Creating Inclusive Practices for LGBTQ+ Community – An Interview with Theresa Garnero

June is Pride Month and in honor of providing best care for our LGBTQ+ community, we are highlighting an expert interview, with my dear friend and colleague, Theresa Garnero, APRN, BC-ADM, MSN, CDCES.

Theresa is a trailblazer and advocate in the field and she reminds us that whether we provide services in the hospital, clinic, or outpatient settings, we can take steps to help all people we serve feel welcome and included. We know that many people from the LGBTQ+ community with prediabetes or diabetes may delay seeking medical care to avoid the pain of social stigma often experienced in medical settings.

“Members of the lesbian, gay, bisexual, transgender and queer (LGBTQ) community have unique health disparities and worse health outcomes than their heterosexual counterparts, which has clinical relevance in the delivery of diabetes care and education. Diabetes care and education specialists are in a pivotal position to help this medically-underserved and vulnerable population get the best possible care.” – ADCES

By paying careful attention to each person’s experience from the moment they walk in the door until we say goodbye, we can find ways to create a more inclusive environment. This awareness of the details, such as inclusive gender questions on intake forms or gender-neutral signage on the bathrooms, are great first steps to show your care and respect for those you work with.

For more information on this topic, we turn to our expert for insights and resources.

Interview with Ms. Theresa Garnero, APRN, BC-ADM, MSN, CDCES

1. What inspired you to write the ground-breaking article for on “Providing Culturally Sensitive Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) community” in Diabetes Spectrum, gosh – already 10 years ago now?

I heard a researcher at a national conference go on and on about needing to screen the daughters of women with polycystic ovarian syndrome (PCOS) for diabetes since there is a strong link between PCOS and type 2. She never discussed the population of women that have the highest rates of PCOS – lesbians (38% of lesbians have PCOS vs. 14% of heterosexual women1). So I went up to the mic and asked her if she was aware of Agrawal’s work showing lesbians have the highest rate of PCOS. I was flabbergasted when she said yes. I responded she might want to include that most vulnerable population in her talk as we need to screen all women at risk.

It got me thinking about how could a well-known professor at a national diabetes conference willingly withhold data about an under-served population? So, I began to comb through the existing research that impacts the LGBTQ community with regards to diabetes care and prevention. And I was astonished what I found. So, I wrote the article and was so glad the ADA published it. But why wasn’t this part of the conversation back then? Even now? And I still ask, why won’t ADA reply to my inquiries to include this special population within their Standards of Care?

2. What’s the first step our readers could do to provide inclusive care to the sexual and gender minority population of people with prediabetes and diabetes who seek care?

Actually take steps to include this special population. I think there are several opportunities to do this, starting with making sure their environment gives clues that it is a safe place for the LGBTQ community to seek care. Remember, this community is used to outright hostility from within the healthcare system and are often reluctant to self-disclose out of fear for getting substandard care.  I once worked with a man with type 1 diabetes who was gay tell me that his endocrinologist told him he deserved every low he got, and that when he’d go to the emergency department, they refused for his husband to be by his side And that happened in the gay mecca of San Francisco! Imagine other “less tolerant” places.

If they see you don’t have a clue because you have old forms with old terms, they most likely won’t come out. And if they don’t come out, then you don’t have all the data to make an individualized plan. So, you can check your assessment forms to see if you use inclusive terms. Do you actually ask for LGBTQ status by asking for sexual orientation, gender identification and relationship status (not marital status)? And collect the aggregate data! Just because it’s not measured doesn’t mean it doesn’t exist. Do you have clues in your waiting room that it’s safe and friendly for this group (like post a little rainbow flag)? Do you include LGBTQ risk factors for health outcomes in your materials? Do you tell people you are here to help everyone, no matter their situation or who they’re with? I realize change is slow, but collectively as individuals, and nationally, we can make it a better place for this underserved population.

3. “Inclusive Care” seems to be the new buzz phrase, but I bet most diabetes care and education specialist think they are being inclusive. I mean, how could you not be?

Because if you don’t even know a certain segment of those you care for have unique risk factors, and arguably worse – you have no clue who that vulnerable population is in your practice – you aren’t doing all you can to provide quality care to all you serve. It’s estimated that the number of LGBTQ individuals with diabetes equals that of the amount of people with type 1, so it’s not a small number we’re talking about. As an example, let’s apply this to Social Determinants of Health. We talk about the research showing how your zip code has more to do with your health than your DNA, particularly as it relates to food insecurity. But did you know LGBTQ individuals and families have the highest rates of food insecurity? Why isn’t that research included in diabetes mainstream publications and conferences?

According to research presented by the Williams Institute2, more than 1 in 4 LGBTQ adults (27%), approximately 2.2 million people, experienced a time in the last year when they did not have enough money to feed themselves or their families, compared to 17% of non-LGBTQ adults.

And when you add racial/ethnic sub-populations within the LGBTQ community, the stats are staggering:

  • Among LGBTQ people, 42% of African-Americans, 33% of Hispanics, 32% of American Indians and Alaskan Natives, and 21% of Whites reported not having enough money for food in the past year.

4. I was thrilled to see the handout that you wrote about inclusive care for the ADCES. That’s a start for sure. How do you think this came about?

Thank you! I am so excited to see our national organization pay attention to the LGBTQ population and help get the word out about what we can do. I think because they are interested in us being the best diabetes care and education specialist that we can and including everyone is part of that. I had also just spoken at the AADE conference in Houston. We had a panel of professionals and researchers that represented the LGBTQ community. (I had spoken previously at AADE, but that was just by myself and this last time was so special.) I’m truly impressed with how much research that has transpired in these 10 years.

5. Any closing thoughts?

I’d say that a willingness to learn is so important. As is recognizing one’s personal biases. We certainly don’t agree with the lifestyles of all we serve, but it is not our role to judge or let those biases interfere with helping someone find a path to thriving with diabetes. And just know, it takes time to get up to speed. I’d encourage readers to check out the ADCES handout and watch this funny video clip that a colleague sent me. Honestly, it is hard to keep up with the terms, even for someone like me who helped to get this topic on the diabetes radar. This video made me crack up and appreciate the nuance of all the terms. I bet your audience would like it too. You can check out the “What “The Sex Talk” Looks Like Now, by Alternatino. Thanks so much, Beverly, for your willingness to discuss the topic. I truly hope it helps your readers improve their care delivery.


Ms. Theresa Garnero, APRN, BC-ADM, MSN, CDCES  trail-blazed several innovations in the field of diabetes in the years that followed being awarded the national Diabetes Educator of the Year by the American Association of Diabetes Educators (2004).

Her latest efforts involve trying to reach people with prediabetes and type 2 who are currently not being reached with our face-to-face programs. How? She created the Sweet People Club  an all online program which uses a flipped classroom concept so people can follow the Diabetes Prevention Program and also manage type 2 through a series of professionally-made videos (ahem, nearly 150 of them!) that they can watch at a time that is convenient for them, then ask questions through the portal, as well as meet virtually face-to-face real time with a Registered Dietitian twice a month.

If you’d like access to experience what the program is like, she is sharing her work and invites your feedback. Visit https://www.sweetpeopleclub.com/pro/ or email her for questions at Theresa.Garnero@sweetpeopleclub.com 

List of Resources

ADCES Inclusive Care for LGBTQ+ People with Diabetes Handout – this handout provides definitions, terms to avoid, and a cultural competency checklist to help you move towards improving inclusivity within your practice.

All Gender Restroom Sign PDF

A Guide To Gender Identity Terms by NPR – A glossary for gender identity terms to use more inclusive language.

Diabetes Prevention and Management for LGBTQ+ People Handout – this handout includes research of diabetes within the LGBTQ community, along with clinical considerations, programs, and resources for diabetes educators to use within their practice.

Policies on Lesbian, Gay, Bisexual, Transgender & Queer (LGBTQ+) issues – this resource by the American Medical Association lists all the current healthcare policies in place for the LGBTQ community.

Helio’s LGBTQ+ Health Updates Resource Center – this is a “collection of news articles and features that provide the latest information on the unique health needs of individuals in the LGBTQ+ community.”

  1. Agrawal et al: Prev. of polycystic ovaries and polycystic ovary syndrome in lesbian women compared w heterosexual women. Fert Steril 82:1352-57, 2004.
  2. FOOD INSECURITY AND SNAP PARTICIPATION IN THE LGBT COMMUNITY. (n.d.).
  3. Sweet People Club

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