Primary care is an ideal place to start improving the health of SGM people due to its person-centered approach, the access it offers to patients of varied social backgrounds, and the prevention, screening, and treatment services it affords to patients across their lifespan.35-38 Yet, it is not unusual for primary care clinics to lack resources to make sure their services fully consider SGM patients.39; 40 Environmental or structural elements (e.g., décor, signage, forms, mission statements) that do not include SGM people may exacerbate feelings of marginalization among SGM patients as soon as they walk through the clinic’s front door.39-43 In addition, insensitive, dismissive, or derogatory attitudes and how providers and staff communicate can profoundly impact experiences of primary care among SGM patients.
Providers and staff require comfort with, or competence in, the fundamentals of interacting with SGM patients, like being able to appropriately use SGM-related language, initiate open discussions of health and sexual health behaviors with SGM patients, and supportively acknowledge the romantic partners and families of SGM patients. Otherwise, SGM patients are less likely to be satisfied with services and may choose not to return for necessary care.44 Importantly, if providers do not ask questions related to being SGM, they may miss out on collecting relevant patient information, which can then factor into misdiagnoses, ineffective treatment, and subpar care.45; 46 Throughout the U.S., providers and staff are often unversed in the nitty-gritty of tailoring services for SGM patients, largely because they are uneducated about this population.47; 48 Consequently, this lack of knowledge is one of the biggest barriers to basic care for SGM people.21
In this toolkit, we provide several recommendations that primary care clinics can act on to prevent disparate care. While health and healthcare disparities affecting SGM people are well documented, there has been little systematic work to implement strategies to reduce them. The key recommendations featured in this toolkit are drawn from and endorsed by nationally respected entities, including The Joint Commission, the American Academy of Family Physicians, the American College of Physicians, the Association of American Medical Colleges, and SGM organizations such as the Fenway Institute and Human Rights Campaign. The recommendations fall under five broad categories:
- Adopt SGM affirmative policies and procedures;
- Create a welcoming physical environment for SGM patients;
- Document sexual orientation and gender identity information;
- Provide ongoing training for all employees in SGM cultural competency, including use of supportive language; and
- Initiate clinical workforce development to encourage the delivery of high-quality services for SGM patients.
There may be barriers that make it difficult to act on these recommendations. Foremost is the expressed position among many providers and staff that there is simply no need to implement SGM inclusive policies and practices because they “treat all patients the same” at their clinics. When health professionals assert this claim, they may be implying that they are not homophobic or transphobic and therefore do not discriminate. However, such assertions are often rooted in hetero- and cis-sexist practices that function to suppress discussions of gender and sexuality, ultimately allowing providers to continue treating patients as cisgender and heterosexual.49 The refrain of treating everyone the same can also lead providers and staff to neglect their own implicit biases and may contribute to unintentional discrimination and disinterest in moving forward with new initiatives related to SGM care. In contrast, many SGM patients DO want their care to be inclusive of and tailored to their sexual orientation or gender identities, suggesting that treating everyone the same is neglecting patient needs.49 The good news is that providers and staff, through SGM-relevant training and careful reflection of their beliefs, can eliminate discriminatory language and behaviors and improve primary care for SGM patients.
For successful implementation of the recommendations, planning should represent a careful and comprehensive organizational effort that involves phasing in selected policies and practices into the clinic’s operations. This toolkit aims to prepare clinics for organizational change by offering resources to improve access to and quality of care for SGM patients in sustainable ways for busy primary care clinics. The resources shared in this toolkit are also applicable to other healthcare settings where improved services for SGM patients are needed.