GLMA Nursing Summit Agenda – September 10, 2014

Join us if you can for the GLMA Nursing Summit to be held in Baltimore, Maryland on September 10, 2014!  Ifpo you cannot be there, watch the GLMA Nursing Section web site for full reports and information about the work we are doing to advance LGBTQ health in nursing and health care!  

Summit Goal and Learning Objectives:

The goal of the GLMA Nursing Summit is to bring together LGBT and ally nurses and nurse supporters to develop an action plan to improve critical LGBT issues in the nursing profession. 

Summit Learning Objectives  

  • Describe major recent accomplishments in nursing related to LGBT health.  
  • Report, evaluate, and build on progress toward a GLMA-sponsored action plan for LGBT health in nursing relating to: education and curricula, patient/clinical care, policy, research, and climate (including homophobia in the profession).  
  • Provide a forum of opportunities for mentorship, support, and networking for nurses and nursing students in the areas of research, academia, policy, and patient care.  
  • Assign leadership for fulfilling the goals of the action plan.  
  • Identify key areas for focus in strengthening nursing participation in GLMA.    

Here is the final agenda for this very important day! You can also download the agenda here.

2014 GLMA Nursing Summit Agenda 

7:30 – 8:30 am  –   Registration & Continental Breakfast 
8:30 – 9:00 am  –   Welcome & Announcements

Henry Ng, MD, MPH, GLMA President  
Hector Vargas, JD, GLMA Executive Director 
Laura Hein, PhD, MSN, GLMA Board Member at Large 
Sarah Fogel, PhD, RN, GLMA Board Member at Large 
Sarah Sanders, RN, Nursing Summit Planning Committee Chair  
Peggy Chinn, RN, PhD 

9:00 – 9:15 am   –   Recognition of Special Guests, Dr. Janet Allan and Dr. Bev Hall 

Peggy Chinn, RN, PhD 

9:15 – 9:30 am   –   Participant Introductions  

9:30 – 10:15 am  – Nursing Section Announcement & Special Recognition (Candidates for Section leadership will be asked to introduce themselves.  There will be an opportunity for floor nominations for those not already on the ballot)

Laura Hein, PhD, MSN & Peggy Chinn, RN, PhD 

10:15 – 10:30 am – Coffee Break & Poster Viewing 

10:30 – 11:00 am – Plenary #1: History and Current Landscape 

Sarah Fogel, PhD, RN 
Mickey Eliason, PhD 

11:00am – 12:00pm – Breakout #1: Action Planning Orientation 

Breakout Groups: Education and Curricula, Patient/Clinical Care, Policy, Research, and Climate 

12:00 – 12:45pm – Networking Lunch  

12:45 – 1:15 pm  – Nursing Section Business: Officer Floor Nominations & Elections  

Sarah Fogel, PhD, RN 

1:15 – 2:00 pm  –  Plenary #2: Breaking Down Silos: How Interprofessionalism Can Advance the LGBT Health Agenda 

Heather Young, PhD, RN, FAAN, Associate Vice Chancellor for Nursing and Dean and Professor, Betty Irene Moore School of Nursing 

2:00 – 2:15 pm  –  Election Results Announcement 

2:15 – 3:45 pm  –  Breakout #2: Action Planning Continues 

3:45 – 4:30 pm  –  Breakout Groups Report Back to Full Group  

4:30 – 5:00 pm  –  Next Steps, Wrap Up & Evaluations 

Sarah Sanders, RN 

5:00 – 5:30 pm  –  Optional: Poster Viewing and Networking 

5:30 pm – GLMA Welcome Reception 

Harborview Ballroom 

Continuing Nursing Education Credits

GLMA is approved by the California Board of Registered Nursing, Provider Number 16038, to provide nursing continuing education credits.  The GLMA Nursing Summit is approved for 8 contact hours.

In order to cover GLMA’s administrative costs, there will be a $30 charge for issuance of CE certificates.  Those attending and claiming credit for the GLMA Annual Conference will only pay the administrative fee once (for both the Nursing Summit certificate and the Annual Conference certificate).  Please see the Registration Desk for more information or to pay the fee.

GLMA would like to extend a special thank you to our sponsors

Sponsors_2014Thank you to the 2014 Planning Committee! 

Amy Wilson-Stronks, MPP, CPHQ , GLMA Vice President for Education 
Sarah Sanders, RN  – Chair, Planning Committee 

Rob Carroll, RN, ACRN 
Diane Bruessow, PA 
Mickey Eliason, PhD 
Sarah Fogel, PhD, RN 
Laura Hein, PhD, MSN 
Michael Johnson, MSN, RN 
Pamela Levesque, RN 
Alison McManus, DNP, FNP-BC 
Jose Pares-Avila, DNP, RN, NP-C 
Lola Pellegrino, MSN, NP-C 
Nicholas Sarchet, RN 
Mimi Snyder, MSN, RN 
Caitlin Stover, PhD, RN

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Gimme That Oldtime Religion: Stigma, Epidemic Disease, and Sexual Minorities

Few things evoke humans’ atavistic reactions as do natural disasters, including epidemics. The scale of epidemic disease and its elusive causes and treatments prompt us to revert to primitive prejudices and fears.

We saw this at work when a virus originating in Africa made its way to the Caribbean and eventually appeared in gay male and Haitian patients in the early 1980s. For many, especially religious fundamentalists, HIV/AIDS became a sign of divine wrath, a punishment for sexual or other sins.

Linking proscribed behaviors (homosexuality, IV drug use) with disease provided the grounds for this judgment.

This habit of thought has an ancient pedigree. In the beginning of both Homer’s Iliad and Sophocles’ Oedipus Rex, divinely sent epidemic plagues punish mortals, who must determine the nature of their violation and to offer propitiation.   

Now, what’s old is new again. The emergence of the most sustained and widespread occurrence of Ebola virus in Western Africa has evoked ancient atavistic impulses.

Liberian Christian leaders, including bishops of mainstream Roman Catholic and Anglican communions, have endorsed a joint statement that claims, “That God is angry with Liberia, and that Ebola is a plague. Liberians have to pray and seek God’s forgiveness over the corruption and immoral acts (such as homosexualism, etc.) that continue to penetrate our society. As Christians, we must repent and seek God’s forgiveness.” Many readers’ comments posted on the Liberian Observer’s website seem to agree.

Back in the United States, fundamentalist Christian radio personality Rick Wiles suggested that, “‘Now this Ebola epidemic can become a global pandemic, and that’s another name for plague. . . . It may be the great attitude adjustment that I believe is coming. Ebola could solve America’s problems with atheism, homosexuality, sexual promiscuity, pornography, and abortion,” according to an article in the Advocate’s online site.

Epidemic disease is terrifying, even in an age of remarkable health technologies and pharmaceuticals. We must always monitor and expose, however, the primitive impulse to blame stigmatized people.


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Cervical Cancer Screening for LGBTQ Women

RibbonWe know that some LGBTQ women do not utilize cervical cancer screening tests as often as heterosexual women do. Although a number of research studies have identified some of the reasons for lower screening rates among LGBTQ women, more data needs to be collected to design health interventions, programs, and services that are culturally sensitive and appropriate for ALL women, including LGBTQ.

If you identify as a LGBTQ woman and are between the age of 21 and 65, please visit our study’s website ( to complete a quick survey and/or sign up to participate in a brief telephone interview. Feel free to share the study’s website with any women you think might be interested, or with any LGBTQ groups. Also, if you want information postcards to distribute, please email me directly ( and I can send you some in the mail.

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Call for Papers

“The Intersections of Trans* and Lesbian Identities, Communities, and Movements”

A Special Issue of the Journal of Lesbian Studies

Genny Beemyn and Mickey Eliason, Guest Editors

Deadline for proposals: November 1, 2014

The Journal of Lesbian Studies, a peer-reviewed academic journal published by Taylor and Francis, invites essay submissions for a special issue on “The Intersections of Trans* and Lesbian Identities, Communities, and Movements,” guest edited by Genny Beemyn and Mickey Eliason.

Possible topics include, but are not limited, to:
• The identity development processes of trans* lesbians
• The experiences of trans* lesbians in different communities and societies
• Trans* lesbians in popular culture, the media, literature, or history
• Sexual and gender fluidity in the lives of younger people today
• Trans* and cisgender lesbian political coalitions
• Butch and FTM struggles and solidarities
• Efforts to include trans women in “women-only” spaces

Please send a 500-word abstract of the work you have written/would like to write to by November 1, 2014. The editors will respond to proposals by December 1. Completed articles of approximately 15-20 pages (5,000-7,500 words) will be due by March 31, 2015 (submitted articles will undergo a peer review process).

For more detailed information about submission guidelines, including copyright requirements and the preparation of tables, figures, and images, please see the homepage for the Journal of Lesbian Studies at =submit~mode=paper_submission_instructions

Please share this Call For Papers widely. Thank you!

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LGBTQ and Straight Professionals Working Together to Advance LGBTQ Health Care

Welcome to Theodora Sirota, who is now a contributor to our blog!  

As an advanced practice psychiatric nurse, I am aware that heterosexism has dominated most LGBTQ health care. Sexual minority communities experience health care disparities Sirotamainly due to homophobia and lack of appropriate education and /or interest in LGBTQ health care needs within the largely straight health care system. I am also aware that LGBTQ health care policy and initiatives have been spearheaded by LGBTQ professionals and it seems obviously appropriate that they should be taking the lead. However, as a straight ally interested in advancing LGBTQ health care, I want to be able to network and connect to others with the same agenda and especially to LGBTQ health care providers who can help extend and shape my own point of view.

Last year I had a very interesting and somewhat disturbing experience as I attended and presented some research at a conference related to LGBTQ health care. The attendees were LGBTQ physicians, nurses, psychologists and others with LGBTQ health-related clinical and research interests. Some, including myself, were straight allies interested in advancing LGBTQ health and human rights. In fact, as my career as a psychiatric mental health nursing clinician and nurse educator and researcher has progressed, LGBTQ health has become my primary professional interest and concern. This was my first conference experience where I knew I’d have the opportunity to meet and talk with prominent leaders and thinkers in the LGBTQ health care community. I was also excited and interested to attend presentations that would allow me to get more immersed in hearing LGBTQ professionals’ current perspectives on LGBTQ health care. Unfortunately, I believe most straight allies have too little direct experience listening to their LGBTQ colleagues and I really wanted to learn as much as I could.

However, at that conference, I experienced a kind of reverse homophobia, or “heterophobia.” It was immediately clear to me, as a straight woman, that I was part of a small minority attending the conference. That in itself was OK; interestingly, my brain isn’t geared to thinking of myself as being in a minority anywhere I go and this realization in itself was revelatory and instructive. But, although a few people did react warmly to me, I felt basically shunned, marginalized, ignored, and very much alone, even when I tried to reach out to interact with people who had been introduced to me. Honestly, at that conference I felt like I was wearing an invisible scarlet letter on my bosom: the big “S” for “straight”. This was a rather eye-opening experience; now I can say that I can truly understand what LGBTQ people must feel in a room filled with mostly hetero folks.

As a straight person who wishes to help eliminate health care disparities and is supportive of social justice for LGBTQ individuals and populations, I don’t intend to stop my scholarship or my clinical interest in advancing LGBTQ health care. However, my experience at the conference made me painfully aware of the fact that there remains a lot of suspicious skepticism and distrust among LGBTQ folks toward straight people who sincerely wish to share and advance their interests. From a historical perspective, I can understand why this is so. However, I would suggest that, at this point in time, not only do straight people need to continue to examine and adjust their homophobic attitudes toward LGBTQ people, but LGBTQ people also need to be more self-reflective about their feelings toward heterosexual allies and attempt to be less heterophobic around straight people who support them. Working on this is critical in a health care climate dominated by heterosexual professionals. Thorough, sensitive health care for LGBTQ individuals and communities cannot be realized until LGBTQ professionals and straight professionals conscientiously work toward forging alliances and mutual understanding that will benefit the advancement of LGBTQ health. LGBTQ professionals need to realize that not all of us are the enemy and not all of us have nefarious agendas. It is imperative that LGBTQ professionals and straight professionals form caring and collaborative partnerships to help end health care disparities faced by LGBTQ people.

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LGBT Cultural Competence Training: Will It Help?

I recently completed a qualitative study that examined the healthcare experiences of LBTQ women. Most of the women described experiences where their providers and/or nurses lacked knowledge about LGTQ specific care, used insensitive terminology, or had a discriminatory or prejudice attitude. The study reconfirmed what similar research has shown – more emphasis is needed on providing safe and welcoming healthcare environments for all LGBTQ individuals.

I asked all of the women in my study what they thought needs to be done to improve healthcare services for LGBTQ individuals. One of the women who lived in rural Oklahoma said that most healthcare providers and nurses want to provide the best care for their patients, and that few of them intentionally make their patients feel uncomfortable or unwelcome. Her response was very profound. As a society, I think there is phenomenon of wanting to “blame” someone or something for an error. The same holds true for the health and healthcare inequities of LGBTQ populations. Who should be held responsible for the uncomfortable and unwelcoming healthcare visits that the women in my study experienced?

I don’t think there is a simple answer to that question. We know that there are multiple factors at all levels of society (the person her/himself, communities, organizations, policies, etc.) that contribute to health and healthcare problems. So, how do we even begin to address the problem of uncomfortable and unwelcoming healthcare environments? Every woman in my study had the same answer – educate the providers and nurses. After all, the one woman said, they aren’t all intentionally making patients feel uncomfortable and unwelcome.

I agree with the women in my study. All healthcare providers and professionals need to be educated to provide appropriate care for LGBTQ patients. And the education curricula and cultural competency programs exist to help accomplish this (see So, the question becomes, how do we ensure that providers and nurses use the resources that are available to them? It is going to require upstream interventions, meaning that governing bodies, accrediting agencies, and professional organizations pressure (or require!) providers and nurses to take continuing education courses on LGBTQ patients, and for nursing and medical schools to include LGBTQ content in their curriculum. Until that happens, I urge everyone to educate your colleagues and students about providing care to LGBTQ patients.

I am going to end this post with a YouTube video that was created by the cultural competence program, Reexamining LGBT Healthcare.

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Gay College Presidents – Organizing for Change!

Last week “Inside Higher Ed” published an article that starts with the sentence “The number of gay college presidents has increased rapidly in the past seven years.”  What a revelation this is!  Even though I have spent my entire career in academia, I have never lgbtqpresidents_orggiven much thought to the life of the presidents of these institutions .. they seem so far removed from the day to day activities of teaching classes, advising students, working on research projects, planning curriculum.  And, the image of most college administrators, as in virtually all other corporate or institutional administrative circles, is laden with heterosexual messages … mostly men photographed with their wives at their side.

Of course I know that “we are everywhere” but somehow it came as a bit of a surprise to see this announcement.  The seven-year “increase” could simply be a function of the wave of “coming out” that has happened in our community across the board, but I suspect that it is also a real increase due in part to a greater acceptance, by those who influence the selection of folks in these positions, to someone who does not fit the heterosexual mold.  The organized group,  LGBTQ Presidents in Higher Education, has grown from 7 in 2010, to a current membership of 48! The nine presidents who formed the group included 4 women and 5 men .. a proportion of women college presidents that would be hard to find in most circles!

But the most exciting news is that this group of college presidents is hosting a conference next summer for LGBTQ academics who are interested in becoming college administrators!  The conference theme will be “LGBTQ Leaders in Higher Education: Shaping Our Futures.” It will coincide with the Chicago gay pride weekend June 25-28, 2015.

I suspect that most readers of this blog do not see themselves as prospective members of this group, or even as potential attendees in the conference.  But the fact that this group exists, and that fact of this conference planned for next summer, is to something major for our community!  We all benefit from the presence of these trailblazers, particularly in a field that has so great an influence in the lives of young people who are completing their education!  Even reading through the current list of members, and their affiliations, is an inspiring experience!  So here’s to yet another breakthrough for LGBTQ visibility, and influence!  lgbtqpresidents_org

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Safe Spaces for Women: Michfest as Exemplar

photo(1)This post was authored by Charlynn Odahl-Ruan who is a doctoral student in the Department of Psychology at DePaul University.

Immersed in the demands and expectations of our patriarchal culture, I sometimes forget to question how this onslaught impacts me or how it might feel to be in a truly women-only space.  I stumbled across such a space last August when I attended the Michigan Womyn’s Music Festival (MichFest) to conduct research. I had heard about Michfest through a friend whose partner was a long-time attendee. I study feminism and empowerment and the festival offered a chance get the perspective of women from diverse ages and backgrounds. I was excited for the chance to interview these women for my research but I had not anticipated how moved I would be by the healing impact of a space designed for women, by women.

MichFest began in 1976 and takes place in the woods of Michigan each summer, filled with music, camping, workshops, and ceremonies. The festival was the U.S’s first women’s music festival and one of the first large showcases for openly lesbian artists, who were mostly operating outside of the mainstream music industry. The majority of attendee identifies as lesbian, but the festival advertises as open to all women-born women. MichFest typically draws several thousand women each year and in the early 80s, reached 8,000 attendees. Most attendees camp in tents, but some come in fancy RVs.

At the festival last year, my colleague and I interviewed 19 women who shared their experiences of empowerment. I expected to hear well-spoken and thoughtful narratives on empowerment and feminism, which I did, but I was surprised about how often I heard about the power of the festival experience as part of healing. The words “dropping my armor” were repeated often. Women talked about adopting a protective tough exterior in the world. But, when they were out of the male gaze and free from patriarchal norms, they were able to let this armor fall away and experiment with more sensual, feminine, or vulnerable aspects of their identity. There was sense of safety in being in a space with thousands of other women, often walking around the woods in various modes of undress. Little girls would run through the fields during concerts in nothing but angel wings or boots and their mothers could relax knowing that their children were lovingly watched over by all the women and that they were safe from male predators. This feeling of freedom is so rare for women that I think we don’t even realize how heavy our protective armor has become.

I resonated with the younger women who expressed a greater sense of body acceptance born from seeing older women of all shapes accepting their own bodies. So rarely are we around women openly accepting and loving their appearance.   This safety and openness at the festival gave the women space to reflect and heal wounds they had suffered in a patriarchal culture. Several women shared stories of survivors of sexual trauma who had come to the festival to heal. The women spoke of having to put the armor back on when they left the festival, but they felt the festival week had given them the strength to make it another year.

Though I came to festival for mostly academic reasons, I learned about the power of safe spaces for women and I found myself reflecting more critically on the impact living in a culture that isn’t safe — physically or psychologically — for women. The women fondly spoke of the festival as being utterly unique to any other setting. I agree with them and found MichFest to be unlike any other setting I had been in. It was a week spent surrounded by women celebrating themselves (ourselves), embracing their power (our power), and building lasting community. The experience caused me to reflect on where I found safe places in my life where I could live without the demands of patriarchal norms. Sadly, those spaces are few. Such safe places need to be cultivated because, like for the women of MichFest said, this is where we find healing, self-acceptance, and growth.

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Should Gay Men Take Preventive HIV Medications?

A recent recommendation by the World Health Organization (WHO) was announced in mass media with headlines like “WHO Says All Gay Men Should Consider Taking Antitretroviral Drugs,” “Healthy Gay Men Urged to Take HIV Drugs,” and “The WHO Wants All Gay Men to Take HIV Prevention Medication.” So called pre-exposure prophylaxis or PrEP involves a daily regimen of a single pill combining two medications (marketed in the U.S. as Truvada).

These headlines are misleading and confusing, and the premise is questionable and troubling.

First, WHO does not use the word “gay” in its announcements of this recommendation: Instead, the more technically precise terminology “men who have sex with men” or MSM (along with other people at risk) is used. To non-experts this may seem like a distinction without a difference, but it points to a global problem with the stigmatization of male homosexual behavior and identity (even among many groups in the U.S.). Many men who regularly have sex with men would not identify themselves as “gay.” Unlike self-identified “gay” men, who are often connected to sexual minority social networks, media, and education, MSM “living on the down low” may live secret sex lives that are impervious to sexual health education and resources.

Moreover, the media’s misuse of the convenient term “gay” further caricatures and stigmatizes gay men as unable to manage their sexual lives safely and responsibly. However, the first decade and a half of the AIDS epidemic (1981-1996) before the introduction antiretroviral pharmaceuticals show that this stereotype is inaccurate. Grassroots gay health movements provided alternatives in a range of risk-reduction strategies.

It is also questionable whether men engaging in stigmatized behavior will have access to or be inclined to seek a pharmaceutical regimen with only one purpose.

Then there is Truvada itself. When I visited the Truvada PrEP website, I was warned before I could enter: “The information on this site is intended for residents of the United States who are 18 years of age or older.” Whom this caution is protecting is unclear, but it suggests its problematic nature.

Taking Truvada poses a risk of a variety of serious health problems, including lactic acidosis, serious liver problems, complications with hepatitis B, complications with other medications, and serious side effects.

And then there is the cost. According to the New York State Department of Health, Truvada can cost $8,000 to $14,000 per year: Inequities in insurance coverage (and the fact that insurers are often more inclined to pay to fix a problem than to prevent it) may make this option prohibitively expensive.

And can we talk about medication “compliance”? Patients notoriously fail to take medications as prescribed, either because of carelessness, economic considerations, or inconvenience. Will inconsistent use of PrEP place MSM at even greater risk?

Given that there are a variety of reasons that people engage in unsafe sexual practices — judgment compromised by alcohol or drugs, coercion, ignorance, calculation, denial, among others — the WHO proposal may seem like a responsible recommendation.

However, it seems to me to be an opportunity for renewed conversations and negotiations around concepts of responsible sexual behavior, consent, and risk reduction.

The answer isn’t in a little blue pill.

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The “Rainbow” Letter

Rainbow-LetterSTIGMA — Take a moment to think about that word. What does it mean to you? What does stigma look like?

To me, stigma happens when others devalue a person or a group of people based on a characteristic (e.g., trait, disease, behavior, etc.). According to the Oxford Dictionary, it is defined as a “mark of disgrace associated with a particular circumstance, quality, or person.” The word dates back to the 16th century when it referred to a mark made by pricking or branding.

Upon reflecting on the word stigma, I immediately think of a favorite classic book of mine, The Scarlet Letter. If you recall, the woman in the book (Hester) has to wear an “A” on her chest for committing adultery. She is shamed, shunned by the community, and isolates herself in a small cottage on the outskirts of town. The resemblance between Hester and LGBTQ individuals is uncanny. If an LGBTQ individual is open about their sexual orientation and/or gender identity, they are in essence wearing an “A” on their chest, a “Rainbow” letter.

It goes without arguing that LGBTQ individuals are stigmatized across the entire globe (some places obviously worse than others are). The consequences of stigma are atrocious in some parts of the world. Some countries sentence LGBTQ people to death, while others do not protect (and often promote) LGBTQ individuals from being attacked, humiliated, or discriminated against. Industrialized countries are not immune to this issue. There are still many areas in the U.S. where LGBTQ individuals are attacked and/or discriminated against. In fact, many laws and policies still discriminate against LGBTQ individuals and same-sex couples. These are the consequences of stigma surrounding LGBTQ – the consequences of wearing the Rainbow Letter. They are being stigmatized based simply on a trait/characteristic.

In The Scarlet Letter book, Hester had to isolate herself because the community shamed her. Reflect on the similarities between Hester and LGBTQ individuals. Imagine wearing your Rainbow Letter in an overly conservative area of the country, or in a homophobic household, or in an unsafe work environment. Just like Hester, LGBTQ individuals will often try to hide their sexual orientation and/or gender identity to avoid being shamed or they will isolate themselves. If their Rainbow Letter is showing, they risk being rejected by family and friends, being attacked, or being discriminated against. Other consequences include the inability to access high quality health care, income inequalities and employment discrimination, poor mental health and unhealthy behaviors, and psychological distress.

Of course, stigma is not the only cause of the consequences I just described; however, it is a major contributing factor for LGBTQ individuals. How should our society address stigma around LGBTQ? Rainbow Letters are here to stay and thus we need to focus on reducing stigma and reducing the effects of stigma. Our society has made tremendous strides in reducing stigma through advocacy, policy changes, more visibility of LGBTQ people in the media, etc. A compilation of all the work that has been done across society (e.g., communities, professions, schools, organizations, etc.) is responsible for the reduction in stigma around and acceptance of LGBTQ individuals.

Although a lot of great work is still being done to reduce stigma, it will remain in our society. Thus, we cannot forget to design solutions to reduce the effects of stigma. Examples include programming offered at LGBTQ centers, Gay Straight Alliances in the school system, and the “It Gets Better Project.” We need to continue to promote these types of programs, especially to youth and other individuals who are at risk because they proudly wear their Rainbow Letter.

As an emerging researcher, I constantly remind myself that it is stigma that has resulted in the health and health care disparities among LGBTQ individuals. Being gay does not inherently put me at risk; it is the stigma society has put on my sexual orientation. It affects every area of an LGBTQ person’s life. It is now up to everyone to reduce the stigma and to reduce the effects of stigma.

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