By: Leanne Quakenbush, OTR/L

Compared with cisgender, heterosexual peers, the LGBTQIA2S+ community experiences higher rates of health and social disparities. Occupational therapy practitioners (OTPs), with our holistic lens and scope of practice, are uniquely qualified to meet the needs of this community. To provide effective care, we need to examine our implicit biases, continue learning evidence-based ways to support LGBTQIA2S+ clients with humility and respect, and enter each therapeutic relationship with an open mind and heart (thank you for doing that by reading this article!).

Unique Challenges Faced by the LGBTQIA2S+ Community 

As of early 2026, the American Civil Liberties Union (ACLU) is tracking 420 state-level bills it identifies as restricting LGBTQIA+ rights in the United States (ACLU, 2026). These include restrictions related to social transitioning (for example, using a chosen name or pronouns), access to gender-affirming health care (such as hormone blockers or surgery for individuals of all ages), and engagement in meaningful school activities such as sports and other extracurriculars for transgender youth. As occupational therapy practitioners, it is our role to co-create pathways that maximize our clients’ ability to overcome barriers to engagement in meaningful occupation whenever possible. We must also advocate for change when we encounter occupational injustice.  

LGBTQIA2S+ individuals face unique challenges and health disparities, including but not limited to: 

• Increased suicide risk, poorer mental health, chronic health conditions, and homelessness. For example, one large survey reported a lifetime suicide attempt rate as high as 41% among transgender respondents (Bolding et al., 2022). In 2022, the national crisis system introduced a specialized support option for LGBTQ+ youth; in 2025, that option was discontinued, raising concerns given ongoing suicide risk and discrimination. 

• High rates of young adults becoming unhoused after coming out to families, especially when home becomes unsafe or they are forced to leave.  

• Discrimination can weaken family and community ties, leaving some LGBTQIA2S+ adults with smaller or less reliable support networks; social isolation can be especially pronounced for people who are also disabled and/or people of color across the aging process. 

• Some individuals are rejected from or shamed by faith communities they once relied on, which can mean losing community, spiritual support and opportunities for religious expression and identity (Oswald & Cooper, 2024). 

• LGBTQIA2S+ individuals with autism have reported experiencing others dismissing their identity and decreased ability to create and sustain meaningful supportive relationships (Schmidt et al., 2026; Vaughn et al., 2025). 

• Transgender and gender diverse (TGD) individuals also face specific unique challenges including:  

• Microaggressions (for example, dismissive comments or assumptions), harassment, and misgendering by health care practitioners (HCPs) have been reported by TGD individuals (Bhatt et al, 2022). In a study by Acker in 2017, occupational therapy students self-reported significantly higher levels of transphobia than social work students at the same institution. Individuals who have negative experiences with HCPs are likely to delay or avoid future care, which can deepen health disparities over time (Bolding et al., 2022). 

• Risk of health disparities, violence, and even death can be higher for TGD people when transphobia intersects with racism, ableism, language barriers, lower income, and lower educational opportunity (Lubitow et al, 2017; Reisner et al., 2015, Shakibaei & Vorobjivas-Pinta, 2022). 

• Decreased access to medical care including gender affirming care such as hormones, puberty blockers or surgery (Stugart et al., 2025). 

• Decreased access to practitioners across all fields who are well-trained and competent to meet their needs, resulting in decreased patient access to critical services. Patients often have to educate practitioners themselves. 

• Higher rate of workplace discrimination, including hiring barriers, harassment, and job insecurity.  

• TGD parents may face bias in custody, visitation or parenting-time proceedings, which can interfere with their ability to fulfill their parenting roles. 

• When a TGD person’s ID (name and/or gender marker) does not reflect their identity, it can create barriers to travel, voting, employment, housing, and health care, and can increase stress and harm mental health. 

OT practitioner’s role in fostering inclusive and affirming care  

• Given high rates of stigma and trauma exposure, consider a trauma-informed approach that prioritizes safety, choice, collaboration, trust, and empowerment.

• Addressing ADLs: 

• Support identity expression by exploring affirming and accessible clothing choices and how this may intersect with neurodivergence and sensory sensitivity. Practice communication strategies, such as how a client might role play to share preferred pronouns with a family member or new friends. 

• Collaborate on bathing, grooming, self-care rituals and routines that help manage dysphoria and support privacy, comfort, emotion safety and quality of life (Guillory, et al., 2023). 

• Create practical safety and coping plans for restroom access, such as identifying gender-neutral and accessible options, preparing a brief self-advocacy script if needed, and planning alternatives when choices are limited.  

• Provide post-operative education, precautions and care for gender-affirming surgery in alignment with the surgeon’s protocol, including mobility and positioning precautions, graded sitting tolerance, and ADL adaptations as healing progresses (Guillory et al., 2023; Steuer & Walker, 2023). 

• Addressing IADLs: 

• Help clients identify and connect local support networks (virtual or in-person), including age-specific groups when available, and problem-solve barriers to participation. 

• Support clients in choosing transportation options that are accessible and safe, considering potential mobility needs. 

• Support the emotional and executive functioning demands required to go through the process of possible name or gender-marker changes related to government IDs for travel, voting, etc. 

• Provide life skills training as needed, such as budgeting, exploring volunteer roles, building meaningful social connections, and navigating the health care system (including health literacy for hormone treatment symptom management or gender-affirming surgery, when applicable) (Van Dyke & Blaskowitz, 2022). 

Key takeaways/action items: 

• Engage in regular continuing education related to these areas of practice.  

• Use inclusive language when speaking with clients and families (for example, “the child” or “the parent”, rather than gendered terms). 

• If you are worried about offending someone by asking their preferred pronouns, start by offering yours or by simply asking, “How do you prefer to be addressed?” A large number of people use a different name than their given name at birth. It is not an uncommon question to ask someone. 

• Include open text fields or a write-in option on intake forms for ‘pronouns’ and ‘name used’, rather than limiting people to a short list (for example, avoid only she/her, they/them, he/him options as these are not the only possible combinations). 

• If a client’s legal name must be used for certain documents, tell the client why and where it will appear, and ask what name you should use in conversation and clinical notes whenever possible. Advocate for system changes that reduce unnecessary exposure to a client’s former name.

• Look up current state laws and policies affecting the LGBTQIA2S+ population (see ACLU resource) and consider how this may affect your clients’ access to care, participation in daily life, and safety. 

• If you are involved in any OTP education system, advocate for improved quantity and quality of educational content related to this population. Include the integration of lived experience panels that feature individuals from the LGBTQIA2S+ community. These types of education between practitioner and community member have been found to be very beneficial to reduce bias as well as improve affirming care and occupational justice for this community (Amin-Arsala et al., 2024; Bolding et al., 2022; Leite & Lopes, 2022). 

• Know that you can make a difference by providing affirming care for LGBTQIA2S+ individuals throughout the lifespan, meeting your clients where they are, and validating their lived experience. 

Helpful Vocabulary 

LGBTQIA2S+: A common acronym that is ever-evolving and symbolizes a community of people including lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and two-spirit. The + symbolizes the inclusion of other identities such as nonbinary, pansexual, and gender-fluid. 

Transgender and gender-diverse (TGD): Describes individuals whose gender identity does not align with the one they were assigned at birth (AOTA, 2023). 

Misgendering: Using a pronoun in relation to someone that does not align with that person’s gender identity, whether intentional or unintentional, is invalidating a person’s identity.  

Resources for further self-exploration 

• Harvard’s “Project Implicit”- the Implicit Association Test (IAT) measures attitudes and beliefs that people may be unwilling or unable to report. The IAT can be especially useful if it reveals implicit attitudes that you did not expect, including attitudes related to sexuality, gender identity, race, skin tones, religions, disability, weight, age and many more (Project Implicit, n.d.). 

• AOTA representative assembly (RA) briefing: Review of AOTA’s practice guide toward trans and queer inclusion (Amin-Arsala et al., 2024). 

• AOTA gender affirming language Glossary (AOTA, 2023). 

• AOTA YouTube webinar series- It’s within our scope: Gender inclusive practice panel series.

References 

Acker, G. M. (2017). Transphobia among students majoring in the helping professions. Journal of Homosexuality, 64, 2011–2029. https:// doi.org/10.1080/00918369.2017.1293404

American Civil Liberties Union. (2026). Mapping attacks on LGBTQ rights in U.S. state legislatures in 2026. Retrieved February 20, 2026, from https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2026

American Occupational Therapy Association. (2023). Gender-affirming language. https://www.aota.org/-/media/corporate/files/practice/dei/aota-gender-affirming-language.pdf

Amin-Arsala, T., Wagner, A., Hoyt, C., Galindo-Jackson, V., Larson, S., Lyons, V., & Warren, A. (2024). RA briefing: Review of AOTA’s practices toward trans and queer inclusion. https://www.aota.org/-/media/corporate/files/secure/governance/ra/2024-spring-meeting/ra-briefingqueer-inclusionsubmitted-11224.pdf

Bhatt, N., Cannella, J., & Gentile, J. P. (2022). Gender-affirming care for transgender patients. Innovations in Clinical Neuroscience, 19(4-6), 23–32. 

Bolding, D. J., Acosta, A., Butler, B., Chau, A., Craig, B., & Dunbar, F. (2022). Working with lesbian, gay, bisexual, and transgender clients: Occupational therapy practitioners’ knowledge, skills, and attitudes. American Journal of Occupational Therapy, 76(3), 7603205130. https://doi.org/10.5014/ajot.2022.049065 

Guillory, B., Rafalski, L., Ashcroft, K., DeRolf, A., Neu, D., & Tickoo, S.. (2023). Caring for transgender and gender diverse individuals: ADLs and IADLs. https://www.aota.org/practice/practice-essentials/dei/transgender-and-gender-diverse-resources/caring-for-transgender-and-gender-diverse-individuals-adls-and-iadls

Leite, J. D., & Lopes, R. E. (2022). Dissident genders and sexualities in the occupational therapy peer-reviewed literature: A scoping review. American Journal of Occupational Therapy, 76(5), 7605205160. https://doi.org/10.5014/ajot.2022.049322

Lubitow, A., Carathers, J., Kelly, M., & Abelson, M. (2017). Transmobilities: mobility, harassment, and violence experienced by transgender and gender nonconforming public transit riders in Portland, Oregon. Gender, Place & Culture, 24(10), 1398–1418. https://doi.org/10.1080/0966369X.2017.1382451

Oswald, A. G., & Cooper, L. (2024). Addressing equity and justice in age-friendly communities: Considerations for LGBTQ+ older adults of color. The Gerontologist, 64(7), gnae050. https://doi.org/10.1093/geront/gnae050

Project Implicit. (n.d.). Education. Retrieved February 23, 2026, from https://implicit.harvard.edu/implicit/education.html 

Reisner, S. L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D., & Mimiaga, M. J. (2015). Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. Journal of Adolescent Health, 56(3), 274–279. https://doi.org/10.1016/j.jadohealth.2014.10.264

Schmidt, E. K., Rexha, F., Williams, M., Bauza, J., Sicherer, M., & Hickman, R. (2026). Contextual factors contributing to social participation for LGBTQIA+ Autistic adults in the United States. Autism in Adulthood, 7(6). https://doi.org/10.1089/aut.2023.0149 

Shakibaei, S., & Vorobjovas-Pinta, O. (2022). Access to urban leisure: Investigating mobility justice for transgender and gender diverse people on public transport. Leisure Sciences, 1–19. https://doi.org/10.1080/01490400.2021.2023372

Steuer, A., & Walker, K. R. (2023). Occupational therapy’s role for gender affirming surgeries: Vaginoplasty and vulvoplasty. Occupational Therapy in Health Care, 39(1), 1–17. https://doi.org/10.1080/07380577.2023.2243333 

Stugart, L. K., Larson, S. C., Lipsey, K. L., Owens, G., & Hoyt, C. R. (2025). Gender-affirming care is not standard care in occupational therapy: A scoping review. American Journal of Occupational Therapy, 79(2), 7902180060. https://doi.org/10.5014/ajot.2025.050883 

Van Dyke, O. M. & Blaskowitz, M. (2022). Operation occupation: A client-centered life skills program for transgender and nonbinary individuals experiencing homelessness. American Journal of Occupational Therapy, 76(Supplement_1), 7610500018. https://doi.org/10.5014/ajot.2022.76S1-PO18 

Vaughn, M., Schmidt, E., & Perdue, T. (2025). Sense of belonging for LGBTQIA+ autistic adults age 35 years & older. American Journal of Occupational Therapy, 79(Supplement_2), 7911500097. https://doi.org/10.5014/ajot.2025.79S2-PO93