Best practices in LGBT care: A guide for primary care physicians

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ABSTRACTLesbian, gay, bisexual, and transgender (LGBT) people have unique healthcare needs. While all LGBT people are at an increased risk for mental health and substance abuse disorders, certain health conditions vary by group. Overweight and obesity are more common in lesbian and bisexual women, whereas sexual minority men are at increased risk for infections such as human immunodeficiency virus (HIV) and syphilis. Breast, cervical, and prostate cancer screening should be offered to all LGBT individuals according to national guidelines and with consideration of a transgender person’s natal and surgical anatomy.


  • Lesbian and bisexual women are at increased risk for overweight, obesity, tobacco use, and drug and alcohol use disorders. Clinicians should screen for these conditions regularly and provide appropriate referral.
  • Annual screening for HIV, syphilis, Chlamydia, and gonorrhea should be offered to men who have sex with men.
  • Pre-exposure prophylaxis against HIV infection may be appropriate for some at-risk individuals who can adhere to daily therapy.
  • “Screen what you have” is a rule that can help physicians to consider the appropriate screening services for transgender individuals.
  • Hormone therapy (estrogen and testosterone) can benefit transgender individuals who are changing their physical appearance to their affirmed gender.



Primary care physicians are very likely to encounter lesbian, gay, bisexual, and transgender (LGBT) patients in their practice, and must be able to provide informed, appropriate, and culturally sensitive care.

Approximately 9 million people in the United States identify as lesbian, gay, or bisexual, and 700,000 adults are transgender.1 In the 2013 National Health Interview Survey,2 which queried 34,557 adults about their sexual orientation, 2.3% reported being lesbian, gay, or bisexual, with only slight differences according to age or sex: of those ages 18 through 44, 1.9% were gay or lesbian and 1.1% were bisexual; of those ages 65 and over, 0.7% were gay or lesbian and 0.2% were bisexual. By sex, 0.9% of women vs 0.4% of men identified as bisexual.2

This article identifies and corrects common myths about LGBT care, addresses disparities in healthcare access, and outlines a step-by-step approach for delivering comprehensive care to LGBT patients.


Myth #1: L = G = B = T

Although LGBT is a commonly used term, each group described by the abbreviation has its own unique healthcare needs. For example, lesbian and bisexual women are more likely than heterosexual women to smoke, and gay men are at increased risk for human immunodeficiency virus (HIV) and other sexually transmitted infections.3,4 Transgender persons have high rates of suicide.5

Primary care of the LGBT patient needs to be individualized but also informed by the knowledge of distinct risks and behaviors associated with particular groups.

Myth #2: Sexual orientation = sexual activity

Sexual identity correlates closely but not completely with sexual behavior; individuals may engage in same-sex behavior but not identify as lesbian, gay, or bisexual.6,7 Many women who identify as lesbian have previously had sex with men, and men may have had same-sex encounters but consider themselves heterosexual.8,9

Since the risk of certain infections is related to sexual activity, providers should query patients about their sexual partners and practices in an open, nonjudgmental way, and avoid labeling patients solely according to sexual orientation. Table 1 suggests questions to use when interviewing patients.

Myth #3: Sexual orientation = gender identity

Gender identity describes a person’s inherent sense of being a woman, man, or of neither gender, whereas sexual orientation refers to how a person identifies their physical and emotional attraction to others.10,11 Conflating the two concepts can alienate patients, lead to incorrect assumptions, and result in an underestimation of an individual’s risk of sexually transmitted diseases.

Using questions such as “Are you sexually active with men, women, or both?” or “When you are sexually active, what parts of your body do you use?” with all patients, regardless of gender identity, will facilitate open and honest conversations that allow for appropriate counseling and risk assessment. Table 2 lists commonly used gender-identity terms.

Myth #4: LGBT people have the same access to healthcare as heterosexual people

People who identify as lesbian, gay, bisexual, or transgender experience significant disparities in access to healthcare compared with cisgender heterosexual people. For example, lesbian women are less likely to receive the human papillomavirus vaccine, cervical cancer screening, and mammograms, and men in same-sex relationships are twice as likely to have unmet medical needs.8,12 In a national survey,5 19% of transgender individuals reported that they had been refused healthcare. Among 152 transgender adults who described their experiences with the healthcare system, 7% reported receiving substandard care.13

We can eliminate these disparities by creating a welcoming environment for all patients (Table 3), and also by being aware of the specific services that should be offered to LGBT individuals.

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