1. Zuzelo, Patti Rager EdD, RN, ACNS-BC, ANP-BC, FAAN

Article Content

Individual sexuality, including sexual orientation and gender, is recognized as a critical attribute of the whole self. The "whole self" notion is included in many corporations' diversity statements when asserting an employee's right and obligation to participate in the work environment as an authentic, whole being. This human resource view of "bring your whole self to work" encourages individual self-expression and sexual diversity in recognition of the positive esprit de corps that grows when employees are able to genuinely and fully participate in work life as whole people. A quick Google search reveals hundreds of thousands of immediate hits when searching for "whole self to work." Relatively recent policy and legal changes have contributed to this apparent openness as required by new Equal Employment Opportunity Commission1 and Supreme Court rulings,2 as well as Affordable Care Act requirements.3 Workplace changes in attitudes, benefits, and protections have proceeded at an astonishing pace for lesbian, gay, bisexual, transgender (LGBT), and queer (LGBTQ) people, and increasing numbers of employees are finding opportunities to contribute as whole beings.


The health care arena is also changing in its efforts to improve LGBTQ health processes and outcomes albeit slowly. There are persistent barriers to authentic self-expression and open disclosure during health care encounters related to patients' and families' reasonable concerns about potentially negative provider reactions to nonheterosexual or gender nonconforming social and medical revelations. The struggle to decide whether or not to fully disclose the whole self is a very real and valid dilemma. Many patients avoid the vulnerabilities associated with sexual disclosures because of real or perceived risks, thereby negating their whole self. Health care professionals, students, and educators may similarly struggle and acquiesce to the safer option of avoiding bringing their whole selves to work because of concerns of workplace hostilities. In fact, published studies support that negatively charged health care interactions occur frequently for LGBTQ people and these traumatic encounters involve a variety of care providers, including nurses and physicians. It is likely that these negative encounters are influenced by heterosexism, an "underlying belief that heterosexuality is the natural/normal/acceptable or superior form of sexuality."4(p98) This worldview contributes to prejudice, negative stereotyping, and disingenuous and untrustworthy provider-patient relationships.



Health providers need to be aware of the rich data sources that support the premise that bringing the whole self into health care encounters may be risky despite the importance of doing so. Lambda Legal's 2010 landmark report, When Healthcare Isn't Caring: Lamba Legal's Survey of Discrimination Against LGBT People and People With HIV,5 describes findings from 4916 participants obtained via efforts of more than 100 partnering organizations about health care experiences. Study findings are disquieting and support the premise that health care providers must do a better job of welcoming the whole self into each and every health care encounter. Findings illustrate the challenges facing LGBT and HIV-positive people, particularly but not exclusively those who are transgender, low-income, or nonwhite. The researchers point out that the sample was comparatively privileged, with demographic characteristics that exceed overall LGBT and HIV-positive peoples' attributes specific to education, employment, and socioeconomic status. In other words, the results are likely positively skewed, a concerning observation, given the disturbing results. Of note, 9% of lesbian, gay, and bisexual respondents expressed concern about being refused medical services when needed. Twenty percent of respondents living with HIV and more than 50% of transgender and gender nonconforming respondents shared this same concern.5


The Agency for Healthcare Research and Quality's 2011 National Healthcare Disparities Report6 cites similar concerns. Two notable findings specific to health care provider relationships and patients' whole selves: 30% of transgender people postponed care during occasions of illness and injury and delayed preventive care as a direct result of discrimination and disrespect from providers; and 20% of transgender people were denied services by a doctor or other provider because of gender. Ethnic and racial minority transgender people fared worse. The 2011 report, Injustice at Every Turn: A Report of the National Transgender Discrimination Survey,7 funded by the National Center for Transgender Equality and National Gay and Lesbian Task Force, points out in its published findings that nearly every system and institution in the United States, including medical providers and health systems, is


failing daily in its obligation to serve transgender and gender non-conforming people, instead subjecting them to mistreatment ranging from commonplace disrespect to outright violence, abuse and the denial of human dignity. The consequences of these widespread injustices are human and real, ranging from unemployment and homelessness to illness and death.8(p8)



Despite the sobering findings from these important national surveys, there is cause for optimism. Health care systems and providers are increasingly responsive to the health needs of LGBTQ people. The Institute of Medicine's report,9The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, provides an excellent assessment of the current state of LGBT science. The report offers a gap analysis of what is known versus topics that require explication and exploration. The report also guides the National Institutes of Health in its research planning activities in an effort to improve the LGBT knowledge base that informs evidence-based practice.


New Healthy People 2020 objectives10 are also of note, with population-based data collection requirements inclusive of LGBT data. The Joint Commission has provided clear expectations of fully LGBT inclusion via its LGBT Field Guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community.11 In addition to recognizing the health care needs of LGBT people, efforts are also underway to improve the work lives of LGBT nurses and other providers. The 10-item Nurse Workplace Climate Scale12 provides a vehicle for evaluating and potentially improving workplace environments for nurse employees. Another indication of meaningful progress is the increasing rate of institutional participation in the Human Rights Campaign Foundation's Healthcare Equality Index 2014 benchmarking tool.13



Individual health care providers vary in their comfort with and knowledge of general sexual diversity concerns and LGBT-specific health needs. There is a broad array of freely available, multimedia LGBT-focused resources that are designed to increase expertise, develop technical skills, and enhance sensitivity and awareness. Journal options include the Journal of Homosexuality and the International Journal of Transgenderism. YouTube videos, including Southern comfort: Full biography, offer learning experiences that testify to the suffering that occurs when health care encounters are damaging. The National LGBT Health Education Center of The Fenway Institute14 makes freely available many resources that may support an enriching program of self-study. The variety of resources and the opportunities to learn how to authentically address sexual diversity offer providers opportunities to increase the breadth and depth of their ability to positively influence LGBT health outcomes.



Authentic interaction with LGBT people and families requires nurses to reflect on personal views, including biases and stereotypes. Self-awareness is an important component of the nurse-patient relationship15 and reflective practice provides opportunities to respond to the tension that exists between what nurses and other providers aspire to create in practice versus current realities.16 Some sexual diversity subject matter may challenge nurses to step outside their usual boundaries to explore topics with patients who may be personally uncomfortable. This discomfort should be rectified or at least recognized to provide effective patient-centered care.


It is important for nurses to encourage all people to bring their whole selves to health encounters, whether as patients, family members, providers, or students. The 30th anniversary year of this journal, Holistic Nursing Practice, provides an ideal opportunity for nurses to recommit to holistic practice by establishing a clear expectation that health experiences will respectfully and comprehensively recognize and celebrate the diverse sexuality of all people, including people who identify as LGBTQ or gender nonconforming, regardless of age, race, culture, or socioeconomic status.




1. Alter C. Discrimination against LGBT workers is illegal, commission rules. Time Magazine. July 17, 2015. Accessed October 19, 2015. [Context Link]


2. Obergefell et al v Hodges, Director, Ohio Department of Health, 576 U.S. ___No. 14-556, Supreme Court of the United States (June 26, 2015). Accessed October 19, 2015. [Context Link]


3. US Department of Health and Human Services. Civil rights. Fact Sheet: Nondiscrimination in Health Programs and Activities Proposed Rule. Section 1557 of the Affordable Care Act (2015). Accessed October 19, 2015. [Context Link]


4. Williamson L. Internalized homophobia and health issues affecting lesbians and gay men. Health Educ Res. 2000;15:97-107. [Context Link]


5. Lambda Legal. When health care isn't caring: Lambda Legal's survey of discrimination against LGBT people and people with HIV. Published 2010. Accessed October 19, 2015. [Context Link]


6. Agency for Healthcare Research and Quality. National Healthcare Disparities Report, 2011. Published 2012. Accessed October 19, 2015. [Context Link]


7. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. 2011. Accessed October 19, 2015. [Context Link]


8. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Executive summary. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. 2011. Accessed November 3, 2015. [Context Link]


9. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011. [Context Link]


10. United States Department of Health and Human Services. Healthy People 2020. Lesbian, Gay, Bisexual, and Transgender Health. Washington, DC: United States Department of Health and Human Services; 2013. Accessed October 19, 2015. [Context Link]


11. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oakbrook Terrace, IL: The Joint Commission; 2011. Accessed October 19, 2015. [Context Link]


12. Nurses Advancing LGBT Equality. Nurse Workplace Climate Scale. Published 2015. Accessed October 19, 2015. [Context Link]


13. Human Rights Campaign. Healthcare Equality Index. Promoting equitable and inclusive care for lesbian, gay, bisexual, and transgender patients and their families. Published 2014. Accessed October 19, 2015. [Context Link]


14. National LGBT Health Education Center. Home. Published 2015. Accessed October 19, 2015. [Context Link]


15. Campbell J. The relationship of nursing and self-awareness. Adv Nurs Sci. 1980;2(4):15-25. [Context Link]


16. Johns C. Becoming a Reflective Practitioner. 2nd ed. Malden, MA: Blackwell; 2004. [Context Link]