nassar, et al. “Medical Students’ Perception of Lesbian, Gay, Bisexual, and Transgender (LGBT) Discrimination in their Learning Environment and their Self-Reported Comfort Level for Caring for LGBT Patients: A Survey Study.” Medical Education Online, vol. 22, no. 1, 2017.

Neira, Paula M. “LGBTQ Health Care: Answers from Expert Paula Neira.” Johns Hopkins Medicine, hopkinsmedicine.org/health/wellness-and-prevention/lgbt-health-care-answers-from-expert-paula-neira. Accessed 17 August 2022.

Romanelli, Meghan, and Kimberly D. Hudson. “Individual and Systematic Barriers to Health Care: Perspectives of Lesbian, Gay, Bisexual, and Transgender Adults.” National Library of Medicine, vol. 87, no. 6, 2017, pp. 714-728, pubmed.ncbi.nlm.nih.gov/29154611/.

Russell, Stephen T., and Jessica N. Fish. “Mental Health in Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth.” Annual Review of Clinical Psychology, vol. 12, no. 1, 2016, pp. 465-487, annualreviews.org/doi/10.1146/annurev-clinpsy-021815-093153.

Sloss, Morgan. “17 Rules That LGBTQ+ People Follow Every Day.” BuzzFeed, 21 March 2022, buzzfeed.com/morgansloss1/lgbtq-unwritten-rules. Accessed 17 August 2022.

Smith, Linell. “Embracing the Rainbow.” Johns Hopkins Medicine, 2015, hopkinsmedicine.org/news/publications/hopkins_medicine_magazine/features/springsummer-2015/embracing-the-rainbow. Accessed 17 August 2022.