Assessing LGBTQ+ stigma among healthcare professionals: An application of the Health Stigma and Discrimination Framework in a qualitative, community-based participatory research study

Abstract

This qualitative, community-based participatory research (CBPR) study examines the occurrence of LGBTQ+ stigma in healthcare guided by the Health Stigma and Discrimination Framework. We conducted focus groups with healthcare professionals, analyzed using a thematic analysis approach. Stigma drivers included knowledge deficits and transphobia. Facilitators were the binary organization of medical education and training, cisnormative system procedures, a lack of enforceable policy to reduce stigma, and workplace culture and norms. Stigma practices, such as prejudicial attitudes, gossip, and misgendering, primarily focused on transgender individuals. This study reinforces the need to reduce LGBTQ+ stigma in healthcare settings, with implications for multi-level interventions.

Introduction

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities (LGBTQ+) experience disparities across an array of health indicators. These include worse perceived health quality, as well as higher prevalence of chronic conditions and sexually transmitted infections among LGBTQ+ individuals compared to their heterosexual, cisgender counterparts (Centers for Disease Control and Prevention, 2020; Dai and Hao, 2019; Elliott et al., 2015; Simoni et al., 2017; Wanta et al., 2019). Further, within the LGBTQ+ community, unique health experiences and needs exist, with additional disparities apparent between the diverse populations that make up the community (Dai and Hao, 2019; Lewis et al., 2019). Disparities in healthcare access partially explain worse health outcomes observed among LGBTQ+ individuals, fueled by a range of social and structural barriers to care (Lerner and Robles, 2017; Lisy et al., 2018).

Stigma and discrimination are among the most pertinent and pervasive barriers to LGBTQ+ healthcare seeking and engagement (Lisy et al., 2018; Stannah et al., 2019). According to Goffman (1963), stigma is an “attribute that is deeply discrediting” which enables a variety of discriminations to deny an individual or a group full social acceptance. For LGBTQ+ individuals, stigmatized identities results in unequal opportunities and differential treatment in all aspects of society, including healthcare (Baldwin et al., 2018; Lelutiu-Weinberger et al., 2020). Stigma can directly affect LGBTQ+ health through psychological and physiological pathways (Hatzenbuehler and Pachankis, 2016), as well as indirectly through increased engagement in unhealthy coping behaviors (e.g., substance use, sexual risk). Stigma also negatively influences LGBTQ+ health by preventing individuals from fully engaging in health services (Jennings et al., 2019; Stannah et al., 2019). In a United States (U.S.) national, probability-based survey, one in six LGBTQ+ adults reported avoiding health care due to anticipated discrimination and 16% reported experiencing discrimination in healthcare encounters (Casey et al., 2019).

Research from the perspective of healthcare providers can shed light on LGBTQ+ stigma and discrimination in healthcare and sources of stigma in this setting. Such data are central to the development of institutional and provider-focused interventions to reduce HIV stigma. Extant research reports a range of knowledge, attitudes, and beliefs among providers that affect the care received by LGBTQ+ patients, including prejudicial attitudes and discriminatory behavior (Aleshire et al., 2019; Stewart and O'Reilly, 2017). Even among providers with positive attitudes towards LGBTQ+ patients, lack of knowledge about LGBTQ+ care and a broader culture of heteronormativity result in inadequate care (Stewart and O'Reilly, 2017).

The application of theoretical frameworks can improve our understanding of stigma within healthcare settings. The Health Stigma and Discrimination Framework (HSD) is used in this study to inform the identification of different manifestations of LGBTQ+ stigma in healthcare, as well as sources of stigma (Stangl et al., 2019). The framework delineates the stigmatization process in the context of health, outlining the constructs of stigma manifestations and sources of stigma (i.e., drivers and facilitators) across socio-ecological levels (McLeroy et al., 1988). The framework first differentiates sources of stigma into drivers and facilitators. Drivers of stigma are inherently negative (e.g., lack of awareness) and primarily occur at the intrapersonal/proximal ecological levels, while facilitators can either increase or reduce/protect against stigma (e.g., cultural norms, health policy) and are located at higher ecological levels (Stangl et al., 2019). Stigmatization is the process by which drivers and facilitators of stigma result in the application of stigma based on a difference (e.g., sexual orientation) in a process known as stigma marking. Once marked, stigma manifests through the constructs of stigma experiences (i.e., lived experiences encountering stigma) and stigma practices (i.e., practices that generate or reinforce stereotypes and prejudice and foster discriminatory attitudes). This study focuses on stigma practices, as the study population included health care professionals, and not LGBTQ+ patients. Stigma practices can include stereotypes (i.e., beliefs about characteristics associated with the group and its members), prejudice (i.e., negative evaluation of the group and its members), stigmatizing behavior (i.e., exclusion from social events, avoidance behaviors, gossip), and discriminatory attitudes (i.e., belief that stigmatized people should not be allowed to participate fully in society). We additionally examine healthcare discrimination as a stigma practice, or stigmatizing behaviors related to healthcare that may fall within the purview of the law in some places (e.g., denial of care or insurance coverage). Collectively, stigma manifestations influence healthcare engagement and health outcomes (i.e., morbidity, mortality, quality of life) for the marked populations.

Community based participatory research (CBPR) partnerships with local stakeholders are uniquely positioned to identify the needs of marginalized communities and leverage local resources to address those needs. CBPR “focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process” (Israel et al., 2001, p. 182). Through community partnership, CBPR can enhance one’s understanding of a given phenomenon with local expertise, and has the ability to integrate the knowledge gained with action to benefit the community involved (Israel et al., 2001). Despite many advantages, challenges associated with CBPR range from difficulties functioning within a cross-cultural setting, quality and equality within collaborative partnerships, ethical issues, and methodological issues (Holkup et al., 2004; Wilson et al., 2018). Israel et al. (2001) provides an overview of the key principles of CBPR and more rationale for its use.

Guided by the HSD framework, this qualitative, CPBR study examines LGBTQ+ stigma within healthcare settings from the perspective of healthcare professionals in a large metropolitan area in the South. This study adds to the current literature by examining stigma in a diverse population of healthcare professionals, including ancillary staff, an understudied population that may play an important role in stigma perpetuating in healthcare settings. Moreover, theory-driven research conducted with this sample has important implications for our understanding of LGBTQ+ stigma in the Southern U.S. more broadly. Research demonstrates greater refusal of healthcare to transgender adults and less legal protections against discrimination by sexual orientation in the Southern U.S. compared to other regions (Cramer et al., 2017; White Hughto et al., 2016). Thus, community-engaged approaches in the South are particularly important to inform stigma reduction interventions and ensure LGBTQ+ populations can fully engage in health services.

Methods

This qualitative study was part of a larger mixed methods study aimed to assess HIV stigma among healthcare professionals. Given that a disproportionate number of people living with HIV are also LGBTQ+, a sub-aim of the qualitative portion of the study was to examine the depth and breadth of LGBTQ+ stigma among healthcare professionals, which is the focus of the present paper. The study was grounded in CBPR to ensure the equitable participation of the community, carried out in partnership between academic researchers and a community-based organization (CBO). This CBO is a local, grassroots organization comprised of representatives from local healthcare and AIDS service organizations, individual healthcare providers, advocates from the community living with HIV, and researchers. The organization aims to reduce HIV and HIV-related stigma, raise sexual health awareness, and promote mental health and resilience locally. In keeping with the principles of CBPR, the CBO members were involved in decision-making at all stages of research. Its members initiated the research study, conceptualized the research questions, and contributed to the literature review and design of the study. They also co-designed the data collection tools, led participant recruitment, provided input throughout data analysis and interpretation, and are co-leading the dissemination of results.

Data were collected through focus group interviews with participants who were sampled from the pool of those completing an online survey as part of the parent study. To recruit participants for the online survey, we used a snowball sampling strategy, inviting healthcare professionals to participate via email. The CBO’s members distributed the email through their social and professional networks, and participants were encouraged to distribute the email to their personal networks. The recruitment email detailed the aims of the study and eligibility criteria, and linked to the study information sheet. Healthcare providers and ancillary healthcare professionals who were 18 years of age or older and working in the metropolitan area were eligible to participate. Participants who provided informed consent and completed the survey could indicate interest in being contacted for a future focus group discussion with a subsample of participants.

An advantage of focus groups over one-on-one interviews is that the method capitalizes on the group process, allowing participants to deliberate and clarify their views through discussion with their fellows (Nyumba et al., 2018). In addition, group discussion allows researchers to capture a variety of communications beyond direct responses to interview prompts (e.g., joking, arguing, telling anecdotes), providing insight into participants’ viewpoints and cultural and group norms, making focus groups particularly useful for examining workplace or professional cultures, as we aimed to do (Kitzinger, 1995). While the method is sensitive to group dynamics, which can result in reluctance to share opinions that result in stigmatization for voicing them (Nyumba et al., 2018), such discussion can be fostered when less inhibited participants broach sensitive subjects and open space for these discussions among their peers (Giacomini and Cook, 2000; Kitzinger, 1995). The study team contacted all survey participants who indicated interest in focus group participation. Eighteen individuals participated in one of three focus group interview sessions, conducted between January and February 2020. Each focus group included between 4-7 participants, which were divided by cadre, including: licensed prescribers (physicians, physician’s assistants, nurse practitioners); licensed, non-prescribing providers (registered nurses, licensed counselors, and social workers); and non-licensed healthcare professionals (office staff/managers, administration, eligibility specialists, patient navigators).

Given the parent study’s focus on HIV stigma, the broader focus group guide covered topics specific to serving HIV populations. Questions specific to LGBTQ+ stigma covered topics such as concern about serving LGBTQ people, probes for narratives on the treatment of LGBTQ patients in healthcare, existing resources, training, or guidelines on LGBTQ care, and suggestions for how to reduce LGBTQ stigma. The 3-page guide (see supplementary materials) was developed to elicit participants’ own attitudes towards and experiences with LGBTQ+ clients. However, given that social desirability can prohibit disclosure of one’s own discriminatory attitudes, questions also elicited participants’ perceptions of stigmatizing attitudes and behaviors in the broader environment in which they work and about healthcare workers generally. Participants provided written informed consent and completed a brief sociodemographic questionnaire before focus groups began. In the groups, participants discussed beliefs about LGBTQ+ patients, perceptions of stigma in healthcare, and offered solutions to reducing stigma in healthcare. One PhD-level team member conducted the interviews, with a student co-moderating and additional team members present to take detailed notes. Participants received a monetary incentive in the form of a gift card for their participation. Groups lasted an average of 74 minutes (standard deviation = 6.58), were audio-recorded with permission, and were sent to a third-party transcription service after audio files were edited to remove identifying information. A research assistant checked the transcripts against the audio for accuracy and corrected them, if necessary. All study procedures were approved by the University of Texas at San Antonio Institutional Review Board.

Data analysis

Focus group data were analyzed thematically (Boyatzis, 1998). Two trained coders (AO, TH) used an iterative process to code each transcript. Codes were applied to transcripts and coders met weekly with study investigators (AB, KS) to discuss new codes and potential themes. Where there were discrepancies, the coders and investigators met to discuss them and come to consensus. The coders first independently coded the transcripts deductively according to the HSD framework, applying codes that were then mapped onto HSD framework constructs (e.g. drivers, facilitators, stigma practices). At this stage, new inductive codes that were drawn from the data were created and applied to the transcripts. After the full coding of transcripts, AB and KS reviewed all excerpts for consensus or re-coding, and began to collate codes that represented thematic elements within the HSD framework constructs. A final round of coding was then conducted to confirm thematic validity. In the final phase, AB and KS merged, renamed, and discarded thematic codes as deemed necessary. Members representing the CBO (BT, CJW, SG, GC) participated in the analysis at two stages: in the development of the initial coding scheme after their own review of transcripts, and again in the interpretation of our findings after initial impression summaries were developed and themes identified. The findings were then presented to the larger body of CBO members for final feedback on interpretation and implications.

Data Sharing Statement

The current article includes the complete raw data-set collected in the study including the qualitative data (not coded) and coding guide for analysis. Pending acceptance for publication, all of the data files will be automatically uploaded to the Figshare repository.

Results

The majority of focus group participants were women. The majority of participants were Hispanic or non-Hispanic, White; only a small proportion of participants reported being Asian, Black or African American , or multiracial. Although we had a large proportion of lesbian, gay, and bisexual participants, the majority of participants identified their sexual orientation as heterosexual or straight. Overall, focus group included 4 physicians, 3 nurse practitioners, 5 nurses, 2 counselors, and 4 office/administrative staff. See Table 1 for details on participant characteristics.

Table 1.

Participant Characteristics, N=18

	n/%
Gender
Woman	14 (77.8%)
Man	4 (22.2%)
Race/ethnicity
Hispanic	9 (50.0%)
White, Non-Hispanic	6 (33.3%)
Asian	1 (5.6%)
Black or African American	1 (5.6%)
Multiracial	1 (5.6%)
Sexual Orientation
Straight	12 (66.7%)
Lesbian or gay	4 (22.2%)
Bisexual	2 (11.1%)
Provider-type
Prescribers
Physicians	4 (22.2%)
Nurse practitioners	3 (16.7%)
Licensed, non-prescribers
Nurses	5 (27.8%)
Counselors	2 (11.1%)
Non-licensed administration/staff
Office/administrative staff	4 (22.2%)
Years in practice/ in profession
2-4 years	1 (7.1%)
5-10 years	3 (21.4%)
11-20 years	5 (35.7%)
More than 20 years	5 (35.7%)

Note: multiracial included American Indian or Alaskan Native & White (n=1)

See Figure 1 for a depiction of all themes mapped onto the HSD framework.

Figure 1.

Study findings mapped onto the Health Stigma and Discrimination (HSD) Framework.

Drivers and facilitators of stigma

Drivers

Knowledge deficits.

Participants expressed concern about their own, and their colleagues’, lack of awareness or ignorance around caring for gender minority populations, which was the most prominent driver of stigma across focus groups. This driver was specific to gender; lack of awareness or knowledge was not a salient driver of stigma for sexual minority patients in our data. This is reflective of an overarching finding in this study: examples of stigma identified were largely related to transgender individuals. The knowledge deficits we identified concerned conducting basic interactions with transgender patients, such as eliciting names and pronouns, as illustrated by the participant below:

“I think somebody my age and older who was maybe raised to use manners of, “Yes, ma’am. No, ma’am. Yes or no, sir,” and then if there is a person in front of you, you’re not sure how to address … I’ve seen people struggle with that like, “What do I do?” … Sometimes it’s just, “I’m not sure.” And I’d wanna be respectful, but how do I approach this unchartered territory? And you come from a very traditional background or family and you don’t have anybody in your family, and [have] not come across anybody in the community, then you’re not real sure how to proceed”

(Non-prescribing provider).

In addition to the challenge posed by the ‘respectful’ but gendered terms commonly used to address people (i.e. ma’am, sir) as exemplified in the quotation, participants also noted that the ‘changing verbiage around gender identity introduces uncertainty into interactions with transgender patients. Participants expressed worry about using words once considered appropriate, but which no longer are, for example the term “preferred pronouns.” Indeed, participants in each of our focus groups used the qualifier “preferred” to discuss transgender patients’ names, genders, and pronouns. Participants largely attributed these knowledge deficits to having little experience with transgender people inside or outside of healthcare.

Transgender-related knowledge deficits extended beyond not knowing proper or current terminology, to not knowing how to ask about a patient’s gender, pronoun use, or anatomy. The prescribing provider’s excerpt below illustrates how not knowing how to ask ‘what physical parts do you have?’ causes confusion and a potentially stigmatizing interaction between provider and patient.

“I could tell by their appearance, that they were transitioning - one way or another, I was not confident which way it was. My nurse had gone in there and said ‘do you prefer to be addressed as Miss or Mr.?’ and the patient answered Miss… So, I got a speculum and I went in the room to do my exam and I was like, this is not what I was expecting. Actually, I don’t know what I was expecting. And I was thinking I don’t know how to appropriately ask a patient ‘what physical parts do you have?’ so, I can do the correct exam.”

For healthcare professionals, lack of knowledge produces uncertainty and drives stigmatizing practices and experiences around misgendering. The specific issue posed by trying to elicit a transgender patient’s gender figured prominently in each of our discussions and participants believed that this problem was more pronounced among their older colleagues.

Transphobia.

Transphobia, or an intense, irrational fear of or aversion to transgender people, is an implicit driver of the manifestations of stigma practices identified in this paper. Although no participants expressed overt dislike or fear of transgender patients themselves, some supposed the behavior of their colleagues toward transgender patients reflected a ‘phobia’, and transphobia is apparent as an underlying driver of some facilitators and stigma practices later discussed. We highlight examples of transphobia as an underlying driver of the other constructs throughout these results.

Facilitators

Medical education and training.

A prominent facilitator of LGBTQ+ knowledge deficits was a lack of LGBTQ+-specific training available in formal medical and professional education. As with the main driver we identified, this facilitator was specific to transgender stigma practices. Participants linked their lack of training and education on transgender health to the gender binary organization of medical curricula and training. Providers in our focus groups shared that they do not feel sufficiently prepared to treat transgender patients because they are taught on a two-sex/two-gender model. This was explained by one prescribing provider, who explained: “At medical school you spend quite a bit of time where they have volunteers that will let you do exams on females, let you do exams on males, but there’s no practice to do an exam on a transitioning person, one way or [the] other.” Moreover, even when providers are knowledgeable about sex and gender diversity or competent treating transgender patients, the inescapable gender binary that organized their education challenges their capacity to move away from it, as the non-prescribing provider describes below.

“I think we have proof, really concrete proof, that gender is not as binary as people think it is. But if all of the history of medical literature is written from one point of view and it’s completely binary, it’s a really hard thing to resolve, even if you do fully acknowledge the reality of the spectrum of genders.”

As with knowledge deficits around interacting with transgender patients, this particular issue featured prominently in our discussions with both prescribing and non-prescribing providers across the three focus groups.

Cisnormative system procedures.

Much like the systems responsible for educating and training medical professional, it was taken for granted that the healthcare systems participants work in are cisnormative and heteronormative systems. The standard patient around whom these systems are built is not a patient who encounters stigma related to gender or sexuality. Intake or registration procedures featured as a prominent example of this in each focus group. One participant highlights the impact of an intake procedure that assumes a cisgender patient: “there’s no form, there’s no documentation that supplies [the patients’ sex and gender] before you have to ask to them” (Prescribing provider). Consider the discussion excerpted below where providers demonstrate uncertainty of whether there is a non-binary option available on the intake form in the Emergency Room (ER):

Participant 1: I think there’s a purple option. I feel like I’ve seen it perhaps, once or twice…

Participant 2: I haven’t seen it in the ER. I have never seen one.

Participant 3: I always thought that was registration. That [purple means] they haven’t been registered yet. Wow, I don’t know anything. I did not, it didn’t even dawn on me, it just - just, yeah…

Participant 4: But isn’t it interesting that we still feel like we have to have pink and purple intake, you know, all of that (Prescribing providers).

As the quote above demonstrates, even providers with access to an inclusive electronic health records may not be aware, continuing to assume a binary intake procedure even when it has the capacity to accurately capture the sex/gender of a patient. Taken together, these examples demonstrate an interaction between drivers and facilitators. The facilitator of normative system procedures is compounded by: 1) the educational system that does not adequately prepare providers to treat transgender patients, 2) individual knowledge deficits, and related/subsequent discomfort asking transgender patients about their names, pronouns, and respectful terminology around anatomy.

Destigmatizing policy and procedure.

Some participants were able to cite standard workplace procedures intended to reduce stigma and discrimination. Inclusive procedures acted as facilitators by reducing the conditions for stigma manifestations, for example, a policy of asking all patients how they would like to be addressed as part of intake procedure. The conversation excerpted below illustrates how such a policy, which is present at Participant 2’s workplace, can address individual knowledge deficits and discomfort, like those expressed by Participant 1:

Participant 1: Is it okay for us to say, “How would you like to be addressed?” I’m not sure. You know?

Participant 2: We do that with all -

Participant 1: - I mean, is that appropriate?

Participant 2: That’s one of first questions we ask our patients when they come into the unit is, “How - how do you want us to address you?”

Participant 1: And do you ask that of every patient or just those patients that you’re -

Participant 2: - Every patient… (Non-prescribing providers).

While some participants were able to rely on inclusive policies and procedures, in our focus groups, the lack of workplace procedures inclusive of LGBTQ+ patients was more prominent. In such cases, the responsibility falls on individual providers to develop and implement their own standards for interacting with LGBTQ+ patients in a non-stigmatizing or non-discriminatory manner—which many still struggled with. During the interviews, there were several occasions where participants described to each other the procedures they personally developed and adopted in their own practice. An example of this is in the description of how one physician altered his approach to taking sexual histories of all patients in a way that was explicitly inclusive of LGBTQ+ patients saying:

“I usually start off asking patients, “Are you sexually active with females, males, or both?” I never assume that because you’re a female you’re gonna have sex with males. And as soon as they tell me “both,” my next question is, “Which pronoun would you like me to use to address you?” And then it becomes a very different conversation, because I’ve accepted them into my ER and it moves on very freely thereafter…There’s absolutely no judgment. At least from my perspective…”

(Prescribing provider).

As the example above illustrates, in the absence of inclusive procedure or protocol meant to preclude stigma, healthcare workers are left to their own devices to fill the vacuum, which often demands that a provider have specific knowledge about gender and sexuality above and beyond their training.

Workplace culture and norms.

Workplace culture, or the norms, values, and basic assumptions of an organization, was also described as a facilitator of LGBTQ+ stigma among those in our focus groups. Workplace culture—and how inclusive/accepting of gender and sexual diversity it is—varied, precluding stigma in some locations, and facilitating it in others. For example, one non-licensed professional described the inclusive culture at their workplace, and reasoned that it originated from the top:

“The owners are gay and so the culture’s been, you know, I mean, who you choose to have sex with or how you choose to live your life, I mean, everyone has a right to healthcare and so, you know, their philosophy is we have to all be committed to excellence so when they do make an ignorant comment … we go over our policies and then we educate ‘em and then we tell ‘em, you know, we’re not gonna tolerate it.”

LGBTQ+ representation in leadership created and sustained an inclusive culture from the top down, leveraging the hierarchy of the practice, and further supported by policies to prevent stigma that appeared to be enforced.

The cultural context of the Southern metropolitan city where our participants worked posed an additional challenge to inclusive workplace culture. Participants recognized that broader societal norms permeate into workplace norms and culture, and that organizations need to reject norms that perpetuate stigma and adopt inclusive norms. However, organizations do not always assume that role: “It’s a culture, I think, on an individual level and maybe a city level even. Just breaking from that…heteronormative standpoint…and seeing that there are other ways that people can live…But it’s not coming from our company level and that’s unfortunate” (Non-licensed professional).

Participants described taking an active role in influencing the workplace culture, having conversations with colleagues about their prejudice and stigmatizing behaviors in order to change the culture and norms in their workplaces. Similar to norms set by those at the top of the hierarchy, many of these conversations took place within the organizational hierarchy, with managers addressing issues they saw among those working under them. However, participants expressed discomfort with engaging in such conversations. Despite having encountered situations where they recognized the need to correct their colleagues’ stigmatizing attitudes or actions, the fear of damaging one’s professional and social relationships prevents many healthcare professionals from intervening.

Stigma manifestations

Stereotypes

HIV is a ‘gay disease’.

Stereotypes about LGBTQ+ individuals intersected with those about people living with HIV. The belief that HIV is a ‘gay disease’ was agreed to be less common than it once was; however, the assumption that HIV patients are gay was said to still be pervasive, as described by one non-prescribing provider:

We don’t know the circumstances about the patient besides he’s been living with [HIV] for a long time. We don’t know if he was gay or not. But I think that’s still really relevant - that assumption… the man sittin’ there with his wife, but he’s newly diagnosed. I don’t know if he considers himself that [gay]. But it is an assumption that I see quite a bit.”

In addition to the stereotype that people living with HIV are gay, participants shared that this stereotype extended to an assumption that transgender individuals are likely to have HIV; beyond acknowledging the prevalence of this assumption among colleagues, participants also directly endorsed this belief. The assumption that transgender women were HIV positive was based on the stereotype that they are promiscuous, and/or engage in high-risk behaviors, including “survival sex.”

Prejudice

Transgender people are mentally ill.

Focus group participants expressed that the view that transgender people are mentally ill, or more broadly, that there is “something not right” with them, was common among their peers. One administrative staff explained: “I think staff would definitely feel that way, like, ‘they’re dirty or there…is something just inherently not right with them’…‘there’s something medically not right and it’s beyond them wanting to transition or transitioning’.” The idea underpinning this prejudice is that transgender people do in fact have a ‘real’ or ‘true’ gender: the one associated with their assigned sex at birth. By this logic, their lived gender is fake, invalid, and indicates evidence of mental illness. The following excerpt from a prescribing provider also exemplifies this prejudice and the underlying driver, transphobia:

“In November I did a regional CME [Continuing Medical Education course] at our school and there was a local physician there, it was a male physician, but I won’t tell you what his specialty was. I’m not sure where it even came up. But he was talking about that transgender people are delusional. They don’t see themselves as what they are, and it’s just the same as anorexic people, who see themselves as terribly overweight when they’re, you know, skin and bones. There’s no difference. And I’m thinking, whoa, I can’t believe he’s saying this.”

(Prescribing provider)

Discriminatory Attitudes

Denial of responsibility.

When it comes to the care of transgender patients, a deferral of responsibility to provide care was present in some narratives. This attitude is discriminatory because it justifies the decision not to develop the knowledge and skills needed to provide care tailored to the specific needs of these groups. For transgender individuals, providers expressed a denial of responsibility in the clinical care of patients, related to a knowledge deficit previously described. This attitude extends to the refusal to learn the LBGTQ+ terminology for some providers. In the following quotation, an ER physician describes debates around this topic that illustrate this discriminatory attitude, tied to transphobia, in Facebook forums for ER providers:

“They’re [ER physicians in Facebook forum] like, ‘I’m supposed know what pronoun to use? I mean this is ridiculous’…And they’re like, ‘it’s my job to find emergencies’. And so, it’s a very hot topic. People don’t really embrace it. You know, there’s hatred and there’s fear.”

(Prescribing provider).

Stigmatizing Behavior

Misgendering.

The most pronounced stigmatizing behavior specific to transgender patients was misgendering. While there was an overall expressed desire among focus group participants to call patients by the appropriate pronoun, there was also expressed discomfort in not knowing how to do so. Driven by knowledge deficits and transphobia, participants had witnessed coworkers both intentionally and unintentionally misgender patients, creating stigmatizing interactions. A non-prescribing provider shared one such instance: “I can remember a client who came to see me recently and they’re sitting in the lobby. So, the receptionist is here. Client is there. And she’s stammering on the phone, uh, “He, she, uh, I don’t know who it is that’s here to see you.” Participants acknowledged that the misgendering of clients was linked to the larger cisnormative culture and worsened by cisnormative health system facilitators as previously discussed.

Gossip.

Other stigmatizing behaviors discussed included gossip among healthcare providers and staff about LGBTQ+ patients. One participant described a “huge rumor mill that that starts and you can trace it all back to one or two nurses.” Examples of gossip centered on LGBTQ+ stereotypes, such as ‘fence-sitting’ comments about bisexuals ‘not making up their minds’ and comments mocking the family structure of same sex couples. One non-prescribing provider shared an example of such gossip: “I think there’s conversation amongst the staff kind of in the corner, ‘Boy or girl? Is that the Mom or the Dad?’…There’s just an uneasiness about who that person is and how it relates within the family group.”

Role reversal

It was evident in the interviews that the burden to teach pronouns or LGBTQ+ terminology to healthcare providers falls on transgender patients. Which, as the quote below demonstrates, was not necessarily understood as a problem:

I was happy to learn the appropriate language that I had never been taught…And, so he shared the things with me…So, I said, “Well, thank you because I had no idea how to even say that. I didn’t wanna offend you”

(Non-prescribing provider).

This is an example of what we termed ‘role reversal’, where patients shoulder the responsibility of addressing the knowledge deficits about LGBTQ+ care. This stigmatizing behavior is driven by knowledge deficits but may be in part an outcome of the discriminatory attitude of denial of responsibility discussed previously.

Healthcare discrimination.

We also found instances of healthcare discrimination, or stigmatizing behaviors related to healthcare that may fall within the purview of the law in some places (e.g., denial of care or insurance coverage), as a stigma manifestation. One non-licensed administrative professional, for example, described how general discomfort with transgender patients results in providers not wanting to treat them: “You have some providers and these NPs/PAs [nurse practitioners and physicians assistants] that don’t feel comfortable treating transgender patients, and they’re not sensitive about how to approach someone who’s transgender.” Embodied in the next quotation, one employee’s refusal to acknowledge someone’s gender, driven by knowledge deficits and by transphobia, and facilitated by cisnormative systems, resulted in a patient having to pay out-of-pocket for care that their insurance coverage would have helped cover.

Participant: We’ve had a couple of instances where, you know, we had, a transgender woman come in and ID marked “female”, their name was changed to a female name, and we - oh no you’re providing false identification bye. Um…

Moderator: And they didn’t receive care?

Participant: Then they paid full cost for their care (Non-licensed professional).

Discussion

This study sought to explore the manifestation of LGBTQ+ stigma in the context of healthcare within a large metropolitan area in the South, extending the current literature by examining stigma through a theoretical framework in a diverse population of healthcare professionals. The study identified possible sources of LGBTQ+ stigma, situated at the higher levels of social ecological model, such as cisnormative medical training and organizational structure, workplace norms and culture, and a lack of organizational policies and procedures to guide LGBTQ+ care and prevent stigma/discrimination. Our results suggest how drivers and facilitators contribute to the manifestation of stigma practices among healthcare professionals in the forms of prejudice, discriminatory attitudes, stigmatizing behaviors, and discriminatory treatment.

Although this study assessed stigma linked broadly to LGBTQ+ identities, many of the stigma practices discussed were specific to transgender patients. These were most salient for our participants. They included prejudicial attitudes said to be present among participants’ colleagues (e.g., transgender individuals are mentally ill), similar to those previously reported in the literature on transgender stigma (e.g., (White Hughto et al., 2016). Such attitudes perceived to be prevalent among participant colleagues suggest ignorance about non-cisgender identities, driven by knowledge deficits. However, they may also reveal intolerance towards transgender individuals, with transphobia a separate and interacting driver of much of the transgender-specific stigma apparent throughout our themes.

We further identified LGBTQ+ stereotypes that intersect with HIV stereotypes including the assumption that HIV patients are gay, and that transwomen have HIV based on the stereotype that they engage in high-risk sexual behaviors. In our parent study focused on HIV stigma, stereotypes that people living with HIV were “dirty” or contagious similarly sometimes extended to transgender women. These findings highlight one possible form of intersectional stigma that transgender and other LGBTQ+ individuals may encounter, especially for LGBTQ+ patients living with HIV (Lacombe-Duncan, 2016). This study did not explicitly explore how stigma associated with race and ethnicity, socioeconomic status, or other marginalized identities intersect with and exacerbate LGBTQ+ stigma. However, a large body of literature demonstrates the compounding effects of LGBTQ+ stigma with other forms of discrimination, pointing to the importance of future research that examines LGBTQ+ healthcare experiences through an intersectional stigma lens (Grant et al., 2011; Lacombe-Duncan, 2016).

This study’s findings sheds light on how knowledge deficits and prejudicial attitudes among healthcare professionals may manifest into stigmatizing interactions between healthcare professionals and patients to the detriment of patient care. The most prominent stigmatizing behavior identified was the unintentional, and at times intentional, misgendering of transgender patients by providers and reception staff, which has known negative effects on patients (Cicero et al., 2019; Hagen and Galupo, 2014). Unintentional misgendering of patients was driven largely by knowledge deficits, but worsened by cisnormative system procedures, particularly a lack of training or procedures for eliciting patients’ gender and the use of binary intake forms. These findings have implications for institutional intervention. First, a systematic review reported positive effects of trainings to reduce LGBTQ+ bias on healthcare students’ and providers’ knowledge, attitudes, and comfort treating LGBTQ+ patients (Morris et al., 2019). Our study provides support for this type of training not only with clinical and mental health providers, but also with ancillary staff who played a role in the reinforcing of stigma in healthcare settings. Second, inclusive intake forms and establishing other routine gender-affirmative healthcare practices reduce confusion and discomfort in patient-provider interactions, while positively influencing the broader workplace culture towards an inclusive environment (Morenz et al., 2020; Reisner et al., 2016). As described by our participants, efforts to change the workplace culture need to come from higher in the institutional hierarchy, along with enforceable workplace policies and procedures to guide LGBTQ+ care and protect against LGBTQ+ stigma and discrimination, which were largely lacking from our participants’ workplaces.

The knowledge deficits underlying many of the stigma practices in this study were linked to broader organizational facilitators, including the cisnormative organization of medical education, and a general absence of LGBTQ+ education in medical school and the workplace. This lack of training/education contributed to stigmatizing attitudes, such as the denial of responsibility to obtain transgender-specific knowledge apparent in our sample (i.e., “it’s not my job”) and poor quality of clinical care, such as patients having to teach providers about their needs (i.e., “role reversal”) or providers being unprepared to give physical examinations to transgender patients. Although the American Medical Association (AMA) and Association of Medical Colleges (AMC) recommend the inclusion of LGBTQ+-focused topics in medical education, coverage is poor (Association of American Medical Colleges, 2014; American Medical Association, 2019; Obedin-Maliver et al., 2011). Three studies analyzed curriculum and identified the need for improvements of LGBTQ+ education in nursing programs (Carabez et al., 2015; Lim, Johnson, & Eliason, 2015; Walsh and Hendrickson, 2015). One study based in Texas found that out of the 15 school respondents, only an average of 1.6 hours of LGBTQ+ health content was taught (Walsh and Hendrickson, 2015). A recent large study of students in healthcare professions generally found that less than 50% believed their formal training had prepared them to treat LGBTQ+ patients (Greene et al., 2018). These findings reinforce the need for greater integration of LGBTQ+ care into the medical school curriculum, as well as continuous gender sensitive trainings for healthcare professionals across roles (Schafer and Baldwin, 2019). Training should aim to help providers understand the different needs of those within the LGBTQ+ community (e.g., sexual vs. gender minorities), as participants tended to conflate these identities.

This study provides important insights into the occurrence of LGBTQ+ stigma in a sample of healthcare professionals in a Southern city, which may have implications for other metropolitan cities in the South. The size of focus groups varied based on participant availability, with the most representation from nurses and counselors. However, being qualitative in nature, generalizability to the broader population was not a goal of this study, but is a gap that could be filled by future quantitative research on this topic. In addition, this paper does not present an exhaustive analysis of all possible drivers and facilitators of LGBTQ+ stigma in healthcare settings, but rather what was salient among our sample. While our findings begin to fill a gap in the literature, future research is needed to explore other important drivers and facilitators of LGBTQ+ stigma that were not present in our data. In addition, individuals opting to participate in a focus group about HIV care may be more accepting of LGBTQ+ individuals than the general population.

Social desirability is another limitation to consider, which may have affected participants’ responses, leading to the underreporting of LGBTQ+ stigma in this study. We intentionally constructed questions to ask about participants’ colleagues to mitigate this bias, and indeed, participants reported greater stigmatizing attitudes and behaviors among their colleagues than themselves. Future research on this topic could employ other methods, including one-on-one interviews and direct participant observation, to get a fuller picture of LGBTQ+ stigma within healthcare settings. The CBPR approach implemented is a major strength of this study. CBPR not only promotes the equitable engagement of the community in research, but it increases the likelihood that research findings translate into community action. The CBO that initiated this study developed it with the goal of using its findings to create guidelines to reduce HIV/LGBTQ+ stigma in healthcare settings. The CBO will disseminate these guidelines to healthcare facilities throughout the metropolitan area. This goal of the study informed our inclusion of a varied sample of healthcare professionals, in order to gather an overall picture of LGBTQ+ stigma within healthcare settings. However, future research that includes more in-depth explorations of stigma among each occupational group will be important for a more nuanced understanding of the occurrence of stigma within each group, which could inform more tailored interventions accounting for variation in training, educational background, and the contexts in which professionals interact with clients.

Conclusion

Despite continuous progress in LGBTQ+ acceptance and rights in the U.S., stigma and discrimination towards sexual and gender minorities remain prevalent contributors to LGBTQ+ health disparities. Stigma and discrimination encountered in the healthcare system may be particularly detrimental to healthcare engagement, making efforts to understand and reduce stigma within healthcare settings paramount to increasing the LGBTQ+ community’s access to and full benefit from healthcare services. This study highlights the need to address prejudice, discriminatory attitudes, stigmatizing behaviors, and healthcare discrimination towards LGBTQ+ patients among health care professionals across occupational categories, particularly for transgender patients. Further, this study demonstrates the need for multi-level approaches to target drivers and facilitators situated at higher levels of the social ecological model, such as LGBTQ+ workplace training, medical curriculum inclusive of cisgender care, eliminating harmful workplace culture, and filling the gap of enforceable workplace policies and procedures to guide LGBTQ+ care and prevent stigma and discrimination in healthcare settings.