The National LGBTQIA+ Health Education Center from The Fenway Institute aims to advance health equity, access, and quality of care for LGBTQIA+ people through evidence-informed and cutting-edge training and education for healthcare providers across the globe.
Building a space of equity and inclusion for lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual and all sexual and gender minority (LGBTQIA+) people in health care is a critical step to address health disparities faced by these communities. However, the process of building inclusive spaces is one that takes significant time, analysis, and investment at every level of leadership. This guide presents strategies and considerations in driving organizational change for LGBTQIA+ inclusion and equity in health care.
Building a space of equity and inclusion for lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual and all sexual and gender minority (LGBTQIA+) people in health care is a critical step to address health disparities faced by these communities. Many LGBTQIA+ people report being denied health care, having to teach their providers about their unique and routine health needs, or delaying necessary health care due to prior experiences with discrimination in these settings.1- 3 For these reasons, health care providers, administrators, and staff must be proactive in creating spaces that are welcoming and inclusive. However, the process of building inclusive spaces is one that takes significant time, analysis, and investment at every level of leadership.
This guide presents strategies and considerations in driving organizational change for LGBTQIA+ inclusion and equity in health care. These strategies can help lay the foundation for health centers, hospitals, or similarly positioned organizations. Further reading and tools are available in the “Resources” section of this document.
A sustainable commitment to change and equity should be driven by a partnership between leadership and impacted communities. This partnership can take many forms; however, the process of organizational change is often best served by identifying a single person or team of people whose role it is to champion these efforts. Where a team is involved, it is important to have representatives from different levels of staffing: leadership, clinical, frontline, administrative, and, where feasible, LGBTQIA+ community members who are clients or patients of your organization. Engagement with local LGBTQIA+ community organizations or representatives is also a critical component for providing accountability and community insight. Some organizations may want to consider forming a community advisory board (CAB), which can involve multiple representative voices from LGBTQIA+ community members, organizations, or groups.
Remember that not all LGBTQIA+ individuals have the same experiences, perspectives, or expertise, especially regarding transgender and gender diverse (TGD) people. Organizations should pay special attention to the invitation and engagement of TGD people in creating a sustainable partnership.
Champions for organizational change will set the tone for efforts and inspire buy-in from different levels of staffing, and community engagement. In order to be successful, these champions need visible support from leadership in their organizations. This support can be communicated through statements and quotes from leadership in any press releases, ensuring members of leadership are present at trainings and events, and/or including members of leadership in meetings of a CAB. By actively involving multiple members of leadership in these ways, or others, organizational leaders can feel invested in the efforts and convey the importance of this work to other members of staff.
Identify a champion and/or champions to drive your organization's change efforts.
Consider how to involve LGBTQIA+ community and staff members in the process.
Ensure leadership is invested in the change efforts.
Organizational change is most effective when driven by data collection and analysis.4 In order to know what areas need change, it is important to assess the existing organizational culture and climate. Data may be collected from surveys or interviews with staff and leadership to assess existing knowledge, skills, and attitudes related to LGBTQIA+ identities and communities. Champions can conduct environmental scans of inclusive representation in the physical environment and access to educational resources among others. To avoid survey fatigue, organizations should be mindful of the number of surveys and questions.
There are many additional opportunities for data collection relative to care and inclusion for LGBTQIA+ people. Surveys and/or opportunities for feedback from LGBTQIA+ patients, for instance, can provide helpful insight into the needs of community members. If you collect sexual orientation and gender identity data in your electronic health records, you can run reports to identify any health care disparities among your LGBTQIA+ patients.5,6
When presenting surveys, focus groups, or other assessments to participants, be sure to clearly communicate the goals of the assessment. Participants should understand why the data are being collected (such as “in the organization's efforts to become a more welcoming and inclusive space”), whom the data are being shared with (such as “this survey is anonymous, and the results will only be shared in aggregate with the DEI Workgroup”), and potential next steps (such as “we are exploring opportunities for further education, inclusive marketing, etc.”). Participants should understand that data collection is just the first in continuing efforts for organizational change.
Use surveys, interviews, and/or focus groups to assess the current climate and needs
Clearly communicate to all participants that these assessments are part of a continued larger effort for organizational change
Following an assessment, many organizational change champions will begin efforts with a staff-wide training to address the gaps in existing knowledge of LGBTQIA+ identities and communities. Training can be an important first step in building a welcoming and inclusive environment; however, it is too often the first and last step in what should be a far more extensive journey.
It is important to consider the ways in which training content can and should be tailored to the unique needs of each department: for instance, LGBTQIA+ cultural responsiveness training for administrators will contain different information than for clinical providers. When making plans to provide introductory trainings, it may be best to train different departments separately, while also communicating that the efforts for inclusivity are happening across all departments in the organization.
One 60- or 90-minute training or learning module is not, alone, sufficient to create or sustain organizational change for LGBTQIA+ inclusion. Champions for equity should consider multiple trainings addressing nuanced topics particular to practice areas/departments, offered throughout the year. Additionally, trainings addressing expectations for LGBTQIA+ inclusive practices should be a part of onboarding trainings for all staff. These trainings should be regularly revisited and updated, as language or policies may change.
Begin with, but do not end with, tailored LGBTQIA+ introductory trainings.
Build on introductory trainings with material unique to individual departments' needs
Inclusion and equity for LGBTQIA+ people in healthcare organizations should not be limited to a focus on patient/client care. Considerations for LGBTQIA+ staff and leadership must be a cornerstone in plans for organizational change. Organizations should be proactive in recruiting and retaining LGBTQIA+ staff, as doing so will significantly contribute to an environment of welcome and inclusion for patients/clients, and staff.
In recruitment and interviewing, organizations should be aware of unique considerations for LGBTQIA+ candidates. Job postings should have a clear nondiscrimination statement that includes sexual orientation, gender identity, and gender expression. Application forms should make space for the name listed on government- issued identity documents and the name a person goes by (sometimes referred to as “common use name”), as well as provide fields for pronouns. Interviewers and Human Resources staff should be prepared for questions about coverage of medical gender affirmation provided by the organization's health insurance benefits.
In addition to recruitment, organizations must take steps to ensure existing and recruited LGBTQIA+ staff have access to the spaces and resources needed to be successful. This includes access to gender-affirming medical care through insurance benefits, clear policies and procedures around name and pronoun changes, the means and avenues to hold colleagues and leadership accountable if discrimination occurs, as well as an inclusive environment and facilities (covered more in section five below). Organizations should assess the existing policies, procedures, and health insurance coverage.
When considering health insurance, organizational leadership may want to discuss gender-affirming care with their insurance representatives, to ensure that coverage is comprehensive: including coverage for insured youth family members, mental health coverage, and access to gender- affirming specialists and surgeons. Current LGBTQIA+ staff and community advisors can be important in identifying areas of need or concern.
Assess the current landscape of LGBTQIA+ staff, policies, and benefits. This should include what departments and levels of leadership LGBTQIA+ staff are currently in, and available pathways to career development.
Proactively make changes to recruitment practices in order to create space and opportunities for LGBTQIA+ candidates.
When entering any kind of health care office or facility, many LGBTQIA+ people will be keenly aware of visual cues or signs indicating the space is welcoming and affirming. Examples of such cues include rainbow flags and health brochures specific to LGBTQIA+ health. Even more important than these visual cues, however, is ensuring that the expectations created by these cues are met.
Some organizations often utilize “Safe Zone” signs or stickers; these notices often feature rainbow flags with text and communicate that the person or place displaying them are supportive and/or open to discussing LGBTQIA+ identities. However, if the person or place has not undergone recent cultural responsiveness training, they may unknowingly communicate anti-LGBTQIA+ biases, thus undermining the intention of the “safe zone” moniker. It is recommended that individuals or organizations interested in becoming a “safe zone” and displaying the notices should commit to a baseline training, along with regular updates.
Along with organization-wide signage, clinicians and other frontline staff may have the opportunity to convey inclusivity through personal accessories, such as pins, stickers, lanyards, or individual office signage. By no means are these individual accessories required to convey allyship, but they can make LGBTQIA+ patients feel more seen in the space. Pronoun indicators, such as buttons, ribbons, or added lines on name badges can be an important tool to convey not only a person's pronouns but can also help open conversations with patients about their pronouns. These should not replace an affirmative introduction of pronouns but can be a helpful reminder.
Facilities that have restrooms available to patients should be mindful of access and the signage involved. While bathrooms are by no means the only important aspects for TGD people, they can be a major point of pressure and concern when accessing services, including healthcare. Failure to have access to affirming restroom spaces, or lacking policies that protect TGD people in restrooms can lead to negative health outcomes.7
Ideally, healthcare facilities should offer single stall/room, gender inclusive bathrooms (also called “gender-neutral,” “all-gender,” or “family” restrooms). However, not all facilities have such spaces available. Buildings with single stall gender-segregated restrooms can turn these into gender inclusive restrooms. A simple change of signage can make the difference of access for TGD patients, clients, and staff on site. Turning one room “women's” and “men's” facilities into two inclusive restrooms can also increase access for families with young children, or people with disabilities who may require the assistance of an aide, and prevent a backup or line for a particular gendered restroom.
Buildings that only offer gender-segregated multi-stall restrooms can potentially make access for TGD people more difficult. In these cases, supplemental signage can be added, articulating a policy of affirmation for TGD patients and staff; for example: “you are welcome to use the restroom that best aligns with your gender identity.” It may also be helpful to describe where the nearest inclusive restroom is for those who may not feel comfortable in segregated spaces.
Review both the public facing, and employee facing spaces and consider what signage, language, or other means of representation are visible for LGBTQIA+ inclusion.
Make available LGBTQIA+ inclusive materials or accessories for staff who may be interested, such as but not limited to pronoun buttons, pride-themed lanyards or pins, brochures, posters, etc.
Consider and review current restroom facilities and ensure access for TGD staff and patients/clients.
Health care organizations do not exist in a vacuum, but rather, should be firmly grounded in the communities they serve. Likewise, when taking steps to affirmatively welcome LGBTQIA+ communities, organizations should work in partnership with local LGBTQIA+ organizations and individuals. This partnership can include inviting members to sit on an advisory board, submit feedback, speak to staff about their lived experience, or provide opportunities to recruit for staff positions. There may also be opportunities to partner with local organizations or individuals to highlight events such as Pride Month, Transgender Day of Visibility, LGBTQ History Month, and Transgender Day of Remembrance. Presence and partnership in these events will build relationships and trust with community members.
However, it is critical that the foundation of trust built with communities through these partnerships also makes space for holding healthcare organizations accountable. Organizations should have space, in advisory board meetings, online feedback forms, or other means of communication to address concerns and ways to do better for the communities they serve. There should also be follow-up and follow through when addressing these concerns.
Consider how local LGBTQIA+ community members and/or organizations can be a partner in your change efforts.
Build sustainable opportunities for feedback and accountability in your efforts to make change for inclusion and equity.
Organizational change is a journey, one that should prioritize the path rather than the destination. Organizations should plan for a long term and sustainable process, where goals may emerge and expand over the course of assessment and action. The goals in organizational change should focus on progress, not perfection.
Foster an understanding that organizational change for equity and inclusion is not a short-term project.
Have clear short- and long-term goals for your change efforts. These goals should be revisited and revised as efforts continue.
Below is a checklist of steps organizations can explore when pursuing organizational change for LGBTQIA+ inclusion. While each organization may vary in structure, capacity, and/or culture, many of these steps can apply to a broad array of characteristics in health care organizations.
Investment and Engagement
Evaluate interest and investment from leadership in LGBTQIA+ equity?
Identify a champion or multiple champions to drive your organization's change efforts.
Create a Community Advisory Board with representative members from organizations or groups.
Assemble a team for an organizational change advisory committee, which includes members from:
Conduct a staff-wide assessment of current LGBTQIA+ awareness, climate, and knowledge.
Host focus groups across departments to determine areas of interest and need.
Make available and/or require introductory training on LGBTQIA+ equity for all staff.
Make available and/or require additional training tailored to more specific departments/areas.
Build LGBTQIA+ inclusion training into new staff onboarding and annual trainings for all staff.
Annually review and make revisions to LGBTQIA+ training materials.
Recruitment and Retention
Assess current policies and benefits relating to LGBTQIA+ staff, including but not limited to:
Health benefits for gender-affirming care.
Family and medical leave policies inclusive for TGD people and non-heteronormative families.
Policies and procedures for name, pronoun, and gender marker updates.
Assess recruitment and interview practices to ensure inclusive opportunities for LGBTQIA+ candidates.
Environment and Facilities
Review both the public-facing and employee-facing spaces and consider what signage, language, or other means of representation are visible for LGBTQIA+ inclusion.
Accountability and Community Partnerships
Reach out to local LGBTQIA+ community members or organizations for partnership in organizational change efforts, events, or other opportunities for collaboration.
Build pathways for accountability to LGBTQIA+ staff and patients/clients, including opportunities for feedback, discussion, or review.
The HRC Foundation | www.thehrcfoundation.org
The HRC Foundation seeks to fundamentally change the way LGBTQ+ people are treated in our everyday lives. The HRC Foundation creates impact through 11 programs and initiatives, working with individuals and organizations to make transformational change in the everyday lives of LGBTQ+ people. These initiatives include the Health Equality Index (HEI), and initiatives around LGBTQ+ non-discrimination for healthcare workers and patients.
The HRC Foundation Health Care Equality Index 2020 Report
This resource provides deeper details about the importance of LGBTQIA+ competent healthcare and includes information from real patient experiences. This resource also discusses the importance of LGBTQIA+ non-discrimination and the HEI standard for non-discrimination in employment.
The HRC Foundation Employment Non-Discrimination Policies
This resource discusses the importance of LGBTQIA+ non-discrimination employment policies. It further discusses recommendations that can help healthcare organizations meet the Healthcare Equality Index's (HEI) standard of best practice.
Transgender-Inclusive Benefits for Employees and Dependents
This publication discusses how employers, as consumers of group health insurance products, can advocate on behalf of the transgender people insured on their group health insurance plans. It details how employers should work with their insurance carriers or administrators to remove transgender exclusions and provide comprehensive transgender-inclusive insurance coverage.
National LGBTQIA+ Health Education Center | www.lgbtqiahealtheducation.org
The National LGBTQIA+ Health Education Center is part of the Division of Education and Training at The Fenway Institute, Fenway Health. The National LGBTQIA+ Health Education Center aims to advance health equity for LGBTQIA+ people and the populations which may intersect with the LGBTQIA+ community and improve the quality of care for LGBTQIA+ people by providing resources, training and technical assistance to health care providers and staff across the globe.
Recruiting, Training, and Retaining LGBTQ-Proficient Clinical Providers: A Workforce Development Toolkit
This publication by Fenway's National Health Education Center provides best practices for recruiting healthcare staff who are proficient in LGBTQIA+ healthcare or who seek to be, how to train staff in providing LGBTQIA+ competent care and creating inclusive policies and practice.
Organizational and Human Resources Policies for an LGBTQIA+ Workforce
This webinar by Fenway's National Health Education Center is aimed at increasing the ability of health centers to improve recruitment, hiring, and retention of LGBTQIA+ staff and providers. Viewers will learn about the integration of staff into professional and clinical teams, the development of affirming and inclusive HR forms, practices and policies, and the importance of an affirming work culture in the retention of an LGBTQIA+ workforce.
The U.S. Equal Employment Opportunity Commission (EEOC) | www.eeoc.gov
The U.S. Equal Employment Opportunity Commission (EEOC) is responsible for enforcing federal laws that make it illegal to discriminate against a job applicant or an employee because of the person's race, color, religion, sex (including pregnancy, transgender status, and sexual orientation), national origin, age (40 or older), disability or genetic information. The laws addressed on their site apply to all types of work situations, including hiring, firing, promotions, harassment, training, wages, and benefits.
Sexual Orientation and Gender Identity (SOGI) Discrimination
This document briefly explains the Supreme Court's decision in Bostock v. Clayton County and information about SOGI discrimination in the workplace, harassment, employment policies/practices, and retaliation.
Protections Against Employment Discrimination Based on SOGI
This document briefly explains the Supreme Court's decision in Bostock v. Clayton County and commonly asked questions about the EEOC's established legal positions on SOGI related workplace discrimination issues.
Inclusive Interview Tips
This article discusses three simple ways to make your hiring practices more inclusive of transgender and gender non-conforming employees.
Creating A Trans-inclusive Workplace
This article discusses the importance of creating a trans inclusive workplace and four key areas of intervention that can cultivate a more trans-inclusive workplace: (1) basic signs of trans inclusivity involving bathroom use, dress codes, and pronouns; (2) effective support for gender transitions; (3) trans-specific diversity trainings; and (4) interventions to build resiliency.
Credit Designation Statement: This activity has been reviewed and is acceptable for up to 1.0 Prescribed credits by the AAFP.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
This publication was developed in collaboration with Steph deNormand, Manager of the Trans Health Program at Fenway Health. We are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of award U30CS22742 totaling $700,000 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
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