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LGBTQIA+ Health Pathway

This pathway complements NNLM’s resources for LGBTQIA+ individuals by exploring evaluation considerations for programs that seek to improve health outcomes for members of this community.

People who are lesbian, gay, bisexual, transgender, non-binary, queer, questioning, intersex, or asexual/agender/aromantic (LGBTQIA+) are members of every community. These individuals often live in discriminatory environments, where their health needs may be inappropriately served or underserved.

Working on a project with a small award (less than $10,000)? Use the Small Awards Evaluation Toolkit and Evaluation Worksheets to assist you in determining key components for your evaluation!

When developing an evaluation, consider the context of your program. The context can change how your evaluation is designed and implemented since different settings and populations have different needs and abilities to participate in evaluations.

Working with members of the LGBTQIA+ community

  • Build trust through compassion and empathy. Members of the LGBTQIA+ community often face discrimination and a lack of cultural competence from service providers in healthcare settings. Examine your own assumptions to understand, empathize, and build trust with stakeholders to reduce harm in healthcare. Approach the evaluation process in a way that respects individual differences in order to create or adapt programming to meet all individuals' needs.
  • There are many kinds of data relevant to the experiences of LGBTQIA+ community members, but only those relevant to the goals of the program should be collected. Depending on the program, these data points may include:
    • Gender identity
    • Gender expression
    • Biological sex
    • Sexual orientation
  • Ensure confidentiality. Clear assurances of privacy of personal information, as well as nondiscrimination policies, should be made before data are collected.
  • De-identify data. Data collected as part of a group sample should be de-identified so that single data points cannot be tied to individuals.

Sexual orientation vs. gender identity

  • Sexual orientation and gender identity are not synonymous and should not be treated as such.
    • Sexual orientation - An inherent or immutable enduring emotional, romantic, or sexual attraction to other people
    • Gender identity - One’s innermost concept of self as male, female, a blend of both, or neither – how individuals perceive themselves and what they call themselves; one’s gender identity can be the same or different from their sex assigned at birth
  • Where it is appropriate and relevant to ensuring the health needs of all LGBTQIA+ program participants are met, the following background questions related to sexual orientation and gender identity are recommended.
    • These questions have been adapted from those tested by the CDC through rural and urban health centers.
    • NNLM grantees should determine if the same information is required in order for their program to equitably serve all participants.
Sexual Orientation
Do you identify as:
  • Straight or heterosexual
  • Lesbian or gay
  • Bisexual
  • Queer, pansexual, and/or questioning
  • Something else; please specify:_____________
  • Don’t know
  • Decline to answer
Gender Identity
Do you identify as:
  • Male
  • Female
  • Transgender man/trans man/ female-to-male (FTM)
  • Transgender woman/trans woman/male-to-female (MTF)
  • Genderqueer/gender nonconforming neither exclusively male nor female
  • Additional gender category (or other); please specify:_____________
  • Decline to answer
What sex is listed on your original birth certificate?
  • Male
  • Female
  • Something else

Gender pronouns

  • As an evaluator or program staff member, it is important to ask for and use each person’s pronouns. Be upfront with participants, asking how they would like to be addressed.
  • The University of California San Francisco shares the following chart of commonly used pronouns and how they are used:
Subject Object Possessive Possessive Pronoun Reflexive
He Him His His Himself
"He studied" "I called him" "His pencil" "That is his" "He trusts himself"
She Her Her Hers Herself
"She studied" "I called her" "Her pencil" "That is hers" "She trusts herself"
They Them Their Theirs Themself
"They studied" "I called them" "Their pencil" "That is theirs" "They trust themself"
Ze (or Zie) Hir Hir Hirs Hirself
"Ze studied" ("zee") "I called hir" ("heer") "Hir pencil" "That is hirs" "Ze trusts hirself"


Image of intersectionality in LGBTQIA+ communities

  • Kimberlé Crenshaw's Intersectionality framework states that people experience multiple, overlapping, and cumulative forms of discrimination, such as racism, sexism, classism, and ableism.
    • These different forms, or dimensions, of oppression intersect in complex ways, so that individuals who identify with multiple dimensions of oppression experience discrimination in different ways.
  • This may justify the collection of additional data related to the needs of specific communities within your group of program participants.
  • Intersectionality influences how questions related to LGBTQIA+ identification are framed. The Center for American Progress offers these examples:
    • For communities where the primary language for a significant proportion of the population is not English, response options must be accurately translated into the local language(s).
    • For communities where LGBTQIA+ terminology is not commonly used, those terms that are used frequently – like “two-spirit” in many Native American communities – should be used instead.
  • In surveys, always include a fill-in option that allows each individual to describe themself and their background in their own words.
  • More information on intersectionality

Disparities in programming areas

  • The sample population should reflect the real population of the program. For example, the distribution of race/ethnicity, gender, etc. in the sample of survey respondents should be similar to the distribution of these characteristics in the full population of program participants.
  • Consider barriers to participation. Where there are barriers to participation for certain groups, consider how these groups' needs can be met to ensure equitable participation in the evaluation.