Lesbian, gay, bisexual, transgender and or queer patient experiences in Canadian primary care and emergency departments: a literature review

Figures & data

Figure 1. PRISMA diagram detailing reasons for exclusion and arrival at final included studies.

Table 1. Characteristics of included studies.

Reference	Location	Study design	Study setting	Recruitment	Study population	Methodology for data collection	Sample size
Baker and Beagan (2014)^a	BC, NS	Qualitative	Primary care	Convenience + snowball sampling	LGBTQ women	Interviews	38
Bauer et al. (2014)	ON	Cross-sectional questionnaire	Emergency department	Respondent driven sampling	Transgender individuals >16	Internet survey	167
Bauer et al. (2015)	ON	Cross-sectional questionnaire	Primary care	Respondent driven sampling	Transgender individuals >16	Internet survey	356
Bell and Purkey (2019)	ON	Qualitative	Primary care	Convenience sampling	Transgender adults	Interviews	11
Clark, Marshall, and Saewyc (2020)	BC	Constructivist grounded theory	Primary care providers prescribing hormones	Purposive sampling	Transgender youth (ages 14-18)	Interviews	21
Clark et al. (2018a)	Canada-wide	Mixed-methods survey	Primary care	Convenience sampling	Transgender youth (age 14-25)	Internet survey	923
Clark et al. (2018b)	Canada-wide	Mixed-methods survey	Primary care	Convenience sampling	Transgender youth (age 14-25)	Internet survey	923
Coleman et al. (2017)	ON	Cross-sectional questionnaire	Primary care	Convenience sampling	Adult gay, bisexual men or men who have sex with men	Internet survey	202
Fredericks, Harbin, and Baker (2017)^a	NS	Qualitative	Primary care	Convenience sampling	QLB women	Interviews	18
Gahagan and Subirana-Malaret (2018)	NS	Cross-sectional questionnaire	Primary care	Convenience sampling	LGBTQ + individuals >16	Close-ended internet survey	283
Giblon and Bauer (2017)	ON	Cross-sectional questionnaire	Primary care	Respondent driven sampling	Transgender individuals >16	Internet survey	433
Harbin, Beagan, and Goldberg (2012)^a	NS	Qualitative	Primary care	Convenience sampling	Queer women	Interviews	19
Heyes, Dean, and Goldberg (2016)^a	NS	Qualitative	Primary care	Convenience sampling	Queer women	Interviews	19
Heyes and Thachuk (2015)^a	NS	Qualitative	Primary care	Convenience sampling	Queer women	Interviews	20
Logie et al. (2019)	NWT	Qualitative	Primary care	Convenience + snowball sampling	LGBTQ + youth (>14) and adults	Interviews	51
Vermeir, Jackson, and Marshall (2018)	NS	Qualitative	Primary care, emergency department	Convenience sampling	Transgender adults	Interviews	8

BC = British Colombia, NS = Nova Scotia, ON = Ontario, NWT = Northwest Territories.

^adenotes five separate studies that originated from the same dataset.

Table 2. Quality assessment of included articles.

Reference	Clear aims	Rigour of sampling	Suitable design	Methodology	Depth of findings	Rigorous data analysis	Explores exceptions	Clear finding	Reflexivity
Baker and Beagan (2014)	Y	Small sample, convenience	Y	Interviews	Y	Y	N	Y	Y
Bauer et al. (2014)	Y	Large sample, respondent-driven	Y	Online survey	Y	Y	Y	Y	N
Bauer et al. (2015)	Y	Large sample, convenience	Y	Online survey	Y	Y	Y	N	Y
Bell and Purkey (2019)	Y	Small sample, convenience	Y	Interviews	Y	Y	Y	Y	N
Clark, Marshall, and Saewyc (2020)	Y	Small sample, purposive	Y	Interviews	Y	Y	N	Y	N
Clark et al. (2018a)	Y	Large sample, convenience	Y	Online survey	Y	Y	Y	Y	N
Clark et al. (2018b)	Y	Large sample, convenience	Y	Survey	Y	Y	Y	Y	N
Coleman et al. (2017)	Y	Large sample, convenience	Y	Online survey	Y	Y	Y	Y	N
Fredericks, Harbin, and Baker (2017)	Y	Small sample, convenience	Y	Interviews	Y	Y	Y	Y	N
Gahagan and Subirana-Malaret (2018)	Y	Large sample, convenience	Y	Online survey	Y	Y	Y	Y	N
Giblon and Bauer (2017)	Y	Large sample, convenience	Y	Online survey	Y	Y	Y	Y	N
Harbin, Beagan, and Goldberg (2012)	Y	Small sample, convenience	Y	Interviews	Y	Y	N	Y	N
Heyes, Dean, and Goldberg (2016)	Y	Small sample, convenience	Y	Interviews	Y	Unclear	N	N	N
Heyes and Thachuk (2015)	N	Small sample, convenience	Y	Interviews	Y	Unclear	N	Y	N
Logie et al. (2019)	Y	Medium sample, convenience, snowball	Y	Interviews	Y	Y	N	Y	N
Vermeir, Jackson, and Marshall (2018)	Y	Small sample, convenience	Y	Interviews	Y	Y	N	Y	Y

*Large sample size was defined as >100 participants; Medium as 20-100 participants; Small as <20 participants.

Y = yes, N = no.

Table 3. Similarities in themes between LGBTQ + and trans-specific primary care and emergency department experiences.

Lack of positive space signalling Trans-specific Lack of health care provider knowledge Trans-specific

Theme	Population	Description	Supporting quotes	No. of studies	No. of participants
Discomfort/disclosure concerns	LGBTQ+	Feeling invisible, feeling on edge/ uncomfortable in health care provider interactions, fear of being denied healthcare. Difficult patient decision to disclose or not; unsure of how or when	‘I want to say something [and come out] but I’m scared and I don’t know how to say it, and I keep thinking, “How am I going to say it?”’(Harbin, Beagan, and Goldberg 2012)	Seven (Baker and Beagan 2014; Coleman et al. 2017; Fredericks, Harbin, and Baker 2017; Gahagan and Subirana-Malaret 2018; Harbin, Beagan, and Goldberg 2012; Heyes and Thachuk 2015; Logie et al. 2019)	574
	Trans-specific	High rates of discomfort with discussing trans status with care providers, less comfortable with new doctors or previous negative experience	‘I feel uncomfortable because almost consistently, the older doctors I see looking to get a refill on my [hormone therapy] don’t understand what being trans is, and will treat me with scepticism and concern…’ (Clark et al. 2018a)	Three (Bauer et al. 2015; Clark et al. 2018a; Clark et al. 2018b)	1276
LGBTQ+	Makes patients uncomfortable, having small inclusive symbols (e.g. Pride flag, safe space sticker) would likely increase feelings of comfort, lack of pamphlets about queer health in waiting rooms	‘I think as a queer person, you’re kind of always looking for signals… that other people are queer or queer friendly. It just kind of gives me a different feeling around the, like regarding that whole office’(Baker and Beagan 2014)	Four (Baker and Beagan 2014; Fredericks, Harbin, and Baker 2017; Heyes, Dean, and Goldberg 2016; Logie et al. 2019)	70
Having positive space stickers or signals would likely increase feelings of comfort, make patients feel safer	‘even a small tiny sticker means the world to me’(Bell and Purkey 2019)	Two (Bell and Purkey 2019; Vermeir, Jackson, and Marshall 2018)	19
LGBTQ+	Concern about having to educate, about receiving poor healthcare, providers not knowing best practices, unsure of care provider competence	‘Don’t assume that the doctor or the medical practitioners are going to be there to assist you, if you can’t assist yourself.’(Baker and Beagan 2014)	Two (Baker and Beagan 2014; Gahagan and Subirana-Malaret 2018)	321
Some health care providers lack basic knowledge of trans healthcare, others refuse to learn, many patients felt more educated than their providers on trans healthcare	‘Interviewer: “Do you think your current family physician would have been able to support you on your [trans] journey?” Participant: “Not at all … I don’t think. No, she knows nothing”’(Bell and Purkey 2019)	Six (Bauer et al. 2014; Bauer et al. 2015; Bell and Purkey 2019; Clark et al. 2018; Clark et al. 2018; Vermeir, Jackson, and Marshall 2018)	1465

Table 4. Unique themes between LGBTQ + and trans-specific primary care and emergency department experiences.

Barriers to accessing care Self-advocacy Avoidance of care Disrespectful communication

Theme	Population	Description	Quotes	No. of studies	No. of participants
Hetero-normative assumptions	LGBTQ+	Assuming patients are straight and cisgender, not understanding/ believing when patients tell them otherwise, patients are uncertain if they should correct health care providers, one-size-fits-all approach doesn’t work	‘It’s just assumed that everybody that walks through your [clinic] door is going to be straight and married.’ (Baker and Beagan 2014)	Seven (Baker and Beagan 2014; Coleman et al. 2017; Fredericks, Harbin, and Baker 2017; Harbin, Beagan, and Goldberg 2012; Heyes, Dean, and Goldberg 2016; Heyes and Thachuk 2015; Logie et al. 2019)	291
Trans-specific	Difficult to access providers, long wait times, geographically isolated, lack of parental support, difficult to access hormones for non-binary patients, poor quality care	‘I’m afraid that I’ll take my life before I can get the surgery to help me, because it’s such an arduous and unnecessarily difficult path. I just want to live.’ (Clark et al. 2018b)	Five (Clark, Marshall, and Saewyc 2020; Clark et al. 2018a; Clark et al. 2018b; Giblon and Bauer 2017; Vermeir, Jackson, and Marshall 2018)	1385
Trans-specific	Needing to teach providers and work hard to get appointments, exhausting to always be fighting for appropriate healthcare	^‘It’s just exhausting emotionally to, like, constantly always be teaching. Like, I’ve taught so many nurses and doctors so many things’ (Bell and Purkey 2019)	Three (Bauer et al. 2014; Bell and Purkey 2019; Vermeir, Jackson, and Marshall 2018)	427
Trans-specific	Refusal to seek emergency care after transitioning, concern regarding doctor response, hoping it would go away, avoided more mental health care than physical health	‘When I was a young queer kid, and I felt like when I went to the doctor, my doctor was discriminating against me because of my sexual orientation, or gender identity, I would stop going to the doctor’(Logie et al. 2019)	Four (Bauer et al. 2015; Clark et al. 2018a; Clark et al. 2018b; Logie et al. 2019)	1090
Trans-specific	Deadnaming, misgendering, asking inappropriate questions	‘Up until 6 months ago his secretary was still calling me by my old name. Still calling me ‘him’ … and I go to correct her and she’s “I’ll try to remember eventually,” which, every other place I deal with they get it right…’ (Bell and Purkey 2019)	Four (Bauer et al. 2014; Bell and Purkey 2019, Clark, Marshall, and Saewyc 2020; Vermeir, Jackson, and Marshall 2018)	437

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