Promoting Equitable and Inclusive Care for Lesbian, Gay, Bisexual, Transgender & Queer Patients and Their Families
Published by the Human Rights Campaign Foundation, March 2022
In the last year, members of the LGBTQ+ community in the United States have endured an onslaught of political attacks, many of which have specifically targeted LGBTQ+ healthcare. The discriminatory healthcare legislation we have endured, coupled with the ongoing COVID-19 pandemic and its impact on the medical field, have made it difficult for LGBTQ+ people to know what the future of our healthcare will look like. This is why it is truly heartening to know that the Human Rights Campaign Foundation’s Healthcare Equality Index (HEI) has seen record participation this year. More facilities than ever have joined the HEI to make it clear that they stand on the side of fairness and are committed to providing inclusive care to their LGBTQ+ patients. I am truly grateful to all of the HEI participants for their commitment to providing inclusive care for all.
Joni Madison (She/Her/Hers) , Interim President , Human Rights Campaign Foundation
Why the HEI?
Why the HEI
The Human Rights Campaign Foundation developed the Healthcare Equality Index to meet a deep and urgent need on the part of lesbian, gay, bisexual, transgender and queer Americans: the need for equitable, knowledgeable, sensitive, and welcoming health care, free from discrimination. No one facing health concerns should also have to worry about receiving inequitable or substandard care because of their LGBTQ+ status.
Yet many LGBTQ+ Americans experience these challenges when seeking health care, which can intensify whatever worries they may have about their health. In Lambda Legal’s landmark study, When Health Care Isn’t Caring, 73% of transgender respondents and 29% of lesbian, gay, and bisexual respondents reported that they believed they would be treated differently by medical personnel because of their LGBTQ+ status. Equally disturbing, 52% of transgender respondents and 9% of lesbian, gay and bisexual respondents reported that they believed they would be refused medical services because of their LGBTQ+ status.*
When asked why they had such concerns, more than half of all respondents reported that they had experienced at least one of the following types of discrimination from healthcare providers: refusing to provide needed care, refusing to touch them or using excessive precautions, using harsh or abusive language, blaming them for their health status, or being physically rough or abusive. Transgender and gender non-conforming people are particularly vulnerable: 70% of transgender and gender non-conforming respondents reported at least one of these experiences. Fifty-six percent of lesbian, gay or bisexual respondents reported at least one of these experiences.
The HEI exists because the HRC Foundation believes that most of American healthcare facilities do not want LGBTQ+ individuals in their communities to have — or to worry about having — these kinds of experiences. But facilities are often unsure how to protect their LGBTQ+ patients from discrimination, provide them with optimal care and extend a warm welcome to allay their concerns.
The HEI was developed to give healthcare facilities the information and resources they need to ensure that LGBTQ+ people have access to truly patient-centered care. HRC also uses this report to applaud the facilities that have shown their commitment to LGBTQ+ patient-centered care by taking the HEI survey and to award those facilities that receive the top score in the survey the coveted designation of “LGBTQ+ Healthcare Equality Leader.” During the past decade, the HEI has become even more relevant and useful. In 2011, The Joint Commission issued a standard that required accredited facilities to include sexual orientation and gender identity in their non-discrimination policies, thus extending vital protection to LGBTQ+ patients.**
In another giant step toward LGBTQ+ equality in healthcare, both The Joint Commission and the federal Centers for Medicare and Medicaid Services require that facilities allow visitation without regard to sexual orientation or gender identity.*** Additionally, Section 1557 of the Affordable Care Act prohibits sex discrimination in any hospital or health program that receives federal funds. Federal courts have determined that this prohibition extends to claims of discrimination based on gender identity and sex stereotyping. Additionally, the Supreme Court of the United States ruled in Bostock v. Clayton County that a corollary statute that prohibits discrimination on the basis of sex must be understood to also prohibit discrimination on the basis of sexual orientation and gender identity.
The HEI offers healthcare facilities a powerful way to affirm that they comply with these requirements and are committed to LGBTQ+ patient-centered care. The HEI also urges facilities to extend non-discrimination protections to their LGBTQ+ employees, who play a key role in ensuring sensitive, knowledgeable LGBTQ+ care.
Equally important, the HEI offers all participating facilities expert training in LGBTQ+ healthcare needs, recognizing that staff education is critical to the success of any policy. Facilities may enroll as many staff as they would like in free, online training, which has been widely hailed as groundbreaking and invaluable.
In short, the HEI offers healthcare facilities unique and powerful resources for providing the care everyone deserves to a long-overlooked group of patients, while also complying with new regulatory requirements and receiving access to high-quality staff training.
If you are affiliated with an HEI-participating facility, the HRC Foundation extends its deepest thanks for your commitment to LGBTQ+ patient-centered care. And if you are affiliated with or know of healthcare facilities not yet engaged with the HEI, we hope you will bring this report to their attention. We are confident that they will thank you for informing them about this vital resource for ensuring high-quality health care for LGBTQ+ Americans.
* When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV. New York: Lambda Legal, 2010. Available at: http://www.lambdalegal.org/pub...
** See RI.01.01.01 EP 29, Comprehensive Accreditation Manual for Hospitals, Update 1, January 2011 and Comprehensive Accreditation Manual for Critical Access Hospitals, Update 1, January 2011.
***See RI.01.01.01 EP 28, Joint Commission manuals referenced above and Code of Federal Regulations 42 C.F.R. § 482.13(h) (for hospitals) and 42 C.F.R. § 485.635(f) (for critical access hospitals).
In its 15th year, the Human Rights Campaign Foundation’s Healthcare Equality Index continues to show incredible growth in the number of healthcare institutions that are embracing and adopting LGBTQ+inclusive policies and practices. A record 906 healthcare facilities actively participated in the HEI 2022 survey, at the same time that they were battling a global pandemic.
The HEI began transforming healthcare for LGBTQ+ people in 2007 when the first report contained 10 recommendations for healthcare facilities to be more welcoming and inclusive of LGBTQ+ patients and families. Those recommendations included four foundational elements of LGBTQ+ patient-centered care: an LGBTQ+ inclusive patient non-discrimination policy, an LGBTQ+ inclusive visitation policy, an LGBTQ+ inclusive employment non-discrimination policy, and staff training in LGBTQ+ patient-centered care. Since 2016, HEI-participating facilities have been demonstrating near-perfect levels of adoption of the three foundational policies.
In addition to active survey participants, the HRC Foundation proactively researched the foundational policies at over 1,300 non-participating hospitals. While we have seen improvements over the years, unfortunately, the adoption rate at these researched hospitals is significantly lower with only approximately 70% of hospitals ensuring non-discrimination protections for their patients and employees.
This year marks the fifth year that HEI participants were given a score based on how many LGBTQ+ inclusive policies and practices they have in place in four different criteria. The first criteria consist of the foundational elements of LGBTQ+ patient-centered care. The three remaining criteria are Patient Services and Support, Employee Benefits and Policies, and Patient and Community Engagement. In addition, participants have to demonstrate that they offer transgender-inclusive healthcare benefits to their employees to receive the top score of 100 points and earn HRC’s coveted “LGBTQ+ Healthcare Equality Leader” designation. An impressive 496 participants earned this designation this year.
This year the criteria to earn the “Top Performer” designation was strengthened to require full credit in criteria one and at least partial credit in the other criteria sections, combined with a total score of between 80-95. Another 251 participants met this criteria and earned the "LGBTQ+ Healthcare Equality Top Performer” designation.
The fact that 82% of participating facilities earned either the Leader or Top Performer designations demonstrates that the healthcare facilities that participate in the HEI are going beyond the basics when it comes to adopting policies and practices in LGBTQ+ care. Percentages for the adoption of each policy and practice surveyed in the HEI can be found in the findings section of this report.
As this overview of the HEI 2022 indicates, diverse healthcare facilities across the U.S. are making tremendous strides toward LGBTQ+ patient-centered care. In unprecedented numbers, they are changing key policies, implementing best practices, and training their staff. We heartily applaud all the facilities that participate in the HEI and make a commitment to LGBTQ+ patient-centered care. We also encourage healthcare facilities that have yet to participate in the HEI to use this unique and invaluable resource to enhance LGBTQ+ care and signal their commitment to LGBTQ+ equity and inclusion. The HRC Foundation looks forward to welcoming them to the HEI in future years — and helping them extend a warm welcome to LGBTQ+ Americans.
Becoming an HEI Leader has reinforced LGBTQ health equity as a high priority for UC Davis Health. Not only does the HEI report give us a roadmap for advancing this mission, it is also a designation that we enthusiastically celebrate and discuss with our collaborators, employees, faculty, students, and patients. Being an HEI leader has helped us to garner support and build partnerships that take our efforts to greater levels.
Hendry Ton, MD, MS
Associate Vice Chancellor for Health Equity, Diversity & Inclusion
UC Davis Health
By The Numbers
HEI 2022 Participants at a Glance
Facilities from more than 160 different non-profit, for-profit and public health systems / Systems with 15 or more participating facilities:
Participants by Bed Size
Bed Size Not Predictive of HEI Score
I’m so proud that Beebe Healthcare participates annually in the HEI Survey. As we strive to provide the best clinical care and experiences for our patients its critical that we understand the needs and best practices to serve people better. The HEI survey is a wonderful tool for us to gauge our efforts to connect to and care for the LGBTQ community. It reminds us to continue to evaluate what we do and how we do it so we can be flexible to meet the ever-changing needs of our patients. It’s wonderful to be connected with best practices of facilities all over the country so we can learn from each other and ensure our LGBTQ patients are always receiving the best possible care with the best possible experience.
Loretta Ostroski, MSN, RN
Assistant Vice President of Nursing
During the 15 years of the Healthcare Equality Index we have seen tremendous progress towards LGBTQ+ equality in every sector of society. Some of this progress has come from federal legislation including the Matthew Shepard and James Byrd, Jr., Hate Crimes Prevention Act, the reauthoization of the Violence Against Women Act with enumerated protections for LGBTQ+ people, and the repeal of Don’t Ask, Don’t Tell. Some of this progress has come from major Supreme Court rulings, such as the decision in Obergefell v. Hodges that gave same-sex couples nationwide the right to marry and the decision in Bostock v. Clayton County that established that Title VII of the Civil Rights Act of 1964 protects against discrimination based on sexual orientation and gender identity. Numerous states and cities also contributed to this progress by passing non-discrimination laws and ordinances to protect their LGBTQ+ residents in the absence of explicit federal non-discrimination protections for LGBTQ+ people.
And finally, this progress has come from the institutions that most impact people’s everyday lives — the places where they work, go to school, worship and receive their healthcare. As documented each year in HRC’s Corporate Equality Index, many of our nation’s leading corporations have embraced sexual orientation and gender identity employment protections and provided LGBTQ+ inclusive benefits to millions of employees. Many schools have embraced and protected their LGBTQ+ students. The healthcare sector has experienced tremendous progress on LGBTQ+ equality as well. Since we launched the Healthcare Equality Index 15 years ago, we have seen incredible growth in the number of healthcare institutions that participate in the HEI and embrace LGBTQ+ inclusive policies and practices. The timeline below highlights the growth in the HEI as well as a few key external events that have impacted the policies and practices promoted by the HEI.
The Healthcare Equality Index was created in partnership with the Gay and Lesbian Medical Association (GLMA) in order to create a national standard for LGBTQ+ patient care. The first HEI report includes aggregate responses from 78 hospitals on questions related to 10 recommended policies and practices, including LGBTQ+ inclusive patient, visitation, and employment non-discrimination policies.
CMS regulations regarding equal visitation go into effect. The Institute of Medicine releases a historic report on LGBT Health. The Joint Commission standard that prohibits discrimination based on sexual orientation and gender identity goes into effect and they release a field guide to help hospitals create a welcome, safe and inclusive environment for LGBTQ+ patients and their families. The HEI launches the “Leader in LGBT Healthcare Equality” designation.
The Obama administration issued final regulations to implement Section 1557 of the Affordable Care Act. This is the provision that prohibits discrimination in healthcare on the basis of a number of protected characteristics including sex. The regulations codified existing informal guidance from HHS interpreting this provision to include protections from discrimination on the basis of gender identity and sex stereotyping. Legal challenges and the Trump administration would work to undermine and change these regulations in subsequent years but HRC secured a nationwide injunction preserving the protections for LGBTQ+ people.
In 2021, the Biden administration announced that consistent with the Supreme Court decision in Bostock as well as Title IX, the HHS Office for Civil Rights would interpret and enforce Section 1557’s prohibition on discrimination on the basis of sex to include sexual orientation and gender identity. A notice of proposed rulemaking to revise the regulations implementing Section 1557 are anticipated in 2022.
The following charts show how the adoption of LGBTQ+ policies and practices have grown among HEI participants over the years.
Fifteen Years of Participation
The HEI is thrilled to welcome 178 new healthcare facilities that participated in the HEI 2022 for the first time. However, we would also like to recognize and acknowledge the 33 healthcare facilities that have been with us since the very beginning in 2007 and have participated in every HEI survey.
When the hospital’s Diversity & Inclusion Committee wanted to focus their efforts on improving the patient experience for our LGBTQ community, we saw an opportunity to use the HEI designation as a roadmap for how we could build an inclusive environment for the many diverse communities we serve. In reviewing the Healthcare Equality Index resources, I was pleased to realize that we already had many of the foundational pieces in place, and I am looking forward to the HEI roadmap paving our way to becoming a more inclusive organization for our LGBTQ community.
Eric Cecava, MBA
President & Chief Executive Officer
McLaren Port Huron
The HEI 2022 LGBTQ+ Healthcare Equality Leaders
HEI participants are given a score based on how many LGBTQ+ inclusive policies and practices they have in place in four different criteria. The first criteria consist of the foundational elements of LGBTQ+ patient-centered care. The three remaining criteria are Patient Services and Support, Employee Benefits and Policies, and Patient and Community Engagement. Participants that have earned the LGBTQ+ Healthcare Equality Leader designation have received the highest score in each criteria and have demonstrated that they offer transgender-inclusive healthcare benefits to their employees to receive a top score of 100 points and earn this coveted designation. An impressive 496 (55%) of HEI 2022 participants met this higher standard and earned the LGBTQ+Healthcare Equality Leader designation.
Denise Martinez, MD
Associate Professor of Family Medicine
Associate Dean for Diversity, Equity, and Inclusion
Carver College of Medicine
Located within one of the largest LGBTQ+ communities in the United States and with a history of both inpatient and outpatient specialized services to the LGBTQ+ community, it came as no surprise that Advocate Illinois Masonic Medical Center (IMMC) stepped up and was one of only four individual hospitals to participate in the very first HEI survey back in 2007. IMMC was one of the earliest hospitals to recognize that by serving and supporting their local LGBTQ+ community, that community would in turn make IMMC a trusted and preferred provider.
In subsequent years, IMMC would continue to participate in the HEI and with each survey would reach the highest level of designation. In 2016, ten additional hospitals from the Illinois-based Advocate Health system would join IMMC in the HEI survey for the first time. While these hospitals were designated as Leaders in that survey, they would not fare as well in subsequent years after the HEI became a scored index and required more robust policies and practices.
Meanwhile, the Diversity, Equity, and Inclusion (DEI) team at Wisconsin-based Aurora Health System knew that they wanted to focus on improving care to the LGBTQ+ population so in 2017 they began working to develop a deeper understanding of the needs of the LGBTQ+ community through a survey, focus groups, and visits and conversations with other healthcare providers that had strong programs focused on the LGBTQ+ community such as Howard Brown Health and Fenway. This work led to the establishment of community partnerships and a systemwide LGBTQ+ Health Steering committee with community members and the development of an LGBTQ+ health strategy.
That strategy led to one hospital, Aurora Sinai Medical Center in Milwaukee participating in the HEI for the first time in the 2019 survey and earning the Leader designation. Meanwhile, the Advocate and Aurora Health systems officially merged in 2019. The leadership for the newly merged health system asked how long it would take to ensure that the DEI commitment to the LGBTQ+ population was infused throughout the system and bring all of the system’s hospitals into the HEI. The DEI team at Advocate Aurora Health took on the challenge to bring all of their hospitals on the following year. Using the HEI as a road map in conjunction with their LGBTQ+ health strategy, strong leadership backing, the DEI team worked with HEI champions, ombudsmen, and LGBTQ+ task forces at each hospital in an organized and coordinated fashion to engage all system hospitals to participate in and earn Leader status in both the HEI 2020 and the HEI 2022.
SVP, Chief Diversity & Inclusion Officer
Advocate Aurora Health
Many participating healthcare facilities use the Healthcare Equality Index as a self-assessment tool to discover their facility’s baseline for LGBTQ+ inclusion–countering a common belief that a facility must already have a strong portfolio of LGBTQ+ policies and practices in place prior to participating in the survey. Hospital Damas in Ponce, Puerto Rico chose to participate in the HEI to demonstrate their commitment to the LGBTQ+ community and used their results to spur greater change at their facility and, coincidentally, increase their HEI score.
Responding to a 2019 government-issued Executive Order requirement in Puerto Rico that all physicians must receive 2 contact hours of training on issues of LGBTQIA+ sensitivity in order to retain their license, Hospital Damas first participated in the HEI in 2020. The Governing Body of Hospital Damas assembled an advisory group made up of employees of the hospital, along with cross-departmental teams and external allies, to access the various LGBTQ+ training options made available to HEI participants and assess its own LGBTQ+ inclusivity.
In Hospital Damas’ first year of HEI participation, their team was challenged with identifying the health disparities faced by the Puerto Rican LGBTQ+ community and also with garnering employee buy-in on the importance of this work. Reviewing their HEI 2020 custom needs assessment results and providing access to LGBTQ+ training options to their staff, Hospital Damas began working through these challenges to better meet the needs of the LGBTQ+ community.
“We were aware not only of the inequity in health against patients, family members and employees of the LGBTQIA+ community, but also, thanks to the Healthcare Equality Index, Hospital Damas found strategies and tools to achieve health care equity for this community,” says María Mercedes Torres, MHAS, Hospital Damas’ Chief Operations Officer.
Using their first year score of 45 as a launching pad for improving their LGBTQ+ inclusion, Hospital Damas focused on its opportunities for improvement in the HEI 2022. After much work implementing new initiatives and updating policies over the course of two years, including updates to their electronic health records and external facing website and multiple employee education initiatives including an “LGBTQIA+ Sensitive Health Care Education” module that all employees must complete annually, Hospital Damas doubled its original score to 90 in the HEI 2022 and achieving the “Top Performer in LGBTQ+ Healthcare Equality” designation.
Hospital Damas is one of only two participating facilities from Puerto Rico. With continued efforts in outreach and proactive research of healthcare facilities, the HEI team hopes to increase participation from facilities in Puerto Rico.
María Mercedes Torres, MHAS
Chief Operations Officer
Kathy Armijo Etre, PhD
Vice President of Mission
CHRISTUS St. Vincent
THE HEALTHCARE EQUALITY INDEX 2022 ASKED PARTICIPANTS a series of questions about LGBTQ-inclusive policies and practices. Those questions are divided into four criteria outlined in more detail in our HEI Resource Guide. In addition, a fifth criteria section focuses on known activities or policies that may undermine LGBTQ+ equality or patient care.
Responses to the criteria are reported in aggregate to indicate national trends and facilitate benchmarking. Individual facility scores for these criteria can be found online at hrc.org/hei/search.
Criteria 1: Non-Discrimination and Staff Training
● Patient Non-Discrimination
● Equal Visitation
● Employment Non-Discrimination
● Staff Training
Criteria 2: Patient Services and Support
● LGBTQ+ Patient Services and Support
● Transgender Patient Services and Support
● Patient Self-Identification
● Medical Decision-Making
Criteria 3: Employee Benefits and Policies
● Employee Benefits and Policies
● Transgender-Inclusive Health Insurance
Criteria 4: Patient and Community Engagement
● Patient and Community Engagement
Criteria 5: Responsible Citizenship
Criteria 1: Non-Discrimination and Staff Training
The first section of the HEI Non-Discrimination and Staff Training criteria calls for a written patient non-discrimination policy (or patients’ bill of rights) that includes both “sexual orientation” and “gender identity.” Lesbian, gay, bisexual, transgender, and queer people continue to face discrimination in healthcare because of their sexual orientation and/or gender identity, creating a need for explicit non-discrimination policies. Learn more about this criterion in the HEI Resource Guide.
of HEI participants documented that they include both “sexual orientation” and “gender identity” in their patient non-discrimination policy.
of researched hospitals that published or provided an enumerated patient non-discrimination policy included both “sexual orientation” and “gender identity” in the policy.
97% of HEI participants with an LGBTQ+ inclusive patient non-discrimination policy documented that the policy is readily accessible and communicated to patients in at least two different ways and 99% documented that the policy is readily accessible and communicated to staff in at least one way.
The second section of the HEI Non-Discrimination and Staff Training criteria calls for a written visitation non-discrimination policy or an equal visitation policy. Since 2011, all hospitals that accept Medicare or Medicaid payments have been required to have an equal visitation policy as part of the Conditions of Participation. Learn more about this criterion in the HEI Resource Guide.
of the HEI 2022 participants for which this question was applicable (in-patient respondents) documented that they have equal visitation policies.
of the researched hospitals that published or provided a policy were found to have an equal visitation policy in place.
97% of HEI participants with an equal visitation policy documented that the policy is readily accessible and communicated to patients in at least two different ways and communicated to staff in at least one way.
The third section of the HEI Non-Discrimination and Staff Training criteria calls for an employment non-discrimination policy (or an equal employment opportunity policy) that includes both “sexual orientation” and “gender identity.” Federal law and most state laws do not protect employees from discrimination based on real or perceived sexual orientation or gender identity. Learn more about this criterion in the HEI Resource Guide.
of HEI participants documented that they include both “sexual orientation” and “gender identity” in their employment non-discrimination policy.
of researched hospitals that published or provided a policy or non-discrimination statement were found to have an LGBTQ-inclusive employment non-discrimination policy in place
98% of HEI participants with an LGBTQ+ inclusive employment non-discrimination policy communicated the policy publicly.
Staff Training in LGBTQ+ Patient-Centered Care
The fourth section of the HEI Non-Discrimination and Staff Training criteria calls for key facility employees to receive expert training in LGBTQ+ patient-centered care. This criterion recognizes that training is critical for policies to be successful and for LGBTQ+ patients to feel welcome. Learn more about this criterion in the HEI Resource Guide.
LGBTQ+ Patient Services and Support
The first section of the HEI Patient Services and Support criteria asks about key best practices in support of LGBTQ+ patients as a group. This section includes best practices from The Joint Commission and other sources to enhance care for LGBTQ+ patients. Learn more about this criterion in the HEI Resource Guide.
Planning to Serve LGBTQ+ Populations
Serving LGBTQ+ Populations
Communicating with LGBTQ+ Patients
Transgender Patient Services and Support
Transgender patients are particularly vulnerable in healthcare settings. A large survey by Lambda Legal revealed that 70% of transgender respondents had experienced serious discrimination in health care at some point in their lives.* In a 2015 survey of more than 27,000 transgender Americans, 33% of respondents who had seen a provider in the past year reported one or more negative experiences due to their transgender or gender non-conforming status and 23% of respondents reported that they avoided seeking necessary health care when sick or injured in the past year because of fear of being mistreated as a transgender person.**
Learn more about this criterion in the HEI Resource Guide.
* When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination Against LGBT People and People Living with HIV. New York: Lambda Legal, 2010.
** James, S. E.; Herman, J. L.; Rankin, S.; Keisling, M.; Mottet, L.; and Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality.
For more information about best practices for care of transgender patients see the publication, Creating Equal Access to Quality Health Care for Transgender Patients: Transgender-Affirming Hospital Policies, from HRC Foundation, Lambda Legal, and the LGBT Rights Committee of the New York City Bar Association.
For more information about best practices for clinics and hospitals that seek to promote the health and well-being of transgender and non-binary youth through the creation of multidisciplinary care clinics see the publication, Comprehensive Care Clinics for Transgender & Non-Binary Youth from the HRC Foundation.
Many healthcare authorities such as the Institute of Medicine and The Joint Commission have recommended the routine collection of sexual orientation and gender identity data in healthcare settings. These critical data provide hospitals with information on the potential cultural needs of each patient, as well as an opportunity to monitor and analyze health disparities at the population level. Learn more about this criterion in the HEI Resource Guide.
Patient Self-Identification Related Training
Unfortunately, healthcare organizations have sometimes failed to honor LGBTQ patients’ right to designate the person of their choice, including a same-sex partner, to make medical decisions on their behalf should they become incapacitated, even when legally valid medical decision-making documents have been presented. Learn more about this criterion in the HEI Resource Guide.
This year, the HEI added a new question asking if hospitals have a policy or official practices related to the treatment of intersex children that delay medically unnecessary procedures until the patient is old enough to make an informed decision.
Intersex is an umbrella term that refers to approximately 0.5 to 1.7 percent of the population born with variations in sex characteristics such as chromosomes, gonads, and/or genitals that vary from what is considered typical. Non-medically necessary procedures intended to change the genital appearance and reproductive anatomy to fit arbitrary norms are frequently performed on intersex infants and youth children before the child can have a voice in the matter and make an informed decision.
Only 2% of HEI participants have a policy related to postponing medically unnecessary procedures on intersex children.
For more information about best practices for the care of intersex children see the publication, Providing Ethical and Compassionate Health Care to Intersex Patients: Intersex Affirming Hospital Policies written by interACT: Advocates for Intersex Youth, Lambda Legal, and Proskauer Rose LLP.
LGBTQ+ employees of healthcare organizations play a vital role in ensuring LGBTQ+ patient-centered care by informally educating co-workers about patient concerns, offering feedback about organizational policies and practices, and conveying to the local community the organization's commitment to equality and inclusion. It is critical that LGBTQ+ employees, like LGBTQ+ patients, receive equal treatment, particularly regarding health-related benefits and policies. Learn more about this criterion in the HEI Resource Guide.
Competitive employer-provided benefits packages are critical to attracting and retaining talent. Providing LGBTQ employees and their families with inclusive benefits, from healthcare coverage to retirement investments and more, is a low-cost, high-return proposition for businesses. HRC strongly urges employers to maintain domestic partner benefits for their workers going forward as a sign of sustained commitment to family diversity, inclusion and protection of LGBTQ+ employees whose rights outside the workplace are not guaranteed under law in many states. Domestic partner benefits ensure that all employees will be treated equally.
Transgender Inclusive Healthcare Benefits
Access to healthcare benefits that cover gender-affirming care are critical for the health and well-being of transgender people. While there has been an improvement over the past several years, healthcare facilities continue to lag behind their corporate counterparts when it comes to providing this important and necessary benefit. To receive credit for this criterion, which is necessary to obtain HEI Leader status, participants must provide to all employees at least one health plan that explicitly covers medically necessary health services for transgender people, including gender transition-related treatment.
Other Support for LGBTQ+ Employees
In addition to providing equal benefits, there are a number of other ways that employers can be inclusive of and supportive of their LGBTQ+ employees.
In addition to ensuring healthcare coverage for gender-affirming care, one of the most important policies an employer should have is a set of written gender transition guidelines that document the necessary policies and practices in place to support a respectful and successful workplace transition.
The HRC Foundation’s Transgender Inclusion in the Workplace: A Toolkit for Employers is a comprehensive resource to guide employer transgender inclusion. The toolkit includes HRC’s best practice advice for implementing transgender-inclusive policies and practices (including sample policies) as well as guidance for implementing transgender-inclusive healthcare benefits.
Healthcare organizations can welcome LGBTQ+ people in their service area by implementing community engagement initiatives like those recommended in this section.
In previous years, the vast majority of participants displayed their support for the LGBTQ+ community by participating in and sponsoring local pride events. However, with pride events canceled and/or turned virtual due to the pandemic, healthcare facilities had to find other ways to reach out to the community. Facilities actively engaged with LGBTQ+ patients, employees, and local communities through a variety of events and programs, including LGBTQ+ COVID vaccination events, educational talks for providers and community members, and celebration of LGBTQ-recognition days such as National Coming Out Day and Transgender Day of Remembrance.
34% publicly supported LGBTQ+ equality under the law by speaking out on local, state, or federal legislation or policy initiatives. During the 2021 state legislative sessions, over 260 anti-LGBTQ bills proliferated across the states. In turn, businesses spoke out and rebuked attempts to undermine LGBTQ+ civil rights at record rates. Hospitals and other healthcare providers have been slower to add their voice to those that support LGBTQ+ equality by speaking out against anti-LGBTQ bills in their states or supporting pro-equality legislation.
For more information on LGBTQ+ related legislation in the states, view HRC’s 2021 State Equality Index.
This section focuses on known activities that undermine LGBTQ+ equality or patient care. Healthcare organizations can have points deducted from their score if they have policies in place that may lead to discriminatory treatment or a large-scale official or public anti-LGBTQ+ blemish on their recent records. Learn more about this criterion in the HEI Resource Guide.
The largest deduction of 25 points is for major offenses that come to the attention of the HRC Foundation such as revoking LGBTQ+ inclusive policies and practices or having policies in place and/or engaging in proven practices that are contrary to the organization's written LGBTQ+ patient or employment policies. HRC realizes that no institution is perfect and that situations may arise where an individual or small group act in a way that is not in alignment with the organization’s policies and commitment to LGBTQ+ equality and patient care. This criterion is not intended to penalize an organization in those situations where an isolated negative action takes place, provided that the organization addresses the situation and takes action to ensure that their commitment to LGBTQ+ patient care remains uncompromised.
The HRC Foundation does not take the application of this penalty lightly and prior to this year, it has only been used in one instance. Unfortunately, this year three hospitals have received the 25 point deduction: University of Texas Southwestern Medical Center and Children’s Health in Dallas received the deduction for discriminating against transgender children by not providing them with the same care that they provide to other children; and Mercy San Juan Medical Center for discriminating against a transgender man, Evan Minton by denying him a hysterectomy. Learn more about each of these cases by following the links above.
This year, the HEI introduced a new penalty option under the Responsible Citizenship criteria. This penalty is for organizations that either follow a religious directive or have a policy in place that prevents them from providing specific medically necessary treatments, such as hysterectomy or mastectomy, to some patients based on a diagnosis of gender dysphoria, but allows them to provide the same treatment to other patients based on other diagnoses, this may result in discriminatory treatment that is in conflict with their non-discrimination policy.
This year, this penalty was applied to 137 HEI 2022 participants. The majority (115) of these participants are facilities operated by the Veteran’s Health Administration, which due to an exclusion in the VA medical benefits package are unable to provide gender-affirming surgeries. The other group of 22 hospitals that received this penalty are Catholic healthcare facilities that interpret one or more of the Catholic Ethical and Religious Directives in a way that means they will not perform certain gender-affirming surgeries while they would provide the same surgeries for other patients based on other diagnoses.
Organizations with this type of directive or policy in place may only be subject to a five-point deduction (to offset the points received for the Patient Non-Discrimination Policy) if they take certain actions to mitigate the potential for discriminatory situations to occur. These actions include providing a statement on their website about the services that are not provided, having a referral mechanism in place, and communicating this limitation to area surgeons.
After taking these communication steps an organization would only be assessed a 5 point deduction. If after this deduction, the organization has a final score of between 80-95 and meets the other criteria for earning the Top Performer designation (full credit in criteria 1 and at least partial credit in criteria sections 2, 3, & 4), the organization may earn the Top Performer designation.
The Healthcare Equality Index is a project of the Health & Aging Program at the Human Rights Campaign Foundation. In addition to the HEI, the Health & Aging Program also operates the Long-Term Care Equality Index (LEI) in partnership with SAGE. The Health & Aging Program researches, develops, and advocates for LGBTQ+ health and aging initiatives at the federal, state, and local levels, and provides support to institutions seeking to enhance LGBTQ+ wellbeing via education, policy, research, and technical assistance.
Tari Hanneman (she/her) is the Director of the Health & Aging Program at the Human Rights Campaign Foundation and the author of the HEI. In addition to managing the development and publication of the Healthcare Equality Index, she oversees other projects related to LGBTQ+ health and aging including the new Long-Term Care Equality Index. Tari has more than 25 years of experience in the nonprofit and philanthropic sector, primarily focused in the areas of health and women’s issues. She holds a master’s degree in public administration with an emphasis on nonprofit management from the University of Southern California, where she also did her undergraduate work – Fight On!
Marcos R. Garcia (he/him) is the Associate Director of the Healthcare Equality Project at the Human Rights Campaign Foundation and co-author of the HEI. In this role, he engages directly with hospitals and other healthcare facilities nationwide to identify and improve LGBTQ+ inclusive policies and practices. Marcos also manages all aspects of the HEI database and survey implementation. Born and raised in New Jersey, Marcos holds a bachelor’s degree in neuroscience and behavior from Columbia University in the City of New York and previously worked in melanoma research at the National Cancer Institute.
Shannon Touhey (she/her) is the Coordinator for the Health & Aging Program at the Human Rights Campaign Foundation. In this role, she fields questions from hospitals and other healthcare facilities nationwide about the HEI process, works on HEI survey review, and provides logistical support for the Health & Aging team. She holds a bachelor's degree in public health and sociology from American University.
Dan Stewart (he/him) is the Associate Director of the Aging Equality Project at the Human Rights Campaign Foundation. In this role, he manages the Long-Term Care Equality Index, a tool that supports residential long-term care communities to adopt LGBTQ+ inclusive policies and provides technical assistance to long-term care communities to help them become more LGBTQ+ inclusive. In addition, he develops resources on LGBTQ+ aging and supports the Health & Aging team with HEI survey review. Dan holds a bachelor’s degree in psychology from Saint Louis University and a master of science degree in gerontology from the University of Missouri - St. Louis.
Thank you to HRC Foundation Senior Vice President Jay Brown and HRC Senior Director of Programs & Partnership Ellen Kahn for their leadership stewardship of the Health & Aging Program.
Thank you to HRC’s Data and Analytics Team for all of their assistance managing the HEI data with a special shout-out to Alec Carrasco, who always finds a way to make it work. Thanks to the team at Heller Consulting who built the database behind the HEI and continue to help us improve upon it.
Thank you to Joseph Glover, Health & Aging Program Intern, for his assistance in researching hospital policies and for working through particularly trying times.
Thank you to our temporary assistant Keerat Gill for her invaluable assistance in reviewing HEI surveys and HEI training credit requests.
Thank you to Robert Villaflor and Josette Matoto for design guidance and support.
The HEI 2022 was designed by Tony Frye Design.
Special thanks to the LGBTQ+ patients and HEI 2022 participants who provided material for this report.
Thank You to GLMA: Health Professionals Advancing LGBT Equity, an endorsing partner of the Healthcare Equality Index
The HEI was funded in part by grants from PhRMA and Pfizer, Inc.
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Take advantage of free online, on-demand staff training from expert sources that includes CME/CEU credits
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Improve quality and safety
Reduce risk of litigation, complaints and negative publicity
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What Organizations are Eligible?
The HEI is primarily intended for inpatient facilities that provide general medical and surgical care. However, specialty hospitals and certain outpatient healthcare facilities may request to participate in the HEI. Typically, a facility or organization must have at least 100 employees to be eligible to participate.
Clinic organizations with multiple locations such as Federally Qualified Health Centers (FQHCs) and FQHC look-alikes, Planned Parenthood Affiliates and other similarly structured organizations are eligible to participate - however, they have special guidelines related to meeting the training criteria. These organizations should register for the primary organization only, not for individual clinic sites.
Physician practices, medical groups, mental healthcare providers, and solo health practitioners are NOT eligible to participate in the HEI.
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