Enhancing LGBT + primary healthcare in Slovenia: A national qualitative study of experiences and expectations of LGBT + people and family doctors

Abstract

Background

Despite growing acceptance of LGBT + individuals, an underlying stigma persists even in healthcare, resulting in substandard care and worse healthcare outcomes for LGBT + individuals.

Objectives

To examine and compare the experiences and expectations regarding primary healthcare among LGBT + individuals and general practitioners (GPs) in Slovenia.

Methods

We conducted an online national qualitative study using open-ended questions. To reach LGBT + population snowball method of recruitment was employed by sharing the questionnaire through LGBT + organisations, while GPs were invited by email of Association of family doctors in Slovenia. Anonymous data was collected from October to December 2021 and the questionnaires of 25 GPs and 90 LGBT + individuals of various ages, backgrounds, gender identities and sexual orientations were reviewed using thematic analysis.

Results

Both LGBT + participants and GPs expressed a desire for equal treatment. However, while all GPs claimed to treat all patients equally, LGBT + participants reported more varied experiences. Specific knowledge, especially on LGBT + terminology and healthcare, was perceived as lacking among GPs, leading LGBT + individuals to seek advice from specialists or community counselling. Systemic barriers, including societal stigmatisation and limited formal education on LGBT + issues, were identified, highlighting the need for designated safe spaces and improved GP training. Safety emerged as a central theme, crucial for fostering trust and disclosure between patients and healthcare providers.

Conclusion

The study underscores the significance of a sense of safety in the patient-doctor relationship and highlights the need for improved training and attitudes to provide inclusive and affirming healthcare for LGBT + individuals.

KEY MESSAGES

• Primary care settings must prioritise creating safe and non-judgmental environments for better LGBT + healthcare.

• Addressing formal GP education on LGBT + terminology, identities, and healthcare needs is crucial to provide inclusive care.

• Overcoming systemic barriers, such as societal prejudice and homophobia, requires creating visible safe space signals in primary care settings.

Introduction

While recently there appears to be increasing acceptance of LGBT + individuals, research worldwide indicates that an underlying stigma still remains [1]. The situation is no different in Slovenia, where research confirms that LGBT + people continue to encounter discrimination, intolerance, and prejudice based on gender and sexuality [2–5].

Research indicates that discriminatory attitudes persist within healthcare [6]. Some healthcare professionals may feel uncomfortable providing services to this community, even resulting in denied medical care [7,8]. Covert homophobia can also manifest [9,10], leading to the provision of substandard care for LGBT + individuals [8,11]. Due to these attitudes and previous experience with societal discrimination, LGBT + people mistrust the healthcare system [12] and may withhold information about their sexual orientation or gender identity [13,14], resulting in poorer healthcare outcomes [1,7,15], and even avoid seeking medical assistance altogether [16,17]. The management of LGBT + individuals might also be deficient not due to overt discrimination, but because healthcare workers lack awareness regarding LGBT + specific needs [11,18], such as sexual health, family planning and medical gender transition. Furthermore, they might be unaware of the negative impact of societal attitudes towards LGBT + individuals’ well-being, particularly on mental health.

In Slovenia, general practitioners (GPs) have a particularly important role within the healthcare system. Establishing long-term professional relationships with their registered patients, they work on the primary level and act as a first contact for any non-urgent and non-gynaecologic health concern. They also function as gatekeepers for accessing specialist care. Hence, the mutual attitude between the GP and the LGBT + person, along with the GP’s knowledge on LGBT + healthcare is of the utmost importance to the quality-of-care LGBT + person receives. In principle, the area is well regulated at the legislative level, as the Slovenian Constitution and the Protection against Discrimination Act supposedly guarantees everyone equal treatment. However, limited research conducted in Slovenia has reported instances of LGBT + people avoiding seeking medical attention due to lack of safety, hiding their sexual orientation or identity when appointments are inevitable, and discriminatory management upon disclosure [2–5]. A European survey in 2019 revealed that in Slovenia, 59% of the LGBT + respondents have not disclosed their orientation to any healthcare providers, and a third of trans people have had discriminatory experiences in healthcare [19]. For trans people, general practice is associated with most positive reported experiences, which was attributed to selecting known trans-friendly GPs, but negative experiences are still highlighted, and a positive experience is seen as surprising, rather than expected [3].

Our objective was to understand the challenges encountered by LGBT + individuals in Slovenian primary healthcare, their needs, expectations as well as their opinions on how to improve the level of care. By including both LGBT + participants and GPs in our survey we aimed to compare and contrast their healthcare experiences, view the issues from multiple perspectives and gain a better assessment of the current situation and potential areas for improvement.

Methods

Design of the study

A national qualitative study using open-ended questions in an online questionnaire asking for the experiences and expectations of LGBT + persons with their GPs and family medicine practice. Opting for an online questionnaire, our intention was to enhance response rates by enabling participants to complete the survey within the secure and private environment of their own home.

The study was granted ethical approval no. 0120-246-2021-3 in July 2021 by the National Medical Ethics Committee of the Republic of Slovenia.

Development of the questionnaire

The questionnaire was developed according to the study objectives and research question, based on extensive review of existing literature and in collaboration between researchers. Subsequently, the questionnaire was reviewed by LGBT + organisations whom we contacted for participation through email. The questionnaire consisted of demographic data (Table 1), including sexual identity and orientation and then eleven open-ended questions about experience with personal doctor, obstacles and ideas for improvement of medical care at the primary level. Participants were also asked to evaluate specific competencies of their GPs. The questionnaire for the GPs was structured in the same way and asking the same questions, but from the doctors’ perspective. The full questionnaire is available as supplementary materials.

Table 1.

Demographic data of LGBT + participants.

Sexual orientation	No.	%
Lesbian	25	28
Gay	20	22
Heterosexual	3	3
Bisexual	25	28
Asexual	3	3
Pansexual	4	4
Queer	5	6
Biromantic Asexual	2	2
Heteroromantic Asexual	1	1
Gay on aromantic/asexual spectrum	1	1
Omnisexual	1	1
Gender identities	No.	%
Cisgender man	22	24
Cisgender woman	48	53
Transgender man	4	4
Transgender woman	2	2
Nonbinary	8	9
Gender fluid	3	3
Queer	1	1
Demiboy	2	2

The participants had the option to refrain from answering any of the questions. Regarding the questions about gender and sexual identity we chose not to precategorise responses. Instead, we gave respondents full autonomy in expressing their preferred forms of identification.

Participants and recruitment

We invited people who define themselves as a part of the LGBT + community in Slovenia, from various age groups, urban and rural settings, and the following categories: men who have sex with men, women who have sex with women, asexual persons, trans men, trans women, and non-binary persons. To engage a hard-to-reach population we used the chain referral (snowball) method of recruitment: we approached to organisations Legebitra, Ljubljana Pride and Koroška Pride, through their contact emails. We asked them to share the survey through their internal channels and social media leading to suggestions for many more organisations to include and share the questionnaire on social media. We asked for feedback during recruitment, resulting in a questionnaire revision for gender-neutral phrasing.

The invitation to participate and explanation of the purpose of the study were written at the first page of the questionnaire. Consent was implied by taking part in the survey.

All 349 members of the Association of family doctors in Slovenia were invited to participate via email by the website administrator.

Data collection

Data was collected from October to December 2021. The questionnaire was hosted on the 1 Ka web platform which doesn’t gather IP addresses, ensuring full anonymity. The data was password protected and stored securely on the server of the Department of Family medicine, Faculty of medicine, University of Ljubljana.

Data analyis

We used thematic analysis, an inductive approach that starts from raw data [20,21]. The two researchers independently reviewed the data, each determining significant quotes and attributing codes to them. Through a merging process, they identified subthemes and main themes at a higher hierarchical level. The researchers compared the analysis already at the code level in several personal and on-line meetings, achieved agreement in any differences in coding and then throughout the process to reach consensus on the final list of main themes.

Results

The questionnaire was completed by 214 LGBT + participants, of whom 90 were considered sufficient (defined as having answered at least 3 open-ended questions). The median age was 24 years, with the youngest and oldest participant being aged 18 and 44 respectively. 76 (84%) reported their GP practicing in urban environment, and 14 (16%) reported rural environment.

Among physicians, 34 responded to the questionnaire, out of which 25 were considered eligible (defined as having answered at least 3 open-ended questions). The median age was 58 years, with the youngest and oldest participant being aged 37 and 70 respectively. 21 (84%) reported practicing in urban environment, and 4 (16%) reported rural environment. 19 were women (76%), and 6 were men (24%).

Thematic analysis revealed three common themes, which were shared among LGBT + respondents and GPs: communication and relationship, specific knowledge, and overcoming systemic barriers in family medicine practice, 15 subthemes for LGBT + participants and 12 subthemes for GPs (Table 2).

Table 2.

Thematic analysis featuring themes and subthemes of LGBT + participants and GPs.

Themes	Subthemes LGBT participants	Subthemes GPs
Communication and relationship	Important for disclosure Non-judgmental communication Feeling of safety No stigma, presumptions from GPs Addressing with LGBT terminology	Equality in management No higher standard approach is needed. trust in relationship information protection
Medical knowledge	Acquainted with LGBT + terminology and sex identities Can consult on LGBT + specific issues Basics of psychological counselling Community services	Variable experiences Lack of prof. recommendations Lack of experience and knowledge on management transition
Overcoming barriers in system and family medicine practice	Improve formal education of GPs Improvement of visibility and positive representation Improvement in professional communication Categorisation of clinics according to LGBT inclusion General issues in family medicine Improvement in legal protection	More knowledge and skills, clinical recommendations and pathways needed Improve public awareness General issues in family medicine (allocated funds and time, waiting times, access) Nothing else is needed Communication, no need for special signs

Ultimately, we concluded that all three themes were related to a larger overarching theme of safety (Figure 1).

Figure 1.

Representation of the three themes as relating to a larger overarching theme of safety.

Communication and relationship

Within this theme, the LGBT + participants desire a non-judgmental and non-stigmatizing relationship. They expect from the doctors to overcome their own prejudices and stereotypes for the benefit of patients. The persons referenced in the citations are identified by sex, age and sexual orientation.¹

• I especially like the openness and specifically the fact that there is no judgement about who I am and what I do (F, 30, lesbian).

• That they (GPs) work out their own stereotypes and limitations, whether it’s sexual orientation or whatever…(F, 26, bisexual)

They anticipate and value ethics and professionalism within relationships, encompassing well-meaning intentions, respect, a positive supportive attitude along with discretion when handling sensitive information. Above all, they desire a feeling of security and wish to be treated equally to others. Many expressed a fear of rejection upon disclousure, and wished for explicit acceptance.

• It’s not just about not saying something negative, it’s about saying something positive, because we expect the negative and I think you can ensure safety by explicitly emphasising it, without assuming that it’s a safe space, until we feel that it is. That’s not how it works with topics like this. (F, 26, bisexual)

• Openness, acceptance, a discreet approach to create a sense of safety and a space for open conversation about these topics in connection with health. (genderqueer, 20, biromantic asexual)

All the responding GPs assessed that this is the same kind of relationship and communication that they share with their patients. All of them reported treating all patients equally, and frequently emphasised the importance of trust within a relationship. However, some individual GPs exhibited a negative and microaggresive stance towards LGBT + matters, expressing a dismissive attitude and displaying a somewhat hostile tone towards our research.

• First explain to me why LGBT people would even need birth control?… I don’t know why they need more attention than they get. Everything is available to them as it is to others. Sometimes they have to change jobs because their environment does not understand them, but this is their own free choice and not by a decree. This must also be done by many others who cannot be among co-workers due to some innate defect…Stop creating problems where there aren’t any. (M, 70, GP)

• I believe that LGBT individuals should not be treated as exceptional, because then we would have to treat other groups the same way, for example, the elderly…. (GP, 55, F)

This behaviour reflects the experiences of LGBT + respondents in the survey. While many reported immensely positive experiences with their GPs, describing a warm, supportive environment where they feel comfortable and accepted,

• Plus, the relationship with my doctor and the nurses in the office is, I can’t say anything other than ‘home’ from the very beginning. When I have to go to the doctor, regardless of the reason, I always feel comfortable going to them. (F, 30, lesbian)

there is a significant number of individuals who have had negative experiences with non-verbal (facial expression of discomfort, silence, surprise, tension in the air, cold relationship, lack of empathy) or verbal GP communication (rudeness, ridicule, inappropriate comments), feelings of stigma and being addressed inappropriately in terms of LGBT + terminology.

• The doctor is very cold towards me but remains professional. Disrespecting pronouns, projecting their ideology onto people who exist outside of their notion. (trans woman, 41, pansexual)

• Also, one of the reasons why I was looking for a new doctor years ago was that all the previous ones were rude, unprofessional, gossiping, shared information without consent and often had inappropriate comments on various topics, LGBT + among them. (queer, 36, queer bisexual)

Specific knowledge

When asked about specific knowledge GPs should possess when interacting with LGBT + people, the participants emphasised the importance of understanding LGBT + terminology, and diverse sexual and gender identities. The significance of understanding non-binary concepts and using appropriate pronouns was underscored as particularly crucial.

• I doubt he fully understands the concept of gender identity. (F, 37, lesbian)

• I expect that personal doctors are well educated about this (that they know what at least the most common sexual identities and orientations mean) and understand what is actually relevant to our health. I also expect them to better educate themselves about transgender people, respect personal pronouns, not discriminate against transgender people and educate themselves in the field of transgender people’s health (because there are many specifics here). (demiboy, 22, gay on the aromantic/asexual spectrum)

Considering these medically relevant topics (sexual health, mental health, medical transition), a number of participants would welcome advice by their GPs, especially basic mental health counselling. However, many think that GPs don’t have enough expertise in these areas.

• I definitely think that a personal physician could also be one of those people who educates LGBT + people about safe sex, diseases, etc. (F, 22, lesbian)

• (Medical transition): Absolutely no knowledge, I teach her everything. (trans woman, 41, pansexual).

This is true even of participants who do not have a personal experience with their GPs regarding their competencies (didn’t look for help or disclose to their GPs). Some might look for advice from specialists like gynaecologists, psychiatrists or therapists,

• No, I don’t trust a personal doctor very much in this area (mental health). I prefer to mention the problem briefly and talk to a specialist through referral. (F, lesbian, 20).

but many prefer to rely on community counselling provided by more experienced peers and the guidance offered by LGBT + organisations.

• I'm worried that he’s (GP) not very competent and therefore I wouldn’t want his advice either. I also think that many of us LGBTQ+ people already ‘by default’ don’t rely on a personal doctor and look for the health information we need elsewhere (internet, friends). (non-binary, 21, queer)

• Bad. We only get information (about transition) about trans people in Slovenia through the TransAkcija institute (thanks to them!), it is not even discussed elsewhere (even at the doctor’s). (non-binary, 21, queer)

GPs reported substantial differences in their understanding of sexual orientation and identities. Likewise, there was noticeable variability in assessing their knowledge of medically relevant topics, with a favourable average regarding sexual health (safe sex, sexually transmitted diseases, contraception, family planning, preventive activities, e.g. testing for sexually transmitted diseases, vaccinations, screening for certain cancers), a weaker understanding regarding medical transitions and limited understanding of the needs related to mental health.

• I think I have a lack of knowledge about the new gender identities that have emerged in recent years, I don’t know all of these identities, nor do I fully understand what they mean. (GP, 48, F)

• To a certain extent, mental and emotional problems can be treated in the same way as for all patients. However, I do not know enough about the specifics or the most common reasons or circumstances of these problems. I think we covered few of these topics in various trainings. (GP, 60, F)

Systemic barriers

When asked about systemic barriers to better healthcare and potential solutions within primary healthcare, both GPs and LGBT + participants emphasised the detrimental impact of societal stigma and the necessity to change homophobic viewpoints. Additionally, LGBT + participants expressed the general need for improved professionalism and reduced prejudices in family medicine. They proposed the idea of setting up dedicated LGBT + clinics staffed with trained professionals, or alternatively, designating existing clinics as LGBT + friendly.

• People don’t seek help because they are afraid. The clinic should exhibit clear LGBT + friendliness, rather than merely displaying a single sticker on the door that the actual staff might not genuinely support. (F, 27, bisexual)

Both GPs and LGBT participants further stressed the need for improved education of GPs concerning LGBT + matters. GPs expressed their frustration over the absence of formal training and professional guidelines in this regard.Both also recognised the already fragile and overburdened primary care system that exacerbates the problem.

• There is insufficient awareness, training and education on these topics for all healthcare personnel, young and old, including those who come to work in Slovenia from other countries and regions. (M, 55, gay)

• There are no proper recommendations for specificities in medical treatment. No adequate resources are foreseen for this. Referrals to secondary level tend to have excessively long waiting times.

• General problems in health care – too long waiting lists, overcrowded clinics, underpaid nurses, too frequent double shifts, etc. When you have an outpatient clinic that is overcrowded, it is difficult to get quality medical care, plus no one there has the capacity to learn something new. (non-binary, 27, bisexual)

Discusson

Main findings

This study allows us to gain a deeper understanding of the experiences and expectations of LGBT + patients in Slovenia regarding primary healthcare. By involving GPs, we can compare their perspectives and comprehensively evaluate challenges and solutions within general practice clinics.

When asked about communication and relationship, both the LGBT + participants and GPs described a similar ideal of equal treatment. However, while the GPs unanimously stated that they treated all patients equally, the experience among LGBT + participants showed more variability. Regarding specific knowledge (LGBT terminology and specifics regarding sexual health, mental health and medical transition) both groups reported highly diverse results, but regardless of actual experiences, LGBT + people were likely to perceive GPs as lacking expertise and leaned towards seeking community support. Considering systemic barriers, both groups identified societal prejudice and homophobia as significant obstacles. They proposed strategies of designating clinics and staff as safe spaces free from judgement. Both groups expressed the need for improved education, acknowledging the challenge this poses within the already overburdened primary care system.

Communication and relationship

While many of the participants reported exceedingly positive experiences, describing situations where they felt welcomed, accepted and supported by their GPs, a significant number also reported incidents of rejection, disrespect and prejudice. Overt and subtle forms of prejudice have shown to be a persistent finding of research dealing with LGBT + experiences in healthcare worldwide [11,22]. Domestically, some of the few Slovenian studies describe experiences with rudeness, insults and hostility in medical encounters [2,3].

Although the LGBT + participants in our study described a variety of experiences, GPs unanimoulsy asserted treating all patients equally. This contrast raises questions about its underlying reasons. Interestingly, some of the GPs who initially claimed to treat LGBT + patients ‘like everyone else’, later in the questionnaire revealed contemptuous attitudes towards LGBT + people. This contradiction, even if denied by the GPs, might still be evident to their patients. In fact, literature suggests that as society moves forward, bias becomes more implicit and though still noticed by the patients, is often underestimated by provider self-report [23]. Similarly, discriminatory behaviour shifts from explicit to microaggressions, that may not even be conscious, but affect interactions with the patient [9]. As in ours, other qualitative studies describe examples in which healthcare workers asserted providing service in an ‘equal’ manner, but at the same time described instances of microaggressions in their interactions with LGBT + patients [24].

Furthermore, it’s possible that in some cases, the same interactions were perceived as more negative by LGBT + participants than by GPs. Research indicates that LGBT + individuals, who frequently face lifelong stigmatisation and discrimination due to their LGBT + identity, may be more inclined to anticipate and perceive rejection even in well-intentioned situations. This phenomenon is known as gay-related rejection sensitivity [25]. Indeed, anticipation of discriminatory behaviour has previously been reported abroad [8] and in Slovenia as well [3].

Many of the participants in our study expressed fear of negative consequences to their relationship with their GP, should they disclose their LGBT + identity. Naturally, this fear, along with negative experiences, contributes to diminished sense of safety. Apart from its adverse effects on the patient’s emotional well-being, this results in avoiding healthcare, withholding disclosure, and other consequences, leading to diminished quality of care and worse outcomes for LGBT + patients [1,7,8,11,13–17,26]. Hence, establishing a feeling of safety within the healthcare system and in the GP-patient relationship is of immense importance in LGBT + healthcare.

Specific knowledge

When assessing specific knowledge such as LGBT + terminology and identities, as well as clinical knowledge concerning sexual health, mental health and medical transition, the experienced levels of competency varied greatly within both groups. Irrespective of the factual competency level of GPs, the LGBT + participants in the study were likely to presume that GPs lacked expertise on these matters. Instead, they preferred seeking advice from gynaecologists or mental health professionals. But most commonly they turned to community support, such as more experienced peers and NGOs who undertook the responsibility of educating and advocating regarding healthcare. This was particularly true regarding transgender health.

Literature review shows that LGBT + patients, particularly transgender patients, lack confidence that physicians could provide accurate counselling [27]. This perception is firmly validated by research, as study after study shows knowledge deficits and lack of education and training of healthcare providers in LGBT + healthcare, particularly trans healthcare [1,8,10]. This places the burden on patients to not only advocate for themselves but also educate the physician, be the leading source of medical information and guide the treatment plan researching through trans community networks and internet sources [1,8,10,28], which has been described by trans patients in Slovenia before [3]. As a matter of fact, many trans people in our questionnaire appeared to be unusually informed about medical topics, for example comparing the definition of transgenderism in two issues of the DSM.

In our study, LGBT + participants emphasised the importance of GPs being familiar with LGBT + terminology and gender identity, the most common sexual orientations, using correct names and pronouns, and employing inclusive and gender-neutral language. In the context of LGBT + healthcare, familiarity with these topics is not merely considered academic knowledge, rather, it serves as a safety measure – indicating a respect for the LGBT + identity, and a positive attitude. The three dimensions of awareness of LGBT + identity, in contrast to heteronormativity, positive attitude towards it, and possessing knowledge about it, have previously been shown to be interconnectedly linked to the quality of healthcare [29].

Systemic barriers

When asked about systemic barriers both LGBT + people and physician emphasised the prevalence of societal stigmatisation. In lieu of major societal advancement, however, LGBT + participants stress the importance of designating spaces and people as safe for LGBT + people. So called safe space signals, referring to materials and symbols that imply LGBT + acceptance, have previously been found to foster a sense of safety and facilitate disclosure [28], but can also be misleading [30]. The patients in our study shared a similar scepticism towards signs that could potentially be mandated, such as official LGBT + friendly designations and stickers, as these might not necessarily reflect the genuine beliefs of the personnel. Instead, a sign like a rainbow sticker, badge, poster or pen should serve as an individual indication of genuine beliefs of healthcare workers. Furthermore, using correct names, pronouns and gender-neutral language, for instance, can also function as a non-visual signal of a safe space, signals a respectful attitude and is seen as a key expression of identity affirmation [3,8].

Moreover, both GPs and LGBT + participants stressed the necessity for better education of GPs in LGBT + issues. GPs expressed regret over the lack of formal training and professional guidelines. As previously discussed, a fundamental aspect of providing quality care and fostering a sense of safety revolves around familiarity with LGBT + terminology, identities, and specific needs. These aspects are not yet systematically included in the curriculum of GP training [1,8]. Our research alongside previous studies [9,23,24] indicates that specific training may need to address self-reflection and microaggressions as well.

Importantly, both GPs and patients recognised the significant challenge of enacting change within an already fragile and overburdened primary care system. Participants expressed understanding of the considerable personal commitment that would be required from, in many cases, already overworked and burned-out physicians, to acquire new knowledge. Additionally, with too many patients per physician and limited time, even a culturally competent physician might struggle to provide the required time and attention necessary to provide a sense of safety and trust crucial for disclosure (Figure 2).

Figure 2.

Recommendations for practicing physicians in treating LGBT + individuals as derived from results and discussion.

Strenghts and limitations

A major strength of this study is the inclusion of LGBT + organisations and the snowball sampling method, which allowed us to extensively include members of a vulnerable and hard to reach population on a nation-wide level. Additionally, the questionnaire was approved and adapted in collaboration with LGBT + organisations. Given the population size and the qualitative nature of the study, we considered the response rate quite significant. The material/answers were so extensive, that we are presenting only a part of them here, while heteronormativity and disclosure (‘’coming out’’) will be addressed in another paper. While representativeness of the population is not the goal of qualitative research, the results may reflect the experience and expectation of a younger generation, comfortable using the computer and social media. In the GP sample saturation was not reached, and the responses show notable polarisation, which may indicate that only those with the strongest (positive or negative) opinions responded. Data on sexual orientation of GPs was not collected, though it could be informative in analysing the results.

Additionally, self-report measures are always limited by the respondents’ awareness of their own bias, which research shows may be underestimated [23], and author bias should also be considered. In this study the team was one academic GP, experienced in qualitative research, who still works in the practice, and a student of medicine. The experienced GP found the answers about GPs intolerance surprising given the cultural acceptance has greatly increased in the last years and in personal life she didn’t realise this as a problem. The student who did the preliminary literature was less surprised, but she was struck with the failure of some of the GPs in the study to recognise their homophobic responses as such.

It should also be noted that drawing conclusions from online and survey responses may necessitate further research using more conventional methods of qualitative research to strengthen and validate the results.

Conclusion

The sense of safety is fundamental to the healthcare experience of LGBT + people, as all three identified themes (communication and relationship, medical knowledge, and overcoming systemic barriers) are in some way related to different aspect of safety. GPs can communicate being a safe, accepting person through visible personal signs, yet they must reinforce this with a true non-judgmental approach and understanding of LGBT + terminology and experiences, while also possessing specific medical knowledge.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Ethics statement

The study was granted ethical approval no. 0120-246-2021-3 in July 2021 by the National Medical Ethics Committee of the Republic of Slovenia.