Terminology

This review was commissioned by the Agency for Healthcare Research and Quality (AHRQ). To be consistent with other national reports, AHRQ recommends use of the terms lesbian, gay, bisexual, and transgender throughout this report. While LGBT is probably the most widely used acronym, consensus on terminology for this population is lacking. LGBT may exclude people who do not identify as lesbian, gay, bisexual, or transgender but who are sexually or romantically involved with people of the same or multiple genders or sexes. However, behavior-based terminology, including men who have sex with men (MSM), men who have sex with men and women (MSMW), women who have sex with women (WSW), and women who have sex with women and men (WSWM), may also be problematic. These terms can divide the LGBT community socioeconomically and fail to recognize the important role of identification and community membership.⁸⁶ The American Association of Medical Colleges (AAMC) has recently advocated the form of person-first language; instead of gay patient, patient who may be gay.⁸⁷ This construction is also not yet widely used or accepted.

Although gender and sexual minority populations are often (and in this report) grouped together under the LGBT acronym, sexual orientation and gender identity are distinct concepts and capture different populations with distinct health and health care needs, concerns, and disparities. The following definitions were adapted from the 2011 Institute of Medicine Report on the Health of LGBT People:⁷⁷

• Gender identity—One's basic sense of being a man, woman, or other gender, such as transgender. Non-cisgender may be used to describe individuals and populations whose gender identity differs from the gender typically associated with their sex assigned at birth.
• Sexual orientation—Encompasses attraction (i.e., sexual or romantic feelings for people of the same gender/sex, another gender/sex, or multiple genders/sexes), behavior (i.e., sexual or romantic activity with people of the same gender/sex, another gender/sex, or multiple genders/sexes), personal identity (i.e., one's conception of self as gay, bisexual, straight, etc.) and social identity (i.e., a sense of membership in a social group). “Sexual minority” may be used to describe individuals and populations whose sexual attraction, behavior, and/or identity are not exclusively heterosexual.

The purpose of this report is not to resolve language disputes. For studies included in this report, terminology used to refer to LGBT people is consistent with the source publication whenever possible. However, we have chosen not to use the term homosexual to describe identity in this report, because that term is associated with recent periods in U.S. history when being gay was considered pathological and criminal.

Health Disparities

The most well-studied health disparity in the LGBT population is HIV/AIDS incidence and prevalence. Men who have sex with men are 44 times more likely than heterosexual men to be newly diagnosed with HIV and differences in all-cause mortality rates between gay and heterosexual men are largely attributable to this disparity.⁸⁸ A large proportion of the research on LGBT health has been dedicated to the incidence, prevention, and treatment of HIV/AIDS among men who have sex with men.^89,90 Lumping transgender male-to-female individuals with men who have sex with men masks the higher rates of HIV infection in this subgroup, particularly among African Americans.⁷⁷

However, recent evidence demonstrates that LGBT populations face numerous additional health risks requiring intervention. For example, gay, bisexual, and other men who have sex with men have been found to be at increased risk of sexually transmitted infections (STI) other than HIV, such as syphilis, gonorrhea, chlamydia, human papillomavirus, and hepatitis A and B;⁹¹ lesbian and bisexual women are more likely to be obese and to use tobacco and alcohol than heterosexual women;^82,84,92,93 and gay, lesbian, and bisexual adolescents and young adults of all genders have higher rates of tobacco and alcohol use, unhealthy weight control, and risky sexual behaviors than their straight peers.^94-96 LGBT populations also experience a greater prevalence of mental disorders, such as anxiety and depression, have higher rates of suicidal ideation and attempts, and are subject to significantly more emotional, physical, and sexual trauma than straight and cisgender people, or individuals whose experience of their own gender matches their assigned sex at birth.^97-100 Individuals who identify as bisexual may experience more psychological distress compared with those who identify as heterosexual, gay, or lesbian.⁹⁷ The LGBT population is diverse in terms of race, ethnicity, disability status, socioeconomic status, and immigration status, and risk factor disparities may be further intensified by intersecting identities and multi-minority statuses.^101-103

Despite accumulating evidence of risk factor disparities between LGBT and heterosexual and/or non-cisgender populations, scant research connects these risk factor disparities to intermediate or long-term health outcomes, such as cancer or cardiovascular disease (CVD). For example, apart from research that has found a higher prevalence of virus-linked cancers among men who have sex with men,¹⁰⁴ little is known about cancer incidence or mortality among LGBT populations because sexual orientation or gender identity information is not routinely captured in cancer registries. This lack of surveillance data is particularly problematic, as cancer risk factors may cluster in LGBT populations. For example, lesbian and bisexual women have higher rates of a number of breast cancer risk factors, including increased alcohol use, higher rates of smoking, obesity, and nulliparity, and they may receive breast cancer screening less frequently than heterosexual women (though the evidence regarding cancer screening behaviors among lesbian and bisexual women is conflicting).^105-107 Sexual minority women have also been found to have a higher Framingham general CVD risk score than straight women, indicating that they may be at greater risk of developing CVD.¹⁰⁸

Thomas et al. delineated four phases of disparities research: (1) documenting the disparities, (2) exploring rationales for the disparities, (3) providing evidence for solutions, and (4) moving towards structural, multi-level interventions.⁶ LGBT health disparities research is largely still in the first generation, as it is difficult to document the disparities without data from national health surveys and registries on sexual orientation and gender identity.⁷⁷ This review uses the limited second generation evidence for the causes of health disparities in LGBT populations to discuss the interventions designed to address these barriers in the formal health care system. As the disparities in various LGBT subgroups become better defined, barriers can also be identified more precisely, and interventions can be more tailored to root causes.

Cultural Competence

Cultural competence has been widely promoted as one approach to reduce health disparities. Since cultural competence remains variously defined and operationalized, the term has come to describe a broad range of system- or provider-level interventions. Specific recommendations to create culturally competent health care for LGBT people include: educating staff on specific health disparities experienced by the LGBT communities and how to collect sexual and social history, using gender-neutral language on forms and communication, refraining from making assumptions about a person's sexual orientation or gender identity by asking directly about identity and sexual behavior, displaying LGBT-friendly symbols, and registering with the Gay and Lesbian Medical Association's online directory.^109,110 For many physicians, like many people in society, examining strongly held beliefs and biases may be a necessary first step to creating a welcoming environment for LGBT patients. Inclusive and nondiscriminatory policies can support the work of cultural competence. However, political interventions are beyond the scope of this review.

Scope and Key Questions

PICOTS

Table 9 provides the populations, interventions, comparators, outcomes, timing, and settings (PICOTS) of interest. The analytic frameworks can be found in Chapter 1 and Appendix A.

Table 9

Review PICOTS—LGBT populations.

Literature Search Strategy

We searched Ovid MEDLINE®, PsychInfo, and Cochrane EPOC from 1990, when the concept of cultural competence gained traction, to June 2015. Because cultural competence interventions in LGBT communities are not well defined, and the literature set was relatively small, all intervention studies for the population of interest were reviewed for inclusion (no cultural competence intervention filter was used). Searches and screening were performed iteratively to identify concept boundaries and tighten the working definitions and eligibility criteria. The final search algorithms are provided in Appendix B. We also manually searched reference lists from systematic reviews and employed back and forward searching of key articles recommended by experts.

Study Selection

We reviewed bibliographic database search results for randomized controlled trials (RCTs) systematic reviews, nonrandomized controlled trials, before and after case reports with comparators, and interrupted time series studies published in English language relevant to our PICOTS framework. All studies identified at title and abstract as relevant by either of two independent investigator underwent full-text screening. Two investigators independently performed full-text screening to determine if inclusion criteria were met.

Eligible studies tested an intervention to provide culturally appropriate health care to LGBT adolescents, young adults, and adults.

Interventions that targeted providers, formal health care systems, or the ability of the patient to communicate or interact with the provider or formal health care system in support of culturally competent care were eligible. Such interventions could include remote (such as web- or phone-based) interventions to provide access to care in a manner sensitive to the needs of the LGBT population. Studies that tailored interventions to individuals (patient-centered) rather than the community (cultural competence) were excluded. Interventions that were merely disease-driven (such as HIV) rather than population-driven were not included.

Studies conducted in public-health or specialized LGBT clinics were excluded. While the authors acknowledge the historic and continued importance of public-health clinics and other parallel systems in providing much of the care to the MSM population, particularly gay men with human immunodeficiency virus (HIV), the point of this review is to identify strategies to make the average, nonspecialized provider and system more able to address the specific needs of LGBT populations.

This restriction on setting eliminated a large portion of the LGBT literature that is focused on changing sexual risk-taking behavior related to HIV/AIDS. For example, a 2013 systematic review identified 33 U.S.-based RCTs of behavioral interventions to reduce HIV transmission and infection that were specifically designed for the MSM population.¹¹¹ Nine studies were deemed by the authors to meet the Center for Disease Control and Prevention's Prevention Research Synthesis criteria and thus evidence-based.^112-119 Only one of these studies is included in this review;¹¹⁸ the other eight did not meet inclusion criteria.

We also expanded the criteria to include studies from other developed countries that tested interventions that could possibly transfer to U.S. health care.

Initial search results were vetted by the full team. Differences of opinion regarding eligibility were resolved through consensus. Articles excluded at full text are provided in Appendix C with reasons for exclusion.

Data Extraction, Synthesis, and Presentation

We evaluated the risk of bias in included studies according to study design using criteria from the Cochrane risk-of-bias tool in interventional studies (Appendix D). Given the paucity of literature identified, the heterogeneity of the study populations and interventions, small study samples, the lack of details for complex interventions and comparators, and the high risk of bias assessment for most of the included studies, we determined the strength of evidence for cultural competence interventions, in general, to be insufficient and thus we were unable to draw meaningful conclusions from the literature. Therefore, we focused on summarizing the results into evidence tables and conducted a qualitative synthesis, grouping synthesis results using emergent patterns from identified interventions, and evaluating the challenges of the literature that present barriers to forming inferences from study results. One investigator abstracted the relevant data from eligible trials directly into evidence tables. A second investigator reviewed evidence tables and verified them for accuracy.

Literature Search Results

We identified 6,820 unique English language citations (Figure 5) from 1990 to June 2015. After excluding articles based on title and abstract, full texts of 85 articles were reviewed to determine final inclusion.

Figure 5

Literature flow diagram—LGBT populations. LGBT = lesbian, gay, bisexual, transgender.

The 11 included studies (12 manuscripts) were not easily combined. The studies fell into five categories: interventions aimed at prompting patients to interact with the formal health care system for screening or testing (n=2); a clinic-based mental health and substance use intervention tailored to a LGBT population (n=1); a psychosocial intervention for a LGBT population with cancer (n=1), interventions aimed at behavioral risk reduction that involve formal health care providers (n=4), and interventions aimed at changing provider knowledge, attitudes, and beliefs through trainings or curricula (n=3). Studies were generally high risk of bias (Appendix D). Since the risk of bias and heterogeneity of the studies precluded any strength of evidence other than insufficient, we describe the studies by emergent patterns.

Table 10 describes the included studies by intervention type and LGBT population. Four studies focused on men who have sex with men,^118,120-124 two studies focused on gay and bisexual men,^123,124 three focused on lesbian and/or bisexual women,^125-127 and the three educational interventions focused more broadly on multiple LGBT populations.^110,128,129 We identified no studies specifically addressing the provision of culturally competent services for transgender people.

Table 10

Summary of included LGBT population studies.

Four approaches to cultural competence were observed among the included studies: three included studies used a person to deliver the intervention that was also a member of the LGBT population;^118,125,126 two used a combination of provider training and prompts for the provider and patient during the clinical encounter;^120,121 three studies focused solely on provider education;^110,128,129 and three tailored an existing intervention to better reflect the target population.^122-124,127 Study sample sizes ranged from 20 to 1,396. Less than half of studies (5/11) were randomized trials.^{118,122-124,126,127} Only one study (two manuscripts) used an attention control.^123,124

Interventions Aimed at Prompting LGBT Patients To Interact With the Formal Health Care System for Screening or Testing

Table 11 summarizes the two studies in this category. One study was designed to address screening disparities as a potential modifiable pathway to early detection of breast cancer.¹²⁶ The RCT examined counseling to improve breast self-exam and mammography among women who self-identified as lesbian or bisexual.¹²⁶ The cultural competence approach used in this study was patient/provider sexual identity concordance; a key element of the program was making it clear to participants that all scientists, staff, and counselors involved in the studies were sexual minority women.¹²⁶ The authors reported significant increases in self-breast examination and mammography, and significant decreases in perceived risk, cancer worry, and mental health that were sustained over time compared to a waitlist/delayed control.¹²⁶ However, the study did not include an arm that compared the effectiveness of the counseling program delivered by providers who were not explicitly identified as sexual minority women. One of the more interesting findings of the trial is the differential effectiveness of the intervention by degree of “outness.” Among women in the intervention arm, after controlling for income, education, age, and sexual identity, women whose sexual orientation was known to coworkers and family members were three times more likely to have screening mammography.

Table 11

Interventions aimed at increasing interaction with the formal system for LGBT populations.

Blas et al. tested the effect of an online intervention to encourage men who have sex with men, whether or not they identify as gay, to get tested for HIV on obtaining HIV testing.¹²² The study randomized 142 gay-identified men to the video-based intervention group and 130 to the text-based control intervention. Ninety-seven non-gay identified men (men who have sex with men but do not consider themselves to be gay) were randomly assigned to the video-based intervention and 90 to the text-based control intervention.¹²² Even though this study was conducted outside of the United States (Lima, Peru), it is included because it prompts interaction with the health care system (going to get tested), documents whether testing occurred, and targets an underserved segment of the MSM population, men who have sex with men but do not identify as gay. The intervention itself is tailored to match the behavior and identity of the participant (non-gay or gay).¹²² The 5-minute videos use the health belief model to transition through the stages of change and incorporated common reasons why MSM do not get tested.¹²² Among the gay identified population, the intervention had no effect on intention to test (30 days or next 6 months), appointment making, or actual clinic attendance. However, among non-gay identified MSM, the video intervention significantly increased intention to test over the next 30 days and actual attendance at clinic.¹²² These two studies highlight the importance of considering the multiple dimensions of sexual orientation (i.e., identity, attraction, behavior) when designing and tailoring interventions.

Clinic-Based Mental Health and Substance Use Interventions Tailored to an LGBT Population

Increases in substance use and depression have been observed in the LGBT population.^130-132 We identified only one RCT tailoring a therapy or drug intervention to an LGBT population that met inclusion criteria for this review.^123,124 Self-identified gay and bisexual men (n=263) seeking outpatient behavioral drug abuse treatment for methamphetamine dependence, with a Structured Clinical Interview-verified diagnosed methamphetamine dependence, began a 2-week baseline period that took a similar format to the actual intervention (attendance three times per week, urine sample collection, and group therapy).¹²⁴ After this 2-week baseline period, 162 participants who had attended at least two of the four cognitive behavioral groups during baseline were randomized to one of four study conditions three times a week for 16 weeks: cognitive behavioral therapy (CBT) sessions, contingency management (CM), CBT and CM, or “gay-specific” CBT sessions.^123,124 The comparator, CBT, focused on teaching patients skills to achieve, maintain, and recover abstinence after relapse, including healthier coping strategies, recognition of triggers and cravings management, and stages of recovery.^123,124 Gay-specific CBT included the skills taught in the basic CBT with “referents to cultural norms and values of urban GBM [gay and bisexual men] and providers' emphasis on reduction of HIV-related sexual behaviors.” (p. 126).¹²³ Gay-specific CBT was not differentially effective on treatment retention, number of days of methamphetamine abstinence, or depression outcomes when compared with standard CBT.^123,124 The gay-specific CBT condition significantly reduced unprotected receptive anal intercourse compared with standard CBT arm; however, those gains were not maintained over time.¹²⁴

Interventions Aimed at Behavioral Risk Reduction That Involve Formal Health Care Providers

We identified four studies for behavioral risk reduction interventions in the LGBT population that involved health care providers and were judged to be transferable to the nonspecialized health care system: three studies specific to MSM, and one specific to WSW. No studies were identified that were specific to transgender people. Table 12 provides a summary of the studies.

Table 12

Interventions aimed at behavioral risk reduction for LGBT populations.

Two prospective cohort studies without comparators were included because they represent strong examples of sexual health cultural competence interventions.^120,121 In the Providers Advocating for Sexual Health Initiative (PASHIN), all primary care providers received a 5-hour training that emphasized enhancement of provider communication skills around sexual risk assessment and behavior change.¹²⁰ Similarly, the CDC-funded Partnership for Health intervention (part of the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy [SUN]) trained providers to conduct brief risk-reduction counseling during the clinical encounter. All clinic staff (including support staff) attended a 4-hour training that included lecture, videos, small group activities, and patient-provider simulations before study initiation, and a 1-month post-intervention booster session.¹²¹ Pocket guides and videos also were used to support provider education.¹²¹

In the PASHIN study, participants completed a computerized assessment that generated a tailored, theory-based advice sheet with prioritized objectives for providers to use during the routine clinical encounters that occurred approximately every 3 months.¹²⁰ The intervention also included a prescription to recap the providers' intervention messages that was given to each patient to take home.¹²⁰ For SUN, patients received prevention messages in written form and then had the messages reinforced by providers.¹²¹

The RCT differed from the PASHIN and SUN studies because the counseling, scheduled around a routine primary care visit, was delivered by ethnically diverse, HIV positive members of the MSM community supervised by a clinical psychologist.¹¹⁸ Treatment advocates received 40 hours of training on specific CBT techniques and motivational interviewing. Weekly supervision with doctoral- and masters-level licensed therapists, as well as recorded session audits, allowed for over 85 percent compliance with program protocol.¹¹⁸ During the four-session intervention, a computer was used for the advocate and patient to complete each prescribed module and create a behavioral plan.¹¹⁸

Both prospective cohort studies reported to significantly reduce most unprotected sexual behaviors, but not HIV disclosure.^120,121 PASHIN also found reductions in STI incidence.¹²¹ However, in addition to the lack of comparators, half the invited patients declined to participate, and 40 percent of enrolled patients in PASHIN did not receive all five provider-delivered interventions. The RCT intervention was effective in the short-term, but significant reductions in unprotected anal intercourse and transmission risk were not sustained at 12 months.¹¹⁸ More rigorous evaluation is needed to evaluate the effectiveness of these components used individually and in combination.

One study addressed secondary prevention among WSW diagnosed with bacterial vaginosis (BV). Using focus groups, an informational intervention was developed to target misconceptions held by WSW, such as “women can't get STDs by having sex with other women,” or “women who have sex with women don't need pelvic exams.”¹²⁷ This randomized trial was part of a larger, clinic based study of BV treatment failure among women who have sex with women.¹²⁷ In addition to addressing patient-specific misconceptions, the intervention targeted the use of gloves during digital vaginal sex, condom use for insertive toys, and use of water-based lubricant (gloves, condoms, and lubricant provided to intervention arm).¹²⁷ Participants in the intervention arm were significantly more likely to use gloves during digital-vaginal sex; there were no differences in frequency of other target behaviors including receptive digital-anal sex, sharing sex toys without cleaning them, and vaginal intercourse with men without condom use.¹²⁷ The intervention also had no effect on persistent or recurrent BV.¹²⁷

Interventions Aimed at Changing Provider Knowledge, Attitudes, and Beliefs Through Trainings or Curricula

Three provider training programs and curricula have been developed for providing care to LGBT populations,^110,128,129 but none have been rigorously evaluated. Two programs were short: a 2-hour program for second-year medical students¹²⁹ and a 3-hour seminar for post graduate year residents. One program ran 2 years as part of a medical curriculum.¹²⁸ To evaluate the impact of curricula, short programs used pre-/post-test designs while the undergraduate curriculum used the previous class cohort as a historical control. Table 13 gives summaries of the studies.

Table 13

Summary of provider training interventions for LGBT populations.

After the 2-hour seminar, four of the 16 items were significantly changed by the intervention (largest absolute change .57 on a 5-point scale).¹²⁹ Students more strongly disagreed with the following three statements after the intervention: “Access to health care is the same for LGBT people as for other members of the population;” “LGBT people are less likely than heterosexual people to be in long-term monogamous relationships;” and “I would prefer not to treat patients with gender identity issues.”(p.251)¹²⁹ Students more strongly agreed with the following statement after the intervention: “As a physician, I feel it is important for me to know about my patients' sexual orientation, sexual practices, and gender identity.”(p.251)¹²⁹ This study had several methodological weaknesses, including absence of a control population, low response rate among eligible participants (52 percent), high baseline familiarity with the LGBT population, and no measure of effect of intervention over time.¹²⁹

In another study, after attending the 3-hour seminar, residents felt more prepared to deal with lesbian and gay health care issues (absolute change .47 on a 5-point scale).¹¹⁰ Mean changes in comfort summary scores were not significantly changed by the intervention, but trended in the direction of more comfort.¹¹⁰ Limitations of this study include the lack of a control group, small study population, unclear instruments, absence of measurement of effects over time, and high baseline reported comfort and knowledge of the population.¹¹⁰ It is not clear, however, whether either of these trainings actually produced changes in attitudes or merely elicited the socially desirable response from physicians, immediately post-training.

The 2-year intervention had no effect on medical students' beliefs; students who received the intervention were as or more likely to believe social factors, including class, race, culture, religion, gender or sexual orientation, did not affect their education or practice.¹²⁸ Limitations of this study include: response rates of 50-60 percent of the eligible population participated and an unclear test of statistical significance on individual characteristics.

Psychosocial Interventions

One study conducted a pre and post test of the effect of Supportive-Expressive group therapy on distress, anxiety and depression, self-efficacy, social support, physician satisfaction, and quality of life among 20 lesbian women who were recently diagnosed with primary breast cancer.¹²⁵ Outcome information was collected on all participants at baseline, 3, and 6 months; outcomes were collected for 17 of 20 participants at 12 months.¹²⁵ Participants met in groups of four or more, 12 times, for 90 minutes each session with 95 percent attendance at sessions.¹²⁵ Groups were led by lesbian clinical social workers; no other changes to the Supportive-Expressive therapy protocol were made.¹²⁵ The intervention reduced tension, pain, and anxiety, while improving mood, self-efficacy, and sleep. However, the intervention appeared to have a negative effect on perceived social support and no effect on patients' rating of physicians or body image.¹²⁵ The ability to interpret these findings is limited by the absence of a control group.

Overview

Our main finding is that the evidence on which to base culturally competent LGBT health care does not (yet) exist. Disparities in the LGBT population are not well documented,⁷⁷ and research testing interventions to reduce health disparities is even more rare. Over 6,800 articles were reviewed, resulting in 11 included studies, only five of which were RCTs.

Four approaches to cultural competence were observed: three studies used a person to deliver the intervention that was also a member of the LGBT population;^118,125,126 two used a combination of provider training and prompts for the provider and patient during the clinical encounter;^120,121 three studies focused solely on provider education;^110,128,129 and three tailored an existing intervention to better reflect the target population.^122-124,127 Sample sizes ranged from 20 to 1,396. Less than half of the studies (5/11) were RCTs.^{118,122-124,126,127} Only one study (two manuscripts) used an attention control.^123,124

While research on MSM remains under-resourced relative to HIV/AIDS disease burden,¹³³ a significant body of research has addressed how to deliver HIV prevention for this population using cultural competence approaches. This shows that the next step of conducting rigorous research addressing LGBT health disparities can be successfully undertaken if resources are made available.

This literature highlights the predominance of a parallel health care system for people with HIV/AIDS that grew out of mainstream fear at the height of the epidemic. AIDS service organizations (ASOs) in major urban areas (e.g., San Francisco AIDS Foundation, AIDS Project Los Angeles, and the New York Gay Men's Health Crisis), as well as smaller community health centers throughout the country, provided medical and psychosocial care to gay, bisexual, and other MSM.⁷⁷ These centers became affiliated with universities and received funding from multiple sources, including the government. In the subsequent decades, with the advent of life-changing drugs (highly active antiretroviral therapy, or HAART), these centers continue to provide care and comprehensive services for people with HIV/AIDS, particularly newly diagnosed men of color who have sex with men. However, the infrastructure developed as a result of the AIDS epidemic is now also used to deliver a host of other services to members of the LGBT community (see Fenway Health, fenwayhealth.org). This parallel health care system may inadvertently mask the need for cultural competence in the mainstream or nonspecialized health care system. Although many of the ideas for treating the LGBT population will likely come from the well-developed specialty care, using a segregated or supplementary system of care should be a patient-elected decision, not one driven either by stigma or the mainstream systems' lack of skill. The past 5 years have seen significant attempts to end “AIDS exceptionalism,” by mainstreaming HIV care from ASOs into the health care system.

The health care system plays a key role in eliminating health disparities among populations. However, the 2011 IOM report found that “LGBT individuals face barriers to equitable health care that can have a profound impact on their overall well-being” (p. 297).⁷⁷ LGBT patients report having to teach providers about their health care-related needs, experiencing provider discrimination, receiving inappropriate care recommendations, and even being denied care.^134-136 Past experiences and/or fear of such treatment reduces the likelihood that LGBT patients will disclose their sexual orientation or gender identity to providers.^137,138 Disclosure in a health care encounter is associated with receiving more appropriate health services and better doctor-patient communication.^139-141

Interventions aimed at changing the knowledge and attitudes of providers are a hallmark of cultural competence in other populations (although their effectiveness is not clear),⁵¹ but most providers have little to no training in LGBT health.^142,143 Some protocols and recommendations have been published.^144-147 However, many physicians are not familiar with existing recommendations, hold misconceptions, and about LGBT patients, hold explicit and implicit biases against LGBT people, and are hesitant to inquire about support systems. In addition, many are uncomfortable managing sexually transmitted infections (STIs) in LGBT populations.^148,149 Training programs and curricula have been developed to overcome some of these barriers in knowledge, attitude, and skill,^110,129 but none have been rigorously evaluated. The Fenway Institute is one of the sources of provider LGBT health education and training.¹⁵⁰ The American Association of Medical Colleges (AAMC) has also recently published a guideline including LGBT-based competencies for medical education curricula.⁸⁷

Research Directions

Research into other areas of health across the LGBT population remains extremely thin.⁷⁷ Our understanding of where important additional disparities might exist as well as interventions to address them has not been explored in full. As a result, health professionals may over-identify MSM and transgender populations with one disease (HIV/AIDS). Simultaneously, they may under appreciate or ignore the high rates of physical, mental, chemical, other sexual and relational health challenges facing LGBT patients and communities. Until this disparity is addressed, challenges such as the high rate of suicide in LGBT adolescents may continue to be largely ignored in the health system. Similarly, the lack of studies in transgender health care may contribute to it being viewed more as a specialty than part of competent comprehensive care.

Likewise, across the LGBT population, we observed disparities within the disparity. Although an emerging body of research addresses culturally competent HIV-related services for men who have sex with men, few studies have examined culturally competent services for other LGBT populations. In particular, more research is needed on the provision of culturally competent services to sexual minority women, transgender people, and LGBT youth as well as on the provision of culturally competent services to gay and bisexual men beyond those related to HIV. Dual and multiple minority status also warrant attention and research. For example, LGBT people of color or LGBT people with disabilities may face intersecting and potentially synergistic challenges in health disparities and access to culturally competent care. More research is needed into the inter-relationship between health disparities and how multiple minority status influences risk and resiliency.

The empirical evidence has not kept up with the social and political movements that are rapidly changing societal acceptance and insurance access for LGBT people. A number of individuals and organizations have made recommendations about how to reduce barriers to care for LGBT individuals. Appendix E summarizes some other published recommendations. These suggestions form the basis for future research that assesses the effectiveness of their content.

Limitations

One of the major limitations of this review is the difficulty of distinguishing between cultural competence and the related concept of patient-centered care. For example, individual tailored interventions, such as an individualized cancer risk assessment, were deemed to be patient-centered care rather than cultural competence and were excluded on the basis of this distinction.⁷⁵ Significant trials excluded based on these criteria are Project Enhance and the Healthy Living Project.^151,152 Project Enhance involved an individualized HIV prevention intervention delivered by medical social workers in concert with primary care visits at Fenway Health.¹⁵¹ A movement toward individualized, patient-centered care is underway. Interventions that are adapted individually rather than culturally may prove to be as or more effective. However, this review is focused on cultural tailoring of interventions.

Conclusions

The results of the search show a patchy literature set that highlights the intrapopulation diversity subsumed under the LGBT umbrella terminology. The literature also fails to recognize the intersections of LGBT populations with other populations experiencing health care disparities. The broader concept of diversity competence may be more appropriate for many people at these intersections. Further discussion of population intersectionality and alternative constructions of cultural competence that address structural inequities can be found in Chapter 5. None of the included studies measured the effect of cultural competence interventions on health care disparities. The medium or high risk of bias of the included studies, the heterogeneity of populations, and the lack of measurement consensus prohibited pooling estimates or commenting about efficacy in a meaningful or responsible way.