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NASXXX10.1177/1942602X17691482NASN School NurseNASN School Nurse 691482research-article2017

For Your Information LGBTQ Students: The Role of the School Nurse Position Statement

Summary both sexes, or with others who also identity, or through struggle with their and/or medical or behavioral interventions— All students—regardless of their sexual expression (AAP, 2013). Gender because this practice is not supported by orientation, , or gender nonconforming is a term used for people credible evidence and may cause serious expression—are entitled to a safe, whose gender expression differs from harm to young people. Support of supportive, and inclusive school stereotypical expression, those described perpetuates outdated environment with equal opportunities for as androgynous, and includes people views of gender roles and identities and achievement and participation. It is the who identify outside traditional gender the negative stereotype that being a position of the National Association of categories or identify as both genders sexual or gender minority or identifying School Nurses (NASN) that the registered (, , Straight Education as LGBTQ is an abnormal aspect of professional school nurse (hereinafter Network [GLSEN], 2014). is human development (SAMHSA, 2015). referred to as school nurse) is a vital used to describe a person whose gender Currently, 31 states have no legislation member of the team to support students’ identity is different from that traditionally that protects LGBTQ youth from health and well-being and to advocate associated with his or her biological sex, , and 8 states have “no for policies and practices in the schools external genitalia, or assigned sex at promo homo” laws that forbid educators that provide for the physical, birth (CDC, 2014); this term is also used from discussing LGBTQ issues (Orr, psychological, and social safety of all to encompass a broad range of gender Baum, & Sherouse, 2015; Teaching students. identities associated with gender Tolerance, 2013). Title IX of the nonconformity (GLSEN, 2013). is Education Amendments of 1972 protects Background an umbrella term that is embraced by against discrimination and For the purposes of this position some youth to describe a sexual identity, based on sex in any educational program statement, the terms sexual minority, gender identity, or gender expression, or activity that receives federal funding gender minority, and LGBTQ are used to and some LGBT people may consider and includes those who do not conform describe students who may identify as this term offensive (GLSEN, 2013). It is to stereotypical sexual or gender lesbian, gay, bisexual, transgender, or good practice to use the terms that identities (GLSEN, 2014; Orr et al., 2015; questioning. Sexual minority persons are students themselves use to self-identify U.S. Department of Education, Office for those who identify themselves as gay, their sexual or gender identity or gender Civil Rights, 2015). lesbian, or bisexual or are unsure of their expression. The LGBTQ population is multifaceted , or those who have Gender dysphoria is defined by the and entails many subgroups, such that it had sexual contact with a person of the American Psychiatric Association (2013) is difficult to define the population’s same sex or with both sexes (American as extreme discomfort of individuals with needs (Institute of Medicine [IOM], 2011). Academy of Pediatrics [AAP], 2013; primary and secondary sex characteristics LGBTQ youth are identifying earlier and Centers for Disease Control and of their assigned birth sex. In 2015, the in larger numbers due to internet online Prevention [CDC], 2014; Kann et al., Substance Abuse and Mental Health support and an increase in the number 2011). Questioning is used to describe Services Administration (SAMHSA) of role models (Russell, Kosciw, Horn, & adolescents who do not identify with any supported ending conversion therapy for Saewyc, 2010). GLSEN reported that sexual minority group and may have had youth—which is an attempt to change an transgender students received much sexual relations with the same sex, with individual’s sexual orientation, gender higher levels of harassment and violence

DOI: 10.1177/1942602X17691482 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. © 2017 The Author(s) March 2017 | NASN School Nurse 129 than LGB students, which resulted in been shown to improve school climate zero-tolerance policies, transgender students missing more as they can help to assure LGBTQ youth attend and promote professional school, receiving lower grades, and that they are not alone, improve school development programs for school feeling isolated and not part of the connectedness, and promote leadership and personnel so that they school community (Greytak, Kosciw, & communication and understanding understand and meet the needs of Diaz, 2009). In 2013, 9.5% of students in within the school community (AAP, 2013; LGBTQ students, promote inclusive the National School Climate Survey CDC, 2014; Hatzenbuehler et al., 2014; health education and curricula for all identified as transgender (Kosciw, Kosciw et al., 2014; Teaching Tolerance, students, and contribute to a Greytak, Palmer, & Boesen, 2014). 2013). welcoming and inclusive environment In 2012, the Human Rights Campaign that includes safe spaces in the school survey of LGBTQ youth identified family Rationale (i.e., health office, counselor’s office, rejection (26%), school problems or School nurses have an ethical and classrooms) (AAP, 2013; CDC, bullying (21%), and fear of being out or responsibility to provide care to all 2014; GLSEN, 2013, 2014; Teaching open (18%) as the top three problems students, families, school staff, and Tolerance, 2013). faced by LGBTQ youth. LGBTQ youth community equally regardless of sexual •• Promote student-led Gay Straight experience increased physical, mental, orientation, gender identity, or gender Alliance and other clubs supported by and social health risks compared with expression; to maintain confidentiality; faculty and administrators to improve their heterosexual peers (CDC, 2014; and to respect the individual’s right to the school climate for all students, SAMHSA, 2015). Those increased risks be treated with dignity (American regardless of their sexual orientation, may include but are not limited to Nurses Association & National gender identity, or gender expression loneliness, lack of acceptance, violence, Association of School Nurses, 2011; (AAP, 2013; CDC, 2014; bullying, sexually transmitted infections, NASN, 2015). Using the Framework for Hatzenbuehler, et al., 2014; Kosciw unintended pregnancies, substance the 21st Century School Nursing et al., 2014; Teaching Tolerance, 2013). abuse, anxiety, depression, and suicide Practice (NASN, 2015), school nurses •• Provide support for students by (AAP, 2013; CDC, 2014; Kann et al., 2011; are responsible for care coordination advocating for practices and policies Kosciw et al., 2014). and should be actively involved in that promote the physical, Sexual and gender minorities improving the health and safety of the psychological and social safety of all experience chronic stress as a result of school environment for all students, students regardless of their sexual their stigmatization. This is known as including LGBTQ students. orientation, gender identity, or gender minority stress and is due to the stresses School nurses are uniquely qualified to expression. of , discrimination, parental do the following: •• Encourage the use of gender-neutral rejection, and violence—not the identity school forms, dress codes, changing of these youth (AAP, 2013; IOM, 2011; •• Collaborate with school personnel, space, and bathrooms; use students’ SAMSHA, 2015). According to the 2013 community healthcare providers, preferred names and pronouns; and GLSEN school climate report, 74.1% of families, and LGBTQ students to protect students’ confidentiality if they LGBT youth were verbally harassed; promote improved physical and are not “out” or “open” to family or to 36.2% were physically harassed; 55.5% mental health outcomes and improve others at school (Orr et al., 2015; felt unsafe because of their sexual academic achievement (AAP, 2013; Teaching Tolerance, 2013). identity and 37.8% because of their Orr et al., 2015). gender expression; and 30.3% were •• Recognize that the health risks are Conclusion truant for safety concerns. As well, 55.5% disproportionately higher for LGBTQ School nurses are uniquely positioned of LGBT students faced discriminatory students and provide culturally to model and promote respect for policies and practices at school, and competent care in a safe, private, and diversity, reduce stigma, and provide transgender students were significantly confidential setting (AAP, 2013). confidential health services for LGBTQ more affected by these practices (Kosciw •• Make referrals for evidence-based students in a safe environment. et al., 2014; SAMHSA, 2015). care to healthcare professionals Supportive families, communities, and Studies also indicate that characteristics knowledgeable about the healthcare schools can help to improve health of social environments, including school needs of LGBTQ youth. outcomes for students so they can live and families, can either increase or •• Provide families with support and full lives regardless of sexual orientation, reduce vulnerability, and resilience can resources, such as information about gender identity, or gender expression. shape physical and mental health local and national organizations that School nurses are leaders who can foster outcomes (Hatzenbuehler, Birkett, Van are available to help families support a supportive school environment and Wagenen, & Meyer, 2014; Kosciw et al., their children. make a positive impact in the lives of 2014; Russell et al., 2010; SAMHSA, •• Advocate for the creation and everyone in the school community 2015). School-based organizations have enforcement of inclusive (NASN, 2015). ■

130 NASN School Nurse | March 2017 Notes .glsen.org/sites/default/files/SSK_2013_ 1-133. Retrieved from http://www.cdc.gov/ book_0.pdf mmwr/preview/mmwrhtml/ss6007a1.htm Acknowledgment of Authors: Mary Gay, Lesbian, Straight Education Network, Kosciw, J. G., Greytak, E. A., Palmer, E. A., Blackborow, MSN, RN, CSN-NJ; Jessica (GLSEN). (2014). GLSEN model district policy & Boesen, M. J. (2014). The 2013 national Porter, BSN, RN, NCSN; Darla Rebowe, for transgender and gender nonconforming school climate survey: The experiences of BSN, RN. students. Retrieved from http://www lesbian, gay, bisexual and Adopted: 1994 .glsen.org/sites/default/files/Trans_ in our nation’s schools. New York: Gay, ModelPolicy_2014.pdf Lesbian, and Straight Education Network Revised: June 2003, January 2012, (GLSEN). January 2016 Greytak, E. A., Kosciw, J. G., and Diaz, E. M. National Association of School Nurses (NASN). Formerly titled “Sexual Orientation (2009). Harsh realities: The experiences of transgender youth in our nation’s schools. (2015). Framework for the 21st century school and Gender Identity/Expression (Sexual New York: Gay, Lesbian, and Straight nursing practice. NASN School Nurse, 30(4), Minority Students): School Nurse Education Network (GLSEN). Retrieved from 218-231. doi:10.1177/1942602X15589559 Practice. http://www.teni.ie/attachments/c95b5e6b- Orr, A., Baum, J., & Sherouse, B. (Eds.). (2015). f0e6-43aa-9038-1e357e3163ea.PDF Schools in transition: A guide for supporting References Hatzenbuehler, M. L., Birkett, M., Van Wagenen, transgender students in K-12 schools. A., & Meyer, I. H. (2014). Protective school Retrieved from http://www.nclrights.org/ American Academy of Pediatrics, Committee climates and reduced risk for suicide wp-content/uploads/2015/08/Schools-in- on Adolescence. (2013). Office-based care ideation in sexual minority youths. American Transition-2015.pdf for lesbian, gay, bisexual, transgender Journal of Public Health, 104(2), 279-286. Russell, S. T., Kosciw, J., Horn, S., & Saewyc, and questioning youth. Pediatrics, 132(1). doi:10.2105/AJPH.2013.301508 E. (2010). Safe schools policy for LGBTQ doi:10.1542/peds.2013-1282. Retrieved Human Rights Campaign (HRC). (2012). students. Society for Research in Child from http://pediatrics.aappublications.org/ Growing up LGBT in America: HRC youth Development Social Policy Report, 24(4) 1-17. content/132/1/198 survey report key findings. Washington, DC: Retrieved from http://saravyc.sites.olt.ubc. American Nurses Association & National Human Rights Campaign: Retrieved from ca/files/2012/12/Social-Policy-Report.Safe- Association of School Nurses. (2011). School http://issuu.com/humanrightscampaign/docs/ Schools-for-LGBT-Students_2010.pdf nursing: Scope and standards of practice (2nd growing-up--in-america Substance Abuse and Mental Health Services ed.). Silver Spring, MD: nursebooks.org. Institute of Medicine (IOM). (2011). The health of Administration (SAMHSA). (2015). Ending American Psychiatric Association. (2013). lesbian, gay and transgender people: Building conversion therapy: Supporting and affirming Diagnostic and statistical manual of mental a foundation for better understanding. LGBTQ youth. HHS Publication No. (SMA) disorders: DSM-5 (5th ed.). Washington, DC: Washington, DC: National Academies Press. 15-4928. Rockville, MD. Author. Retrieved from http://iom.nationalacademies. Teaching Tolerance: A Project of the Southern Centers for Disease Control and Prevention org/Reports/2011/The-Health-of-Lesbian-Gay- Poverty Law Center. (2013). Best practices: (CDC). (2014). Lesbian, gay, bisexual and Bisexual-and-Transgender-People.aspx Creating an LGBT-inclusive school climate. transgender health. Retrieved from http:// Kann, L., O’Malley Olsen, E., McManus, T., Retrieved from http://www.tolerance.org/ www.cdc.gov/lgbthealth/youth.htm Kinchen, S., Chyen, D., Harris, W.A., & sites/default/files/general/LGBT%20Best%20 Practices_0.pdf Gay, Lesbian, Straight Education Network, Wechsler, H. (2011, June 6). Sexual identity, (GLSEN). (2013). Safe space kit: A guide sex of sexual contacts, and health-risk U.S. Department of Education, Office for Civil to supporting lesbian, gay, bisexual, behaviors among students in grades 9-12— Rights. (2015). Title IX and sex discrimination. transgender students in your school. New Youth Risk Behavior Surveillance, selected Retrieved from http://www2.ed.gov/about/ York: Author. Retrieved from http://www sites, , 2001-2009. MMWR, 60, offices/list/ocr/docs/tix_dis.html

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