Nursing pre-licensure and graduate education for LGBTQ health: A systematic review

Published:January 07, 2023DOI:


      • ·
        Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ) educational interventions in nursing curricula are increasing
      • ·
        Homophobia and transphobia persist among nursing students
      • ·
        LGBTQ content in curricula can improve students’ knowledge, skills, and attitudes
      • ·
        Students benefit from LGBTQ health didactic content and clinical experiences



      Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ) people experience discrimination and health disparities compared to heterosexual cisgender people. Clinicians report discomfort and insufficient preparation for providing care to LGBTQ people and nursing has been slow to integrate LGBTQ health into curricula.


      Conduct a systematic review to examine and critically appraise peer-reviewed literature on nursing student knowledge, skills, and attitudes (KSAs) regarding LGBTQ health and the development/evaluation of LGBTQ health content in nursing curricula.


      A systematic review was conducted (N = 1275 articles from PubMed, LGBT Health, CINAHL, ERIC, and Health Source-Nursing/Academic Edition).


      Twenty articles met inclusion criteria. Twelve studies described curricular interventions; however, there were few validated tools to evaluate content coverage or KSAs. Four themes emerged specific to LGBTQ health content inclusion.


      While an emerging science of LGBTQ nursing education has been identified, more work is needed to build and evaluate a comprehensive curricular approach for full programmatic integration of LGBTQ health.


      As nursing programs build LGBTQ content into nursing curricula, care must be taken to integrate this content fully with the depth of curricular content in population health, social determinants of health, social justice, intersectionality, cultural competence, and political advocacy.

      Tweetable abstract

      Greater integration of LGBTQ health content into nursing education should be a priority for nursing education.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Nursing Outlook
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. American Nursing Association (ANA). (2012). Position Statement on health care for sexual minority and gender-diverse populations.

        • Acker G.M.
        Transphobia Among students majoring in the helping professions.
        Journal of Homosexuality. 2017; 64: 2011-2029
      2. American Association of Colleges of Nursing. (2017). The Voice of Academic Nursing.

        • American Association of Colleges of Nursing
        Core competencies for professional nursing education. BYU College of Nursing, Salt Lake City2021
      3. American Nurses Association. (2015). Code of Ethics for Nurses.

        • Bonvicini K.A.
        LGBT healthcare disparities: What progress have we made?.
        Patient Education and Counseling. 2017; 100: 2357-2361
        • Bouris A.
        • Everett B.G.
        • Heath R.D.
        • Elsaesser C.E.
        • Neilands T.B.
        Effects of victimization and violence on suicidal ideation and behaviors among sexual minority and heterosexual adolescents.
        LGBT Health. 2016; 3: 153-161
      4. Brennan, A. M. W., Barnsteiner, J., Siantz, M. L. de L., Cotter, V. T., & Everett, J. (2012). Lesbian, gay, bisexual, transgendered, or intersexed content for nursing curricula. Journal of Professional Nursing, 28(2), 96–104.

        • Brown C.
        • Keller C.J.
        • Brownfield J.M.
        • Lee R.
        Predicting trans-inclusive attitudes of undergraduate nursing students.
        Journal of Nursing Education. 2017; 56: 660-669
        • Campinha-Bacote J.
        The process of cultural competence in the delivery of healthcare services: A model of care.
        Journal of Transcultural Nursing. 2002; 13: 181-184
        • Carabez R.
        • Pellegrini M.
        • Mankovitz A.
        • Eliason M.J.
        • Dariotis W.M.
        Nursing students’ perceptions of their knowledge of lesbian, gay, bisexual, andtransgender issues: Effectiveness of a multi purpose assignment in a public health nursing class.
        Journal of Nursing Education. 2015; 54: 50-53
        • Chang E.S.
        • Simon M.
        • Dong X.Q.
        Integrating cultural humility into health care professional education and training.
        Advances in Health Sciences Education. 2012; 17: 269-278
        • Chen K.D.
        • Wu A.
        • Yehia B.R.
        • Greene M.Z.
        • France K.
        • Kreider E.F.
        • Wolfe-Roubatis E.
        Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health.
        PLoS ONE. 2018; 13: 71-81
        • Cicero E.C.
        • Reisner S.L.
        • Silva S.G.
        • Merwin E.I.
        • Humphreys J.C.
        Health Care Experiences of Transgender Adults: An Integrated Mixed Research Literature Review.
        Advances in Nursing Science. 2019; 42: 123-138
        • Clark M.E.
        • Landers S.
        • Linde R.
        • Sperber J.
        The GLBT health access project: A state-funded effort to improve access to care.
        American Journal of Public Health. 2001; 91: 895-896
        • Crenshaw K.
        Demarginalizing the Intersection of Race and Sex: A Black Femenist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. University of Chicago Legal Forum. 1989: 139-168
        • Crisp C.
        The Gay Affirmative Practice Scale: A New Measure for Assessing Cultural Competence with Gay and Lesbian Clients The Gay Affirmative Practice Scale (GAP): A New Measure for Assessing Cultural Competence with Gay and Lesbian Clients.
        Social Work. 2002; 51: 115-126
        • De Guzman F.L.M.
        • Moukoulou L.N.N.
        • Scott L.D.
        • Zerwic J.J.
        LGBT inclusivity in health assessment textbooks.
        Journal of Professional Nursing. 2018; 34: 483-487
      5. Department of Health and Human Services. Healthy people 2020. Washington, DC: U.S. (2022, September 11):

        • Englund H.
        Relationship between marginality and minority status in undergraduate nursing students.
        Journal of Nursing Education. 2018; 57: 339-346
        • Gates G.J.
        • Brown T.N.T.
        Same-sex couples after Obergefell. Williams Institute, UCLA School of Law, Los Angeles2015
        • Greene M.Z.
        • France K.
        • Kreider E.F.
        • Wolfe-Roubatis E.
        • Chen K.D.
        • Wu A.
        • Yehia B.R.
        Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health.
        PLoS One. 2018; 13e0204104
        • Holloway I.W.
        • Ochoa A.M.
        • Wu E.S.C.
        • Himmelstein R.
        • Wong O.
        Perspectives on academic mentorship from sexual and gender minority students pursuing careers in the health sciences.
        Am J Orthopsychiatry. 2019; 89: 343-353
        • Hong Q.N.
        • Pluye P.
        • Fàbregues S.
        • Bartlett G.
        • Boardman F.
        • Cargo M.
        • Dagenais P.
        • Gagnon M.P.
        • Griffiths F.
        • Nicolau B.
        • O'Cathain A.
        • Rousseau M.C.
        • Vedel I.
        Improving the content validity of the mixed methods appraisal tool: A modified e-Delphi study.
        Journal of Clinical Epidemiology. 2019; 111 (.e1): 49-59
        • Hudson W.W.
        • Ricketts W.A.
        A strategy for the measurement of homophobia.
        Journal of Homosexuality. 1980; 5: 357-372
        • Hughes T.L.
        • Jackman K.
        • Dorsen C.
        • Arslanian-Engoren C.
        • Ghazal L.
        • Christenberry-deceased T.
        • Lance Coleman C.
        • Mackin M.
        • Moore S.E.
        • Mukerjee R.
        • Sherman A.
        • Smith S.
        • Walker R.
        How can the nursing profession help reduce sexual and gender minority related health disparities: Recommendations from the national nursing LGBTQ health summit.
        Nursing Outlook. 2022;
        • Human Rights, Campaign. (2014)
        Resources: Health care equality index.
      6. Institute of Medicine (IOM). (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for a better understanding. Washington (DC): National Academies Press.

        • Institute of Medicine
        The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. National Academies Press, Washington (DC)2011
        • James S.E.
        • Herman J.L.
        • Rankin S.
        • Keisling M.
        • Mottet L.
        • Anafi M.
        The report of the 2015 U.S. transgender survey. National Center for Transgender Equality, Washington (DC)2016
        • Jeffreys M.R.
        Teaching cultural competence in nursing and health care: Inquiry, action, and innovation. 3rd ed. Springer, 2016
        • Jeffries P.R.
        • Rodgers B.
        • Adamson K.
        NLN Jeffries Simulation Theory: brief Narrative description. Nursing Education Perspectives. 2015: 292-293
        • Katrak P.
        • Bialocerkowski A.E.
        • Massy-Westropp N.
        • Kumar V.S.S.
        • Grimmer K.A.
        A systematic review of the content of critical appraisal tools.
        BMC Medical Research Methodology. 2004; 4: 1-11
        • Klotzbaugh R.J.
        • Ballout S.
        • Spencer G.
        Results and implications from a gender minority health education module for advance practice nursing students.
        Journal of the American Association of Nurse Practitioners. 2020; 32: 332-338
        • Knochel K.A.
        • Quam J.K.
        • Croghan C.F.
        Are old lesbian and gay people well served? Understanding the perceptions, preparation, and experiences of aging services providers.
        Journal of Applied Gerontology. 2011; 30: 370-389
        • Kuzma E.K.
        • Graziano C.
        • Shea E.
        • Schaller Jr., F.V.
        • Pardee M.
        • Darling-Fisher C.S.
        • CS D.-F.
        • Graziano C.
        • EK K.
        • Pardee M.
        • Jr S.F.V
        • Shea E
        Improving lesbian, gay, bisexual, transgender, and queer/questioning health: Using a standardized patient experience to educate advanced practice nursing students.
        Journal of the American Association of Nurse Practitioners. 2019; 31: 714-722
        • Lim F.A.
        • Brown D.V.
        • Kim S.M.J.
        Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices.
        American Journal of Nursing. 2014; 114: 24-34
        • Lim F.A.
        • Hsu R.
        Nursing students’ attitudes toward lesbian, gay, bisexual, and transgender persons: An integrative review.
        Nursing Education Perspectives. 2016; 37: 144-152
        • Lockwood C.
        • Munn Z.
        • Porritt K.
        Qualitative research synthesis: Methodological guidance for systematic reviewers utilizing meta-aggregation.
        International Journal of Evidence-Based Healthcare. 2015; 13: 179-187
        • Ma L.L.
        • Wang Y.Y.
        • Yang Z.H.
        • Huang D.
        • Weng H.
        • Zeng X.T.
        Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: What are they and which is better?.
        Military Medical Research. 2020; 7: 1-11
        • Maley B.
        • Gross R.
        A writing assignment to address gaps in the nursing curriculum regarding health issues of LGBT+ populations.
        Nursing Forum. 2019; 54: 198-204
        • Maruca A.T.
        • Diaz D.A.
        • Stockmann C.
        • Gonzalez L.
        Using simulation with nursing students to promote affirmative practice toward the lesbian, Gay, bisexual, and transgender population: A multisite study.
        Nursing Education Perspectives. 2018; 39: 225-229
        • McCann E.
        • Brown M.
        Homelessness among youth who identify as LGBTQ+: A systematic review.
        Journal of Clinical Nursing (John Wiley & Sons, Inc.). 2019; 28: 2061-2072
        • McCave E.L.
        • Aptaker D.
        • Hartmann K.D.
        • Zucconi R.
        Promoting affirmative transgender health care practice within hospitals: An IPE standardized patient simulation for graduate health care learners.
        MedEdPORTAL : The Journal of Teaching and Learning Resources. 2019; 15: 10861
        • McNair R.P.
        • Hegarty K.
        Guidelines for the primary care of lesbian, gay, and bisexual people: A systematic review.
        Annals of Family Medicine. 2010; 8: 533-541
        • McNiel P.L.
        • Elertson K.M.
        Advocacy and awareness: Integrating LGBTQ health education into the prelicensure curriculum.
        Journal of Nursing Education. 2018; 57: 312-314
        • Medina-Martínez J.
        • Saus-Ortega C.
        • Sánchez-Lorente M.M.
        • Sosa-Palanca E.M.
        • García-Martínez P.
        • Mármol-López M.I.
        Health inequities in lgbt people and nursing interventions to reduce them: A systematic review.
        International Journal of Environmental Research and Public Health. 2021; 18
      7. National Institutes of Health. (2021). Sexual & Gender Minority Research Office.

      8. Newport, F. (2018). In U.S., estimate of LGBT population rises to 4.5%. Gallup.

      9. National Institutes of Health, Sexual and Gender Minority Research Office (2021). The national institutes of health strategic plan to advance research on the health and well-being of sexual & gender minorities FY21-25.

        • Morrison M.A.
        • Morrison T.G.
        Modern homonegativity scale. Handbook of Sexuality-Related Measures, January. 2019: 639-642
        • Nagoshi J.L.
        • Adams K.A.
        • Terrell H.K.
        • Hill E.D.
        • Brzuzy S.
        • Nagoshi C.T.
        Gender differences in correlates of homophobia and transphobia.
        Sex Roles. 2008; 59: 521-531
        • Ozkara San E.
        • Maneval R.
        • Gross R.E.
        • Myers P.
        Transgender standardized patient simulation: Management of an oncological emergency.
        Journal of Transcultural Nursing. 2019; 30: 627-635
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • Boutron I.
        • Hoffmann T.C.
        • Mulrow C.D.
        • Shamseer L.
        • Tetzlaff J.M.
        • Akl E.A.
        • Brennan S.E.
        • Chou R.
        • Glanville J.
        • Grimshaw J.M.
        • Hróbjartsson A.
        • Lalu M.M.
        • Li T.
        • Loder E.W.
        • Mayo-Wilson E.
        • McDonald S.
        • Moher D.
        The PRISMA 2020 statement: An updated guideline for reporting systematic reviews.
        The BMJ. 2021; 372
        • Pan M.L.
        Preparing literature reviews: Qualitative and quantitative approaches. 5th ed. Routledge, New York2016
        • Peplau H.
        Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. Springer, 1991
        • Peters J.R.
        • Mereish E.H.
        • Krek M.A.
        • Chuong A.
        • Ranney M.L.
        • Solomon J.
        • Spirito A.
        • Yen S.
        Sexual orientation differences in non-suicidal self-injury, suicidality, and psychosocial factors among an inpatient psychiatric sample of adolescents.
        Psychiatry Research. 2020; 284112664
        • Poteat T.
        • German D.
        • Kerrigan D.
        Managing uncertainty: A grounded theory of stigma in transgender health care encounters.
        Social Science and Medicine. 2013; 84: 22-29
        • Rew L.
        • Becker H.
        • Tang M.
        • Liu Y.
        • Wang Y.
        • Croce E.
        Sensitivity toward gender and sexually diverse populations: Development of a scale.
        The Journal of Nursing Education. 2022; 61: 383-389
        • Robert Wood Johnson Foundation Initiative on the Future of Nursing
        The future of nursing: Leading change, advancing health. National Academies Press, Washington (DC)2011
        • Rowniak S.R.
        Factors related to homophobia among nursing students.
        Journal of Homosexuality. 2015; 62: 1228-1240
        • Sabin J.A.
        • Riskind R.G.
        • Nosek B.A.
        Health care providers’ implicit and explicit attitudes toward lesbian women and gay men.
        American Journal of Public Health. 2015; 105: 1831-1841
        • Sakalli N.
        Application of the attribution-value model of prejudice to homosexuality.
        The Journal of Social Psychology. 2002; 142: 264-271
        • Schlub S.M.
        • Martsolf D.S.
        Orthodox Christian beliefs and homophobia in Baccalaureate nursing students.
        Nursing Forum. 1999; 34: 15
        • Schweiger-Whalen L.
        • Noe S.
        • Lynch S.
        • Summers L.
        • Adams E.
        Converging cultures: Partnering in affirmative and inclusive health care for members of the lesbian, gay, bisexual, and transgender community.
        Journal of the American Psychiatric Nurses Association. 2019; 25: 453-466
        • Sherman A.D.F.
        • Klepper M.
        • Claxton A.
        • Deng A.
        • Ling C.
        • Mollenkopf N.L.
        • Bower K.
        Development and psychometric properties of the tool for assessing LGBTQI+ health training (TALHT) in pre-licensure nursing curricula.
        Nurse Education Today. 2022; 110105255
      10. Sherman, A. D. F., She, C. N. E., Smith, S., Bower, K., Moore, S. E., Dorsen, C., Coleman, C. L., & Pre-licensure, T. H. N. (2020). International prospective register of systematic reviews Citation Review question Participants /population Intervention (s), exposure (s) Comparator (s)/ control Main outcome (s) Additional outcome (s) Data extraction (selection and coding) R. 1–4.

      11. Smith, S. K., Ruud, M., & Newman, L. (2021). LGBTQ education in Midwest NP and CNM programs: A pilot study [Poster presentation]. Midwest Nursing Research Society. Virtual.

        • Stockmann C.
        • Diaz D.A.
        Students’ perceptions of the psychological well-being of a transgender client through simulation.
        Journal of Nursing Education. 2017; 56: 741-744
        • Strong K.L.
        • Folse V.N.
        Assessing undergraduate nursing students’ knowledge, attitudes, and cultural competence in caring for lesbian, gay, bisexual, and transgender patients.
        Journal of Nursing Education. 2015; 54: 45-49
        • Sutter Megan E
        • Perrin P.B.
        Discrimination, mental health, and suicidal ideation among LGBTQ people of color.
        Journal of Counseling Psychology. 2016; 63: 98-105
        • Tebbe E.A.
        • Moradi B.
        • Ege E.
        Revised and abbreviated forms of the Genderism and Transphobia Scale: Tools for assessing anti-trans* prejudice.
        Journal of Counseling Psychology. 2014; 61: 581-592
        • Testa R.J.
        • Michaels M.S.
        • Bliss W.
        • Rogers M.L.
        • Balsam K.F.
        • Joiner T.
        Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors.
        Journal of Abnormal Psychology. 2017; 126: 125-136
      12. US Department of Health and Human Services. (2015). LGBT health and wellbeing: HHS LGBT issues coordinating committee 2015 report.

        • Vance S.R.
        • Deutsch M.B.
        • Rosenthal S.M.
        • Buckelew S.M.
        Enhancing pediatric trainees’ and students’ knowledge in providing care to transgender youth.
        Journal of Adolescent Health. 2017; 60: 425-430
        • Vance S.R.
        • Lasofsky B.
        • Ozer E.
        • Buckelew S.M.
        Teaching paediatric transgender care.
        Clinical Teacher. 2018; 15: 214-220
      13. Veritas Health Innovation. (2021). Covidence systematic review software. Available at: Accessed 2/2/2021

        • Watts P.I.
        • Rossler K.
        • Bowler F.
        • Miller C.
        • Charnetski M.
        • Decker S.
        • Hallmark B.
        Onward and upward: Introducing the healthcare simulation standards of best practiceTM.
        Clinical Simulation in Nursing. 2021; 58: 1-4
        • Zeluf G.
        • Dhejne C.
        • Orre C.
        • Mannheimer L.N.
        • Deogan C.
        • Höijer J.
        • Winzer R.
        • Thorson A.E.
        Targeted victimization and suicidality among Trans people: A web-based survey.
        LGBT Health. 2018; 5: 180-190