LGBTQ Students: The Role of the School Nurse
All students -- regardless of their sexual orientation, gender identity, or gender expression -- are entitled to a safe, supportive and inclusive school environment with equal opportunities for achievement and participation. It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (herein-after referred to as school nurse) is a vital member of the team to support students’ health and well-being and to advocate for policies and practices in the schools that provide for the physical, psychological, and social safety of all students.
For the purposes of this position statement, the terms sexual and gender minority or LGBTQ are used to describe students who may identify as lesbian, gay, bisexual, transgender, or questioning. Sexual minority persons are those who identify themselves as gay, lesbian, or bisexual or are unsure of their sexual orientation, or those who have had sexual contact with a person of the same sex or with both sexes (American Academy of Pediatrics [AAP], 2013; Centers for Disease Control and Prevention [CDC], 2014; Kann et al., 2011). Many adolescents do not identify with any sexual minority group and may have had sexual relations with the same sex or with both sexes and those who struggle with their sexual identity and or expression and may be referred to as questioning (AAP, 2013). Gender non-conforming is a term used for people whose gender expression differs from stereotypical expression, those described as androgynous, and includes people who identify outside traditional gender categories or identify as both genders (Gay, Lesbian, Straight Education Network [GLSEN], 2014). Transgender is used to describe a person whose gender identity is different from that traditionally associated with his or her biological sex, external genitalia or assigned sex at birth (CDC, 2014); and it is also used to encompass a broad range of gender identities associated with gender non-conformity (GLSEN, 2013). Queer is an umbrella term that is embraced by some youth to describe a sexual identity, gender identity or gender expression; and some LGBT people may consider it offensive (GLSEN, 2013. It is good practice to use terms that a student uses to self-identify their sexual or gender identity or gender expression.
Gender dysphoria is defined by the American Psychiatric Association (2013) as extreme discomfort of individuals with primary and secondary sex characteristics of their assigned birth sex. In 2015, the Substance Abuse and Men-tal Health Services Administration (SAMHSA) supported ending conversion therapy for youth which is an attempt to change an individual’s sexual orientation, gender identity, or gender expression through medical or behavioral interventions as it is not supported by credible evidence and may cause serious harm to young people. It perpetu-ates outdated views of gender roles and identities and the negative stereotype that being a sexual or gender mi-nority or identifying as LGBTQ is an abnormal aspect of human development (SAMHSA, 2015).
Currently 31 states have no legislation that protects LGBTQ youth from discrimination, and in eight states there are “no promo homo” laws that forbid educators from discussing LGBTQ issues (Orr, Baum & Sherouse, 2015; Teaching Tolerance, 2013). Title IX of the Education Amendments of 1972 protects against discrimination and harassment based on sex in any educational program or activity that receives federal funding and includes those who do not conform to stereotypical sexual or gender identities (GLSEN, 2014; Orr et al., 2015; U.S. Department of Education, Office for Civil Rights , 2015).
The LGBTQ population is multi-faceted with many subgroups, which makes defining the population needs difficult (Institute of Medicine [IOM], 2011). LGBTQ youth are identifying earlier and in larger numbers due to internet online support and an increase in the number of role models (Russell, Kosciw, Horn, & Saewyc, 2010). GLSEN re-ported that transgender students received much higher levels of harassment and violence than LGB students, which resulted in transgender students missing more school, receiving lower grades, feeling isolated and not part of the school community (Greytak, Kosciw, & Diaz, 2009). In 2013, 9.5 % of students in the school climate report identified as transgender (Kosciw, Greytak, Palmer, & Boesen, 2014).
In 2012, the Human Rights Campaign survey of LGBTQ youth identified family rejection (26%), school/bullying problems (21%), and fear of being out or open (18 %) as the top three problems they faced. LGBTQ youth experi-ence physical, mental, and social health risks that are higher than their heterosexual peers (CDC, 2014; SAMHSA, 2015). Those increased risks may include but are not limited to loneliness, lack of acceptance, violence, bullying, sexually transmitted infections, unintended pregnancies, substance abuse, anxiety, depression and suicide (AAP, 2013; CDC, 2014; Kann et al., 2011; Kosciw et al., 2014).
Sexual and gender minorities experience chronic stress as a result of their stigmatization. This is known as minority stress and is due to the stresses of prejudice, discrimination, parental rejection, and violence -- not their identity (AAP, 2013; IOM, 2011; SAMSHA, 2015). According to the 2013 GLSEN school climate report, 74.1% of LGBT youth were verbally harassed; 36.2% were physically harassed; 55.5 % felt unsafe because of their sexual identity and 37.8% for their gender expression; 30.3% were truant for safety concerns. 55.5% of LGBT students faced discriminatory policies and practices at school while transgender students were significantly more impacted by these practices. (Kosciw et al., 2014; SAMHSA, 2015).
Studies also indicate that characteristics of social environments, including school and families can either increase or reduce vulnerability, and resilience can shape physical and mental health outcomes (Hatzenbuehler, Birkett, Van Wagenen, & Meyer, 2014; Kosciw et al., 2014; Russell et al., 2010; SAMHSA, 2015). School-based organizations have been shown to improve school climate as they can help to assure LGBTQ youth that they are not alone, im-prove school connectedness, and promote communication and understanding within the school community (AAP, 2013; CDC, 2014; Hatzenbuehler et al., 2014; Kosciw et al., 2014; Teaching Tolerance, 2013).
School nurses have an ethical responsibility to provide care to all students, families, school staff and community equally regardless of sexual orientation, gender identity or gender expression; to maintain confidentiality and to respect the individual’s right to be treated with dignity (American Nurses Association & National Association of School Nurses, 2011; NASN, 2015). Utilizing the Framework for the 21st Century School Nursing Practice (NASN, 2015), school nurses are responsible for care coordination and should be actively involved in improving the health and safety of the school environment for all students, including LGBTQ students.
School nurses are uniquely qualified to:
Collaborate with school personnel, community healthcare providers, families and LGBTQ students to promote improved physical and mental health outcomes and improve academic achievement (AAP, 2013; Orr, Baum, & Sherouse, 2015).
Recognize that the health risks are disproportionately higher for LGBTQ students and provide culturally compe-tent care in a safe, private and confidential setting (AAP, 2013).
Make referrals for evidence-based care to healthcare professionals knowledgeable about the healthcare needs of LGBTQ youth.
Provide support and resources for families about local and national organizations that are available to help them to support their children.
Advocate for the creation and enforcement of inclusive zero tolerance bullying policies, attend and promote professional development programs for school leadership and personnel to understand and meet the needs of LGBTQ students, promote inclusive health education and curriculum for all students, and encourage a welcoming inclusive environment with safe spaces in the school, i.e., health office, counselor’s office, and classrooms (AAP, 2013; CDC, 2014; GLSEN, 2013; GLSEN, 2014; Teaching Tolerance, 2013).
Promote student-led Gay Straight Alliance and other clubs supported by faculty and administrators to improve the school climate for all students, regardless of their sexual orientation or gender identity or gender expression (AAP, 2013; CDC, 2014; Hatzenbuehler, et al., 2014; Kosciw et al., 2014; Teaching Tolerance, 2013).
Provide support for students by advocating for practices and policies that promote the physical, psychological and social safety of all students regardless of their sexual orientation, gender identity or gender expression.
Encourage the use of gender neutral school forms, dress codes, changing space and bathrooms; use the stu-dents’ preferred names and pronouns and to protect confidentiality when contacting others if the student is not “out/open” to family or to others at school (Orr et al., 2015; Teaching Tolerance, 2013).
School nurses are uniquely positioned to model and promote respect for diversity, reduce stigma and provide con-fidential health services for LGBTQ students in a safe environment. Supportive families, communities and schools are factors that can help to improve health outcomes for students to live full lives regardless of sexual orientation, gender identity or gender expression. School nurses are leaders who can foster the supportive school environment and make a positive impact in the lives of everyone in the school community (NASN, 2015).
American Academy of Pediatrics, Committee on Adolescence. (2013). Office-based care for lesbian, gay, bisexual, transgender and questioning youth. Pediatrics, 132(1). doi:10.1542/peds.2013-1282. Retrieved from http://pediatrics.aappublications.org/content/132/1/198
American Nurses Association & National Association of School Nurses. (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursebooks.org
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, DC: Author.
Centers for Disease Control and Prevention (CDC). (2014). Lesbian, gay, bisexual and transgender health. Retrieved from http://www.cdc.gov/lgbthealth/youth.htm
Gay, Lesbian, Straight Education Network (GLSEN). (2013). Safe space kit: A guide to supporting lesbian, gay, bisexual, transgender students in your school. New York, NY: Author. Retrieved from http://www.glsen.org/sites/default/files/SSK_2013_book_0.pdf
Gay, Lesbian, Straight Education Network (GLSEN). (2014). GLSEN model district policy for transgender and gender nonconforming students. Retrieved from http://www.glsen.org/sites/default/files/Trans_ModelPolicy_2014.pdf
Greytak, E. A., Kosciw, J. G., and Diaz, E. M. (2009). Harsh realities: The experiences of transgender youth in our nation’s schools. New York: Gay, Lesbian, and Straight Education Network (GLSEN). Retrieved from http://www.teni.ie/attachments/c95b5e6b-f0e6-43aa-9038-1e357e3163ea.PDF
Hatzenbuehler, M. L., Birkett, M., Van Wagenen, A., & Meyer, I. H. (2014). Protective school climates and reduced risk for suicide ideation in sexual minority youths. American Journal of Public Health, 104(2), 279-286. doi:10.2105/AJPH.2013.301508
Human Rights Campaign (HRC). (2012). Growing up LGBT in America: HRC youth survey report key findings. Washington D.C.: Human Rights Campaign: Retrieved from http://issuu.com/humanrightscampaign/docs/growing-up-lgbt-in-america
Institute of Medicine (IOM). (2011). The health of lesbian, gay and transgender people: Building a foundation for better understanding. Washington D.C.: The National Academies Press. Retrieved from http://iom.nationalacademies.org/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx
Kann, L., O'Malley Olsen, E., McManus, T., Kinchen, S., Chyen, D., Harris, W.A., & Wechsler, H. (2011) . Sexual iden-tity, sex of sexual contacts, and health‐risk behaviors among students in grades 9–12 — Youth Risk Behavior Surveillance, selected sites, United States, 2001–2009. MMWR, June 6, 2011, 60. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6007a1.htm
Kosciw, J. G., Greytak, E.A., Palmer, E.A., & Boesen, M.J. (2014). The 2013 national school climate survey: The ex-periences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York, N.Y.: Gay, Les-bian, and Straight Education Network (GLSEN).
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Orr, A., Baum, J. & Sherouse, B. (Eds.). (2015). Schools in transition: A guide for supporting transgender students in K-12 schools. Retrieved from http://www.nclrights.org/wp-content/uploads/2015/08/Schools-in-Transition-2015.pdf
Russell, S.T., Kosciw, J., Horn, S., & Saewyc, E. (2010). Safe schools policy for LGBTQ students. Society for Research in Child Development Social Policy Report, 24(4) 1-17. Retrieved from http://saravyc.sites.olt.ubc.ca/files/2012/12/Social-Policy-Report.Safe-Schools-for-LGBT-Students_2010.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Ending conversion therapy: Sup-porting and affirming LGBTQ youth. HHS Publication No. (SMA) 15-4928. Rockville, MD.
Teaching Tolerance: A Project of the Southern Poverty Law Center. (2013). Best practices: Creating an LGBT-inclusive school climate. Retrieved from http://www.tolerance.org/sites/default/files/general/LGBT%20Best%20Practices_0.pdf
U.S. Department of Education, Office for Civil Rights. (2015). Title IX and sex discrimination. Retrieved from http://www2.ed.gov/about/offices/list/ocr/docs/tix_dis.html
Acknowledgement of Authors:
Mary Blackborow, MSN, RN, CSN-NJ
Jessica Porter, BSN, RN, NCSN
Darla Rebowe, BSN, RN
Revised: June 2003; January 2012; January 2016
(Formerly titled “Sexual Orientation and Gender Identity/Expression [Sexual Minority Students]: School Nurse Practice).
Suggested Citation: National Association of School Nurses. (2016). LGBTQ students: The role of the school nurse(Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.