Sexual Orientation and Gender Identity in Nursing

Sexual Orientation and Gender Identity in Nursing

It’s been said that lesbian, gay, bisexual, and transgender (LGBT) nurses form one of the largest minorities within the profession, and yet they are hardly recognized as a subgroup. To date, limited data are available to determine just how many nurses identify as LGBT (or some variation of those letters, such as LGBTQ, in which the “Q” stands for questioning or queer). But according to a 2013 Gallup poll, approximately 3.5% of the US general population identifies as LGBT; so whether or not you identify as LGBT, it’s likely that you will have to treat patients who do at some point during your nursing career. As patient advocates first and foremost, nurses must strive to provide culturally competent care for all, regardless of gender or sexual orientation.

LGBT nurses and patients alike face a unique set of challenges in the health care system: hostile personnel, lack of insurance, and higher rates of certain disorders, such as substance abuse. Yet both seek to make the health care system more supportive and equitable through changes in policy, education, and advocacy. Their aim: to raise cultural competence of health care professionals and lower the health disparities and barriers to care affecting LGBT individuals, families, and couples. Here are the profiles of five professionals committed to leading the charge for an open and accepting health care environment.

Austin Nation, RN, PHN, MSN 

PhD Student at University of California – San Francisco (UCSF)

Veteran nurse Austin Nation has over 30 years of nursing experience to his credit, including stints in hospital supervision and providing AIDS services, before heading back for a PhD program. His aim is to teach nursing, which he is now undertaking as an adjunct professor at San Francisco State University.

He says he’s faced a “triple-whammy” of discrimination—surprising in a city like San Francisco, where he expected more cultural competency around these issues.

“I thought this was the gay mecca, with open, liberal thinkers, but that hasn’t been the case,” he says. “I’ve experienced racism, sexism, and homophobia. I’m a black male in nursing. I’ve been blatantly subjected to all this stress while embarking on a PhD journey, which is already stressful enough.”

Nation wonders why the UCSF system, which dominates the city and cares for a larger LGBT population than any other, is “so provincial when it comes to addressing issues closest to the heart of that community.”

“We have beautiful diversity banners, photos of different kinds of people together all getting along, but it isn’t like that,” he says. “In an academic setting, change happens so slow—it’s like turning the Titanic.”

Nation takes every opportunity to raise consciousness in class. “I’m trying to provide education in real time as it happens.” For example, if a nurse refers to gay patients in a distant or disrespectful way, he’ll step in: “Hey, that’s us you’re talking about—we’re not those people.” In addition, Nation leads a Men in Nursing group and is spearheading an LGBT Cultural Competency for Healthcare Providers workshop that has generated overwhelming interest.

One part of the problem, Nation suggests, is that “the health care community tends to be conservative. We come from a paradigm of heterosexuality.” It wasn’t too long ago that homosexuality was considered a psychological aberration, he adds.

Nurses are often uncomfortable with the subject of sexuality and reluctant to talk to patients about sexual health, Nation has observed. He suggests that discomfort first crops up during physical assessment class as undergraduates.

“We learn about the human sexual reproduction system. Then, during a head-to-toe assessment of a patient, you pull the covers up and look. But what are you looking for?” What happens if a nurse pulls up the gown of a male and sees female sexual organs, say? “That’s a good opportunity to have a conversation about gender variances,” he says.

“There have been many people that didn’t accept me,” explains Nation. “I’m the kid from the ghetto who made good. For me, the saving grace is that I’ve had women who’ve taken me under their wings. They watched over me and protected me in difficult or sensitive situations. I try to create that same sense of belonging for my students.”


Riikka Salonen, MA

Manager, Workforce Equity and Inclusion, Oregon Health & Science University (OHSU)

A bi-national native of Finland, Riikka Salonen leads diversity and inclusion strategy efforts at OHSU in Portland, Oregon. “Our intention is to provide an environment of care which is welcoming and inclusive,” she says, “as well as protective of patient and employee rights and benefits. For instance, we’ve had same-sex partner benefits since 1998, and offered transgender health-specific benefits for employees for over a year.”

Family inclusion is one topic that OHSU focuses on—and for patients, that means visitation is a given for everyone, including same-sex couples or a child who has two mothers. “Family inclusion also means that if a gay employee wants to put out family photos, they feel they can without there being whispering about it.”

OHSU Pride, an employee resource group for LGBTQ employees and allies, was started in 2007 to ensure an inclusive environment. “OHSU Pride has created a significant difference in our campus, which has become very LGBTQ-affirming,” says Salonen.

LGBTQ education and consciousness-raising at OHSU is an ongoing effort, Salonen notes, starting with new employee orientation. From there, it proceeds on an as-needed basis, depending on a nurse’s specialty. For example, Salonen says, OHSU provides “a specific session for pediatric nurses that focuses on providing care for transgender or gender-nonconforming youth.”

Parents worried about a 5-year-old boy who insists he’s a girl, for example, can be referred to TransActive Gender Center (, a national nonprofit with low-cost services for youth and families. (For those living outside Portland, Skype counseling sessions are an option.)


Mary Bylone, RN, MSM, CNML

Regional Vice President, Patient Care Services, Hartford HealthCare, East Region, and Director, American Association of Critical-Care Nurses National Board of Directors 

“I’m 58 and didn’t figure out my lesbian orientation until later in life,” says Mary Bylone. “My brother is gay and so is my son. I didn’t come out at first because of the prejudice and abuse my brother experienced. As a manager, I’m now out; [but] as a staff nurse, I wasn’t.”

Bylone says her sexual orientation doesn’t totally define her: “It’s part of me, not all of me.” She has noticed that fellow employees and patients gravitate toward her to talk about gay issues. Possibly, she suspects, they do it “because I’m an out person in a responsible position. One day, a mother started crying when she told me her son was gay. I was able to comfort her as the mother of a gay son.”

Bylone has experienced situations where patients have discriminated against gay nurses. “I remember a patient who asked to see me when I was a head nurse,” Bylone recalls. “She didn’t want to see her nurse that day. ‘Why? Is it because he’s a man?’ ‘No, that’s just the problem. He’s no man,’ is what she answered. Unfortunately, the nurse was standing outside the door and heard her cruel complaint.”

Bylone adds that managers sometimes treat out nurses differently. “You may be assigned a gay patient when people know you’re gay, misunderstanding that someone’s sexual orientation does not define her or his entire person,” she explains. “I’m a nurse who happens to be lesbian, not a lesbian nurse.”


Emily Pittman Newberry

Trans Woman and Recent Surgical Patient in Portland, Oregon

Emily Pittman Newberry says she lived life for 55 years “pretending to be a man,” before embracing her gender identity as woman and transitioning over a period of five years. “People often ask me, ‘When did you decide you were a woman?’ The question should be: ‘When did you acknowledge it to yourself and choose to live openly?’” Every transgender person Newberry has met or read about says they always knew.

Newberry maintains that health care personnel have been universally professional and even kind to her during this process, though she had trouble with her insurance company. They wouldn’t cover the cost of surgical gender-confirming surgery.

She has some advice for nurses, such as not taking it for granted that you know a patient’s gender. “Ask them to self-identify and tell you what gender pronoun they prefer you use in referring to them,” says Newberry, though she understands that “asking is a tender place for a nurse and a transgender person.”

“Sometimes I see someone who is clearly struggling with it—getting pronouns wrong, getting uptight [such as the time she asked a clerk to change her gender in the clinic patient record system],” says Newberry. “I want to say, ‘This is new for everybody.’ It’s my job to educate people, be kind and humane even when I feel angry. It’s a dance, and we’re all learning the steps.”

Another piece of advice is to not get thrown if a transsexual patient has a health condition that doesn’t match their gender as your records show it. “If you see a prostate problem in a woman, for instance, act like it’s no big deal,” Newberry suggests.

Many health care IT systems only offer “male” or “female” as gender choices, which is limiting and potentially hazardous. Binary options are also being challenged by popular culture. Facebook now allows users to self-select from 56 gender options, such as “transgender” and “intersex” and “Female to Male/FTM.”

There are bound to be many uncertainties and uncomfortable moments for Trans patients and their nurses as we travel this unmarked path. “Do your best to carry on in a professional way,” says Newberry. “Ask yourself: ‘Am I being tender or am I being rational?’ You can be both at all times, of course, but sometimes more on the compassionate side and other times the scientific. Both are a part of every health care professional—you can emphasize one or the other, depending on the situation.”


Desiray Bailey, MD

Hospital Chief of Staff, Central Hospital, Group Health Cooperative, Seattle, WA, and immediate past president of GLMA: Health Professionals Advancing LGBT Equality (formerly known as the Gay and Lesbian Medical Association)

“GLMA was a physician-oriented organization originally, but we decided to be more inclusive and include the whole health care team,” says Desiray Bailey. “We work to provide opportunities to practice openly and more compassionately.”

Nurses are now an active part of the group, as evidenced by GLMA’s annual conference and nursing summit, scheduled for September 10-13, 2014, in Baltimore, Maryland.

One of the aims of GLMA is to improve education and awareness of gay and transgender issues among health care personnel. “It’s a very rare nursing program that provides LGBT education,” says Bailey. “We’d like to see it as part of the curriculum for all health professionals—physicians, nurses, physician assistants, and people in behavioral health training.”

At Group Health, Bailey has been an advocate for equal treatment of LGBT staff and patients for many years, facilitating changes in policy, employee benefits, patient and family visitation, consumer rights, and community outreach.

Additionally, she advocates for equal treatment so that “any professional in a hospital or medical center who is gay, lesbian, bisexual, or transgender won’t experience discrimination as an employee because they can’t be out, or their organization doesn’t provide benefits that are equitable with straight employees.”

In many states where LGBT employees aren’t a protected class, it’s possible to be discriminated against or fired for being gay. Even worse, a few states have “anti-gay laws—where certain sexual acts are illegal—or there aren’t specific protections,” Bailey says. “I’m fortunate to live in Washington State—we’ve had domestic partnerships for a few years and now marriage equality.”

According to Bailey, the Affordable Care Act has benefited the LGBT community. “Insurance plans can’t discriminate based on sexual orientation or gender identity. Legally married couples are still recognized, even if they live in a state that doesn’t recognize their union, and there aren’t lifetime limits for AIDS patients,” she adds.

Among the tools available to improve LGBT equality in a health care setting is the Healthcare Equality Index of the Human Rights Campaign, a civil rights organization. “This is a tool that really changes the atmosphere for employees and patients,” says Bailey. Once a decision has been made to participate, “there’s an organizational will to want to score well. They want to put in place the right policies and training for staff,” she adds.

Seeking out legitimate information about LGBT issues is very important “if you want to take care of all your patients,” Bailey says.


Jebra Turner is a freelance health and business writer based in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at