If We Don’t Ask, Why Would They Tell? Provider and Staff Perceptions of LGBTQ and Gender Minority Women Seeking Services in Women’s Health

*Elizabeth Miller¹, Carly Smith²

¹Penn State College of Medicine, Hershey, PA, ²Department of Humanities, Penn State College of Medicine, Hershey, PA

KEYWORDS: gender minority, sexual minority, LGBTQ, women’s health, provider perceptions, women who have sex with women (WSW), OB/GYN

Introduction

Providers who are informed of their patients’ sexual orientations and gender identities are better able to provide care that is relevant, specific, and compassionate.¹ Previous literature suggests that healthcare providers are uncomfortable directly asking patients to self-identify, due to their own lack of familiarity with these topics and misperceptions that doing so will make their patients feel uncomfortable.^2,4

It is important for healthcare providers to know whether or not a patient identifies as a sexual or gender minority (SGM), as failure to do so may negatively impact quality of care and health outcomes. Lesbian and bisexual women encounter several barriers to healthcare including concerns about confidentiality and disclosure, discriminatory attitudes and treatment, limited access to healthcare and health insurance, and often limited education from healthcare providers on their unique potential health risks.² Healthcare providers are obligated to provide quality care to all patients, regardless of their sexual orientation. Additionally, previous literature demonstrates that certain health behaviors and risk factors are more common among lesbian and bisexual women, who may subsequently be disproportionately affected by their health consequences.^2,3

The present study seeks to explore staff attitudes towards and knowledge of lesbian and bisexual patients at a Women’s Health Clinic embedded in an academic medical center in a semi-rural region of Central Pennsylvania. The data may identify opportunities for additional educational support and other interventions, while also generating hypotheses for future research on SGM patient experiences and relevant health outcomes.

We hypothesize that Women’s Health providers and staff will: inaccurately estimate the percentage of patients who identify as Lesbian, Gay, Bisexual, Transgender and/or Queer (LGBTQ); identify barriers to discussing sexual orientation and gender identity with patients; and endorse having biases about LGBTQ patients.

Methods

Recruitment

All staff at Penn State Women’s Health, including residents, attending physicians, nurses and other auxiliary staff, were invited to complete a survey via email. Use of Qualtrics allowed each participant to receive a unique link to an anonymous survey. After three days, staff who had not yet completed the survey received an email reminder to complete the survey. Participants were entered into a drawing to win one of three $50 Amazon.com gift cards following completion of the survey.

Survey Design and Content

To assess the hypotheses, the research team created a survey based on review of prior literature and adaptation of questions from the National LGBT Health Education Center national survey of healthcare providers.⁴

Patient estimates

Participants were asked to estimate the percent of all clinic patients who identify as lesbian/gay, bisexual/pansexual, asexual, transgender and gender non-conforming, as well as to separately estimate the percent of all patients they personally interacted with who identify as a sexual minority (i.e., not exclusively heterosexual or grouping together patients who identified as lesbian, gay, bisexual, or queer) or a gender minority (i.e., not a cisgender woman). Participants were instructed to type their estimates into a field and were notified that these categories may not be mutually exclusive.

Beliefs and biases about SGM patients

In order to assess socially undesirable biases, beliefs about the preferences of SGM patients were assessed both directly and indirectly. The former was assessed by asking participants to, for example, indicate their agreement with statements such as, “My LGBTQ patients want me to ask them about their sexual orientation or gender identity.” The latter was accomplished by using an unmatched count technique. All participants were presented with three innocuous statements (e.g., “I have never broken a bone,” “I enjoy going to the beach”), and asked to indicate which were true; However, half of the participants also received a fourth critical item assessing bias (I am uncomfortable working with LGBTQ patients and I think that talking with LGBTQ patients about their orientation will create more work for me). Participants were asked to indicate whether the above statements were true or false.

The percent of respondents for which the critical item was true was calculated by taking the difference between the two means. Participants were asked to indicate, using a 4-point Likert scale (strongly disagree, disagree, agree, strongly agree), their level of agreement with statements regarding familiarity with the unique health issues affecting SGM patients, as well as preparedness to meet these health needs.

Individual behavior and motivations

Participants were asked to indicate, using a 4-point Likert scale (never, rarely, sometimes, often), how often they ask patients about their sexual orientation and gender identity. Participants who selected sometimes, never or rarely for either question were subsequently asked to indicate, from a checklist of response options,⁴ the reasons for which they do not talk to their patients about sexual orientation or gender identity. The list included options such as lack of knowledge/familiarity (e.g., lack of experience with this type of discussion), clinical limitations (e.g., not enough time during patient interactions), and potential biases (e.g., my own cultural or moral beliefs about LGBTQ patients).

Departmental and institutional behavior

Participants were asked to identify if, to their knowledge, departmental (i.e., within Women’s Health) resources, practices and policies related to LGBTQ patients were available.

Educational needs

Participants were presented with a list of potential training opportunities and asked to identify which would be beneficial. Training opportunities included:

1. Transgender patients and health needs
2. General LGBTQ health
3. Creating a welcoming environment/cultural competency
4. LGBTQ health training specific to front desk/intake staff
5. LGBTQ resources and referrals
6. LGBTQ youth
7. Reproductive health/family planning
8. Behavioral health
9. Collecting sexual orientation/gender identity data
10. LGBTQ older adults
11. Sexual history taking
12. STD prevention/treatment
13. HIV prevention/treatment.

Descriptive analyses were conducted using SPSS Version 25. Given the small sample size and hypotheses, no inferential statistics were computed. The study was approved by the Institutional Review Board at the Penn State Hershey Medical Center.

Results

Participants

Approximately 200 Penn State Women’s Health staff were invited to participate in the study, of which 34 completed the survey, yielding a response rate of 17.0%. Table 1 displays demographic and other characteristics for all participants in the final study cohort.

Clinic role and length of employment

Clinicians (67.6%) included physicians, nurses, physician assistants, midwives, medical assistants, and sonographers. Non-clinical staff (32.4%) included medical office associates, schedulers, and medical record specialists. The majority (85.3%) of participants had been employed by the institution for at least one year, and nearly a third (32.4%) for over a decade (Table 1).

Gender and Sexual Orientation

Only one male participated in the study (2.9% of the total number of participants), and the rest of the participants were female. The majority of participants described their sexual orientation as heterosexual (76.5%), followed by asexual (11.8%), lesbian (5.9%), and bisexual/pansexual (2.9%), as shown in Table 1.

How many of your patients are SGM?

On average, participants estimated that 15.8% of patients identify as lesbian/gay, 11.6% as bisexual/pansexual, 6.6% as asexual, 5.6% as transgender and 2.7% as gender non-conforming.

Likewise, participants estimated that, on average, 13.7% of their personal patients identify as a sexual minority and 8.4% as a gender minority.

Assessing bias against SGM patients

A comparison of the unmatched count data indicated that 7% of participants are uncomfortable working with LGBTQ patients and that 50% believe that talking with LGBTQ patients about their orientation will create more work for themselves.

Differences in level of bias within groups

Among clinical staff, no participants reported that they are uncomfortable working with LGBTQ patients, while 47% of participants reported that they believe talking with LGBTQ patients about their orientation will create more work for themselves. In contrast, among non-clinical staff, 33% indicated that they are uncomfortable working with LGBTQ patients and 97% believe talking with their LGBTQ patients about orientation will create more work for themselves.

Similarly, among heterosexual participants, 11% reported that they are uncomfortable working with LGBTQ patients and 60% believe talking with LGBTQ patients about their orientation will create more work for themselves. Among LGBTQ participants, none indicated that they are uncomfortable working with LGBTQ patients and 69% believe talking with LGBTQ patients about their orientation will create more work for themselves.

How familiar are providers and staff with SGM healthcare?

On average, participants disagreed (2.2) with the statement, “My patients want me to ask them about their sexual orientation or gender identity.” (Table 2)

Discussing sexual orientation and gender identity: behavior and motivation

For both sexual orientation and gender identity, Never and Rarely were the most common responses chosen to describe how often these conversations occur. (Table 3)

The most commonly cited reasons for not having these discussions were, “It is not relevant to my interactions with patients” (64.7%) and “I’m concerned about making patients uncomfortable” (38.2%). (Table 4)

Individual vs. departmental preparation

Overall, participants agreed with the statement Women’s Health offers a welcoming and inclusive environment for LGBTQ people (patients/clients, their families, and staff), (M = 1.9, SD = 0.5). In contrast, participants felt neutral, on average, towards the statements, “I feel prepared to provide leadership in my department to meet the health needs of LGBTQ patients” (M = 2.3, SD = 0.7) and, “I feel prepared to provide leadership in my department to communicate with LGBTQ staff in a sensitive and appropriate manner.” (M = 2.3, SD = 0.8)

Unknown LGBTQ Resources

Table 5 displays the percentage of participants who responded, “I don’t know” when asked about availability of resources, practices, and policies related to LGBTQ patients. Resources which staff were most often unfamiliar with included:

1. Partnerships with LGBTQ health agencies or community groups (88.2%)
2. Presence of a department LGBTQ champion, liaison, task force or employee resource group (76.5%)
3. Departmental offering of services designated for LGBTQ patients or clients (76.5%).

Similarly, Table 6 displays the percentage of participants requesting each type of training from the list provided. The most commonly requesting training opportunities were transgender patients and health needs (55.0%), general LGBTQ health (44.1%) and creating a welcoming environment/cultural competency (32.4%).

Discussion

A paucity of literature exists on providers’ perceptions of SGM patients, particularly in rural communities such as those served by the Penn State Women’s Health Clinic. The results of this study highlight the need for further training on SGM topics within the department, which may subsequently improve the quality of care provided by both non-clinical and clinical staff to SGM patients.

A study completed in 2009 by Lambda Legal, including over 4,500 LGBTQ individuals, found that 56% of those who identify as lesbian, gay, or bisexual and 70% of those who identify as transgender had experienced discrimination or received substandard care.⁴ Additionally, nearly 8% of lesbian, gay, or bisexual individuals and almost 27% of transgender individuals indicated that providers have previously refused needed health care.³ Similarly, 49% and nearly 90%, respectively, reported a dearth of health professionals who are adequately trained to meet their care needs, because of their sexual orientation or gender identity status.⁴ Such literature demonstrates that SGM patients do not receive equal treatment when compared to their non-SGM counterparts within the realms of healthcare. The current study elucidates opportunities for future interventions aimed at improving the quality of care provided to SGM patients. For example, the results of this study were recently used by Dr. Carly Smith to tailor an educational session for the Women’s Health department.

When compared to national averages, participants rather accurately estimated the percent of patients who identify as SGM.⁵ While these results indicate that participants are aware of the prevalence of SGM patients within their clinic, biases persist, particularly among non-clinical and heterosexual staff. A systematic review by Morris et al in 2019 found that bias-focused educational interventions effectively increased knowledge on LGBTQ health care issues. Likewise, experiential learning interventions increased comfort in working with LGBTQ patients, and intergroup contact was effective in promoting more tolerant attitudes towards LGBTQ patients.⁶ The study also concluded that there is still no consensus on a single standardized method for reducing student and provider bias towards LGBTQ patients.⁶

Similarly, a systematic review by Sekoni et al in 2017 concluded that provider training on LGBTQ health did improve their skills, which may have subsequently led to improved quality of care for such patients.⁷ Like Morris et al, the study again stated that a unified conceptual model for training is currently lacking.⁷ Given the interest in training expressed by staff in our study, future research should focus on establishing a more standardized training regimen to address provider and student bias towards LGBTQ patients.

Of note, the bias was found to be higher among non-clinical participants in comparison to clinical participants, with 33% of non-clinical staff reporting discomfort when working with LGBTQ patients and 97% of non-clinical staff reporting that talking with their LGBTQ patients about their orientation will create more work for them. The differences found between the straight and LGBTQ participants regarding bias was also interesting. When asked about workload increase in relation to asking patients about sexual orientations, LGBTQ individuals reported this question would increase their workload more than straight participants.

The majority of participants reported either rarely or never discussing a patient’s sexual orientation and gender identity. Commonly cited reasons included concern surrounding relevance to the encounter, patient comfort, use of appropriate language, expertise, and legal ramifications. Likewise, participants tended to disagree with the statement, “My patients want me to ask them about their sexual orientation or gender identity.” Contradicting the above findings, previous literature indicates that SGM patients would prefer their provider ask about their sexual orientation and/or gender identity.²

Providers do not ask patients about their sexual orientation or gender identity for a variety of reasons, the largest reason in our study was due to 64.7% of participants feeling that sexual orientation and gender identity are not relevant to the providers’ interactions with their patients. 38% of participants do not ask patients about their sexual orientation or gender identity due to the concern about making the patient uncomfortable. 32.3% of participants did not ask patients about their sexual orientation or gender identity because they are unsure about the appropriate language to use, and 20.6% did not ask due to a lack of experience with this type of discussion. A total of 13.3% of participants reported that they were concerned about legal ramifications in regard to why they did not discuss a patient’s sexual orientation and/or gender identity with the patient.

After collecting data from four diverse patient populations, Cahill et al concluded that the majority of patients, regardless of SGM status, feel it is important for providers to inquire about sexual orientation and gender identity, so that these characteristics are accurately represented in patient documentation.² Such information can help guide providers in meeting the unique care needs of SGM patients and reduce their disparities. For example, substance use and mental health disorders disproportionally effect SGM when compared to non-SGM patients.¹ Additionally, previous literature demonstrates that lesbian and bisexual women access preventative care less frequently then their heterosexual counterparts.³ By identifying SGM patients, providers can offer proper preventative health screenings and address health disparities.

Overall, the vast majority of participants were unfamiliar with existence LGBTQ resources, specifically partnerships between the department and LGBTQ health agencies/community groups (88%) and presence of an LGBTQ champion, liaison, task force, or employee resource group within the department (76%). In a study done by Lambda Legal, more than 24% of lesbian, gay, or bisexual individuals and more than 50% of transgender individuals indicated that not enough support groups are available for SGM.³ With further education on the types of services offered at Penn State Health for SGM, such as the LGBTQ employee resource group and LGBTQ task force, staff could potentially implement positive change in the lives of SGM patients and colleagues alike.

Limitations

Four participants out of the 34 (11%) answered that they are asexual when asked about their sexual orientation. As this percentage is higher than the average number of asexual individuals reported in previous research (0.9% of males and 0.6% of females),⁸ it is possible that participants did not understand what asexual means and selected this option in error.

Because all of the participants were from a single institution, the results may have limited generalizability to other institutions with different training or to other regions of the country. To improve generalizability, future research may focus on disseminating the survey to other Women’s Health Clinics, thereby increasing the sample size and obtaining more comprehensive results. The study may be prone to selection bias, as those who are particularly familiar or unfamiliar with SGM health may have felt more inclined to participate in the survey.

Finally, the study may also be prone to reporting bias, as participants may have provided socially desirable answers despite the survey being anonymous and completed electronically in private settings.

Conclusion

Our study elucidates several opportunities to improve upon staff training on LGBTQ patients in the Women’s Health Clinic at Penn State. Encouragingly, the results of this study indicate that providers are eager for more education in this evolving area of health care.

Author Information

Corresponding Author

*Elizabeth Miller, BS, emiller5@pennstatehealth.psu.edu

Author Contributions

All author(s) have given approval to the final version of the manuscript.

Funding Sources

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Disclosures

No author(s) have any disclosures or conflicts of interest at this time.

Acknowledgements

None.

References

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^2. ACOG Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 525: Health care for lesbians and bisexual women. Obstetrics and Gynecology, 2012 May; 119(5), 1077–1080. Retrieved from https://doi.org/10.1097/AOG.0b013e3182564991

^3. Cahill S, Singal R, Grasso C, King D, Mayer K, Baker K, & Makadon H. Do Ask, Do Tell: High Levels of Acceptability by Patients of Routine Collection of Sexual Orientation and Gender Identity Data in Four Diverse American Community Health Centers. PLOS ONE, 2014; 9(9), e107104. https://doi.org/10.1371/journal.pone.0107104.

^4. Ard K. Understanding the Health Needs of LGBT People. National LGBT Health Education Center. 2016; Retrieved from http://www.lgbthealtheducation.org/wp-content/uploads/LGBTHealthDisparitiesMar2016.pdf

^5. Gates GJ. In U.S., More Adults Identifying as LGBT. 2017 Gallup: Social & Policy Issues. 2017; Retrieved from https://news.gallup.com/poll/201731/lgbt-identification-rises.aspx

^6. Morris M. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Medical Education. 2019; Retrieved from https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-019-1727-3

^7. A Sekoni. The effects of educational curricula and training on LGBT-specific health issues for healthcare students and professionals: a mixed-method systematic review. Journal of The International Aids Society, 2017; 20(1): 21624. doi: 10.7448/IAS.20.1.21624

^8. Poston D. Patterns of asexuality in the United States. Demographic Research. September 2010; 23(18):509-530 Retrieved from https://www.demographic-research.org/Volumes/Vol23/18/