Interactions Between Health Professionals and Lesbian, Gay and Bisexual Patients in Healthcare Settings: A Systematic Review

Figures & data

Figure 1. PRISMA flow diagram.

Table 1. Search String

1. Experience* OR interaction* OR attitude* OR talk* OR knowledge OR perception* OR belief* OR support* OR comfort*

2. Health professional* OR nurse* OR doctor* OR clinician* OR physician*

3. Sexual orientation OR sexual preference OR sexual identity OR sexuality

4. LGB OR lesbian* OR gay* OR bisexual* OR LGBO OR LGB OR Homosexual* OR Men who have sex with men OR MSM OR women who have sex with women OR WSW OR queer

5. 1 AND 2 AND 3 AND 4

Table 2. SPIDER framework

Sample	When considering qualitative studies, the sample size is not the most important issue as qualitative data is used to explore certain experiences by individuals and is not intended to be generalisable. The population of interest was HPs and/or LGB community.
Phenomenon of Interest	The concept being researched is the perceptions, experiences and interactions between two groups of people. In this case it was either HPs and their interaction with the LGB community, or vice versa. The setting is the healthcare setting.
Design of research	The research question is aiming to examine the current state of the interactions between HPs and the LGB community, not an intervention or variable placed by a research team. Therefore, only studies that were considering the current situation were included, not those staging an intervention.
Evaluation	The experiences, perceptions and attitudes will be examined.
Research type	The type of qualitative data chosen was focus groups and interviews as these allow fuller, more spontaneous answers to be given and therefore, more reliable, less biased conclusions. Surveys and structured interviews were excluded.

Table 3. Studies

Author, Title, Setting	Sample, Design	Aim	Findings
(Agénor et al., 2015) Exploring the Cervical Cancer Screening Experiences of Black Lesbian, Bisexual, and Queer Women: The Role of Patient-Provider Communication USA	18 lesbian, bisexual and queer black women 4 Focus Groups Discussion Data analysed with thematic analysis	To understand the facilitators of and barriers to cervical cancer screening in this population.	4 themes emerged: - HP communication style/demeanor - Heteronormative assumptions - Heterosexism, racism and classism - HP background (both professional and sociodemographic) The cervical cancer screening experiences of black LBQ women would be improved by training all health care providers in same-sex sexual health, offering opportunities for clinicians to learn about the effects of various forms of discrimination on women’s health care, and increasing the presence of LBQ women of color in health care settings.
(Bjarnadottir et al., 2019) Assessing Sexual Orientation and Gender Identity in Home Health Care: Perceptions and Attitudes of Nurses USA	Nurses 88% female (acknowledged to be same ratio as workforce) 2/3 white Interviews and Focus Groups were both utilized.	This study aimed to explore home health care nurses’ attitudes, perceptions and experiences related to routine collection and documentation of sexual orientation and gender identity data.	3 themes emerged: - assessment of sexual orientation or gender identity - documenting sexual orientation and gender identity - training and resources Nurses emphasized wanting to provide everyone with the same quality of care and wanted documentation to inform the care. Conclusions: Results from this study can help inform the development of training materials and resources to enable nurses to collect patients’ sexual orientation and gender identity data.
(Bjorkman & Malterud, 2009) Lesbian women’s experiences with health care: a qualitative study. Norway	128 Lesbian Women Qualitative data based on written stories. Web based open ended questionnaire from a convenience sample of self-identified lesbian women. Data were analysed with systematic text condensation. Interpretation of findings was supported by theories of heteronormativity.	To explore lesbian women’s healthcare experiences specifically related to sexual orientation to achieve knowledge which can contribute to increased quality of healthcare for lesbian women.	3 themes emerged: - Perspective of awareness (does the HP think of/facilitate disclosure) - Attitudes towards homosexuality/ respect - Medical Knowledge (do HPs have enough specific knowledge) Conclusion: To obtain quality care for lesbian women, the healthcare professional needs a persistent awareness that not all patients are heterosexual, an open attitude towards a lesbian orientation, and specific knowledge of lesbian health issues. The dimensions of awareness, attitude, and knowledge are interconnected, and a positive direction on all three dimensions appears to
(Burton et al., 2019) “Things are different now but”: Older LGBT adults’ experiences and unmet needs in healthcare USA	10 LGBT individuals 5 gay, 5 non-disclosed Interviews	The aim of this study was to increase understanding of the experiences and needs of older LGBT adults when accessing care.	3 themes emerged: - “Outness” - “Things are Different Now” - “Additional Resources” These describe participant comfort with being “out”; how treatment they received changed over time, and needed services or other options from the community Conclusion: While many older LGBT adults are accustomed to navigating social mores to avoid negative experiences, nurses as well as other health care providers must be prepared to create trusting relationships with these individuals to provide truly comprehensive care
(Chapman et al., 2012) A descriptive study of the experiences of lesbian, gay and transgender parents accessing health services for their children. Australia	11 interviews with LGT parents Both couples and individuals. Descriptive qualitative study. Semi-structured face to face interviews. Thematic analysis	To explore the experiences of LGB families accessing healthcare for their families.	3 themes emerged -Managing healthcare experiences -Attitudes -Transforming bureaucracies Negative experiences included encountering homophobia or transphobia and being required to educate health professionals. Positive experiences occurred when both parents were acknowledged as having an equal say in their child’s health care. Conclusion. Many health professionals lack the skill or knowledge to meet the needs of lesbian, gay and transgender families. Health services are required to ensure that all policies and procedures are inclusive of all family constellations and that staff receive relevant and up-to-date sensitivity training and create an environment that is respectful of all family groups.
(Fish, Williamson, & Brown, 2019) Disclosure in lesbian, gay and bisexual cancer care: towards a salutogenic healthcare environment Britain	LGB 18 men, 12 women Interviews	The aim of this study is to explore the conditions under which a sample of British LGB cancer patients revealed their sexual orientation in hospital settings to enable a more nuanced approach to understanding disclosure in this context.	3 themes emerged: - Authenticity as a driver for disclosure in cancer care - Partners as a (potential) salutogenic resource - Creating safe, healing environments conducive to disclosure. Conclusion: Our findings enable a more nuanced approach to understanding disclosure in this context. This study contributes to the literature through its articulation of the salutogenic potential of disclosure (if responded to appropriately) for LGB patients as individuals, in relationship to their partners or carers and the role of creating a visible healing-oriented optimal environment to promote quality of life and recovery.
(Haider et al., 2017) Emergency department query for patient centred approaches to sexual orientation and gender identity: the equality study Baltimore, Maryland, and Washington DC	Mixed Methods: Qualitative interviews -53 patients -26 healthcare professionals Online survey -1516 potential patients (50/50 straight/LGB) -429 emergency HCPs (50/50 nurse & doctor) 50/50 African American and Caucasian	To identify the optimal patient centred approach to collect sexual orientation data in emergency healthcare settings. Qualitative interviews – to obtain perspectives of HCPs on sexual orientation data collection Survey – to gauge pts’ and HCPs willingness to provide or obtain sexual orientation information	3 themes emerged: - Medical relevance - Normalisation - Recognition Providers understood need if medically relevant, while patients thought it was relevant to every Emergency Department encounter. Interviews suggested that pts were less likely to refuse than providers expected. 10% stated they would refuse, 78% of providers thought patients would refuse. Bisexual individuals are more likely to refuse. ‘If you are counted, you are visible, a form of recognition’
(Harbin, Beagan, & Goldberg, 2012) Discomfort judgement and healthcare for queers Halifax, Nova Scotia, Canada	19 women who self-identified as ‘queer’ (10 lesbian, 5 bisexual, 1 queer, 2 transgender, 2 other – ranged from 23-73) 9 family physician’s self-identified as working with LGBQ patients (8 women, 1 man) Women – 90min face-to-face interview Physicians – 60min interview asked about their experiences and where they felt most and least confident in their practice Team discussed narratives and creating memos to distill each participants story, began to code the data but also continue the narrative whole story reflection.	To explore how routine practices of healthcare can perpetuate or challenge the marginalisation of ‘queers.’	Both sets regularly noted the importance of feeling comfortable in their interactions with each other. Physicians were aware of homophobia and were trying hard to work against it. Women felt more discomfort than physicians, suggested as a result of fear that they will not receive quality care due to sexuality. Both avoided discomfort by 1) avoiding each other 2) putting like with like (i.e. queer with queer providers) 3) not discussing anything uncomfortable 4) not expressing discomfort 5) denying difference (i.e. treat all the same) 6) becoming ‘happy in your skin’. Patients leave when uncomfortable, so it’s important enough to target. Discomfort linked with judgement. Suggests that removing discomfort works best when patient and physician work together to relieve discomfort.
(Heyes, Dean, & Goldberg, 2016) Queer Phenomenology, Sexual Orientation, and Health Care Spaces: Learning From the Narratives of Queer Women and Nurses in Primary Health Care Canada	Interviews with both Queer and Nurses. 19 Queer women 12 Nurses: 11female 1male	To frame our understanding of the experiential narratives drawn from interviews with self-identified queer women and nurses in primary health care. To examine the ways in which primary care providers potentially perpetuate, sustain, challenge, or transform the oppression of queer women in the context of their clinical care.	3 themes emerged: - Creating spaces for possibility - Orientation as trajectory - Power and prejudice: manging difficult spaces Our interviews with queer women participants and primary care nurses offer an implicit critique of heteronormative health care space, temporality, and power relations, as they form the lived experiences of our participants. We conclude by pointing to the limits of our methodology in exposing the larger relations of power that dictate experiences of heteronormative health care. Authors stated that drawing broad conclusions from interviews was ‘naïve’.
(Keleş, Kavas, & Yalım, 2018) LGB+ Individuals’ Perceptions of Healthcare Services in Turkey: A Cross-sectional Qualitative Study. Turkey	55 LGB individuals Face to face in depth interviews. Do you think LGB individuals have been neglected in terms of their access to healthcare services? Thematic analysis	To assess how activist LGB individuals, reflecting on their own bodies, sexuality, and gender evaluate their experiences when receiving healthcare services.	The findings were evaluated within the framework of access to healthcare service theme related to healthcare service demand context. Additionally, the ‘interaction with physicians’ theme was addressed in the context of physician–patient/counselee relationship. LGBT+ individuals state that they are exposed to stigmatizing and segregating discourses by healthcare professionals, which might pose an obstacle for adaptive health-seeking behaviours. These results suggest that physicians’ professional approach has a considerable influence on LGBT+ individuals’ capacity for utilizing healthcare services.
(Knight et al., 2014) Examining clinicians’ experiences providing sexual health services for LGBQ youth: considering social and structural determinants of health in clinical practice British Colombia, Canada	24 clinicians (5 doctors and 19 nurses) providing sexual health services to LGBQ In depth, semi-structured interviews Data analysis Constant comparative techniques, open coding approach then organised into trees as themes emerged. In doing so, a thematic analysis was conducted.	To explore the perceptions and experiences of clinicians providing sexual health services for LGBQ youth.	Many clinicians provided services to LGBQ youth with a lack of cultural competency. (i.e. implicit – describing heteronormative practices, or explicit – expressing frustration about lack of education and training. Institutional norms and values were identified as the dominant barriers in the effective provision of LGBQ tailored services. Clinicians feel unprepared to provide culturally competent sexual health services. Clinicians felt their heterosexuality left them unable to identify or relate to LGBQ patients. Clinicians aware of lack of space to talk about sexual orientation
(Lee, Taylor, & Raitt, 2011) ‘It’s not me, it’s them’: How lesbian women make sense of negative experiences of maternity care: A hermeneutic study Scotland	8 lesbian women Interviews	The paper is a report of one aspect of a hermeneutic study of lesbian women’s experiences of maternity care, specifically interpretations of negative experiences. The aim of the main study was to describe lesbian women’s experiences of maternity care, specifically interpretations of negative experiences.	The participants not only described their experiences of maternity care as being positive but also offered examples of negative experiences. These were analysed separately to explore the ways in which the women made sense of them in the context of an otherwise positive experience. These experiences were expressed in ways that distanced the negative and that seemed to rationalize behaviour or ascribe it to the health professional. Conclusions. Negative encounters with health professionals are processed by women in a way that protects their overall experience. Health professionals in maternity care should consider the impact of negative responses to lesbian mothers and the effect that it has in reducing the overall quality of this significant life event.
(McCann & Sharek, 2014) Challenges to and opportunities for improving mental health services for LGB people in Ireland: A narrative account Ireland -mental health service	125 did the survey - 20 used for phone interview Found by LGB and mental health organisations, including hospitals and clinics. 75% were from Ireland, 70% single, 45% gay and 45% lesbian, one bisexual. 15% transgender Qualitative Exploratory design. Survey and semi-structured interviews. Interview 45min-1hour over 3-month period. First 2 transcripts were open coded, then coding guide developed to analyse remaining transcripts	To examine the experiences of LGB people concerning mental health services in Ireland. The objectives included uncovering positive and negative experiences: identifying potential barriers, opportunities and gaps within mental health service; and highlighting evidence of good practice that might inform future mental health policy directives.	Some reported positive experiences. Patients hoped for holistic services. Participants would like to see existing provision changed and reviewed – more responsive to needs of LGB. (i.e. increasing access, providing knowledgeable and responsible practitioners, allowing for a range of therapeutic approaches. Suggested media campaigns to reduce stigma and discrimination and also suggested equality training. Good practice guidelines should be put in place. Acknowledged minority stress and suicide risks – therefore educate in schools. Paper suggests nurses are at forefront to reduce discrimination and bias.
(Müller, 2017) Scrambling for access: availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa. South Africa	16 semi structured interview 2 focus groups 14 individual interviews Qualitative study comprised of 16 semi structured interviews and 2 focus group discussions with LGB health service users. Data analysed within the UN international covenant on economic, social and cultural rights general comment 14	This study analyses the experiences of LGB health services users using South African public sector healthcare	All interviewees reported experiences of discrimination by healthcare providers based on their sexual orientation and/or gender identity. Participants recounted violations of all four elements of the UN General Comment 14: 1) Availability: Lack of public health facilities and services, both for general and LGBT-specific concerns; 2) Accessibility: Healthcare providers’ refusal to provide care to LGBT patients; 3) Acceptability: Articulation of moral judgment and disapproval of LGBT patients’ identity, and forced subjection of patients to religious practices; 4) Quality: Lack of knowledge about LGBT identities and health needs, leading to poor-quality care. Participants had delayed or avoided seeking healthcare in the past, and none had sought out accountability or complaint mechanisms within the health system. Conclusion: Sexual orientation and gender identity are important categories of analysis for health equity, and lead to disparities in all four dimensions of healthcare access as defined by General Comment 14. Discriminatory and prejudicial attitudes by healthcare providers, combined with a lack of competency and knowledge are key reasons for these disparities in South Africa. Keywords:
(Neville et al., 2015) Perceptions towards lesbian, gay and bisexual people in residential care facilities: a qualitative study. New Zealand	Focus Groups with care workers 47 care workers 45female 2male	To explore the perceptions of care staff working in residential care homes towards older lesbian, gay and bisexual people.	3 themes emerged: - Knowing me, knowing you - Out of sight out of mind - It’s a generational thing Subtle and explicit homophobia were outlined in all themes. Care staff felt unprepared to give specific care to LGB people. Conclusion. This small-scale New Zealand study identifies that the residential care sector is not always supportive, or prepared, to provide a care service to those people identifying as lesbian, gay and bisexual.
(Pellegrini et al., 2015) ‘Never in all my years’ nurses education about LGB health USA San Francisco Bay area	268 practicing nurses Convenience sample Interview (conducted by undergraduates) 3 main questions 1) does your organisation provide training for key staff members in LGB patient-centred care? 2) Have you received training or orientation regarding care of LGB? 3) How prepared/comfortable are nurses working with LGB patients?	To assess the current state of the art of LGB sensitive nursing practice	Most nurses (80%) revealed that they had no education of training on LGB health issues. These gaps in knowledge and discomfort in practice may adversely affect patient care. LGB training needs to start in nursing schools. 30% reported discomfort - often linked to lack of education. Used ‘we treat everyone the same’ as a rationale for not learning. Some respondents stated stereotypical beliefs about LGB (e.g. us v them, “regular” patients)
(Rufino et al., 2018) Disclosure of Sexual Orientation Among Women Who Have Sex With Women During Gynecological Care: A Qualitative Study In Brazil. Brazil	Interviews with 34 women who have sex with women (WSW)	To investigate the experiences WSW have after disclosure of sexual orientation during gynecological care in Brazil.	WSW described negative experiences/ environments when disclosing. Gynecologists displayed heteronormative attitudes and did not ask about sexual orientation. The reactions of gynecologists were discriminatory, resulting in abbreviated consultations and un-comfortable gynecological exams. This study suggests that gynecologists missed an opportunity to use WSW’s sexual orientation disclosure to offer specific care to them. Conclusion: The results point out the need for a change in medical training and guidelines to assist WSW in the country. Rufino
(Rutherford et al., 2012) Development of expertise in mental health service provision for lesbian, gay, bisexual and transgender communities Canada	Mental Health clinicians Interviews with Mental health clinicians: psychiatry (n = 2); social work (n = 3); psychotherapy (n = 2), and psychology (n = 1). All providers self-identified as members of LGBT communities. 5 female 3male	To describe the common elements of the lived experiences of a phenomenon, in this case health care providers’ development of expertise in LGBT mental health.	Lack of LGBT education and resources for delivering mental health services was highlighted. Provider recommendations included the introduction of mandatory LGBT health content in education curricula that addresses basic LGBT-related terminology, appropriate interview questions to facilitate the disclosure of sexual orientation and gender identity, information regarding the health impact of hetero- sexism and homophobia, and specific health care needs of sexual and gender identity minority people. Most agreed that being LGBT was not necessary to provide supportive, appropriate care for LGBT individuals. CONCLUSIONS Data from this study suggest there are few opportunities for medical providers to access training and gain expertise in the provision of care to LGBT people. Additional research is needed to consider whether the lack of LGBT health con- tent in medical and psychiatric training programme curricula indirectly contributes to the health dis- parities experienced by these populations.
(Sefolosha et al., 2019) Reframing Personal and Professional Values: A Substantive Theory of Facilitating Lesbian, Gay, Bisexual, Transgender and Intersex Youth-Inclusive Primary Health Care by Nurses Reframing Personal and Professional Values: A Substantive South Africa	Interviews with nurses 7 participants 7 female	The aim of this study was to develop substantive theory focused on the basic social processes involved in facilitating LGBTI youth inclusive PHC in an urban area in SA. The research objectives were to: ● Explore and describe the experiences of nurses regarding caring for LGBTI youth in PHC clinics. ● Explore and describe the basic social processes involved in facilitating LGBTI youth inclusive PHC.	The theory was developed: “reframing personal and professional values” which is outlined in three phases. Phase 1 illuminates subtle and covert ways that nurses used to identify value-laden tension and conflict as barriers to LGBTI youth-inclusive care. Phase 2 and 3 reflect thoughtful and reflexive strategies that nurses used to facilitate nurse–patient interaction to resolve value- laden tension and conflict. The substantive theory provides a way of improving the healthcare and health-seeking behaviour of LGBTI youth.
(Stover, Hare, & Johnson, 2014) Healthcare experiences of lesbian, gay, and bisexual college students : Recommendations for the clinical nurse specialist USA	Focus Groups with LGB individuals 11female 7male	The purpose of this study was to describe the healthcare experiences of lesbian, gay, and bisexual college students (ages 18Y24 years) in the local college community. A specific aim of the study was to describe the factors (e.g., healthcare system, patient, provider, clinical encounter) that influence this experience.	1 main theme - comfort during the clinical encounter 3 subthemes - personalizing the clinical encounter - deciding to disclose and social stigma - seeking support of self-identified sexual orientation Participants provided recommendations that are helpful to clinical nurse specialists to promote positive clinical encounters. Implications for clinical nurse specialist practice and recommendations for further research are addressed.

Table 4. Quality Appraisal

Author/ Title	Was there a clear statement of the aims of the research?	Is a qualitative methodology appropriate?	Was the research design appropriate to address the aims of the research?	Was the recruitment strategy appropriate to the aims of the research?	Was the data collected in a way that addressed the research issue?	Has the relationship between researcher and participants been adequately considered?	Have ethical issues been taken into consideration?	Was the data analysis sufficiently rigorous?	Is there a clear statement of findings?	How valuable is the research?	Total
(McCann & Sharek, 2014)	y	y	y	y	y	n	y	y	n	y	8
(Harbin et al., 2012)	y	y	y	n	y	n	n	y	y	y	7
(Haider et al., 2017)	y	y	y	y	y	y	n	y	y	y	9
(Knight et al., 2014)	y	y	y	y	n	n	y	y	y	y	8
(Pellegrini et al., 2015)	y	y	y	n	n	y	n	y	y	y	7
(Keleş et al., 2018)	y	y	y	n	y	n	y	y	y	y	8
(Müller, 2017)	y	y	y	n	y	n	y	n	n	y	6
(Chapman, Wardrop et al., 2012)	y	y	y	n	y	n	y	y	y	y	8
(Bjorkman & Malterud, 2009)	y	y	y	y	y	y	y	y	y	y	10
(Neville et al., 2015)	y	y	y	y	y	n	y	y	y	y	9
(Burton et al., 2019	y	y	y	n	y	n	n	y	y	y	7
(Sefolosha, 2019)	y	y	y	n	y	y	y	y	y	y	9
(Bjarnadottir et al., 2019)	y	y	y	y	y	n	y	y	y	y	9
(Fish, Williamson, & Brown, 2019)	y	y	y	n	y	n	y	y	y	y	8
(Rufino et al., 2018)	y	y	y	n	y	n	y	y	y	y	8
(Lee, Taylor, & Raitt, 2011)	y	y	y	n	y	y	y	y	y	y	9
(Heyes, Dean and Goldberg, 2016)	n	y	y	n	y	y	y	y	n	y	7
(Stover, Hare, & Johnson, 2014)	y	y	y	y	y	y	y	y	y	y	10
(Rutherford et al., 2012)	y	y	y	y	y	n	y	y	y	y	9
(Agénor et al., 2015)	n	y	y	n	y	n	y	y	y	y	7

Agénor, M., Bailey, Z., Krieger, N., Austin, S. B., & Gottlieb, B. R. (2015). Exploring the cervical cancer screening experiences of black lesbian, bisexual, and queer women: The role of patient-provider communication. Women and Health, 55(6), Routledge, 717–736. doi:10.1080/03630242.2015.1039182

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Bjarnadottir, R. I., Bockting, W., Trifilio, M., & Dowding, D. W. (2019). Assessing sexual orientation and gender identity in home health care: Perceptions and attitudes of nurses. LGBT Health, 6(8), 409–416. doi:10.1089/lgbt.2019.0030

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