Best Practice Guideline JUNE 2021 Promoting 2SLGBTQI+ Health Equity Disclaimer These guidelines are not binding on nurses, other health providers, or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury, or expense arising from any such errors or omission in the contents of this work. Copyright With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from RNAO. Appropriate credit or citation must appear on all copied materials as follows: Registered Nurses’ Association of Ontario (RNAO). Promoting 2SLGBTQI+ health equity. Toronto (ON): RNAO; 2021. Funding This work is funded by the Government of Ontario. All work produced by RNAO is editorially independent from its funding source. Declaration of Conflict of Interest In the context of RNAO best practice guideline development, the term “conflict of interest” (COI) refers to situations in which a RNAO staff member or expert panel member’s financial, professional, intellectual, personal, organizational or other relationships may compromise their ability to conduct panel work independently. Declarations of COI that might be construed as constituting a perceived and/or actual conflict were made by all members of the RNAO expert panel prior to their participation in guideline development work using a standard form. Expert panel members also updated their COI at the beginning of each guideline meeting and prior to publication. Any COI declared by an expert panel member was reviewed by the RNAO best practice guideline development and research team and expert panel co-chairs. No limiting conflicts were identified by members of the expert panel. See “Declarations of Conflicts of Interest Summary” at https://RNAO.ca/bpg/guidelines/promoting-2slgbtqi-health-equity. Acknowledgements We acknowledge that the office of the RNAO is located on the traditional and unceded territory of the Huron- Wendat, Haudenosaunee, and most recently, the territory of the Mississaugas of the Credit. This territory was the subject of the Dish With One Spoon Wampum Belt Covenant, an agreement between the Iroquois Confederacy and the Ojibwe and allied nations to peaceably share and care for the resources around the Great Lakes. This land is still the home to many First Nations, Inuit and Métis peoples from across Turtle Island and we are grateful to have the opportunity to work on this territory. By making a land acknowledgement, we are taking part in an act of reconciliation, honouring the land and Indigenous heritage, which dates back over 10,000 years. We encourage you to learn about the land you reside on and the treaties that are attached to it; land acknowledgements are an act of reconciliation and we must all do our part. Cover Images Top left and bottom right cover images from The Gender Spectrum Collection. Contact Information Registered Nurses’ Association of Ontario 500-4211 Yonge St., Toronto, Ontario M2P 2A9 Website: www.RNAO.ca/bpg Promoting 2SLGBTQI+ Health Equity Promoting 2SLGBTQI+ Health Equity Greetings from Doris Grinspun, Chief Executive Officer, Registered Nurses’ Association of Ontario The Registered Nurses’ Association of Ontario (RNAO) is delighted to present the best practice guideline (BPG) Promoting 2SLGBTQI+ health equity. Evidence-based practice supports the excellence in service that health providers are committed to delivering every day. We offer our heartfelt thanks to the many stakeholders who make our vision for BPGs a reality. First, and most important, we thank the Government of Ontario that recognized in 1999 RNAO’s capacity to lead a program that has gained worldwide recognition and is committed to funding it. We also thank the co-chairs of the RNAO expert panel, Sheena Howard (past-president, RNAO’s Primary Care Nurses of Ontario) and Dr. Elizabeth Saewyc (director and professor, School of Nursing, University of British Columbia), for their invaluable expertise and stewardship of this BPG. Thanks to RNAO staff Amy Burt and Deborah Flores (guideline development co-leads) and Glynis Gittens and Verity Scott (guideline development project coordinators), and the rest of the RNAO best practice guideline development and research team for their intense and expert work in the production of this BPG. Special thanks to the expert panel for generously providing their time, knowledge and perspectives, especially during these challenging times of the COVID-19 pandemic, to deliver a rigorous and robust evidence-based resource that will guide the education and practice of health providers. We are grateful to the many persons with lived experience who were instrumental in developing this guideline from panel members, to stakeholders, to the advocacy work of the rainbow nursing interest group. We couldn’t have done it without you! Successful uptake of BPGs requires a concerted effort from educators, clinicians, employers, policy-makers, researchers and funders. The nursing and health communities, with their unwavering commitment and passion for excellence in care, provide the expertise and countless hours of volunteer work essential to the development of new and next edition BPGs. Employers have responded enthusiastically by becoming best practice spotlight organizations (BPSO®) -- with over a 1,000 service and academic institutions in Canada and abroad. BPSO® have sponsored best practice champions, implemented BPGs and evaluated their impact on patient and organizational outcomes. Governments at home and abroad have joined in this awesome journey. Together, we are building a culture of evidence-based practice that benefits everyone. We invite you to share this BPG with your colleagues from nursing and other professions, with the patient advisors who are partnering within organizations and with the government agencies with which you work. We have so much to learn from one another. Together, we must ensure that the public receives the best possible care every time they come in contact with us – making them the real winners of this great effort! Doris Grinspun, RN, MSN, PhD, LLD(hon), Dr(hc), FAAN, FCAN, O.ONT Chief Executive Officer and Founder Best Practices Guidelines Program Registered Nurses’ Association of Ontario 2 REGISTERED NURSES’ ASSOCIATION OF ONTARIO Promoting 2SLGBTQI+ Health Equity Table of Contents How to Use This Document . 5 A Note on Terminology and Language . 6 Purpose and Scope . 8 Interpretation of Evidence and Strength of Recommendations . 12 BACKGROUND Summary of Recommendations . 15 Best Practice Guideline Evaluation . 18 RNAO Best Practice Guideline Development and Research Team . 23 RNAO Best Practice Guideline Expert Panel . 25 Stakeholder Acknowledgment . 26 Background Context . 30 RECOMMENDATIONS Recommendations . 40 Research Gaps and Future Implications . 113 Implementation Strategies . 117 REFERENCES References . 119 BEST PRACTICE GUIDELINES • www.RNAO.ca 3 Promoting 2SLGBTQI+ Health Equity Table of Contents Appendix A: Glossary of Terms . 141 Appendix B: RNAO Position Statement . 154 Appendix C: Foundational Reading . 156 Appendix D: RNAO BPGs and Resources that Align with This BPG . 159 Appendix E: Pharmacotherapy and Transition Related Surgery Resources . 161 Appendix F: Best Practice Guideline Development Methods . 163 Appendix G: PRISMA Diagrams for Guideline Search and Systematic Reviews . 179 Appendix H: Indicator Development Process . 188 APPENDICES Appendix I: Examples of Inclusive Pronouns . 190 Appendix J: Examples of Inclusive Symbols and Flags . 192 Appendix K: Two-Spirit and LGBTQI+ Indigenous Resources . 194 Appendix L: List of Organizations Offering Group-based Interventions . 199 Appendix M: Example of Inclusive Form . 205 Appendix N: Description of the Leading Change Toolkit™ . 211 Endorsements . 214 ENDORSEMENTS ENDORSEMENTS Notes . 215 NOTES 4 REGISTERED NURSES’ ASSOCIATION OF ONTARIO Promoting 2SLGBTQI+ Health Equity How to Use This Document BACKGROUND This best practice guidelineG* (BPG) is a comprehensive document that provides guidance and resources for evidence-based nursing practiceG. It is not intended to be a manual or “how-to” guide; rather, it is a tool to guide best practices and enhance decision making for nursesG, members of the interprofessional teamG, educators, health- service organizations, academic institutions, and persons and their chosen familyG. This BPG should be reviewed and applied in accordance with the needs of individual health-service organizations, academic institutions or other practice settings and with the preferences of Two-SpiritG, lesbianG, gayG, bisexualG, transG, queerG, intersexG and other people who identify as a sexual or gender minority (2SLGBTQI+G). This document provides evidence-based recommendationG statements and descriptions of: (a) inclusive communication, safer spaces,