Sexual and gender minority (LGBTQ+) individuals face dramatic inequities in health outcomes. Growing research documents disproportionately worse mental (e.g., depression and anxiety) (1, 2) and physical (e.g., breast, anal, and lung cancers) (3) health compared to cisgender heterosexual adults. For example, LGBTQ+ youth are 2–3 × more likely to be homeless and to attempt suicide (2), and many older LGBTQ+ individuals are isolated and struggle to identify advocates in end-of-life care (4). Furthermore, inequities are exaggerated among racially/ethnically diverse LGBTQ+ (5), especially those residing in the Deep South (due to pervasive LGBTQ+-related stigma and discrimination). Despite dramatic shifts in the political and social acceptability of LGBTQ+ people across the United States (6), progress remains tenuous in the Deep South, especially in Alabama, recently identified by the Human Rights Campaign as a ‘high priority to achieve basic equality (7).

Research has documented how LGBTQ+ populations experience significant health disparities due to a lack of culturally responsive healthcare, both nationally (8) and in the Deep South (9). Within nursing education, efforts to integrate LGBTQ+ affirming curricula remain inconsistent and often insufficient. Nurses play a pivotal role in addressing health inequities, advocating for inclusive programs and policies, and implementing patient-centered care models. But many nursing programs dedicate limited time—often fewer than 5 h—to LGBTQ+ health topics, leaving future nurses inadequately prepared to deliver equitable and inclusive care. The absence of structured, evidence-based training in LGBTQ+-affirming care perpetuates biases, restricts patient-provider communication, and contributes to adverse health outcomes for LGBTQ+ individuals.

To bridge this gap in nursing education, it is crucial to examine existing curricular frameworks, identify best practices, and explore ways to integrate LGBTQ+ content into nursing training programs. The objective of this study is to synthesize findings from a systematic scoping review and qualitative interviews with nursing educators and students to offer recommendations for improving LGBTQ+ health in nursing education.

We conducted a systematic scoping review to identify core domains and didactic strategies to include in the curriculum; we supplemented the review with qualitative interviews to provide additional context. We describe our multiple methods approach below. The methods project protocol, IRB-300012345, was submitted to the Institutional Review Board and deemed exempt. Further, our multiple methods approach detailed several different theories and frameworks critical to underpinning future curriculum, these are noted in the results and summarized in Table 1 which summarizes the theoretical and conceptual frameworks informing this study. These frameworks highlight how power, identity, and structural contexts shape curricular content, teaching strategies, and learner experiences. We drew on these frameworks when interpreting themes from both the scoping review and the qualitative interviews. In the below manuscript, we have included narrative descriptions and citations for each framework.

The above methods were combined to develop a course designed for a university setting. The target audience involves teaching faculty at accredited schools of nursing. The faculty of the course, described in detail below, involves a hybrid of trained LGBTQ+ experts (both clinicians and research faculty) as well as people with lived experience. The learning objectives are to differentiate among terms that describe LGBTQ+ identities, describe the developmental concerns of LGBTQ+ community members across the lifespan, discuss the evolution of LGBTQ+ rights and their influence on health care policy in the United States, incorporate developmentally and culturally appropriate assessment strategies into the care of LGBTQ+ populations, diagnose and manage health concerns unique to transgender individuals and other members of the LGBTQ+ communities, effectively advocate for socially just health policy formation at the local, state, and national levels, use affirmative communication skills to build trusting relationships and promote health among members of LGBTQ+ communities, and describe evidence-based teaching strategies to build competence in caring for members of LGBTQ+ communities among student nurses and other health team members. The lessons learned will be informed by formal assessment of its feasibility and acceptability within 1 year of the course's implementation.

Our multiple methods results fall into three broad domains: (1) Course Content (i.e., LGBTQ+-focused theories & framework, evolving terms and concepts, empirical evidence of health inequities, and clinical considerations); (2) course delivery considerations (i.e., balancing hybrid modalities, varying lengths, balancing personal and lived experience among instructors, minimal costs, and validated approaches to course evaluation); and (3) experiential and simulation-based pedagogies for affirming and inclusive clinical practice. Table 3 presents the studies informing the Course Content domain and provides a visual overview to support interpretation of the themes that follow. Figure 1 offers a synthesized visual summary of the studies contributing to the Course Delivery Considerations domain and complements the accompanying narrative analysis. Table 4 highlights the studies addressing Experiential and Simulation-Based Pedagogies and visually supports the thematic synthesis for that domain.

As federal and state landscapes shift toward “whole person health”, questions remain regarding how to address the needs of populations experiencing health inequities. Executive Orders released in 2025 suggest that certain subpopulations, including LGBTQ+ people, are no longer a priority population. Given the number of LGBTQ+ people across the United States, especially in the South, we are unlikely to “make America healthy again” without addressing the needs of LGBTQ+ communities. Structural changes are needed, engaging healthcare providers and specifically nurses who have the most touchpoints with patients. Our results offer a roadmap for educating nursing faculty to achieve the highest attainable standard of health for all.

Over the past several years, the nursing education literature has shown notable forward movement in preparing students to provide affirming care for LGBTQ+ populations. Recent studies demonstrate a clear expansion of transgender and gender-diverse curricular content in particular, with programs increasingly embedding gender-affirming care principles into foundational coursework rather than treating them as supplemental topics. Simulation-based pedagogy has also accelerated, particularly the use of transgender and gender-nonconforming standardized patients, prerecorded simulation scenarios, and structured debriefing models that invite self-reflection, cultural humility, and bias awareness (23, 43, 71, 72, 74). Many of these interventions emphasize inclusive communication, therapeutic engagement, and confidence-building, reflecting a shift from “competence” framed as knowledge acquisition toward competence as an integrated clinical, relational, and ethical practice (26, 44). Several newer studies additionally highlight the role of interprofessional simulation and team-based learning in strengthening gender-affirming care behaviors (45). Taken together, these developments suggest meaningful progress in both the breadth and sophistication of LGBTQ+-focused nursing education since earlier stages of the literature.

Despite these advances, important gaps remain. Few studies evaluate long-term retention of LGBTQ+-affirming skills or examine whether educational gains translate into sustained practice change in clinical settings. Most interventions emphasize transgender care specifically, leaving comparatively limited attention to sexual minority health needs, intersectional identities, and barriers faced by older adults, rural communities, and racially minoritized LGBTQ+ populations. Measurement approaches also vary widely, with few validated tools available to assess communication, attitudes, or behavioral outcomes, and even fewer studies incorporating patient-reported experiences. Future research would benefit from longitudinal designs, rigorous evaluation frameworks, and attention to how nursing programs can embed LGBTQ+ health content across curricula rather than relying on one-time exposures. Continued work is also needed to co-design educational interventions with LGBTQ+ communities themselves, ensuring that training efforts reflect lived experience and community priorities.

To advance the knowledge gained from our multiple methods research, we are currently developing a self-paced, asynchronous online course for nursing faculty who teach primarily pre-licensure students. The aim of the course is to increase faculty capacity to teach their students to provide LGBTQ+ affirming care. The focus is on pre-licensure students because registered nurses provide most of the bedside care and are more likely to be one of the first health care professionals whom a patient encounters. Initially, the course was planned with eight modules: historical and theoretical perspectives; basic terminology; physical health assessment; mental health concerns common to members of LGBTQ+ communities; common general health concerns; treatments to include pharmacology; subgroup differences and special considerations; and role of the health care provider. After developing the initial course outline, the team met to discuss potential challenges that could impact the success of the course given the current political climate, anti-DEI mandates, and open hostility toward LGBTQ+ communities. In January 2025 the American Nurses Association published a revision of the Code of Ethics for Nurses that underscored the need to develop an eighth module titled: Teaching Strategies for Student Nurses and Related Health Team Members. This module addresses how to communicate critical concepts to students whose values, beliefs, and behaviors are antithetical to the Code and are barriers to providing equitable care.

To bolster the course, we addressed competency-based education (CBE) via embedded quizzes to check knowledge and understanding of content. The course will conclude with an online simulation to test faculty knowledge and application of concepts. We will pilot the course with faculty who teach in the pre-licensure program. There will be two assessment points where data on the course's feasibility and acceptability as well as preliminary efficacy in advancing nursing faculty's knowledge and ability to teach LGBTQ+ focused content are assessed. Information from the sessions will be used for mid-course correction. End-of-course feedback will be used to refine the course for the second pilot cohort.

The complexity of teaching and researching LGBTQ+ health cannot be understated. In our home state of Alabama, an anti-diversity, equity, and inclusion legislation went into effect on October 1, 2024. This law made it illegal to select students based on core identities for training opportunities. However, it did not prohibit the teaching of concepts related to what have become known as “divisive concepts” (e.g., discussion of race and ethnicity, LGBTQ+ and other marginalized identities). Many core aspects of the legislation were consistent with existing tenets of higher education (e.g., that faculty would not force students to agree with them) (75). However, the dramatic shift in the state and federal political landscape has significantly undercut many efforts that remained in place even after our legislation went into effect. Although much remains unknown as legislative sessions are ongoing, the potential retribution for engaging with these concepts in both the teaching and research spheres is significantly shifting institutional support across the U.S. in higher education in general, and especially in deeply conservative states such as our own. During such times we must work to develop strategies that enable us to prioritize the health of our most vulnerable, such as our LGBTQ+ communities, and articulate (in our grants and publications such as this one) that we cannot achieve health equity for all without actively addressing and improving the health of those who we know have the poorest health. As we balance political and empirical priorities, we lean heavily on our commitment to science, and our collaboration with communities, to ensure that we persevere in advancing health equity for all.

Together, findings from the scoping review and interviews suggest several practical implications for nursing education. First, programs should incorporate LGBTQ+ focused theories, evolving terminology, empirical evidence of inequities, and clinical considerations into foundational coursework to ensure a consistent knowledge base across learners. Second, schools may strengthen implementation by balancing didactic content with experiential and simulation-based approaches that offer structured opportunities to practice gender affirming communication and clinical skills. Third, partnerships among faculty, community-based organizations, and LGBTQ+ community members may support sustainability and accountability as courses evolve.

Future research is needed to evaluate the effectiveness of these curricular strategies, identify which combinations of content and pedagogy produce the strongest learning outcomes, and explore how political and institutional contexts shape implementation. Additional work should also examine how these curricular components can be adapted for diverse educational settings, including community colleges, accelerated programs, and schools with limited resources. The three domains identified in this study offer a flexible structure for replication, allowing programs to tailor content while maintaining core commitments to inclusivity and evidence informed teaching.

This study has several methodological limitations. First, the scoping review relied solely on PubMed for the literature search, which may have excluded relevant articles indexed in other databases. Second, the qualitative interviews involved a relatively small, purposive and snowball sample of nursing faculty and students who were engaged in or connected to LGBTQ+ curriculum development and implementation. This approach may have overrepresented individuals who already have interest, expertise, or institutional support in this area, and the findings may not fully capture the perspectives of educators or learners who are less engaged or who work in more constrained environments. Third, recruitment procedures may have introduced selection bias by attracting individuals with preexisting interest in LGBTQ+ health or curriculum development. Fourth, some interviewers and participants were members of the same academic community, and existing professional relationships may have influenced how openly participants discussed concerns or critiques, even though reflexivity practices were used during data collection. Finally, the broader socio-political environment surrounding LGBTQ+ health and education, including increasing legislative restrictions in some states, may have shaped participants' perceptions of feasibility, safety, and institutional support.

As the federal and state landscape shifts toward “whole person health,” significant questions remain regarding how best to address the unique needs of populations like LGBTQ+ people, who experience pervasive health inequities. In particular, the Executive Orders released in January 2025 (76) suggest that certain subpopulations, such as LGBTQ+ people, are no longer a priority population. Given the substantial number of LGBTQ+ people across the United States (2024 Gallup Poll shows 9.3% of the country's population identifies as LGBTQ+) (77), and especially in the South (home to the largest LGBTQ+ population across Census Bureau regions), we are unlikely to “make America healthy again” without addressing the needs of LGBTQ+ communities. To do so, structural level change is needed to make the promise of good health for all Americans a reality, engaging nurses, who have the most touchpoints with our patients.

Our results highlight a gap in the ability of the nursing profession to adequately teach care for all populations. However, we have drawn a clear roadmap for educating our nursing faculty, empowering them to deliver on our collective commitment to prepare the next generation of nurses. We must equip our students with the skills to provide evidence-based, high-quality care that allows all individuals to attain their optimal health.