A Review of Primary Care Providers' Attitudes Toward Lesbian, Gay, Bisexual, Transgender, and Questioning People

Aleshire, Mollie E.

Background: Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals experience health disparities at higher rates than their heterosexual counterparts, and some of these health disparities may be directly attributed to delays in seeking health care (Clift & Kirby, 2012; Institute of Medicine, 2011; Kates, 2015). Understanding health care providers’ attitudes related to LGBTQ people is an essential part of the foundational knowledge necessary to guide future interventions to address these inequalities (Abdessamad, Yudin, Tarasoff, Radford, & Ross, 2013; Daniel & Butkus, 2015; Institute of Medicine, 2011; Smith & Mathews, 2007). Nurse practitioners and other primary care providers (PCPs) often serve as a common portal of entry into the health care system and actual or perceived discriminatory attitudes may cause LGBTQ patients to not disclose their sexual orientation or gender identity or to delay seeking appropriate health care. When health care is postponed or avoided, this can potentially lead to suboptimal treatment or health outcomes (Baker & Beagan, 2014; Fallin-Bennett, 2015; Johnson & Nemeth, 2014).

Purpose:The purpose of this presentation is to provide a systematic review of current literature describing primary care providers’ attitudes related to LGBTQ people.

Method: A systematic review of the literature was completed using Cumulative Index for Nursing and Allied Health Literature (CINAHL) and PubMed (Medline) databases and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009). Inclusion criteria were peer-reviewed, research articles; articles pertaining to PCPs; articles published in English; and articles published from 2005 through October 2015. All fields were searched and the key search terms used were LGBT (lesbian, gay, bisexual, transgender), attitude, and primary care provider. Seven articles were identified that were eligible for review based on inclusion and exclusion criteria.

Results: Of the seven studies included in the review, two were qualitative interviews and the remaining five utilized quantitative, self-survey designs. There was significant variability in the studies’ countries of origin. All studies assessed attitudes of health care providers related to lesbian, gay, bisexual, transgender, queer, or questioning people; but there was significant heterogeneity in the studies’ purposes, research questions, and the specific LGBTQ population(s) focused on. All studies used convenience samples and all samples included primary care providers, but no reviewed studies specifically included nurse practitioners or physician assistants. Most samples were small in size (Abdessamad et al., 2013; Baker & Beagan, 2014; Dunjic-Kostic et al., 2012; Hinchliff, Gott, & Galena, 2005; Kitts, 2010), but the sample sizes ranged from 22 to 247,030 participants (Abdessamad et al., 2013; Baker & Beagan, 2014; Dunjic-Kostic et al., 2012; Hinchliff et al., 2005; Kitts, 2010; Sabin, Riskind, & Nosek, 2015; Smith & Mathews, 2007). No consistent instrument was used to measure health care providers’ attitudes related to LGBTQ people. Although all study results were indicative of overall positive attitudes by health care providers toward sexual and gender minorities, each study also had a minority of participants that had negative attitudes toward lesbian, gay, bisexual, transgender, or questioning people. Age did not emerge as a predictor of attitudes related to LGBTQ people in this literature review (Abdessamad et al., 2013; Baker & Beagan, 2014; Dunjic-Kostic et al., 2012; Hinchliff et al., 2005; Kitts, 2010; Sabin et al., 2015; Smith & Mathews, 2007). Providers who identified as not being heterosexual endorsed more favorable attitudes toward LGBTQ people in all studies where this relationship was assessed and reported (Abdessamad et al., 2013; Sabin et al., 2015; Smith & Mathews, 2007). Knowledge related to LGBTQ people or LGBTQ health was not correlated with health care provider attitudes (Abdessamad et al., 2013; Dunjic-Kostic et al., 2012; Hinchliff et al., 2005; Kitts, 2010).

Conclusion: Research implications: Currently, gaps abound in the literature describing the attitudes of PCPs regarding LGBTQ people and a reliable, valid, contemporary instrument to measure health care provider attitudes toward LGBTQ populations is lacking. Further research is needed to foster a more complete understanding of LGBTQ health, to address how PCPs’ attitudes may affect LGBTQ health care, and to determine best primary care practices to eliminate LGBTQ health disparities (Daniel & Butkus, 2015; Institute of Medicine, 2011). Education implications: Curricula for all primary care providers must include training in communication, sexual health, and LGBTQ health and social issues as an integral part of the curriculum that is normalized and required. Education on these topics should not only be didactic, but must include clinical experiential learning and reflective practice to prepare clinicians to meet the health care needs of LGBTQ people(Daniel & Butkus, 2015; Gay and Lesbian Medical Association, 2006; "Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: a position paper of the Society for Adolescent Health and Medicine," 2013; Stott, 2013; The Joint Commission, 2011). Practice Implications: Primary care providers must have sensitivity, knowledge, and awareness related to the health and social needs of LGBTQ people and be prepared and willing to engage in communication with their LGBTQ patients and to facilitate a trusting healthcare provider-patient relationship (Daniel & Butkus, 2015; Gay and Lesbian Medical Association, 2006; Lim, Brown, & Justin Kim, 2014; "Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: a position paper of the Society for Adolescent Health and Medicine," 2013; Stott, 2013; The Joint Commission, 2011). Strategies to promote culturally sensitive care for LGBTQ people include creating a welcoming, supportive environment; facilitating disclosure of sexual orientation and gender identity; advancing effective communication; and advocating LGBTQ people in the health care system and community (The Joint Commission, 2011).