Finding the Perfect Doctor: Identifying Lesbian, Gay, Bisexual, and Transgender–Competent Physicians

Abstract

Objectives. We assessed the existence of procedures and policies for identifying lesbian, gay, bisexual, and transgender (LGBT)–competent physicians at US academic faculty practices, and sought to identify physician training programs that enhance LGBT competency.

Methods. We invited all 138 Liaison Committee on Medical Education–accredited US academic faculty practices to participate in a survey in 2012. We systematically assessed their procedures and policies to identify LGBT-competent physicians and their LGBT-competency training. We also assessed geographic region, funding source, and an LGBT health center in the same state. We performed univariate, bivariate, and multivariate logistic regression analyses.

Results. The response rate was 50%. Few participants had existing procedures (9%) or policies (4%) to identify LGBT-competent physicians. Procedures included online directories with self-identified LGBT-competent physicians available to the public. Sixteen percent of participants reported having comprehensive LGBT-competency training, and 52% reported having no training. Of note, 80% of participants indicated interest to do more to address these issues.

Conclusions. There exist both need and interest for US academic faculty practices to develop procedures, policies, and programs that improve access to LGBT-competent physicians and to train physicians to become LGBT-competent.

Lesbian, gay, bisexual, and transgender (LGBT) individuals experience significant barriers to receiving equitable health care.^1–4 They face both individual and system-level barriers in the health services system that may prevent them from receiving high-quality care and achieving the best possible health care outcomes.¹ Lesbian, gay, and bisexual (LGB) individuals are documented to be significantly more likely to delay or avoid necessary medical care compared with heterosexuals—29% versus 17%, respectively.⁵

Individual-level characteristics that affect LGBT health care access include lower income, lower rates of health insurance, and previous negative experiences with the health care system. Lesbian and gay individuals aged 18 to 44 years are less likely to have financial resources and health insurance than heterosexuals.^6,7 Partnered lesbian and gay individuals are more than 2 times more likely to be uninsured, compared with married heterosexuals.⁸ Furthermore, it has been documented that past negative experiences and the fear of homophobia and stigmatization lead to decreased access to care and an unwillingness to disclose sexual or gender identity, which may have an impact on receipt of equitable health care.²

System-level barriers are pervasive and prevent equal access to quality health care for LGBT individuals.^1–3 Examples include the lack of culturally competent health care providers, lack of nondiscrimination policies, and the presence of discriminatory behaviors.^9,10 Cultural competency is defined as the awareness and adequate responsiveness to patient populations with cultural factors that may affect health care, including language, beliefs, attitudes, and behaviors of health care providers.¹¹ Explicit homophobia in health care continues to exist, including refusal to provide accepted standard of care and verbal abuse.¹ In a 2007 survey, 16% of 736 San Diego, California, physicians surveyed reported that they were sometimes or often uncomfortable providing treatment of gay patients.⁹ In addition, there is a lack of institutional practices and policies that would facilitate equal health care opportunities and venues for LGBT individuals. To ameliorate this issue, The Joint Commission on Accreditation of Healthcare Organizations released an LGBT health–related field guide in 2011. It recommends that health care organizations educate all staff about existing LGBT-inclusive nondiscrimination policies and procedures and to develop such policies if they do not currently exist.¹⁰

Healthy People 2020 describes a shortage of health care providers who are culturally competent in LGBT health, a major system-level characteristic that affects equitable health care access for LGBT individuals.⁴ Many of the barriers that the LGBT population faces are similar to those experienced by racial and ethnic minorities in the United States, including discrimination, stigma, higher uninsured rates, and inadequate access to culturally competent care.¹² Limited research exists to directly link cultural competency with the reduction of racial and ethnic health care disparities.^11,13 However, cultural competency training has been demonstrated to increase health care provider knowledge and awareness, and to improve communication skills.^14,15 These changes in provider behavior enhance physician–patient interactions, which is associated with improvement in patient outcomes and satisfaction with care.^15–17 Furthermore, national health care leaders in government, managed care, and academia endorse policies that promote racial and ethnic diversity in leadership and in the health care workforce, and cross-cultural training that increases awareness of disparities in health care outcomes for minority populations and builds communication skills.¹¹

Despite the existing resources available for the development of LGBT-competency training, there is currently limited information on the existence of LGBT programs, policies, and competency training for physicians at US academic faculty practices. More information is known about LGBT training for medical students and resident physicians than for faculty physicians. A Canadian study documented that opportunities for LGBT-related health training are inadequate for mental health professionals; it cited the lack of training as a significant challenge to meeting LBGT mental health needs.¹⁸ A 1998 study of 92 US family medicine department predoctoral chairs found that most departments reported zero hours spent teaching about LGB-related issues.¹⁹ A 2011 survey of 132 US medical schools’ deans revealed that a median of 5 preclinical and clinical hours were dedicated to LGBT-related topics; many institutions reported having zero hours of training.²⁰ However, a 3-hour LGBT health seminar course for resident physicians at Rhode Island Hospital was found to increase trainee preparedness to treat LGBT individuals.²¹

To address the current gaps in the medical literature, we performed a systematic survey of US academic medical institutions’ faculty practices. We identified the existence of procedures and policies available for identifying LGBT-competent health care physicians and assessed the presence of programs that focus on enhancing physician competency around LGBT health.

METHODS

We conducted a survey from June to December 2012 of all US academic medical institutions’ faculty practices to assess the existence of programs and policies to identify and train LGBT-competent medical physicians. We identified and contacted to participate all 138 allopathic medical schools in the United States and Puerto Rico that were Liaison Committee on Medical Education–accredited as of May 2012.

Recruitment

We conducted an Internet-based search to identify the chief medical officer (CMO) of the main hospital associated with each medical institution’s faculty practice and the dean of each medical school. Each CMO was contacted up to 3 times via phone or e-mail, with each communication providing an invitation to participate in a confidential phone survey. If the identified CMO did not respond after 3 attempts, the dean of the medical school was contacted similarly up to 3 times via phone or e-mail with an invitation to participate in the study. In each situation the respondent was asked if there was a more appropriate contact at the institution to participate in the study. Among the study participants, responses were only included from individuals who claimed they had knowledge regarding questions on the survey; this resulted in responses collected from CMOs, deans, and CMO or dean designees.

The study investigator obtained verbal consent before initiation of the audio-recorded phone interview. Participants were given the option to independently complete the survey if they could not participate in the recorded phone interview. These participants were provided with and acknowledged receipt of a consent form before survey completion, with an additional opportunity to ask questions about the study.

Survey

The study investigators developed the 15-minute survey (available as a supplement to the online version of this article at http://www.ajph.org) to assess the existence of programs, policies, and training to facilitate the provision of culturally competent care for LGBT individuals. Responses to the survey items were both dichotomous and open-ended.

The content of the survey assessed the existence of procedures and policies to identify LGBT-competent health care physicians. Specifically, respondents were asked if the institution had documented policies for the identification of LGBT-competent physicians, and if the institution had a procedure to refer patients to LGBT-competent physicians. Participants were also asked if their institutions had a list of LGBT-competent physicians available to individuals or patients requesting the information. Participants were asked about the availability of LGBT competency training for their physicians or if there were any plans to develop LGBT competency training. In addition, participants were asked if they thought that their institution could be doing more to address the issues of culturally competent LGBT health care. Lastly, the survey included questions to assess the respondent’s awareness of nationally available resources (e.g., the Gay and Lesbian Medical Association’s [GLMA’s] online provider directory, which is a public online directory of self-identified health care providers interested in LGBT health)²² and to elicit specific suggestions regarding how their institution could improve LGBT health care.

Data Collection

The telephone interviews were conducted by J. K. and were recorded. After completion of the phone interview, responses from the audio recording were transcribed, and then all audio recordings were destroyed. Transcriptions of the phone interviews were sent via e-mail to each participant who completed a phone interview to verify the accuracy of his or her responses and to provide an opportunity to add additional information. Forty-four phone interviews were conducted, and 13 of those participants returned their transcription with edited responses. Twenty-five independently completed surveys were collected via e-mail. To maintain confidentiality, each completed survey (phone or independently completed) was assigned a unique identifier only accessible by the principal investigator (A. D.) and J. K.

Variables

Dependent variables reflected the objectives of the study. These variables included the presence of procedures or policies to identify LGBT-competent physicians, the existence of a list of LGBT-competent physicians, the reported level of LGBT-competency training (comprehensive, some, none), and an institutional interest to do more around developing procedures or policies to improve LGBT culturally competent care. We considered LGBT competency training comprehensive if the institution had specific LGBT-competency training programs available for their physicians; “some” training reflected institutions that have a small amount of LGBT-related training as part of broad diversity training programs (e.g., brief inclusion of LGBT-related issues in employee orientation training).

Independent variables focused on institutional characteristics, specifically region, type of school funding, and the existence of an identified LGBT health center in the same state as the participating institution.

The 4 specified regions are based on the American Association of Medical Colleges regional categorizations of medical schools (West, Central, Northeast, and South). Data identifying whether a school is publicly or privately funded was also collected from the American Association of Medical Colleges Web site; 61% (84 of 138) of all institutions are publicly funded and 39% (54 of 138) are privately funded.

Expert opinion and comprehensive research by investigators have identified LGBT health centers to be nationally renowned institutions in metropolitan areas that are leaders in providing comprehensive health care to LGBT individuals, participating in significant LGBT advocacy, and providing education for LGBT health. These centers provide LGBT-competency training for physicians and other health care providers affiliated with academic institutions and some have developed nationally recognized resources regarding health care for LGBT individuals. Seven centers have been identified: Lyon Martin Health Services (San Francisco, CA), LA LGBT Center (Los Angeles, CA), Howard Brown Health Center (Chicago, IL), Mazzoni Center (Philadelphia, PA), Whitman Walker Health (Washington, DC), Callen Lorde Community Health Center (New York, NY), and Fenway Health (Boston, MA).

Statistical Analyses

We performed descriptive and unadjusted analyses with the Fisher exact test. We performed adjusted analyses of dichotomous data with factorial logistic regression, and adjusted analyses of ordered data with ordered logistic regression. In multivariate regression analyses, we made adjustments for the following institutional variables: region (West, Central, Northeast, or South), type of school (public vs private), and the presence of an identified LGBT health center in the same state as the medical school (yes or no).

We conducted statistical analyses with Stata version 12.0 (StataCorp LP, College Station, TX).

RESULTS

Fifty percent (69 of 138) of faculty practice representatives approached completed the survey. Thirty percent (21 of 69) of the surveys were completed by CMOs, 30% (21 of 69) by CMO designees; 20% (14 of 69) by medical school deans, and 19% (13 of 69) by dean designees. The CMO and dean designees included designated physicians knowledgeable about LGBT health issues and the faculty practice (53%; 18 of 34), faculty practice staff director or manager (29%; 10 of 34), and dean or director of diversity (18%; 6 of 34). Participation by region varied with a high of 88% in the West to a low of 34% in the Northeast (P < .01; Table 1). Approximately half of publicly funded (46%; 39 of 84) and privately funded institutions (56%; 30 of 54) participated in the survey (P > .05). Sixty percent of institutions with an LGBT health center and 46% without one in the same state participated in the survey (P > .05).

TABLE 1—

Characteristics of US Academic Faculty Practices Participating in 2012 Survey of Procedures and Policies to Identify Lesbian, Gay, Bisexual, and Transgender–Competent Physicians and Their Competency Training

Characteristic	Participation, % (No.)
Overall (national)	50 (69/138)
Region**
West	88 (15/17)
Central	56 (18/32)
Northeast	34 (13/38)
South	45 (23/51)
Type of school funding
Public	46 (39/84)
Private	56 (30/54)
LGBT health center in same state
Yes	60 (25/42)
No	46 (44/96)

Note. LGBT = lesbian, gay, bisexual, and transgender.

**P < .01.

LGBT-Related Procedures and Policies

Fewer than 9% of participating institutions had a procedure to identify LGBT-competent physicians who are affiliated with their institution (Table 2). No significant differences were found when we compared them by region, type of funding, or the existence of an LGBT health center in the same state. In the regression analyses, when we controlled for region, type of funding, and the existence of an LGBT health center in the same state, we found that none of these characteristics were independently associated with having a procedure in place to identify LGBT-competent physicians. Procedures that exist include having lists of self-identifying physicians available to call center employees, offering the ability for physicians to list “LGBT health” as a particular clinical interest on their profiles available on the Web, and having lists available through the institution’s diversity office.

TABLE 2—

Existence of Procedures, Policies, or Lists to Identify Lesbian, Gay, Bisexual, and Transgender–Competent Physicians Among US Academic Faculty Practices, 2012

Variable	Procedure to Refer LGBT-Competent Physicians to Patients, % (No.)	Policy to Identify LGBT-Competent Physicians, % (No.)	List of LGBT-Competent Physicians, % (No.)
National	8.7 (6/69)	4.4 (3/69)	14.5 (10/69)
Region
West	6.7 (1/15)	0.0 (0/15)	13.3 (2/15)
Central	11.1 (2/18)	5.6 (1/18)	16.7 (3/18)
Northeast	7.7 (1/13)	7.7 (1/13)	15.4 (2/13)
South	8.7 (2/23)	4.4 (1/23)	13.0 (3/23)
Type of school funding
Public	7.7 (3/39)	0.0 (0/39)	15.4 (6/39)
Private	10.0 (3/30)	10.0 (3/30)	13.3 (4/30)
LGBT health center in same state
Yes	12.0 (3/25)	8.0 (2/25)	20.0 (5/25)
No	6.8 (3/44)	2.3 (1/44)	11.4 (5/44)

Note. LGBT = lesbian, gay, bisexual, and transgender.

Even fewer institutions (4%) had a policy in place to identify LGBT-competent physicians (Table 2). We found no significant differences in bivariate or multivariate analyses. The 3 institutions with policies in place allowed physicians to self-identify as being LGBT-competent or LGBT-friendly, which is viewable to the public via online provider registries offered by the institution.

A minority of participating institutions (15%) had an available list of LGBT-competent physicians affiliated with their institution. There were no significant differences when we compared by institutional characteristics in bivariate or multivariate analyses (Table 2). All of the reported lists were created on the basis of physician self-identification as being LGBT-competent. Eight of these lists are available online for public access and 2 are circulating internal documents.

Existence of LGBT-Competency Training

Sixteen percent of participating institutions reported having comprehensive LGBT-competency training, 32% indicated that they have some training available, and the remaining 52% had no LGBT training (Table 3). Academic medical institutions’ faculty practices with an LGBT health center in the same state had a significantly higher rate of providing comprehensive LGBT cultural competency training (28.0% vs 9.0%; P < .05). There were no significant differences in the existence of training by region or type of funding. In the regression analyses, none of the characteristics were independently associated with having physician training around LGBT-competent care.

TABLE 3—

Availability of Lesbian, Gay, Bisexual, and Transgender–Competency Training and Interest to Do More Among US Academic Faculty Practices, 2012

Variable	Comprehensive LGBT-Competency Training, % (No.)	Some LGBT-Related Components in Training, % (No.)	No LGBT Components in Training, % (No.)	Interest to Do More, % (No.)
National	15.9 (11/69)	31.9 (22/69)	52.2 (36/69)	79.7 (55/69)
Region
West	13.3 (2/15)	40.0 (6/15)	46.7 (7/15)	66.7 (10/15)
Central	16.7 (3/18)	27.8 (5/18)	55.6 (10/18)	83.3 (15/18)
Northeast	23.1 (3/13)	23.1 (3/13)	53.9 (7/13)	92.3 (12/13)
South	13.0 (3/23)	34.8 (8/23)	52.2 (12/23)	78.3 (18/23)
Type of school funding
Public	10.3 (4/39)	38.5 (15/39)	51.3 (20/39)	74.4 (29/39)
Private	23.3 (7/30)	23.3 (7/30)	53.3 (16/30)	86.7 (26/30)
LGBT health center in same state
Yes	28.0* (7/25)	16.0 (4/25)	56.0 (14/25)	84.0 (21/25)
No	9.1 (4/44)	40.9 (18/44)	50.0 (22/44)	77.3 (34/44)

Note. LGBT = lesbian, gay, bisexual, and transgender.

*P < .05.

Components of comprehensive training offered at participating institutions included “LGBT 101” courses for faculty health care providers and other staff, LGBT health webinars or online modules available to all providers, “SafeZone” training that aims to create LGBT-competent and supportive environments, training developed with collaborating local LGBT organizations, LGBT health continuing medical education workshops, and grand rounds or faculty development lectures specific to LGBT health issues. Institutions with “some” training reported having small amounts of LGBT-competency material in employee orientation manuals, online cultural competency modules, or in-person diversity trainings provided to all employees affiliated with the institution.

Although 32% (22 of 69) of participating institutions reported awareness of GLMA’s online health care provider database, only 7% reported that their institution encourages individuals to use the database to find a physician.

Most participants (80%) indicated an interest to do more regarding developing and implementing policies and programs to enhance the care of LGBT individuals (Table 3). Two participants explained their institution’s lack of interest to do more, indicating that “I don’t think we’ve had much of a problem with it [providing LGBT-competent care]” and “It’s not really a problem that we have here.” There were no significant differences in interest by institutional characteristics in bivariate or multivariate analyses.

DISCUSSION

Awareness of LGBT health disparities has increased since 2011, with the release of the Institute of Medicine’s report on LGBT health issues and the Joint Commission’s field guide to help address and alleviate LGBT health disparities. Likewise, important studies have recently emerged regarding LGBT health in postgraduate curricula.^18–21 Our study further contributes to the LGBT health literature with a survey on the presence and the characteristics of various LGBT health-related procedures, policies, and training at US academic medical institutions’ faculty practices.

At the initiation of this study, a majority of participating institutions reported having no procedures or policies in place to identify LGBT-competent physicians for their patients. Only 6 institutions had existing procedures to assist patients to find affiliated LGBT-competent physicians or physicians providing LGBT-focused health care. Procedures consisted of directing inquirers to search online for physicians that self-identify as being affiliated with LGBT health, such as listing LGBT health as a clinical interest on their online profiles. One institution’s referral call center offers names of physicians who are self-identified as LGBT-competent. Some institutions operate on a “word-of-mouth” system in which patients are given names of physicians known to be LGBT-identifying or interested in LGBT health. Ten institutions have a list of LGBT-competent physicians, but may not have any procedure that facilitates access to LGBT-competent care.

Only 3 institutions reported having an explicit policy—in addition to a procedure—to identify LGBT-competent health care physicians associated with their medical groups. Policies consisted of institutional guidelines that allowed physicians to self-identify as being LGBT-competent or interested in LGBT-specific health. All 3 institutions were private academic institutions with more possible resources to develop policies related to LGBT-competent care. Most participants had never thought about having procedures or policies in place to identify LGBT-competent physicians; some respondents questioned the necessity or utility of facilitating patient access to LGBT-competent health care. Such responses suggest that many participants were unaware that health disparities exist for LGBT individuals.

Although several participants were aware of GLMA’s provider directory, only a few were directing patients to it as a resource to find a physician. Potential reasons that the GLMA directory may not be more widely used include, but are not limited to, hesitance of providers in identifying with a national LGBT directory or lack of physician and patient knowledge of the directory’s availability.

Health care provider cultural competency has been established to change physician behavior, which leads to improved patient outcomes.^14–17 Effective training of physicians is a key component of cultural competency.¹¹ Although the literature is rich with regard to the benefits of racial and ethnic cultural competency for physicians and other health care providers, there is a lack of published literature around the existence or effectiveness of LGBT competency. Most studies regarding LGBT-competency training are focused on medical school curricula, demonstrating that the teaching of LGBT health issues is still in its infancy.^20,21 The Joint Commission on Accreditation of Healthcare Organizations’ field guide associated with LGBT competency has a number of different recommendations, including the development of workforce competency around LGBT-related issues. Hospitals are strongly encouraged to incorporate training around LGBT health care disparities and patient care for all health care providers and hospital employees.¹⁰ Training physicians to ensure the provision of LGBT-competent care may significantly help reduce LGBT disparities.

Most participating institutions in our study reported having no LGBT-related training available for their affiliated physicians, with only 16% reporting comprehensive training programs. Among institutions with some training, the offerings for physicians are varied. “Some training” ranged from a limited amount of LGBT-related material to training with LGBT-health specific lectures, workshops, webinars, or seminars for providers and staff.

The likelihood of having comprehensive LGBT-competency training increased among participating institutions if there was an identified LGBT health center in the same state. It is known that LGBT health centers provide training to local institutions. For example, Fenway Health is an LGBT health center located in Boston that provides training and educational resources locally and nationally. The Mazzoni Center located in Philadelphia has an education department that provides LGBT and transgender-specific training for health care providers. Academic medical institutions’ faculty practices may benefit from collaborating with LGBT health centers or other local LGBT organizations to develop training programs to enhance LGBT competency of their physicians.

In addition, the Human Rights Campaign offers its Healthcare Equality Index, which assesses hospital performance associated with LGBT care. The 2012 Healthcare Equality Index included 27 of 69 study participants and 14 of 69 nonparticipating faculty practices. A “leader” on the Healthcare Equality Index meets the following criteria: patient and employee nondiscrimination policies that explicitly include the terms sexual orientation and gender identity, an equal visitation policy that grants visitation rights to LGBT patients and their visitors, and key staff training in LGBT patient-centered care that is offered by the Human Rights Campaign.²³ The Human Rights Campaign serves as a useful and free resource for institutions seeking assistance with training their health care providers around LGBT competency in addition to strategies on implementing vital policies that influence LGBT care.

Kaiser Permanente has focused on LGBT health for many years and offers many provider resources for LGBT-competent health care. Resources include a comprehensive, 87-page handbook that reviews topics integral for providing LGBT-competent health care.²⁴ In addition, 1 California Kaiser Permanente hospital offers an LGBT health care webinar for all of its physicians. Successful participation in the webinar allows physicians the option to have their names included on a list of LGBT-competent providers that is available to the hospital’s referral call center and online.

There are potential limitations of our study. Our response rate was 50% with differential response by region. Despite being unequal in its distribution, our data still include broad geographic representation from US academic medical institutions’ faculty practices. In addition, there is limited availability of institutional characteristics—other than region, type of school funding, and having an LGBT health center in the same state—that could be associated with our outcomes of interest. Finally, survey participants may have had varied knowledge regarding their institutions’ policies and procedures around LGBT care.

In conclusion, we have identified a great need and high level of interest in participants to develop policies, procedures, and training programs around LGBT health; however, some institutions still do not perceive lack of LGBT cultural competency as an issue and may benefit from increased awareness of LGBT health disparities. Although most study participants did not have any procedures, policies, or training for provision of LGBT-competent health care, we identified different existing strategies and many additional accessible resources for institutions interested in providing LGBT-competent care.