Conceptualizations of Allyship with 2S/LGBTQ+ Groups in the Context of Health Settings: A Scoping Review

Abstract

Background

Two-Spirit, lesbian, gay, bisexual, transgender, queer, and other sexual and gender identity diverse (2S/LGBTQ+) individuals experience health inequities rooted in discrimination. Efforts to redress this discrimination in health settings is frequently termed allyship. However, definitions of allyship remain ambiguous, posing challenges for health providers.

Review Question

How is allyship defined in the literature specific to 2S/LGBTQ+ people and health settings and/or health care in countries where English is the primarily spoken language (Canada, the United States, the United Kingdom, Australia, and New Zealand)?

Methods

This scoping review drew on the Joanna Briggs Institute (JBI) approach and qualitative descriptive analysis of 46 sources.

Conclusions

The dearth of specificity in definitions of allyship poses challenges for health-care provision and education.

Implications for Practice, Education, or Research

Community-engaged research is needed to elicit the perspectives of 2S/LGBTQ+ people about conceptualizing allyship. A clear definition of allyship is necessary for integration into classroom and clinical curriculum. Further, a clear definition of allyship will inform practice via education and via institutional guidelines, policies, and practice standards with the overarching goal of improving health outcomes for 2S/LGBTQ+ people.

Keywords

allyship 2S/LGBTQ+ health nursing health systems

Implications for Research and Practice

Research

Community-engaged research to garner perspectives of 2S/LGBTQ+ people as a central component of conceptualizing allyship.

Additional investigation into conceptualizing allyship inclusive to approaches such as interpretive synthesis to enable application of critical theoretical approaches to conceptualize allyship.

Practice

In-services for nurses and health providers to communicate the importance of clearly defining allyship as a central concept for providing care for 2S/LGBTQ+ people inclusive to offering up preliminary understandings of how allyship is currently conceptualized and the implications for practice.

Disseminating the state of knowledge pertaining to conceptualizations of allyship within nursing and health discipline education highlighting advocating for a clearer definition of allyship as essential to guide practice to support the health and well-being of 2S/LGBTQ+ people.

Two-Spirit, lesbian, gay, bisexual, transgender, queer, and other sexual and gender identity diverse people (2S/LGBTQ+) historically and currently experience poorer health outcomes in comparison to heterosexual and/or cisgender people (Casey, 2019; Giblon & Bauer, 2017; Gil et al., 2021; Schreiber et al., 2021). The identities in the 2S/LGBTQ+ acronym are ever-evolving, with the inclusion of Two-Spirit as an umbrella term to describe Indigenous peoples of diverse gender and/or sexual orientation identities and prefaced in the acronym to honour Indigenous communities that were the first to recognize gender diversity (Carrier et al., 2020). It is well substantiated that inequities experienced by 2S/LGBTQ+ people are rooted in discrimination at structural and interpersonal levels: heteronormativity and cisnormativity reside in the realm of the unconscious as normalised, uncontested beliefs and become perpetuated and reproduced within interpersonal interactions (Berg et al., 2013; van der Toorn et al., 2020). Consequently, heteronormativity and cisnormativity powerfully shape the norms and dynamics of societal structures and institutions (e.g., sites of health care, employment, and education) in which the assumptions of heterosexuality and cisgender identity imbue interactions and effectively alienate those who do not ascribe to these ‘norms’ (Aguinaldo, 2008; van der Toorn et al., 2020). Interpersonal discrimination is frequently termed homophobia, queerphobia, and/or transphobia; it encompasses physical acts of violence, name-calling, exclusion, and more subtle conscious and unconscious microaggressions towards those who do not comply with ascribed heterosexual or cisgender norms, and is directly and indirectly implicated in a range of health challenges (Aguinaldo, 2008; Ferlatte et al., 2018; Pinna et al., 2022). The poorer health outcomes among 2S/LGBTQ+ people were aggravated by the COVID-19 pandemic; recent research highlights that 2S/LGBTQ+ people were particularly vulnerable to mental health challenges, isolation, and unmet health needs during the pandemic (Adamson et al., 2022; Drabble & Eliason, 2021).

Allyship

One response to redressing discrimination towards 2S/LGBTQ+ individuals, groups, and populations has been allyship (Grova et al., 2021; Phillips, 2022). Current definitions of allyship vary, but generally agree that allyship involves individuals or groups with social privilege working in solidarity with marginalized people to challenge and dismantle systems that produce inequity (Communities: What Is Allyship?, 2018). Recognition of social location is central to allyship, in that allies must occupy some degree of power and privilege to mobilize change. While the word “allyship” has appeared in English-language sources since the 1840s (Sitkoff, 1971), its current meaning has been used since the 1970s (Blumenfeld, 1993). The term is believed to have originated among discourses on the concept of straight allies, who were supporters of what was termed at that time the lesbian, gay, bisexual and transgender (LGBT) community (McKinnon et al., 2017) and the civil rights movement, at a time when there were formidable legal and social barriers to LGBT people's full participation in society (Blumenfeld, 1993). Specifically, a body of literature documents allyship efforts amid the pre-retroviral therapy period of HIV/AIDS; this literature describes allyship as the organizing of supportive resources and personnel by allies to support gay men, given the dearth of any public health response to the stigma-laden crisis (Handlovsky et al., 2024; Santo, 2021; Tester, 2018), and identifies allies as members of the broader LGBT community in the 1980s (McKinnon et al., 2017) and health and social service providers (Handlovsky et al., 2024; Santo, 2021; Tester, 2018).

Although the term allyship first appeared in the Oxford English Dictionary in March 2021 (New Words List 2021, 2021), other literature uses the term as far back as 1943, when it was used in a racial justice context amidst World War II (Sitkoff, 1971), While the term is plentiful in the rhetoric of some social justice activists and in diversity, equity, and inclusion initiatives, it has not found widespread acceptance or usage outside of the English-speaking world (The Problem with Allyship, 2021). Allyship is a concept that is increasingly used within community and media circles in relation to 2S/LGBTQ+ groups (Allies, 2021; Arif et al., 2022), offering relevance and utility for health professionals including nurses, to provide meaningful care provision by enacting the guiding principle of social justice in professional practice and education. Studies have utilized the concept of allyship in health settings (Peck et al., 2022; Phillips, 2022; Wang et al., 2022); however, conceptualizations remain ambiguous. The health-care system persists as a key setting for the subjugation of 2SLGBTQ+ people, the consequences of which can be dire for health outcomes (Government of Canada, S. C., 2022; Kia et al., 2022; Kia, Pang et al., 2024; Salway et al., 2022). Studies demonstrate that many 2SLGBTQIA+ people simply avoid seeking care altogether due to experiences of marginalization which can lead to unaddressed health complications and even death (Campbell et al., 2023; Kruse et al., 2022; Quinn et al., 2015). A clear conceptualization of allyship, with roots in equity-advocating processes, has the potential to guide health provider practice, which is essential given the wealth of literature demonstrating that health provider approaches greatly shape the overall health-care experience (Kia, Pang et al., 2024; Quinn et al., 2015; Quinn et al., 2023). Care approaches guided by a clear conceptualization of allyship can ensure 2S/LGBTQ+ people feel respected and safe in health settings, which contributes to their enhanced health and well-being.

Review Question

How is allyship defined in the literature specific to 2S/LGBTQ+ people and health settings and/or health care in countries where English is the primarily spoken native language (Canada, the United States, the United Kingdom, Australia, and New Zealand)?

Design

A scoping review is an effective and suitable approach to identify, collate, and analyze the evidence pertaining to the use of allyship as a term in health settings to date, to identify differences and similarities in use among settings and users, and contribute to understanding the implications of the term in health care with the intent of guiding future practice (Tricco et al., 2018). Given that the concept of allyship remains poorly understood, a scoping review enabled us to explore and synthesize the state and extent of knowledge pertaining to allyship in the context of health settings (Peters et al., 2020). Our motivation to conduct a scoping review on the topic of current conceptualizations of allyship with 2S/LGBTQ+ people and health settings was greatly inspired by our involvement in community-engaged work, where conceptual understandings must be rooted in community perspectives (Kantamneni et al., 2019; Luger et al., 2020). This knowledge informed our investigation and indeed, Levac and colleagues (Levac et al., 2010) highlighted the importance of consulting invested parties in the process of conducting scoping reviews such that the implications of findings are situated within broader societal contexts.

Our team comprised individuals who maintain membership in the 2S/LGBTQ+ community with connections to community members who provided insights into the scoping review from the review question, to approaching the grey literature search, and considerations for disseminating findings. In preparation for conducting the scoping review, we carried out a preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis and found there were no current or ongoing systematic reviews or scoping reviews on this topic. We drew on the Joanna Briggs Institute (JBI) approaches for conducting scoping reviews and reported in line with the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; Peters et al., 2020; Tricco et al., 2018). This review was conducted in accordance with an a priori protocol (Handlovsky et al., 2023) registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/VZSXE). Zotero 6.0.30 (The Corporation for Digital Scholarship) reference managing software was used. In our search strategy we aimed to locate published and unpublished literature.

Inclusion Criteria

Literature on allyship related to 2S/LGBTQ+ people in health care and health settings published between 1970 and 2024 was included. The lower bound reflects recognition that the term allyship emerged in the 1970s (Blumenfeld, 1993). Studies using the terms allyship or ally-ship were included; given the relative novelty of the term, studies using gay–straight alliance, gay–straight ally, or gay–straight allies were also considered. To support consistent decision-making, a term map was developed and is available in the published protocol (https://doi.org/10.17605/OSF.IO/VZSXE). Included literature focused on health-care delivery, health settings (e.g., acute, community, urban, rural), and the education of health professionals, recognizing that clinical education occurs within health settings. Health care was defined as health-focused practices, including direct care, counselling, and education, across all age groups. Literature was limited to Canada, the United States, Australia, New Zealand, and the United Kingdom; studies from other regions were excluded due to allyship being an English neologism primarily used in English-speaking contexts. All qualitative, quantitative, mixed-methods studies, literature reviews, and opinion papers were included. Gray literature sources included magazines and newspapers, theses and dissertations, editorials, clinical presentations, books, and websites.

Literature Search

The search began with a preliminary search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), Elton B. Stephens Company (EBSCO), and Medical Literature Analysis and Retrieval System Online (OVID Medline) to identify articles on the topic. In collaboration with the academic librarian on our research team, the text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy for CINAHL (EBSCO), Medline (OVID), APA PsycInfo (EBSCO), LGBTQ+ Source (EBSCO), Scopus, Web of Science, and Dissertations and Theses (ProQuest). Specifically for health databases where results were by default health-related (CINAHL and Medline), we focused the search to only two concepts (allyship, 2S/LGBTQ+ groups). In the other databases, we searched for three concepts (allyship, 2S/LGBTQ+ groups, health care) to contain the focus to health-care settings.

The full search strategy for each source can be found in Supplemental File 1, Search Strategy. We also searched unpublished studies and gray literature through Dissertations and Theses (ProQuest). The systematic search of databases was run in June 2023, and the searches were rerun before the final analysis in October 2024. We also conducted a grey literature search via google.ca in May 2024 for websites, online magazines and newspapers using the search terms (lgbt OR 2slgbt) AND (allyship OR “ally-ship”) AND (healthcare OR “health care”) and screened the first 100 results for relevance (also in Supplemental File 1, as Grey Literature Google Search Strategy).

Following the search, all citations were collated in EndNote v.X9.2 (Clarivate Analytics, PA, USA) and Covidence (Veritas Health Innovation, Melbourne, Australia), and duplicates were removed. The team developed and piloted an abstract screening tool in Covidence, which was revised to ensure comprehensive capture of relevant literature. Although initial screening required the term allyship to appear in the abstract, this criterion was expanded to retain abstracts inclusive of 2S/LGBTQ+ populations, health settings, and health-care practices to avoid excluding studies referencing allyship only in the full text. Abstracts were screened by two or more independent reviewers against the inclusion criteria. Full texts of relevant sources were retrieved and assessed independently by two or more reviewers, with disagreements resolved through discussion or consultation with a third reviewer. Reference lists of included studies were also screened to identify additional relevant literature.

We identified 1799 records through database searches. Following the removal of duplicates, 1311 records remained; the titles and abstracts of those were screened for relevance. In addition, 15 sources were identified from websites, and 43 sources were identified from citation searching. Ultimately, 349 sources were subject to full-text screening, of which 288 were excluded, primarily for no definition of allyship (n = 112), key terms not present (n = 75) and/or ineligible concept (speaking to the therapeutic alliance between counsellor and client in counselling psychology; n = 57). The source selection process and search results are shown in Figure 1.

Figure 1.

PRISMA flow diagram of search results.

Forty-six sources were retained in the final review. A full list of retained sources and relevant characteristics is included in Supplemental File 2, Allyship Characteristics of Retained Sources.

Data Extraction

Two independent reviewers extracted data from documents retained in the scoping review using a data extraction tool developed collaboratively by the research team (two team members who maintain extensive experience with scoping reviews and the academic librarian) along with 2S/LGBTQ+ community member input. Our protocol included two extraction tools, one specific to database sources and one designed for grey literature. However, after piloting the extraction tools, our review team determined that one tool was sufficient to capture data from both database and grey literature sources and extraction proceeded with one data extraction instrument (see Supplemental File 3, Data Extraction Instrument). Following extraction of data for each included document by two team members, a spreadsheet was created to capture key elements of the data for review by the research team. The spreadsheet allowed for presentation of key elements of the retained citations: author, year, country, title, study design, methods, target audience, definition of allyship, primary aim, application of allyship, findings and recommendations. The results of the search, the study inclusion process, and the reasons for exclusion of full-text sources of evidence that did not meet the inclusion criteria were recorded and are presented in a PRISMA flow diagram (see Figure 1).

Data Analysis and Synthesis

Data from included sources were extracted into a table of key findings to organize information relevant to the research question. Using a qualitative descriptive approach (Sandelowski, 2010), the data were analyzed to identify patterns and themes in how allyship is conceptualized. Analysis began with an initial broad reading to establish familiarity, followed by the development of preliminary codes that captured key concepts (e.g., ‘standing with 2S/LGBTQ+ people’, ‘gaining knowledge and ‘a process of unlearning’). Throughout the analysis, the research team engaged in reflexive practice, documenting assumptions, positionalities, and responses to the data. Reflexivity was essential given the team's intersecting identities, including members of the 2S/LGBTQ+ community, health professionals, and shared commitment to advancing 2S/LGBTQ+ health and well-being. The analysis progressed through iterative coding, re-reading, and comparison of codes to identify evolving patterns, culminating in the identification of key themes describing how allyship is defined (see Table 1).

Table 1.

Themes and Related Subthemes.

Themes	Supporting 2SLGBTQ+ People	Recognizing Privilege as Prompting Support of 2SLGBTQ+ People	Actively Redressing Discrimination and Oppression of 2SLGBTQ+ People
Related Subthemes	Support in relation to groups encountering struggle Support in relation to understanding unique needs Support as buffering discrimination	Privilege as a product of societal dynamics -e.g., discrimination (cisheteronormativity) Discrimination as reference to the non-dominant group and disadvantage endured by non-dominant groups Allyship thus is understood as a process of responding to discrimination via advocacy, a commitment to unlearning and lifelong relationship building Consequently allyship is not self-defined, but an identity bestowed upon others one seeks to ally with.	Active vs. passive language (moving beyond recognition to action) Action to end oppression and enhance equity, justice and/or fairness Action as embodied in care and social service provider approaches

Findings

Although our search was inclusive of literature from 1970 to present day, our search illustrates that the concept of allyship in relation to 2S/LGBTQ+ people in health settings appears in the literature from 2012 to 2024, with most concentrated representation in the past 5 years (Figure 2).

Figure 2.

Retained sources by year.

The majority of retained sources were situated in the United States (n = 34) followed by the United Kingdom (n = 6), and Canada (n = 6). The retained sources (n = 46) comprised 26 journal articles: 10 opinion papers, eight quantitative studies, four qualitative studies, two mixed methods studies, one literature review, and one proposed competencies paper. Of the eight quantitative sources, five were pre-post-test designs to determine the efficacy of training programs to support allyship with 2S/LGBTQ+ people within clinical settings and within curriculum for health professionals. The final two quantitative sources were survey designs, one which explored the extent of 2S/LGBTQ+ ally activism amongst social work students and one that explored experiences of discrimination amongst 2S/LGBTQ+ orthopaedic trainees and professionals. Of the four qualitative sources, three were interpretive phenomenological studies and one was a qualitative descriptive design. Three of these sources explored health provider experiences of allyship and one explored the experiences of 2S/LGBTQ+ people. Twenty sources comprised gray literature, with seven online newspaper/magazine articles, six theses/dissertations, two online guest editorials, two books, one best practice guideline, one clinical presentation, and a document featured on a website.

Of the 46 retrieved sources, the intended audience was predominantly allopathic health professionals (n = 21; DiFrancesco, 2023; Gilmore et al., 2024; Grova et al., 2021; Haghiri-Vijeh, 2023; Herron, 2020; Huynh et al., 2024; Koch et al., 2023; Kruk, 2022; Kumaran et al., 2024; Lane et al., 2019; Letzelter & Samora, 2023; Lutman, 2018; Martinez et al., 2021; Murry, 2019; Nichols, 2023; Oblea et al., 2022; Registered Nurses’ Association of Ontario, 2021; Werezak, 2023; Westafer et al., 2022; West-Livingston et al., 2021; Wu et al., 2019) defined as providers who practice allopathic or traditional Western medicine (e.g., physicians, nurses and dentists), followed by counselling psychologists (n = 14; ALGBTIC LGBQQIA Competencies Taskforce et al., 2013; Asta & Vacha-Haase, 2013; Finnerty et al., 2014; de la Fuente, 2018; Goodrich & Luke, 2015; Harper & Singh, 2014; Kolasinski, 2018; LaMantia et al., 2015; Lister et al., 2020; Moe et al., 2014; O’Connor, 2024; Pinto, 2014; Rivers & Swank, 2017; Yoder, 2022), and allied health professionals (n = 7; Chartered Society of Physiotherapy, 2022; Frontline, 2022; Grundmann et al., 2020; Holloway et al., 2022; Mills et al., 2024; Mpinga, 2022; Peate, 2020; Wang, 2012) who provide a range of therapeutic and preventative services (i.e., physiotherapists, occupational therapists, social workers; Institute of Medicine, 1989). Two sources were intended for paramedics, one for the Centers for Disease Control and Prevention (CDC) employees, and one for health professionals generally.

We also categorized sources by application of the term allyship; that is, how the utility and relevance of allyship was described in the context of health settings. The majority of retained sources (n = 35; ALGBTIC LGBQQIA Competencies Taskforce et al., 2013; Asta & Vacha-Haase, 2013; de la Fuente, 2018; DiFrancesco, 2023; Finnerty et al., 2014; Frontline, 2022; Gilmore et al., 2024; Goodrich & Luke, 2015; Grova et al., 2021; Grundmann et al., 2020; Haghiri-Vijeh, 2023; Harper & Singh, 2014; Herron, 2020; Holloway et al., 2022; Huynh et al., 2024; Koch et al., 2023; Kolasinski, 2018; Kruk, 2022; LaMantia et al., 2015; Letzelter & Samora, 2023; Lister et al., 2020; Lutman, 2018; Martinez et al., 2021; Mills et al., 2024; Moe et al., 2014; Mpinga, 2022; Murry, 2019; Nichols, 2023; O’Connor, 2024; Peate, 2020; Pinto, 2014; Rivers & Swank, 2017; Wang, 2012; Werezak, 2023; West-Livingston et al., 2021) pertained to direct patient care.

Of these sources, we further categorized direct patient care by virtue of health professional, e.g., counselling psychology (n = 12; ALGBTIC LGBQQIA Competencies Taskforce et al., 2013; Asta & Vacha-Haase, 2013; de la Fuente, 2018; Finnerty et al., 2014; Goodrich & Luke, 2015; Harper & Singh, 2014; Kolasinski, 2018; LaMantia et al., 2015; Lister et al., 2020; Moe et al., 2014; Pinto, 2014; Rivers & Swank, 2017), health professionals generally (n = 7; Gilmore et al., 2024; Herron, 2020; Huynh et al., 2024; Koch et al., 2023; Lutman, 2018; Mills et al., 2024; Murry, 2019), physicians (n = 6; DiFrancesco, 2023; Grova et al., 2021; Kruk, 2022; Letzelter & Samora, 2023; Martinez et al., 2021; West-Livingston et al., 2021), nurses (n = 3) (Haghiri-Vijeh, 2023; Nichols, 2023; Werezak, 2023), pharmacy (n = 2; Grundmann et al., 2020; Mpinga, 2022), social work (n = 2; Holloway et al., 2022; Wang, 2012) health-care assistant (n = 1; Peate, 2020), mental health professionals (n = 1; O’Connor, 2024), physiotherapy (n = 1; Frontline, 2022). Additionally, four sources were specific to curriculum considerations which were categorized, once again, by discipline: health providers generally (n = 1; Wu et al., 2019), nursing (n = 1; Lane et al., 2019), nursing practice guidelines (n = 1; Registered Nurses’ Association of Ontario, 2021) and medicine (n = 1; Kumaran et al., 2024). Six sources were in reference to allyship training in health settings, and four of those sources pertained to health providers generally, and two were specific to paramedics. One additional source was specific to physician's experiences providing care to 2S/LGBTQ+ people.

Many of the definitions of allyship across the 46 retained sources were limited to descriptions of supporting or helping 2S/LGBTQ+ people (ALGBTIC LGBQQIA Competencies Taskforce et al., 2013; Asta & Vacha-Haase, 2013; de la Fuente, 2018; DiFrancesco, 2023; Finnerty et al., 2014; Grundmann et al., 2020; Holloway et al., 2022; Koch et al., 2023; Kolasinski, 2018; Kumaran et al., 2024; Letzelter & Samora, 2023; Martinez et al., 2021; Mills et al., 2006; Moe et al., 2014; Mpinga, 2022.; Murry, 2019; Nichols, 2023; Oblea et al., 2022). Some of these articles expanded to include language that situated support more specifically as providing therapeutic or personal support to 2S/LGBTQ+ people (ALGBTIC LGBQQIA Competencies Taskforce et al., 2013; Asta & Vacha-Haase, 2013; Mpinga, 2022).

Although at first glance the retained sources appeared to have a degree of consistency, upon more critical appraisal it became evident that there were distinctions via appreciation of societal dynamics. Specifically, there was explicit recognition of cis-heteronormative privilege as the key motivator to prompt the support of 2S/LGBTQ+ people (Harper & Singh, 2014; Huynh et al., 2024; Kruse et al., 2022; Lane et al., 2019; Lister, 2018; Lutman, 2018; Registered Nurses’ Association of Ontario, 2021; Sengstock, 2023). Cis-heteronormativity recognizes discrimination rooted in societal assumptions and expectations of cisgender and heterosexual norms and how those norms and assumptions intersect to create disadvantage for 2S/LGBTQ+ people (Daroya et al., 2023). The integration of cisnormativity into definitions of allyship with 2S/LGBTQIA+ people is crucial because it reflects growing recognition of the deleterious impacts that stigma and discrimination pose for the health and well-being of 2S/LGBTQ+ people. This finding emphasizes the need for providers to integrate specific approaches to care that seek to redress stigma and discrimination to support the health and well-being of 2S/LGBTQ+ people. Further, we noted that descriptions of allyship often drew on passive language that spoke to simply being cognizant of discrimination, in contrast to active language that spoke to participating in strategies and practices to redress discrimination. Consequently, the three themes we identified across definitions of allyship were: Supporting 2S/LGBTQ+ People, Recognizing Privilege as Prompting Support of 2S/LGBTQ+ People, and Actively Redressing Discrimination and Oppression of 2S/LGBTQ+ people (see Table 1 for an overview of the themes and related subthemes).

Theme 1: Supporting 2S/LGBTQ+ People

Many sources defined allyship simply as support, as captured by Nichols (2023): “allyship, at its simplest level, means being a supporter” (para. 1). Other definitions framed support more generally in relation to groups experiencing ongoing “struggle” (Grundmann et al., 2020; Mills et al., 2024; Mpinga, 2022). While this acknowledges the disadvantage experienced by 2S/LGBTQ+ people, it falls short of critically examining the drivers of that disadvantage or articulating how it might be redressed. Additional sources positioned support as understanding the unique needs of 2S/LGBTQ+ people or buffering discrimination (ALGBTIC LGBQQIA Competencies Taskforce et al., 2013; de la Fuente, 2018; DiFrancesco, 2023; Finnerty et al., 2014; Holloway et al., 2022); however, these definitions often lacked specificity regarding the mechanisms of discrimination and how health providers might operationalize responses within health settings to improve care experiences.

In a small number of cases, support was described more concretely as creating safe spaces through visible non-verbal cues (e.g., pride symbols), inclusive provider practices, and affirming language in forms and documentation (Koch et al., 2023; Kruk, 2022; Westafer et al., 2022). These examples provided clearer guidance for how allyship can be enacted at the systems and provider levels. Overall, however, definitions of allyship frequently lacked explicit justification for why support from nurses and health providers is critical for 2S/LGBTQ+ people in health settings – a notable omission given the well-documented influence of provider practices on health-care experiences and outcomes (Campbell et al., 2023; Kia et al., 2022; Quinn et al., 2015).

Theme 2: Recognizing Privilege as Prompting Support of 2S/LGBTQ+ People

This theme expands definitions of allyship that frame it primarily as support by situating support within broader societal dynamics. Numerous sources linked allyship to recognition of interpersonal and structural discrimination experienced by 2S/LGBTQ+ people due to non-adherence to cis-heteronormative expectations (Asta & Vacha-Haase, 2013; Harper & Singh, 2014; Herron, 2020; LaMantia et al., 2015; Lane et al., 2019; Wang et al., 2022). Awareness of these inequities informs provider approaches that foster safety in health settings and increase the likelihood of future care-seeking among 2S/LGBTQ+ people (Government of Canada, S. C., 2022; Quinn et al., 2015). In some cases, discrimination was referenced implicitly by identifying 2S/LGBTQ+ people as a non-dominant group warranting support due to the systemic disadvantage experienced by non-dominant groups within societal institutions, including health settings (Asta & Vacha-Haase, 2013; LaMantia et al., 2015; Wang et al., 2022).

Many sources positioned allyship broadly as a response to discrimination, using language that ranged from acknowledging privilege in relation to marginalization (Harper & Singh, 2014; Herron, 2020; Lane et al., 2019) to explicitly defining allyship as supporting and advocating for groups subjected to oppression and disadvantage (Pinto, 2014; West-Livingston et al., 2021). Several sources extended this framing by emphasizing unlearning as integral to enacting allyship, with one describing it as a “life-long relationship-building process contingent upon trust and accountability” (O’Connor, 2024, para. 7). Relatedly, allyship was described as a process rather than an identity, oriented toward building trust and credibility between allies and 2S/LGBTQ+ people.

Importantly, multiple sources emphasized that allyship is not self-defined but conferred by the communities one seeks to support (Haghiri-Vijeh, 2023; Lutman, 2018; Yoder, 2022). As articulated by the Registered Nurses’ Association of Ontario (2021), “allies listen to, and are guided by, communities and individuals affected by oppression” (p. 141). This community-engaged perspective, reinforced through consultation with 2S/LGBTQ+ partners during the review process, advances allyship beyond general support toward recognition of privilege, discrimination, and social justice. Such emphasis aligns with social justice as a core commitment within nursing practice and its mandate to advance health equity for equity-owed groups.

Theme 3: Allyship as Action to Redress Discrimination and Oppression of 2S/LGBTQ+ People

Across these sources, allyship was distinguished by the use of active rather than passive language, emphasizing movement beyond recognition of disadvantage or discrimination toward initiating change. Conceptualizing allyship in active terms has important implications for nurses and health providers, as it shifts allyship from critical awareness to purposeful action aimed at redressing inequities within health settings. Understanding allyship as both the evaluation of disadvantage and the enactment of strategies to address it provides guidance for advancing equity and social justice and ultimately improving health experiences and outcomes for 2S/LGBTQ+ people.

Several sources emphasized that allyship must move beyond passive acknowledgment of disadvantage to actions demonstrating commitment to advocacy and the redress of discrimination. These included broad framings of allyship as transitioning from recognition of inequity to efforts to end oppression or leveraging privilege to promote equity, justice, and fairness for 2S/LGBTQ+ people (Finnerty et al., 2014; Oblea et al., 2022; Peate, 2020; Sengstock, 2023; Werezak, 2023). Other sources operationalized action through health provider practices, ranging from incorporating sexual and gender identity into care delivery to addressing microaggressions in health settings (Gilmore et al., 2024; Grova et al., 2021). More specific approaches, such as culturally congruent care, were also identified as essential to enacting allyship (Werezak, 2023). Together, these action-oriented definitions provide a foundation for translating allyship into concrete provider practices that support positive health-care experiences for 2S/LGBTQ+ people.

Discussion

The purpose of this scoping review was to examine how allyship is defined in the literature related to 2S/LGBTQ+ people and health settings in countries where English is the primary language. This work contributes to the growing body of knowledge on allyship and 2S/LGBTQ+ health, particularly given recognition of allyship as a response to increasing discrimination targeting this community (Johnson, 2024; Latimer, 2023; Sethi & Miller, 2024). As such, how allyship is conceptualized has important implications for nursing and health provider approaches to supporting the health and well-being of 2S/LGBTQ+ people. This review highlights that allyship remains underdeveloped as a concept, with oversights in the literature ranging from the use of the term without definition to definitions that lack clarity.

The absence of a concise conceptualization of allyship poses challenges for health providers, as ambiguity persists regarding what allyship entails and how it should be embodied and operationalized in practice with 2S/LGBTQ+ people. Allyship is ultimately a means of addressing the discrimination that 2S/LGBTQ+ people have experienced and continue to experience in health settings and is central to improving health care experiences and outcomes. Given the rise in discrimination targeting 2S/LGBTQ+ people (Johnson, 2024; Latimer, 2023; Sethi & Miller, 2024) and its significant implications for health and well-being (Kia, Robinson et al., 2024; Salway et al., 2022), allyship as a guiding practice in health settings is both timely and essential. Accordingly, guidance on how to systematically enact allyship has considerable value for nurses and health providers seeking to promote 2S/LGBTQ+ health and well-being. Similar challenges related to conceptual ambiguity and practice barriers have been identified in social justice–oriented scholarship across nursing, social work, and counselling psychology (Cohen et al., 2022; De Sousa et al., 2024; Finn, 2020; Slemon et al., 2024; Valderama-Wallace, 2017). Nursing scholarship, in particular, has increasingly critiqued the social justice literature for relying on vague definitions that are often conflated with related concepts, despite social justice being positioned as an ethical imperative and guiding principle of the discipline (Dillard-Wright & Gazaway, 2021; Thurman & Pfitzinger-Lippe, 2017; Willgerodt et al., 2021).

Definitions that extend allyship beyond support to include recognition of privilege have important implications for how health providers engage with 2S/LGBTQ+ people and warrant careful consideration to ensure meaningful and effective practice. When privilege—specifically the societal privileging of cis-heteronormativity – is understood as central to allyship, the historical and ongoing discrimination experienced by 2S/LGBTQ+ people necessitates community-engaged consultation to determine what meaningful allyship entails (Haghiri-Vijeh, 2023; O’Connor, 2024; Registered Nurses’ Association of Ontario, 2021). The literature consistently emphasizes that efforts to support communities subjected to disadvantage must be guided by the active participation of those communities (Hostetler, 2012; Huang et al., 2022; Miller et al., 2024). The importance of community participation in external support efforts has been widely articulated through the disability rights movement's principle of “nothing about us without us” (Charlton, 1998), later adopted by people living with HIV/AIDS (Jurgens, 2005; Stewart, 2017). This principle remains foundational to research and practice aimed at improving the health and well-being of groups experiencing diverse forms of disadvantage. Members of the research team, as community-engaged researchers, similarly foregrounded questions of community participation as a motivating factor for this scoping review.

Lastly, we wish to highlight the importance of our findings in relation to definitions limited to recognition of disadvantage, or seeking to support 2S/LGBTQ+ people, and those that emphasized that what is essential to allyship is action and operationalization of a commitment to supporting 2S/LGBTQ+ people. Those definitions that situated action as central to allyship were inconsistent in terms of what comprises action, again creating challenges for meaningful integration into health provider practice. The tendency for sources to draw on individual practices to encompass allyship is helpful, but a fundamental sense of what constitutes allyship remains obscured in the absence of more coordinated understandings of action that integrates disciplinary approaches and principles (e.g., the adoption of established approaches such as culturally competent care; Brandt, 2025; John et al., 2019; Pacquiao et al., 2023). Establishing clear understandings of what actions are necessary for providers to truly be allies of 2S/LGBTQ+ people will ensure that individual efforts are thoroughly supported and guided by institutions, and also serve to temper performative allyship, whereby providers statements may not align with necessary actions indicative of allyship (Haghiri-Vijeh, 2023; Thimsen, 2022).

Limitations of Review

Our decision to include only sources that provided an explicit definition of allyship introduced limitations with regards to grey literature sources. Some grey literature sources such as websites or online magazines referred to allyship implicitly with terms and/or statements that could be interpreted as defining allyship, but in the absence of explicit identification of a definition, we did not include such sources. Further, we excluded non-English sources and sources from regions where English is not the dominant-spoken language on the premise that allyship is an English neologism. However, inclusion of non-English sources would offer additional content pertaining to definitions of allyship that would, however, require consideration of the historical and geographical context of the source content. The same can be said for regions where English is not the primary-spoken language. Including such materials would offer novel insights into how the term is conceptualized outside of predominantly English-speaking regions and offer interesting insights into potential differences. Additionally, the relatively small number of retained sources that explicitly defined allyship is also a limitation of our findings.

Implications for Research/Practice/Education

Based on the findings from this scoping review, the need for additional research to track how conceptualizations of allyship have evolved over the past five years is indicated, given the documented trend of increased usage of this term. Community-engaged research that elicits the perspectives of community members pertaining to what allyship means is foundational. The literature pertaining to groups subject to disadvantage emphasizes that community input is paramount to research endeavours generally (Hostetler, 2012; Huang et al., 2022; Miller et al., 2024), necessitating the involvement of 2S/LGBTQ+ groups in inquiry about what constitutes allyship. Research that considers the dynamics of health systems and how to disseminate understandings of allyship with the input of community representation is fundamental to effective integration of allyship into institutional policies and guidelines.

The need for clarity pertaining to allyship is essential to the dovetailing processes of practice and education, given that practice is deeply guided not only by curriculum but also by unit standards, institutional policies, and practice standards (Hosseinzadegan et al., 2021; Yanicki et al., 2015). The results of our review highlight that the majority of allyship definitions remained at the level of support, which limits the possibility of meaningful integration into practice, education, and policies, given the lack of specificity to inform guidelines, institutional or otherwise. The involvement and commitment of health disciplines to encourage the co-development of allyship definitions with community input is needed to ultimately enable opportunities to guide disciplinary mandates, scope of practice, and subsequent responsibilities to support the health and well-being of equity-owed groups. Given that health provider actions at the individual and disciplinary level are situated within institutions that house health service settings, it is of fundamental importance to engage institutions in the coordination of allyship efforts. Active involvement of health systems in efforts to operationalize allyship is a perspective that is echoed in the literature pertaining to conceptualizations of social justice and health provider practice specific to nursing and social work (Donley, 2010; Logsdon & Davis, 2010).

Conclusion

This scoping review was conducted to better understand how allyship is defined in the literature specific to 2S/LGBTQ+ people in health settings where English is the primarily spoken language The review ultimately produced 46 sources. We determined that despite a recent surge in popularity of the term—within the past five years in particular—the trend remains for the term to be stated but not actually defined. Of the retained sources that defined allyship, ambiguity remains with regards to specificity such that allyship remains conceptually underdeveloped, with the overarching tendency to simply define allyship as support of 2S/LGBTQ+ people, raising queries pertaining to how allyship ought to be operationalized by nurses and other health providers to support positive health setting experiences—and ultimately improved health outcomes—of 2S/LGBTQ+ people. Further, for those sources that defined allyship specifically as action, there is inconsistency with regards to what constitutes action, particularly in the context of health service delivery. For allyship to truly be operationalized within health settings, the need for health disciplines to work collaboratively with community representatives and health settings to determine expectations for practice that embodies allyship is necessary to meaningfully and effectively support the health and well-being of 2S/LGBTQ+ people.

Supplemental Material

sj-docx-1-cng-10.1177_10784535261439715 - Supplemental material for Conceptualizations of Allyship with 2S/LGBTQ+ Groups in the Context of Health Settings: A Scoping Review

Supplemental material, sj-docx-1-cng-10.1177_10784535261439715 for Conceptualizations of Allyship with 2S/LGBTQ+ Groups in the Context of Health Settings: A Scoping Review by Ingrid Handlovsky, Allie Slemon, Lenora Marcellus, Lorelei Newton, Sage Schmied, Jaymelyn Hubert, Bernadette Zakher and Jessica Mussell in Creative Nursing

Supplemental Material

sj-docx-2-cng-10.1177_10784535261439715 - Supplemental material for Conceptualizations of Allyship with 2S/LGBTQ+ Groups in the Context of Health Settings: A Scoping Review

Supplemental material, sj-docx-2-cng-10.1177_10784535261439715 for Conceptualizations of Allyship with 2S/LGBTQ+ Groups in the Context of Health Settings: A Scoping Review by Ingrid Handlovsky, Allie Slemon, Lenora Marcellus, Lorelei Newton, Sage Schmied, Jaymelyn Hubert, Bernadette Zakher and Jessica Mussell in Creative Nursing

Supplemental Material

sj-docx-3-cng-10.1177_10784535261439715 - Supplemental material for Conceptualizations of Allyship with 2S/LGBTQ+ Groups in the Context of Health Settings: A Scoping Review

Supplemental material, sj-docx-3-cng-10.1177_10784535261439715 for Conceptualizations of Allyship with 2S/LGBTQ+ Groups in the Context of Health Settings: A Scoping Review by Ingrid Handlovsky, Allie Slemon, Lenora Marcellus, Lorelei Newton, Sage Schmied, Jaymelyn Hubert, Bernadette Zakher and Jessica Mussell in Creative Nursing

Footnotes

Acknowledgements

The authors wish to wholeheartedly thank the 2S/LGBTQ+ community members who inspired and supported this scoping review.

Author contribution(s)

Ingrid Handlovsky: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Allie Slemon:Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Supervision; Validation; Visualization; Writing – review & editing.

Lenora Marcellus: Conceptualization; Formal analysis; Investigation; Methodology; Validation; Visualization; Writing – review & editing.

Lorelei Newton: Conceptualization; Data curation; Formal analysis; Methodology; Supervision; Validation; Visualization; Writing – review & editing.

Sage Schmied: Formal analysis; Validation; Visualization; Writing – review & editing.

Jaymelyn Hubert: Formal analysis; Validation; Visualization; Writing – review & editing.

Bernadette Zakher: Conceptualization; Data curation; Writing – review & editing.

Jessica Mussell: Data curation.

Availability of Data and Material

The data that support the findings of this study are available on request from the corresponding author.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval and Informed Consent

Ethical approval and informed consent were not required.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Ingrid Handlovsky

Lorelei Newton

Jessica Mussell

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Ingrid Handlovsky, PhD, RN, (she/her), is an Assistant Professor in the School of Nursing and a Research Fellow at the Institute on Aging & Lifelong Health at the University of Victoria.

Allie Slemon, PhD, RN, (she/they), is an Assistant Professor in the School of Nursing and a Research Fellow at the Institute on Aging & Lifelong Health at the University of Victoria.

Lenora Marcellus, PhD, RN, (she/her), is a Professor and Director of the University of Victoria School of Nursing.

Lorelei Newton, PhD, RN, (she/her), is an Associate Professor in the School of Nursing and a Research Fellow at the Institute on Aging & Lifelong Health at the University of Victoria.

Sage Schmied, BA, MACP, (she/they), is a Research Manager at the University of Victoria School of Nursing.

Jaymelyn Hubert, BSN, RN, (she/her), is a Master of Nursing student and Research Assistant at the University of Victoria School of Nursing.

Bernadette Zakher, MPH, (she/her), is a Research Coordinator at the University of Victoria School of Nursing.

Jessica Mussell, BA, MLIS, (she/her), is the Continuing Studies & Health Librarian in McPherson Library, Mearns Centre for Learning, at the University of Victoria

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