The terms “equity” and “equality” both stem from the constitutional provision of “equal protection under the law”, as well as laws and regulations prohibiting discrimination on the basis of race and/or gender.¹ Contemporary distinctions between the two terms describe equity as attempting to undo persistent disparities based on gender, sexual orientation, ethnicity, and other inherent characteristics which are not consistent with dominant norms.¹

Sexual and gender diverse (SGD) persons, commonly referred to as LGBTQ+, are one such marginalized group that suffer from health care disparities. Sexual orientation and gender identity are two separate concepts, both related to identity.² Dimensions of sexual orientation refer to sexual and/or romantic attraction and behavior. Gender identity dimensions include a personal, deeply held sense of gender identification, sex assigned at birth, gender presentation or expression, current or former anatomy, and gender as perceived by others.² It is important to note that these concepts are extremely fluid, and can vary. Limiting terms such as heterosexual, homosexual and bisexual do not adequately describe variations in sexual orientation just as the binary terms male and female do not reflect the spectrum of gender identities.

Although the Affordable Care Act (ACA) was a great step forward in health care equity for marginalized groups, protections for sexual and gender diverse persons were removed in 2020 and efforts to reinstate them have failed to date.³ Since then, several states, including Florida have enacted discriminatory laws specifically targeting SGD people, deepening already existing health care disparities.⁴ As a result, SGD people do not enjoy the same presumption of care as do cis-gender (gender identity consistent with sex assigned at birth), heterosexual people. In other words, people identifying as “straight” have no reason to believe they will be denied health care based on their sexual orientation or gender identity. Sexual and gender diverse people do not share this confidence in getting health care and in fact fear and frequently experience discrimination.⁵ Increased personal experiences of discrimination and legalized discrimination add to already-existing stress related to being a member of a sexual minority, resulting in reduced access to and use of health care and increased burden of disease and disparities.^6,7

Health equity is a fundamental principle in health care that aims to ensure everyone has equal access to achieve optimal health outcomes, regardless of their social position or circumstances.⁸ Equitable care has a significant impact on health outcomes. Health outcomes improve when existing barriers are overcome, giving all individuals equal access to high-quality healthcare. Barriers include social determinants of health such as socioeconomic status, education, social norms, economic policies and systems, racism, sexism, and all forms of discrimination. Equitable care promotes patient trust and satisfaction and can lead to better prevention, early detection, and earlier treatment of diseases, ultimately reducing disparities in morbidity and mortality rates.8 This trust and satisfaction can increase patient compliance with treatment plans, improve patient-provider communication, and improve overall health outcomes.9 Distrust of providers and experiences of discrimination are barriers to care not only for SGD persons, but also for patients belonging to minority racial and ethnic groups. By offering more equitable care, nurses and healthcare organizations can help reduce health disparities and improve the overall health of communities.⁹

Below are some recommendations for nurses and healthcare organizations to promote equitable health care, trust in providers, and greater satisfaction with care received:

1. Identify and address implicit biases: Nurses and healthcare organizations need to identify and address their implicit biases that may contribute to disparities in care.¹⁰
2. Provide cultural competency training: Ongoing education and training should be provided to enhance understanding of cultural beliefs, practices, and healthcare needs.⁹
3. Strive for diversity in staffing: A workforce that reflects the populations served is essential to promote equitable care.¹¹
4. Use health literacy strategies: Utilizing plain language, visual aids, and culturally appropriate materials can improve communication and understanding with patients from diverse backgrounds.¹⁰
5. Inclusive language practices: Nursing professionals should use inclusive language and respect individuals’ diverse identities. This includes training on gender-neutral language, updating documentation forms and communication materials, and encouraging open communication with patients to understand their preferred terminology.¹⁰
6. Address socioeconomic factors through community engagement: Engaging with community resources, advocating for policies that address social determinants of health, and providing support and referrals for patients to access essential services can help address disparities.¹²
7. Advocate for public policies and decision-making: Nurses and healthcare organizations should participate in decision-making processes and advocate for policies that promote health equity, such as supporting affordable healthcare and social justice initiatives.⁸
8. Ensure accessible and inclusive healthcare services: Healthcare services should be accessible to all individuals, including those from marginalized communities, and facilities should be physically accessible and inclusive for individuals with disabilities.¹⁰
9. Data collection and analysis: This can involve analyzing patient outcomes and satisfaction data and conducting surveys or focus groups with patients and community members to gather feedback.¹³

Nurses and healthcare organizations play a crucial role in promoting health equity. They can contribute to health equity by implementing practices that address obstacles to care, such as language barriers or lack of health literacy. By providing patient education and resources in a culturally sensitive and easily understandable way, nurses can help to create a more equitable healthcare system.

Healthcare organizations and professional organizations such as the FNA can support nurses in this mission by providing ongoing training and education on cultural competence, equity, and diversity. They can also partner with community organizations to address social determinants of health and create programs that target underserved populations.⁸ By implementing these strategies, healthcare organizations and nurses can contribute to a more equitable healthcare system that seeks to provide all individuals have fair and equal access to high-quality care, regardless of their race, ethnicity, gender identity, sexual orientation, socioeconomic status, or any other factors. Additionally, nurses are ethically bound to advocate for their patients and address any disparities or barriers to care they might encounter. When equipped with the knowledge, skills, and resources to address healthcare inequities, nurses can promote equal access to care and address social determinants of health.⁸

The JEDI Special Interest Group will be hosting a series of webinars in 2025 to provide training and education on how justice, equity, diversity and inclusion play a role in healthcare. The dates of the webinars are January 21, March 18, April 15, and June 17. Go to www.floridanurse.org/events for registration and additional information.

References

1. Minow M. EQUALITY VS. EQUITY. American Journal of Law and Equality. 2021;1:167-193. doi:10.1162/ajle_a_00019

2. Suen LW, Lunn MR, Katuzny K, et al. What Sexual and Gender Minority People Want Researchers to Know About Sexual Orientation and Gender Identity Questions: A Qualitative Study. Archives of Sexual Behavior. 2020;49(7):2301-2318. doi:10.1007/s10508-020-01810-y

3. Malina S, Warbelow S, Radix AE. Two Steps Back – Rescinding Transgender Health Protections in Risky Times. New England Journal of Medicine. Nov 19 2020;383(21):e116. doi:10.1056/NEJMp2024745

4. Kline NS, Griner SB, Neelamegam M, Webb NJ, Morales JJ, Rhodes SD. Responding to “don’t say gay” laws in the us: research priorities and considerations for health equity. Sexuality Research and Social Policy. 2022;19(4):1397-1402.

5. Scout N. Unique Issues Facing Sexual and Gender Minorities in Cancer. Cancer Discovery. 2023;13(6):1297-1300. doi:10.1158/2159-8290.Cd-23-0455

6. Flentje A, Clark KD, Cicero E, et al. Minority stress, structural stigma, and physical health among sexual and gender minority individuals: Examining the relative strength of the relationships. Annals of Behavioral Medicine. 2021;56(6):573-591. doi:10.1093/abm/kaab051

7. What We Know Project. What does the scholarly research say about the effects of discrimination on the health of LGBT people. Cornell University. https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-scholarly-research-say-about-the-effects-of-discrimination-on-the-health-of-lgbt-people/

8. Flaubert, J L., Menestrel, S L., Williams, D R., & Wakefield, M. (2021, May 11). The Role of Nurses in Improving Health Equity. https://www.ncbi.nlm.nih.gov/books/NBK573898/

9. Nair, L., & Adetayo, O. A. (2019). Cultural Competence and Ethnic Diversity in Healthcare. Plastic and reconstructive surgery. Global open, 7(5), e2219. https://doi.org/10.1097/GOX.0000000000002219

10. Marjadi, B., Flavel, J., Baker, K., Glenister, K., Morns, M., Triantafyllou, M., Strauss, P., Wolff, B., Procter, A. M., Mengesha, Z., Walsberger, S., Qiao, X., & Gardiner, P. A. (2023). Twelve Tips for Inclusive Practice in Healthcare Settings. International journal of environmental research and public health, 20(5), 4657. https://doi.org/10.3390/ijerph20054657

11. Williams, S L., Hansen, K., Smithey, M., Burnley, J E., Koplitz, M., Koyama, K., Young, J C., & Bakos, A. (2014, January 1). Using Social Determinants of Health to Link Health Workforce Diversity, Care Quality and Access, and Health Disparities to Achieve Health Equity in Nursing. Public Health Reports, 129(1_suppl2), 32-36. https://doi.org/10.1177/00333549141291s207

12. Douglas, M K., Rosenkoetter, M M., Pacquiao, D F., Callister, L C., Hattar-Pollara, M., Lauderdale, J., Milstead, J A., Nardi, D., & Purnell, L D. (2014, February 18). Guidelines for Implementing Culturally Competent Nursing Care. https://doi.org/10.1177/1043659614520998

13. Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool towards quality improvement. Oman medical journal, 29(1), 3–7. https://doi.org/10.5001/omj.2014.02