Article Figures & Data
Tables
Initial Search Source Initial Result Satisfied Inclusion Criteria Selected for Full Appraisal ICGP = Irish College of General Practitioners; LGB = lesbian, gay, and bisexual; LGBT = lesbian, gay, bisexual, and transgender; NHMRC = National Health and Medical Research Council; NICE = National Institute for Health and Clinical Excellence; PACE = Project for Advice, Counselling and Education; RACGP = Royal Australian College of General Practitioners; RCGP = Royal College of General Practitioners; RNZCGP = Royal New Zealand College of General Practitioners; STI = sexually transmitted infection. Notes: Values are numbers of documents. The $ symbol is a truncation symbol enabling the search engine to find word variations on that stem or alternate spellings. a MEDLINE, Web of Science, CINAHL Plus, PsycINFO, PubMed, Academic Search Premier (EBSCO host); no date restriction used. Electronic databasesa Lesbian, gay AND primary care NOT HIV,STI 598 Lesbian, gay AND physician, family NOT HIV,STI 436 Guideline$ AND lesbian AND physician, family 129 Guideline$ AND bisexual women AND physician, family 78 Guideline$ AND lesbian AND primary care 164 Guideline$ AND bisexual women AND primary care 101 Recommend$ AND lesbian health 63 Recommend$ AND lesbian AND physician, family 31 Recommend$ AND bisexual women AND physician, family 19 Recommend$ AND lesbian AND primary care 45 Recommend$ and bisexual women AND primary care 30 Polic$ AND lesbian health 34 Guideline$ and male homosexual AND physician, family 103 Guideline$ and bisexual men AND physician, family 104 Guideline$ and male homosexual AND primary care 124 Guideline$ and bisexual men AND primary care 126 Recommend$ AND male homosexual AND physician, family 50 Recommend$ AND bisexual men AND physician, family 29 Recommend$ AND male homosexual AND primary care 63 Recommend$ and bisexual men AND primary care 36 Polic$ AND gay men’s health 17 10 0 Cochrane Collaboration Database of Systematic Reviews 0 Central Register for Clinical Trials 2 0 0 Guidelines databases NHMRC (Australia), Guidelines International Network (Europe), NICE (UK), Canadian Medical Association Clinical Practice Guidelines, New Zealand Guidelines Group 0 US National Guidelines Clearinghouse 13 0 0 Primary care and public health organizations RACGP (Australia), RNZCGP (New Zealand), RCGP (UK), ICGP (Ireland), College of Family Physicians (Canada), American Academy of Family Physicians (US) 0 UK Royal College of Nursing 1 1 1 Government Departments of Health Massachusetts, Washington, Quebec, British Columbia, Ontario, Kaiser Permanente (US), Department of Health (UK), NHS Scotland 8 8 5 LGBT-specific textbooks 12 6 2 LGB organization Web sites Stonewall (UK), US National Coalition for LGBT Health, Mautner National Lesbian Health Project (US) 0 Gay and Lesbian Health Victoria, Gay and Lesbian Medical Association (US), International Lesbian and Gay Association, PACE (UK), Gay and Lesbian Equality Network (Ireland) 5 5 3 Total 2,421 30 11 Country Document No., Title, and Authors Funder/ Publisher Target Type and Length GLMA = Gay and Lesbian Medical Association; NHS = National Health Service; NNLM = National Network of Libraries of Medicine. a UNISON is a trade union for public sector workers. United States11,27 1. Community Standards of Practice for Provision of Quality Health Care Services for Gay, Lesbian, Bisexual and Transgendered Clients; GLBT Health Access Project Massachusetts Department of Public Health Public health care services Booklet, 7 pages United States31 2. A Provider’s Handbook on Culturally Competent Care: Lesbian, Gay, Bisexual and Transgendered Population; Kaiser Permanente National Diversity Council Kaiser Permanente Kaiser Permanente clinicians Booklet, 71 pages United States36 3. Guidelines for Care of Lesbian, Gay, Bisexual and Transgender Patients; GLMA GLMA; sponsored by Pfizer US Clinicians Booklet, 45 pages + online Canada2 4. Caring for Lesbian and Gay People: A Clinical Guide; Peterkin and Risdon None disclosed Clinicians Textbook, 378 pages + online Australia33–35 5. Health and Sexual Diversity. A Health and Well-being Action Plan for Gay, Lesbian, Bisexual, Transgender and Intersex (GLBTI) Victorians; Leonard Department of Human Services, Victoria Health care services Reports, 136 pages, and booklet, 4 pages + online United Kingdom26 6. Not ‘Just’ A Friend: Best Practice Guidance on Health Care for Lesbian, Gay and Bisexual Service Users and Their Families; Royal College of Nursing and UNISON Royal College of Nursing & UNISONa NHS health workers Booklet, 12 pages United States28 7. Culturally Competent Care for GLBT People: Recommendations for Health Care Providers; Public Health, Seattle and King County NNLM grant Clinicians Web site, 10 Web pages United Kingdom29 8. Fair for All—The Wider Challenge. Good LGBT Practice in the NHS; NHS Inclusion Project and Stonewall Scotland NHS Scotland and Stonewall Scotland Staff in all areas of NHS Report, 51 pages United States32 9. Fenway Guide to Lesbian, Gay, Bisexual and Transgender Health; Makadon et al American College of Physicians Primary care clinicians Textbook, 526 pages Canada30 10. Caring for Lesbian Health: A Resource for Canadian Health Care Providers, Policy Makers and Planners; Hudspith Health Canada Canadian clinicians, policy makers, planners Report, 37 pages Ireland37 11. Lesbian, Gay & Bisexual Patients: The Issues for General Practice; Allen Irish College of General Practitioners Irish general practitioners Report, 24 pages Domain Document No.a Scope and Purpose Stakeholder Involvement Rigor of Development Clarity and Presentation Applicability Editorial Independence AGREE = Appraisal of Guidelines for Research and Evaluation. a See Table 2 for details on each document. Notes: Domain scores are mean percentage score of the 2 reviewers calculated according to the AGREE scoring system, wherein possible scores range from 0% to 100%.24 The higher the percentage, the higher the quality of the guideline for that AGREE domain. 9 100 42 29 100 11 17 11 100 54 33 83 6 42 1 94 83 21 75 61 42 4 89 21 21 83 22 8 6 89 17 5 71 6 17 2 89 38 24 46 0 0 5 83 67 12 58 22 33 3 78 21 5 79 11 0 7 78 8 0 75 0 42 8 72 92 29 42 44 0 10 50 42 0 71 28 25 Recommendation Document No.a LGB = lesbian, gay, and bisexual; SES = socioeconomic status; STI = sexually transmitted infection. a See Table 2 for details on each document. b Sample intake forms: documents 2, 3, 7, 9. c Patient interview suggestions: documents 2, 4, 9, 10, 11. Principles Cultural competency/social model of health Person-centered, LGB as a cultural and lifestyle issue 1, 2, 3, 4, 6, 7, 9, 10 Equity and human rights Importance of antidiscrimination policy including sexual orientation 1, 2, 3, 5, 6, 7, 8, 9, 10, 11 Awareness of the LGB population Understanding the proportion of LGB patients and removing assumptions of heterosexuality 1, 2, 3, 4, 6, 7, 8, 9, 10, 11 Aware of multiple minority status: SES, disability, race 2, 3, 4, 8, 9, 10 Inclusive of LGB families 1, 2, 4, 5, 6, 7, 8, 9, 10, 11 Inclusive clinical environment Overt signs/displays Rainbow sticker, posters, brochures, information 3, 4, 5, 7, 8, 9, 10, 11 LGB magazines, newspapers 3, 8, 9 Receptionists and other staff Sensitive language and positive attitudes 1, 4, 5, 8, 9 Paperwork Intake forms inclusive and culturally appropriateb 1, 2, 3, 5, 7, 8, 9, 10, 11 Optional self-identification on forms 1 Policies and procedures Antidiscrimination, specifically include LGB 1, 4, 10 Have policy visible to clients 1, 3, 4, 5, 7, 9, 10, 11 Complaints procedures available 1, 9 Involve LGB people: feedback, service planning 4, 5, 7, 8, 10 Clinician-patient communication Attitudes Overtly nonjudgmental 2, 3, 4, 7, 9, 10, 11 Affirming 7, 9, 11 Conceal negative attitudes 2 Challenge negative attitudes in colleagues 6, 10, 11 Confidentiality assured 1, 3, 4, 5, 6, 7, 8, 9, 10, 11 Languagec Gender-neutral, culturally aware, inclusive 2, 3, 4, 6, 8, 9, 10, 11 Clarify and use patient’s terms 2, 3, 6, 7, 9 Interviewing skills Open questions 2, 3, 4, 7, 9, 10, 11 Inclusive of partner 2, 3, 5, 10 Inclusive of nonbiological parent 5, 11 Normalize sexual history: ask all patients 9, 11 Avoid assumptions (eg, about congruence, fluidity) 2, 3, 4, 5, 7, 8, 9 Disclosure Facilitation of disclosure, explain why asking 2, 6, 8, 11 Care with reactions to disclosure, respond positively 2, 3, 11 Direct inquiry about sexual behavior/identity 2, 7, 9, 10, 11 Respect nondisclosure 2, 3, 7 Documentation Medical notes Permission to document sexual orientation 4, 6, 7 Inform patient what is written 3 Referral letters – Decision makers/next of kin Ask and document emergency contact, who makes decisions 6, 9 Special knowledge for cultural awareness Impact of discrimination on health Experiences of violence and harassment 2, 3, 4, 5, 8, 9, 10, 11 Reduced level of support from family and community 9 Mental health Higher rates of depression, anxiety, suicidality 2, 3, 4, 5, 7, 9, 10, 11 Drugs, alcohol, smoking Higher rates of use over a longer period of time 2, 3, 4, 5, 7, 9, 10, 11 Fertility, pregnancy, parenting 2, 4, 5, 9, 10 Sexual health, safer sex Differing STI patterns and specific safer sex methods 2, 3, 4, 5, 9, 10, 11 Higher risks 3, 4, 5, 9, 10, 11 Men: higher rate of anal cancer, risk for heart disease Women: risks for breast and ovarian cancer, heart disease Coming out issues 2, 3, 4, 5, 7, 9, 10 Body image, weight, exercise, diet 2, 3, 4, 5, 9 Same-sex relationships including domestic violence 4, 5, 7, 10 Legal recognition of relationship and parenting 4, 5, 9, 10 Referral LGB support groups, information network 3, 4, 5, 7, 11 LGB-sensitive specialists and allied health 1, 2, 4, 10 LGB-specific health care professionals 1, 6, 7 Staff and training Receptionists: confidentiality, use of intake forms 1, 3, 5 All staff: antihomophobia, relevant LGB issues 1, 5, 7, 8, 9, 10, 11 Nondiscrimination policy including sexual orientation 1, 8, 9 Support visibility of LGB employees 1, 5, 9 Affirmative action to hire LGB staff 7 Population health Marketing service to LGB community 7, 9, 10 Health promotion targeted to LGB 1, 5, 9 Community outreach: relationship with LGB agencies 1, 5, 8, 10 Advocacy 1, 2, 9
Additional Files
The Article in Brief
Guidelines for the Primary Care of Lesbian, Gay, and Bisexual People: A Systematic Review
Ruth P. McNair , and colleagues
Background This study reviewed existing research to determine whether current guidelines for the primary care of lesbian, gay, and bisexual (LGB) people meet appropriate standards of rigor in their development and provide consistently practical guidance for primary care clinicians.
What This Study Found A systematic review of studies in the United States, Canada, United Kingdom, Australia, Ireland, and New Zealand identified only 11 existing guidelines for the primary care of lesbian, gay, and bisexual people worthy of full appraisal. None of the guidelines met appropriate standards of quality and developmental rigor as measured by the Appraisal of Guidelines for Research and Evaluation instrument, and only two were specifically designed for primary care. Researchers did find, however, that currently available guidelines are philosophically and practically consistent and provide a degree of evidence-based clinical and systems support to primary care clinicians.
Implications
- The authors conclude that there is a need for evidence-based LGB guidelines that are more rigorously developed, disseminated, and evaluated specifically for the primary care setting.
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