Guidelines for the Primary Care of Lesbian, Gay, and Bisexual People: A Systematic Review

Ruth P. McNair, MBBS, DRAN-ZCOG, DA(UK), FRACGP, PhD; Kelsey Hegarty, MBBS, FRACGP, PhD

Disclosures

Ann Fam Med. 2010;8(6):833-841. 

In This Article

Abstract and Introduction

Abstract

Purpose We assessed whether existing guidelines for the primary care of lesbian, gay, and bisexual (LGB) people meet appropriate standards of developmental rigor, and whether they provide consistent recommendations useful for primary care clinicians.
Methods We performed a systematic review of such guidelines using the Cochrane Collaboration method. The countries searched were Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States. For sources, we used electronic databases, guidelines databases, primary care professional organizations, government departments of public health, LGB health care textbooks, and national LGB organizations. We assessed the quality of existing guidelines using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and compared the recommendations from all fully appraised guidelines.
Results Our search did not identify any previous systematic reviews on primary care of LGB people. Of 2,421 documents identified, we initially reviewed 30 and fully appraised 11, none of which completely satisfied the AGREE criteria for quality and only 2 of which were specifically designed for primary care. Developmental rigor was poor. Particular gaps were a lack of explicit inclusion criteria, independent reviewers, and updating procedures. Nonetheless, we did identify several consistent recommendations pertinent to primary care settings: guidance on inclusive clinical environments, standards for clinician-patient communication, sensitive documentation of sexual orientation, knowledge for cultural awareness, staff training, and addressing population health issues.
Conclusions Currently available guidelines for LGB care are philosophically and practically consistent, and provide a degree of evidence-based clinical and systems support to primary care clinicians. There is a need, however, for evidence-based LGB guidelines that are more rigorously developed, disseminated, and evaluated specifically for the primary care setting.

Introduction

The primary care of lesbian, gay, and bisexual (LGB) people is compromised by gaps in clinical care and practice systems.[1] These gaps include documented deficiencies in the LGB-specific knowledge and skills of health care professionals,[1] which are, in part, explained by a lack of training about LGB health at all levels of their education.[2,3] Clinician knowledge is also limited by the dearth of available population-based data,[4] although such studies are increasingly being conducted.[5] Further, the practice environment is affected by the contentious and stigmatized nature of homosexuality, with health care professionals holding a range of beliefs about minority sexual orientation that are occasionally pathologizing and commonly minimizing.[6] Clinician beliefs that sexual orientation is irrelevant form a major barrier to patient disclosure within consultations,[7] and few primary care services create a practice environment that demonstrates awareness of and respect for LGB patients as a group.[8] This lack of awareness and respect has been described as a "blind spot" among family physicians toward LGB patients,[9] and it leads to reports by LGB people of difficulty in accessing culturally competent primary care services.[10]

LGB-specific services have been developed to overcome these deficiencies;[11] however, there is a pressing need for mainstream services to become culturally competent in this area.[12,13] We assert that such cultural competence should be LGB-specific rather than generic to overcome a tendency to disregard minority sexual orientation in clinical care. Many family physicians prefer to avoid stereotyping and remain neutral by ignoring numerous specific cultural attributes; as a result, crucial differences that influence health are missed.[14]

Clinical practice guidelines for LGB health care would assist in improving clinicians' knowledge and skills;[15] however, few guidelines are available, creating a further barrier to effective practice.[2] Policies on lesbian and gay health do exist within some medical associations,[16,17] although the associations have been slow to translate these policies into standards of practice and education.[18] Health policy at the government level also often lacks LGB-specific focus, which further discourages LGB sensitivity among educators or clinicians.[19] To be most effective, guidelines must be accompanied by a range of other educational methods including audits, training, and feedback;[20] nevertheless, they can serve to raise the awareness of clinicians to the LGB population group. Guidelines that provide easy access to current evidence in the area and clear recommendations on day-to-day care are more likely to be put into practice by clinicians.[21,22]

We undertook a systematic review to determine whether existing LGB guidelines for primary care meet appropriate standards of rigor in their development and to summarize areas of consistency that provide practical guidance for primary care clinicians.

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