Web-Based, Open-Source LGBTQ+ Affirming Care Education for Primary Health Care Providers: Descriptive Analysis

Affirming care for lesbian, gay, bisexual, transgender, queer, and other individuals with diverse sexual orientations and gender identities (LGBTQ+) populations refers to culturally and clinically competent health care that recognizes specific health needs and provides respectful, inclusive, equitable, and nondiscriminatory services that are supportive of diverse identities. LGBTQ+ populations face greater discrimination in health care, leading to higher levels of unmet health needs than the general population. Very few primary care practices in the United States have training for staff and clinicians on LGBTQ+ health care needs. Despite the growing need for LGBTQ+ affirming care, there are no national standards or requirements for LGBTQ+ cultural competence training for primary health care providers in the United States.

This study explores the accessibility and quality of online "gray literature" providing LGBTQ+ affirming and culturally competent care information for primary health care providers in the United States. Gray literature is produced by government, academic, business, and industry sources in formats not controlled by commercial publishing.

We conducted a Google search of the gray literature to identify readily available resources and training materials in January 2024. A total of 2000 websites were screened using inclusion and exclusion criteria. Those published in a language other than English before January 1, 2014, as well as those that were peer-reviewed literature, or behind a paywall, were excluded. Fifty-four websites met the inclusion criteria for a full-text review.

We identified six themes from the existing academic literature: (1) affirming physical and visual environments; (2) sexual orientation and gender identity (SOGI) data collections; (3) training on LGBTQ+ health needs; (4) antidiscrimination policies; (5) appropriate, relevant services for LGBTQ+ patients; and (6) use of inclusive language. We then applied these themes as a deductive coding framework to the web-based sources, and during analysis, two additional emerging themes were identified: (1) staff diversity and (2) health inequalities and inequities. Findings revealed that not every web-based source addressed all themes. This unequal distribution of coverage across these themes means that primary health care providers must consult multiple web-based sources to obtain a comprehensive understanding. Additionally, existing gray literature resources often lacked depth, technical detail, and practical guidance, making it difficult for primary health care providers to access actionable information on LGBTQ+ affirming care. "Training on LGBTQ+ health needs" was the most frequently covered theme, and "SOGI data collection" was the least addressed. Study limitations included geolocation biases and embedded advertisements in the Google search results.

The study highlights that the gray literature is insufficient for self-guided training. We recommend integrating formal LGBTQ+ affirming care training into medical and nursing curricula, as well as professional associations and continuing education, particularly amid growing federal and state-level restrictions on LGBTQ+ health care.