Associations Between Non-discrimination and Training Policies and Physicians' Attitudes and Knowledge About Sexual and Gender Minority Patients

A Comparison of Physicians From Two Hospitals

Jennifer M. Jabson; Jason W. Mitchell; S. Benjamin Doty


BMC Public Health. 2016;16(256) 

In This Article


Sexual (gay, lesbian, bisexual) and gender (i.e., transgender) minority (SGM) individuals report significant dissatisfaction with healthcare, interactions with providers, and have more unmet needs than their heterosexual counterparts. According to McNair and colleagues,[1] sexual minority women are 85 % more likely to leave a primary care setting with unmet needs and 50 % less likely to receive healthcare that was needed,[2] including preventive screenings such as annual physical exams and pelvic and cervical screening[3] than heterosexual women. Sexual minority women also perceive that physicians do not spend enough time with them compared to heterosexual women.[4] Sexual minority men also report less satisfaction with healthcare than heterosexual men.[4] Using a representative sample of sexual minority men, Clift and Kirby found that more sexual minority men reported disrespect from their medical doctor than heterosexual men;[4] 15 % of sexual minority men also felt that they did not get enough time with their provider compared to 7 % of heterosexual men.

Physicians' awareness, knowledge, and attitudes, about SGM patients and non-patients may contribute to these problems. As noted in two studies, 44–63 % of physicians reported being unaware of having sexual minority patients in their practice.[5,6] Physicians have also reported a lack of knowledge about the health concerns and issues faced by sexual minority patients. Such concerns include, but are not limited to, risk behaviors such as alcohol, tobacco, and substance use, sexual health education, mental health including anxiety and depression, as well as overweight/obesity.[6,7] Dahan and colleagues and Westerstahl and colleagues indicate that 63–92 % of physicians report no knowledge about these health concerns or the unique health issues faced by SGM patients and non-patients.[5,6] Homophobia and heterosexism also shape the expectation that all physicians treat all patients the same and that discrimination and bias do not influence medical treatment. However, in their seminal report on anti-gay discrimination in medicine, Schatz and colleagues found that sexual minority individuals received substandard care and denial of care due to physician's discrimination based on patient sexual orientation.[8] In their report 88 % of respondents reported witnessing a physician make disparaging remarks about sexual minority patients because of their sexual orientation.[8] A more recent report by Grant and colleagues found that 28 % of patients who identified as transgender experienced verbal harassment in a medical care setting and 50 % reported providers lacked the knowledge needed to provide necessary medical care.[9]

Physicians' attitudes and knowledge about SGM individuals may vary by gender. In multiple studies published across several decades, females tend to show more positive attitudes about SGM than males.[7,10–12] Using a national probability sample of heterosexual adults in the United States, Norton and colleagues (2014) found that females had significantly more positive attitudes about gender minority people as compared to their male counterparts. Larsen and colleagues (1980) reported similar findings where females held more positive attitudes about toward homosexuality than did males. One study conducted with medical students has shown that female medical students hold more favorable attitudes about sexual minority people than male medical students.[7] The previous studies did not involve medical physicians and it is not clear from these studies if gender differences would persist in a sample of physicians.

Legal rights have expanded to sexual and gender minorities in recent years. However, discrimination of SGM individuals remains present in healthcare settings, which may contribute to health disparities. One possible solution is policies at the level of the healthcare organization that make mandatory non-discrimination and training in SGM health.[13] Non-discrimination policy exists at the federal level; the Joint Commission for the Accreditation of Healthcare Organizations mandated the development and implementation of nondiscrimination policies in medical care and equal visitation rights for sexual and gender minorities.[14] Additionally, the Centers for Medicare and Medicaid Services has changed their Conditions of Participation requiring hospitals to allow "equal visitation for patients", including SGMs.[15] However, whether or not mandates influence physician attitudes and knowledge is unknown. Further, training for physicians in SGM health issues has not been federally mandated.

The Human Rights Campaign developed the Healthcare Equality Index (HEI) to document and promote healthcare organizations' voluntary policy implementation that mandates non-discrimination and training according to four core criteria.[16] The four core criteria are: 1. Patient non-discrimination policy written into the patient bill of rights that specifies non-discrimination to sexual and gender minorities and is communicated to patients in two formats; 2. Equal visitation for SGM patients and their non-biological family members; 3. Employment non-discrimination that specifies non-discrimination against SGM employees; and 4. Training in SGM patient centered care for physicians, non-physician healthcare providers, and staff. If a healthcare organization meets all four of the core criteria they earn the commendation of 'criterion leader' in SGM patient-care. If an organization does not meet any of the four core criteria, HEI provides the organization with recommendations to resolve unmet criteria.

The intention of the HEI is to recognize and promote SGM patient-centered care and safe healthcare settings in which SGM individuals can receive care. However, there is a dearth of published empirical evidence that informs the relationship between receipt of commendation given by the HEI and physicians' attitudes and knowledge about SGM patients. In fact, to our knowledge there is no documentation of these relationships. The goal of the current study is to begin to address this gap. We hypothesize that physicians who were affiliated with a medical hospital that received HEI commendation as a criterion leader in SGM patient-centered care would have more positive attitudes, greater knowledge about SGM health issues, and better SGM affirmative practice than physicians affiliated with a hospital that did not receive such commendation.