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


In 2011, the Institute of Medicine published "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a foundation for better understanding" to raise awareness with a call for action to researchers to address the specific health and health care needs of SGM people.[30] The goal of the present study was to investigate how fulfilling the four core criterion and receiving HEI commendation, including policies that mandate non-discrimination policy and training for physicians, relates to physicians' attitudes and knowledge about SGM patients.

Our findings provided partial support for our hypotheses. Physicians' attitudes about SGM non-patients were less negative at Hospital A, the hospital with HEI commendation and non-discrimination policy and training. However, no differences were found in physicians' attitudes and knowledge about SGM patients or gender and sexual minority affirmative practice between physicians at either of the two hospitals. Most physicians (95 %) in the sample were aware of SGM patients in their practices. This proportion is significantly higher than the findings reported by Westerstahl and colleagues and Dahan and colleagues who reported that 35–56 % of physicians, respectively, were aware of sexual minority patients in their practices.[5,6] Elevated awareness among the physicians in our study could reflect a larger social change toward greater awareness. This type of large-scale change could be a positive first step toward improving quality of care received by SGM patients; physician's awareness of SGM patients is a first step in addressing the unique medical care and treatment needs experienced by SGM patients.

The physicians who participated in the current study held less negative attitudes about sexual minority non-patients and sexual minority patients, than those reported by others. Compared to a randomly selected sample of non-physicians,[31] the physicians in the current study reported less negative attitudes about non-patients who identified as gay (M = 8.6 vs M = 6.7) or lesbian (M = 8.5 vs M = 6.7). Compared to a sample of social workers, psychologists, and nurses the physicians in the current study also held significantly less negative attitudes about patients who identified as a sexual minority (M = 49.4 vs M = 12.2).[24] Comparisons of attitudes about patients who identify as transgender were not possible. These differences in attitudes could be attributed to the difference in samples; neither Herek[31] nor Harris et al.[24] samples included medical physicians. It is possible that there is something about physician-focused medical education that could result in more positive attitudes about sexual minority individuals. However, it may be more likely the case that nationally attitudes about sexual minority individuals have been steadily improving nationally.[32] In a study of physician's attitudes about sexual minorities, Smith and Mathews demonstrated a 39 % decrease in physician's negative attitudes and stigma about sexual minority individuals from 1982 to 2007.[33] It is possible that the less negative attitudes reported by physicians in the current sample could be an artifact of the growing, wide-scale, and positive changes in attitudes about sexual minority individuals.

We found some evidence of gender differences. The proportion of females at Hospital B (40 %) was greater than Hospital A (29 %), and it is possible that gender contributed to the differences in attitudes about SGM individuals (non-patients) between the two hospitals. Interestingly, the possibility of a gender effect was not evident in any other measures.

Differences in physicians time in providing direct care between Hospital A and Hospital B were noted, which also aligned with their attitudes toward SGM non-patients. Unlike Hospital A, Hospital B is a research hospital. It is possible that physicians at Hospital B had less time to provide direct care because of their involvement in research activities, which may have included direct interaction with study participants outside of the hospital setting (e.g., in the community, schools, online). Their involvement in these types of research activities could also help explain why they had more positive attitudes toward SGM non-patients.

Physicians' attitudes about treating gender and sexual minority patients did not differ by hospital in this study. This similarity may be an artifact of social desirability; physicians have repeatedly self-reported that they treat all patients equally.[34,35] The measure used in the current study asked physicians questions about preference to care for, refusal of care for, and inability to talk with, gender and sexual minority patients. To better understand these attitudes, and their existence in HEI criterion leader designated and undesignated facilities, a study design that removes the threat of social desirability must be used. One such strategy involves direct or recorded observations of physicians' interaction with gender and sexual minority patients. This approach could help determine if differences exist in physicians' attitudes toward gender and sexual minority patients by observing their interactions with patients.

The geopolitical context of a region in which physicians reside and practice could also have influenced the findings.[24,31] However, the current study was conducted in the state of Tennessee; a state where many state level policies to protect SGM individuals' access to healthcare, health and wellbeing do not exist. For instance, at the time that this study was conducted Tennessee did not support marriage equality, non-discrimination in housing based on sexual orientation or gender identity, second-parent or step-parent adoption for same-sex couples, employment discrimination based on sexual orientation or gender identity, discrimination in schools or anti-bullying, transgender healthcare or gender marker change. There is no evidence available at this time to support that state level policy or other geopolitical characteristics of the region positively biased physician's attitudes and knowledge to make them less negative.

Another possibility to help explain these findings stems from the type and frequency of training that physicians received at their hospital. Less than 20 % of physicians at either Hospital in this study reported having had training in SGM patient care. Although Hospital B had earned the Health Equality Index (HEI) commendation of 'criterion leader' in sexual and gender minority patient-care centeredness, it appears that not all physicians from this hospital had received this specific training. This calls into question how often, and at what intervals, physicians receive training on implementing SGM patient-care centeredness, particularly among those who newly join a hospital and how often hospitals (and other healthcare centers) should provide such trainings to their physicians, staff and other healthcare providers. In addition, some physicians may have received training in SGM patient care and non-discriminatory practices before joining their current hospital; this may in part explain why a higher proportion of physicians at Hospital A (non-commendation) indicated they received training compared to those at Hospital B (commendation).

The lack of difference in physicians' attitudes and knowledge by hospital could represent lack of awareness about and purpose of the HEI criterion leader designation. Advocates for the HEI could argue that physician lack of awareness is addressed with the fourth core criterion which states that physicians (and other providers and staff) receive training in SGM patient-centered care. However our results suggest that the fourth core criterion may not have the impact intended as only 15 % of physicians in this study recall receiving this training.


Despite the use of evidence-based approaches to guard against low response rate,[21] the low response rate for this study is a limitation; there are several possible reasons for the low rate. First, the survey was included in a package of materials that described the study and requested consent from respondents. In this package of materials the purpose of the study, to understand physician's attitudes and beliefs about SGM patients, was clearly stated. It is possible that the low response rate reflects physicians disregard for and lack of awareness of SGM patient care issues. Second, Hospital A was located in the same region as the study's principal investigator and is affiliated with the area's most prominent academic institution. This may have motivated physicians affiliated with Hospital A to participate in the study at a greater rate than those affiliated with Hospital B. Future efforts to involve physicians in survey research should consider the use of unconditional incentives to improve response rates. Abdulaziz and colleagues recently showed that in a national survey of physicians, using unconditional incentives boosted participation to more than 60 %.[36] The use of a cross-sectional study design with a convenience sample is also a limitation because it does not allow for casual inference or generalizability of these findings to all physicians in Hospitals A or B, the state of Tennessee or elsewhere. Further, social desirability may have influenced the sample and the findings. It is also possible that physicians with an interest in SGM health or who held SGM in a positive regard were more likely to respond to the survey than physicians who did not share these attitudes. According to the 2013 HEI, Hospital B, the HEI criterion leader in SGM patient-centered care, has policy that includes all four HEI criteria, including training for physicians, other care providers, and staff.[16] According to electronic materials publicly available online, Hospital B's patient bill of rights specifies non-discrimination against SGM patients, however Hospital A's patient bill of rights does not. The absence of non-discrimination language at Hospital A may contribute to the policy-practice gap. Further, in-depth analysis of policy materials at each facility could have allowed for deeper consideration for how policy relates to physicians attitudes and knowledge. Regretfully our study is limited because the necessary documents for such an analysis were unavailable. Additionally, our study was limited by the lack of in-depth analysis of the training materials used to fulfill the fourth core criterion. A range of trainings are available to physicians in gender and sexual minority patient-centered care, including online trainings and classroom trainings of varying lengths and intensity. Training differences with respect to content, duration, and delivery modality could influence the effect on physician attitudes and knowledge. Future research should address these limitations by collecting data from physicians anonymously, using a larger, nationally representative sample and by conducting in-depth analyses of policies and trainings in gender and sexual minority patient-centered care.

The HEI commendation for achieving the four core criteria is intended to improve health care for, and guide SGM patients to, high quality, safe sources of health care. Unfortunately, our findings do not give us faith that having an HEI commendation is indicative of more positive attitudes toward SGM patients, more SGM affirmative practice, or more knowledge of SGM patients. This is concerning because many national organizations promote HEI designated healthcare organizations to SGM patients and these patients rely on HEI commendations to make informed choices about where to receive safe health care. Despite our findings, we do believe that institutional anti-discrimination policy and policy that mandates trainings about SGM healthcare are important for physicians. We recommend that all healthcare facilities provide and require their physicians, staff and other healthcare providers to be trained on how best to provide SGM patient-care centeredness. Within these healthcare facilities, we also recommend that SGM patient outcomes along with their medical providers be rigorously evaluated to monitor whether the providers training translates to mastering these skills in order for SGM patients to receive the most appropriate care for their respective needs.