Adolescence is a time of rapid emotional, physical, and social development. “Typical” adolescents desire to be included and accepted by their peers and by the outside world. Add to these complexities an identity aligning with the lesbian, gay, bisexual, transgender, queer, intersex, asexual, plus (LGBTQIA+) community, and you have a child worried about being accepted and understood not only by their family and peers but also by their healthcare team. Research has shown that individuals identifying as LGBTQIA+ generally face poorer healthcare quality outcomes and limited access compared to their non-LGBTQIA+ peers. Among those who seek medical care, 48% report experiencing at least one negative encounter, including being misgendered, denied healthcare resources, and facing discrimination and stigma (Cygan et al., 2022; Schultz et al., 2024). The consequences of untreated depression are significant, and the more risk factors contributing to depression that an adolescent is exposed to — such as being part of a sexual or gender minority group, being exposed to domestic abuse, or experiencing bullying — the more significant the impact on their mental, physical, and social well-being (de Jong-Heesen et al., 2021; World Health Organization [WHO], 2021).

Using NPD Roles to Discover a Need

During the COVID-19 pandemic, it became very apparent to many that our LGBTQIA+ youth were struggling more than ever. Their connections to the outside world were limited and they were confined to their homes, and many were not yet “out” to their families. Their lack of ability to be their genuine selves, which some may only have been able to find outside the home, took a toll on their mental and physical health. At our children’s hospital, we saw an increase in patients with eating disorders, intentional overdoses, and self-harming behaviors especially among this population. One adolescent in particular put his struggles into perspective through his artwork. He was trans male struggling with an eating disorder and severe depression. I visited him several times on the unit as he was with us for almost two months, and his room was full of art that he completed during his admission. One piece always stood out to me: it was an image of him as a female, but in the background was his real identity as a male, who looked like he was screaming to be heard. In his struggle to become male, he stopped his menses by limiting his food intake and doing excessive exercise, he wore a chest binder, and he kept his hair short. As supportive as the team was to his struggles, the nursing staff confessed this was challenging for them, as they did not always know what to say or how to approach a conversation with him or other patients who had been admitted with similar care needs. Nurses felt uncomfortable if families did not know their child was a member of the LGBTQIA+ community and were worried about using the incorrect pronouns.

This young man’s story, along with ongoing environmental scanning of the challenges raised, called upon the nursing professional development (NPD) roles Change Agent and Leader. These led me to the throughput role of education — I developed develop a course called “Care of the Adolescent Patient” to help nursing staff feel more comfortable caring for this population. The course covers several important topics surrounding challenges nurses may face when caring for adolescents, including sexual health, eating disorders, mental health, high-risk behaviors, and the dangers of social media. Notably, although a typical adolescent may be struggling with one or two of the above concerns, a patient who is struggling with their identity is more likely to be affected by additional or all these challenges, which was the case with our trans male patient.  The class has been held three times over the past two years, and the class evaluations indicated a desire for more — over 65% of the comments included requests for additional information on how to provide care for LGBTQIA+ youth.

Expanding the Educational Offerings

In response to this need, in 2024, I advocated and collaborated with applicable team leaders to develop the Special Populations Committee for our children’s hospital. The goal of this committee was to actively involve team members in creating education and resources they felt were missing or limited. The committee comprises two subcommittees, one focusing on behavioral health and one focusing on LGBTQIA+ youth. While these two topics often overlap, the needs of each child are unique. Each subcommittee consists of team members from various disciplines, such as adolescent medicine, social work, behavioral health, and nursing. Their goal is to identify challenges they observe at the bedside and to focus on finding solutions. Since last year, each subcommittee has demonstrated incredible enthusiasm and is actively engaged in projects to improve bedside care and outcomes for our patients.

One of the original goals of the LGBTQIA+ subcommittee was to create an education module that would be assigned to all team members across the facility. Our NPD department has approved the module, and it is currently under review by our network’s diversity, equity, and inclusivity department. An additional goal was to increase a sense of safety and communication from the healthcare (or nursing) team and the LGBTQIA+ patients. A committee member suggested wearing a pin that states, “you are safe with me,” which I purchased and offered to any team member who wanted to wear it. These have become incredibly popular and are worn by many interdisciplinary team members.

Our subcommittee’s current project is focused on Pride Month and is titled “Kid Pride.” For this event, we are hosting tables in various institution locations (main hospital cafeteria, ambulatory care lobby, and the children’s hospital lobby), to provide information and resources for our youth and caregivers. At our table, we provide flyers on hospital resources, QR codes that link to reputable LGBTQIA+ organizations, such as the Gay and Lesbian Alliance Against Defamation (GLAAD), Parents, Families, and Friends of Lesbians and Gays (PFLAG), and the Trevor Project. Our goal is to allow adolescents to easily download information and resources to their phones to access hotlines and services our facility offers (adolescent medicine, dermatology, child and adolescent behavioral health). In addition to referring youth to these organizations, we provide reading materials from their websites, along with examples of recommended books for various age groups focusing on inclusivity, LGBTQIA+ youth, and their families. As news of our Kid Pride tables has spread, we are now including resources from our Network Autism Program to raise awareness that neurodivergent children are at a higher risk for suicide when facing challenges related to gender and sexuality.

Providing Youth With Support Year-round

Team members' feedback on these projects has been positive, with staff from various departments expressing interest in becoming involved with the committee focusing on education and unit-based resources to provide for caregivers and patients. Questions I have received from team members have revolved around creating a safe space, asking a patient how they want to be addressed, and understanding LGBTQIA+-related definitions. While we recognize that our organization’s programs are a work in progress, each positive step forward brings us closer to our committee goal: to provide our youth with a safe, nonjudgmental environment that supports their right to adequate and equitable healthcare. Incorporating clinical staff into their own learning has fostered enthusiasm and active participation in promoting improved healthcare outcomes for our LGBTQIA+ patients and their families.

References

• Cygan, H. R., Lemke, S., McIntosh, E., & Vail, M. (2022). Achieving health equity for LGBTQ+ adolescents. The Journal of Continuing Education in Nursing, 53(8), 348–354. https://doi.org/10.3928/00220124-20220706-05
• de Jonge-Heesen, K. W., Rasing, S. P. A., Vermulst, A. A., Scholte, R. H. J., van Ettekoven, K. M., Engels, R. C. M., & Creemers, D. H. (2021). Secondary outcomes of implemented depression prevention in adolescents: A randomized controlled trial. Frontiers in Psychiatry, 12, 1–9. https://doi.org/10.3389/fpsyt.2021.643632
• Schultz, T. R., Edemba, D., Lecuyer, M. E., Garzone, A., Henise, S., Liljestrand, A., Hinds, P. S., & King, S. (2024). LGBTQ+ population well-being: Health equity implementation science in action. Public Health Nursing, 42, 957–965. https://doi.org/10.1111/phn.13480
• World Health Organization. (2021, November 17). Mental health of adolescents. Retrieved September 25, 2024, from https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health