Enhancing Nursing Education to Address LGBTQ+ Healthcare Needs: Perspectives from the Philippines

Abstract

Enhancing healthcare professionals’ education and training to effectively manage the healthcare needs of People Identifying as Lesbian, Gay, Bisexual, Transgender, Queer, and other Sexual and Gender Minorities (LGBTQ+) is imperative. Recognizing the importance of mitigating LGBTQ+ health disparities, healthcare associations have affirmed their commitment to providing inclusive and culturally competent healthcare. However, despite these efforts, there is still a gap in LGBTQ+-specific teaching within nursing and other healthcare professionals’ schools, resulting in healthcare professionals being ill-equipped to meet the unique needs of LGBTQ+. To address this gap, we suggest integrating LGBTQ+ health content into healthcare training programs, focusing on the Philippine nursing curriculum. Drawing from various reports, including insights from discussions with the local LGBTQ+, the suggested topics include LGBTQ+ identities, sexual health, trans health, mental health, and social determinants of LGBTQ+ health. By fostering understanding and competence through education, equitable and inclusive healthcare practices for LGBTQ+ can be better cultivated, helping to ensure that the unique healthcare needs of LGBTQ+ are met effectively. Furthermore, it is necessary to share best practices for providing health services to LGBTQ+ people. Additionally, future studies can explore the median time allocated to LGBTQ+ teaching, the optimal number of teaching hours for LGBTQ+ content, and the specific contents of local nursing curricula that can better address their needs. By undertaking these steps, we can move toward effectively addressing the unique healthcare needs of LGBTQ+.

Introduction

Raghavan et al. (2023) advocate for enhancing the gender-related competencies of nursing students by ensuring equal learning opportunities, particularly for men, in clinical settings predominantly serving women. This recommendation aligns with efforts to promote inclusivity in nursing practice, which extends beyond traditional gender binaries to encompass the needs of People Identifying as Lesbian, Gay, Bisexual, Transgender, Queer, and other Sexual and Gender Minority (LGBTQ+) (Stanford, 2020). The Code of Ethics for Nurses of the International Council of Nurses (2021) emphasizes nursing care rooted in human rights, advocating for inclusivity regardless of sexual orientation and gender identity (SOGI). Similarly, the World Health Organization advocates for healthcare services without discrimination (World Health Organization, n.d.).

In the Philippines, the Code of Ethics for nurses emphasizes equitable care without discrimination and respect for rights (Board of Nursing, 2004; Oducado, 2023). The government mandates that nursing education align with international and local nursing ethics standards, ensuring respect for rights regardless of SOGI (Commission on Higher Education, 2008, 2017). Consequently, Philippine nursing education can foster inclusivity, addressing the needs of LGBTQ+.

The Philippine government reinforces inclusivity toward LGBTQ+ through its Development Plan, which emphasizes gender-responsive interventions to promote the well-being of vulnerable populations, including LGBTQ+ (National Economic and Development Authority, 2022). The country's Department of Health (DOH) also conducts awareness programs addressing issues affecting LGBTQ+, including sexual and mental health and their social determinants (Department of Health, 2018).

However, a gap persists in LGBTQ+-specific teaching within Philippine nursing and other healthcare professional schools (Abesamis, 2022; Oducado, 2023). Although research within the country is limited, studies suggest minimal time dedicated to LGBTQ+ teaching in medical and nursing schools, with only 2.12 h and 5 h allocated in the US and Canada, respectively (Lim et al., 2015; Obedin-Maliver et al., 2011). This limited exposure may result in healthcare professionals lacking the competencies to address the needs of LGBTQ+ (Karpel et al., 2023).

Brief Review

Philippine-Based Health Professionals’ Knowledge and Attitudes

In the Philippines, discrimination against LGBTQ+ occurs at home, schools, and workplaces (UNDP and USAID, 2014). Despite this, the Philippine Senate has not passed legislation safeguarding against SOGI-based discrimination for two decades (Abesamis & Alibudbud, 2024). Furthermore, discrimination is reported within the healthcare sector. In 2011, the Secretary of the DOH faced criticism for suggesting that parents should control their children identified as LGBTQ+ and test them for HIV (UNDP and USAID, 2014). Similarly, a mental health professional was criticized for advocating conversion therapy in gay and lesbian children during a television program to achieve family happiness (Manalastas & Torre, 2016). These incidents underscore the imperative for an assessment of LGBTQ+ health-related competency among healthcare workers.

Although a nationally representative study on LGBTQ+ health-related competency is lacking in the Philippines, Rubio and Echem (2022) found that most of their participants (N = 396), who were Filipino healthcare professionals, expressed comfort in providing care, ranging from genitourinary to venipuncture procedures, without showing prejudice toward LGBTQ+. Moreover, 86% of the participants acknowledged their need for more information regarding the care of LGBTQ+, while 77% emphasized the importance of hospitals providing policies and guidelines for the proper treatment of LGBTQ+ (Rubio & Echem, 2022). Nonetheless, the study also revealed that 13–17% of the participants could have preferential treatment for heterosexual patients, suggesting negative attitudes toward LGBTQ+ (Rubio & Echem, 2022). These negative attitudes are lower than the 27.9% negative attitudes toward gays and lesbians previously found in a nationally representative sample (N = 1,200) of the Philippine general population (Manalastas et al., 2017).

Overall, findings suggest that while health professionals may demonstrate more accepting attitudes toward LGBTQ+ than the general population, their knowledge of addressing LGBTQ+ healthcare needs remains limited. This knowledge gap can be due to the limited integration of LGBTQ+ needs in the health professional curricula (Abesamis, 2022). Therefore, the Philippines can integrate LGBTQ+ inclusivity within its curricula, aligning with the ethical mandates and inclusivity regardless of SOGI. As a start, we suggest integrating topics, including LGBTQ+ identities, sexual health, trans health, mental health, and social determinants influencing LGBTQ+ health, into the country's nursing curriculum.

Current Insights

Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minorities Identities

A key suggestion from local LGBTQ+ groups to address their health-related concerns was for the DOH to integrate SOGI into its health programs, services, research, and policies (UNDP and USAID, 2014). Furthermore, there was a call to recognize intersectional vulnerabilities, where other social identities intersect with SOGI, leading to increased marginalization (UNDP and USAID, 2014). Therefore, the nursing curriculum could integrate SOGI teaching. This could extend to include discussions on gender expression and sexual characteristics, while also being localized to include local LGBTQ+ culture, norms, terminologies, and policies (Abesamis & Alibudbud, 2024).

Sexual Health

Lesbian, Gay, Bisexual, Transgender, Queer, and other Sexual and Gender Minorities in the Philippines have expressed concern regarding the local response to the HIV epidemic, highlighting a predominant focus on testing (UNDP and USAID, 2014). With a growing number of HIV cases nationwide, it has been recommended to incorporate sexual health education into the nursing curriculum (Gangcuangco, 2019). A significant segment of the LGBTQ+ community in the Philippines, particularly men who have sex with men and trans women, remains disproportionately affected by the local HIV epidemic (Gangcuangco & Eustaquio, 2023). Thus, it may be necessary to include discussions about their vulnerability, treatment options, and prevention strategies within medical–surgical nursing courses covering infectious diseases. Moreover, these discussions can extend to the interaction between antiretroviral medications and gender-affirming hormone therapy (GAHT). Recent evidence suggests that trans women living with HIV who undergo GAHT may experience higher rates of viral suppression (Summers et al., 2021).

Trans Health

Lesbian, Gay, Bisexual, Transgender, Queer, and other Sexual and Gender Minorities have emphasized the marginalization of trans health needs within Philippine health programs (UNDP and USAID, 2014). This sentiment is echoed by Abesamis (2022), who underscores the invisibility of trans health in the country's healthcare curricula. Furthermore, transgender people have reported a lack of information on GAHT (UNDP and USAID, 2014). Compounding these challenges, Eustaquio et al. (2023) suggest limited accessibility to GAHT in the Philippines due to low utilization, with many resorting to self-administration of hormones without medical guidance. Therefore, it may be necessary to integrate trans health topics, including GAHT and gender dysphoria, into nursing curricula—specifically within psychiatric and medical–surgical nursing. Given the increasing evidence supporting the benefits of GAHT, such as reduced psychological difficulties and increased life satisfaction (Anderson et al., 2022; D'hoore & T'Sjoen, 2022), educating future nurses about GAHT may be crucial. Similarly, evidence from the Philippines suggests that addressing healthcare-related barriers, like stigma, among transgender people can promote sexual health and overall well-being (Dinglasan et al., 2022; Restar, Adia, et al., 2020; Restar, Jin, et al., 2020).

Mental Health

A UNDP and USAID (2014) report underscored the shortage of mental health professionals equipped to address the needs of LGBTQ+ despite evidence indicating their higher rates of mental health conditions (Alibudbud, 2023). For instance, a nationally representative study demonstrated that young same-sex attracted Filipino men had twice the likelihood of experiencing suicidal ideations than their peers (Manalastas, 2013). These disparities can be due to minority stressors, such as abuse and discrimination (Alibudbud, 2023; Manalastas, 2013). Consequently, integrating local evidence on mental health disparities among LGBTQ+ Filipinos and their determinants into nursing curricula may be necessary. One approach is incorporating this evidence into mental health courses, including psychiatric nursing.

Social Determinants of LGBTQ+ Health

As affirmed by LGBTQ+ organizations and various reports (Abesamis, 2022; Alibudbud, 2023; UNDP and USAID, 2014), the Philippine government acknowledges the significant role of social determinants in shaping health outcomes (National Economic and Development Authority, 2022). These determinants encompass socioenvironmental factors that influence well-being, such as transportation, safety, work and living environments, and sanitation facilities (National Economic and Development Authority, 2022). For LGBTQ+, these determinants include minority stressors, such as stigma and discrimination, that contribute to mental health conditions and decrease healthcare seeking (Alibudbud, 2023; Gangcuangco & Eustaquio, 2023; Manalastas, 2013). Therefore, it is crucial for nursing curricula, particularly in community health nursing, to incorporate discussions on social determinants of health, including SOGI-based stigma and its repercussions.

Helpful Resources

To further enhance their competencies in inclusive nursing practice for LGBTQ+, nurses can refer to several resources (i.e., https://www.lgbtqiahealtheducation.org, https://www.nln.org/). Nurses can also refer to the UNDP report to explore the local LGBTQ+ culture, context, and terminologies (https://www.undp.org/publications/being-lgbt-asia-philippine-country-report).

Conclusion

In the Philippines, there is an opportunity to integrate the healthcare needs of LGBTQ+ into the nursing curriculum. This integration can help future nurses in understanding how to address the needs of LGBTQ+. By incorporating LGBTQ+ health into their curriculum, nursing students gain exposure to existing research and insights, enabling them to bridge current research gaps and develop local interventions. Filipino nurses can also improve their competencies to address LGBTQ+ needs by sharing their best practices and experiences to develop culturally appropriate interventions. Moreover, nurses can conduct research that informs both nursing education and practice. As a start, nurses can investigate aspects related to LGBTQ+ teaching within the curriculum, including the median time allocated to LGBTQ+ teaching, the optimal number of teaching hours, and the efficacy of various teaching methodologies and content.