Keywords
Key points
- •LGBTQ-affirming behavioral health providers in primary care can offer a unique service by conducting tailored evaluations and interventions targeting the sexual and gender minority stress influences that perpetuate psychological distress in LGBTQ patients.
- •Evidence-based specialty behavioral health treatments can be tailored to meet the needs of LGBTQ patients more adequately while also adhering to the brief, structured primary care behavioral health model.
- •Establishing collaborative partnerships with LGBTQ people and ensuring that their perspectives are reflected in practice improvement initiatives can result in innovative and obtainable solutions for advancing LGBTQ population health.
Behavioral health and primary care services are interconnected systems, particularly in the lives of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people. Difficulties in accessing LGBTQ-affirmative integrated behavioral health services can have implications for LGBTQ people’s physical, psychological, and sociocultural well-being.
1
For example, a transgender patient may present to primary care seeking treatment of difficulties related to stress, stigma, and discrimination while also seeking to access transition-related medical services. LGBTQ people can benefit from an integrated approach to behavioral health and primary care services wherein practitioners work together to adopt a multicause, multi-effect approach to health and illness, rather than a fragmented and siloed approach.2
The effective integration of LGBTQ-affirmative behavioral health services in primary care requires provider-level and structural-level changes that work toward the application of evidence-based psychological interventions and community-engaged models, moving them from the theoretic realm into a practical one.The following elements are necessary for the advancement of LGBTQ-affirmative behavioral health services in primary care: (1) systematic identification of LGBTQ patients, (2) application of LGBTQ-affirmative assessment and treatment of behavioral health conditions, and (3) availability of affirming behavioral health specialists to accept referrals. Each element requires that primary care providers know about LGBTQ physical and mental health concerns, must have sufficient experience in working with LGBTQ patients and patients with mental illness, and have time available to consult with LGBTQ community partners and LGBTQ-identified practitioners. Despite the appeal of such elements, this article concludes that behavioral health and primary care delivery systems face multilevel barriers to integrating LGBTQ-affirmative behavioral health services in primary care. To date, few integrated primary care clinics have adopted practices that intentionally establish a culture of respect for patients across LGBTQ subgroups. Although recent efforts to advance health equity for LGBTQ patients include the dissemination of inclusive practice guidelines,
3
these recommendations are not widely known or integrated into primary care settings. Furthermore, the few guidelines available fail to provide practical strategies for defragmenting behavioral health and primary care services for LGBTQ people. Although some guidelines speak to the importance of including the perspectives of LGBTQ people in the formation and delivery of their care, no previously published guidelines offer strategies for establishing collaborative relationships between integrated behavioral health systems and the LGBTQ communities they serve.Primary care and LGBTQ-affirming behavioral health
LGBTQ individuals experience a higher prevalence of physical and mental health conditions compared with non-LGBTQ individuals. Specifically, LGBTQ people demonstrate increased incidents of HIV/AIDS and other sexually transmitted infections,
4
sexual and reproductive cancers,5
tobacco and substance use,6
and obesity.7
LGBTQ people also are more likely to experience psychological trauma,8
injury and violence,9
depression,10
and suicide-related behaviors.11
,12
Minority stress theory suggests that LGBTQ communities are at greater risk for mental and physical health problems because they face greater exposure to social stressors related to prejudice and stigma.13
Minority stress theory differentiates between distal (eg, rejection, prejudice, and discrimination) and proximal (eg, internalized queer-negativity, expectations of social rejection, and perceived need for identity concealment) stress factors that accrue overtime, leading to chronically high levels of psychological distress, ineffective coping, and high-risk health behavior.Despite the multilevel stressors, LGBTQ communities also exhibit individual and collective resiliency characteristics that promote well-being. When present, resiliency factors actively buffer against competing minority stressors and reduce the risk for mental and physical health conditions. The most studied resiliency factors among LGBTQ individuals are identity pride
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and social support.15
Identity pride describes positive and internalized beliefs and feelings about one’s LGBTQ identity. This coping resource bolsters self-esteem and fosters a sense of belongingness within the broader LGBTQ community. Increased identity pride not only may allow LGBTQ individuals to negotiate and manage minority stress but also may reduce individuals’ perceived need for identity concealment. Social support broadly describes the extent to which an individual can readily receive emotional and tangible assistance from others. Similar to identity pride, social support promotes self-esteem, belongingness, and persistence through life challenges. Among LGBTQ individuals, perceived support from close others, such as family members, is one of the most substantial protective factors against suicide.16
For LGBTQ individuals who experience rejection within their families or communities of origin, chosen family and connections with other LGBTQ people often confer significant coping benefits. Additional resilience factors might include strengths-based spiritual or cultural beliefs, personality characteristics, and utilization of evidence-based coping skills and strategies.In summary, behavioral health providers in primary care must recognize the unique minority stress and resilience factors that influence the well-being of LGBTQ patients. Through informed assessment, providers can identify and prioritize the most consequential drivers of the patient’s presenting concerns, and in turn, can create culturally responsive treatment plans and interventions to meet the needs of LGBTQ patients in primary care.
LGBTQ-affirmative integrated behavioral health care
Welcoming and Inclusive Health Care Environments
LGBTQ patients face numerous barriers in accessing quality health care services. In particular, transgender and gender nonbinary (TGNB) people are likely to avoid medical settings due to fear of discrimination or past experiences of maltreatment in medical settings.
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To increase LGBTQ engagement in primary and preventative care services, clinicians and administrators can aim to establish welcoming health care environments. Displaying visible nondiscrimination policies that include statements prohibiting discrimination based on gender identity, gender expression, and sexual orientation can create a welcoming clinic atmosphere. The inclusion of a 2-question method on intake forms that include gender identity and sex assigned at birth18
promotes an affirming experience to TGNB individuals. Providers can further promote an affirming patient experience when additional questions about pronouns and affirmed/chosen name are included on intake forms and reflected in clinical notes. To identify sexual orientation diversity, intake forms can include questions about patients’ sexual and romantic attraction and behaviors. Furthermore, LGBTQ-themed artwork, posters, and reading materials can be displayed in public spaces, such as waiting areas and hallways. Restroom policies can be posted to specify that patients may choose any restrooms based on their gender identity. Additionally, gender-neutral bathrooms can be made available for nonbinary people and individuals who feel uncomfortable in binary, gendered spaces.19
Systematized Sexual Orientation, Gender Identity, and Gender Expression Screening
Minority stress factors (eg, fear of discrimination) and systemic barriers (eg, lack of LGBTQ training for providers) can prevent LGBTQ individuals from discussing matters of sexual orientation, gender identity, and gender expression (SOGIE) with their primary care providers. Systemic SOGIE screening enables primary care providers to identify LGBTQ patients earlier and can serve as a reminder to engage in behaviors that communicate openness to sexual and gender diversity. To identify LGBTQ patients presenting in primary care and to increase understanding of their unique health care needs, the US Institute of Medicine,
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The Joint Commission, Healthy People 2020, and the US Department of Health and Human Services Affordable Care Act recommend the routine collection of SOGIE data.A common barrier to routine screening in medical settings is the belief that asking SOGIE questions is offensive to patients. To date, no studies have corroborated this belief. Instead, the collection of SOGIE data as part of routine clinical practice has shown acceptable to most patients, including those who are heterosexual, cisgender, and older than 50 years of age.
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Furthermore, failure to collect SOGIE data can result in negative repercussions, including the invisibility of sexual and gender diverse patients to policymakers and researchers22
; difficulties in tracking the preventative health needs of LGBTQ people3
; and reduced patient satisfaction due to failure to use LGBTQ-affirming communication skills.23
To systematize SOGIE screening, primary care stakeholders can partner with electronic health record (EHR) vendors to develop systems for the administration of SOGIE questions and private storage of data within the EHR. Additionally, primary care stakeholders and EHR vendors can collaborate to identify opportunities for expanding SOGIE questions to include assessment of pronouns (eg, he/him, she/her, and they/them), affirmed/chosen name, anatomic inventory (ie, organ inventory), and relationship structures (eg, monogamy and polyamory).Education and Training of Integrated Behavioral Health and Primary Care Providers
Although systematic screening for LGBTQ patients in primary care may improve identification, screening alone may place patients at risk for health care discrimination if providers are ill-equipped to provide LGBTQ-affirmative care.
24
,25
A review of the literature in health care education identified LGBTQ health care as a topic that merits attention given that this domain often is unstructured and inconsistently integrated into medical26
and behavioral health27
training programs. Although lack of culturally responsive training and service delivery always is concerning, it can have incredibly far-reaching consequences for LGBTQ patients. For example, transgender patients have been shown to postpone or not seek care at higher rates than LGB patients and are more likely to feel responsible for teaching their providers about their health care needs.28
Additionally, transgender patients navigate “trans broken arm syndrome” in medical appointments, wherein providers casually misattribute unrelated medical problems to their gender identity or aspects of their transition.29
To address this curricular gap, medical educators within the New York University School of Medicine developed an objective structured clinical examination involving a standardized transgender patient presenting to a primary care clinic.
30
Medical resident participants indicated that they felt prepared for the case but found it difficult to discuss gender identity and non–gender transition–related health issues. Additionally, fewer than two-thirds of trainees made the patient feel comfortable and most did not assess the patient’s long-term health care goals. Although good communication skills helped residents overcome a lack of LGBTQ-specific health knowledge, the need for routine and evidence-based provider education is evident. Structural-level interventions, such as departmental trainings, have been implemented to increase provider knowledge and positive attitudes toward TGNB people. Comparison of pretraining and post-training evaluations suggest that large-scale training seminars can decrease negative attitudes significantly, increase the use of affirmative clinical skills, and increase provider readiness to serve gender diverse patients.31
These findings speak to the feasibility and acceptability of stigma-reduction interventions in primary care and establish a precedent for the development of similar training for integrated behavioral health providers.Implementing Integrated Care Models: A Focus on LGBTQ-Affirmative Assessment and Intervention
Behavioral health providers in primary care are uniquely suited to deliver affirming services to LGBTQ patients navigating the health care system. The effective integration of LGBTQ-affirmative behavioral health services in primary care requires skills for addressing the wide range of biological, psychological, social, and cultural health factors relevant to LGBTQ people. LGBTQ-affirmative behavioral health providers seeking to work in primary care settings must develop skills for interacting effectively within interdisciplinary teams where some colleagues may be less familiar with LGBTQ communities and their health care needs.
Although a full summary of collaborative care models is outside the scope of this review, the following key points are noteworthy. First, the Agency for Healthcare Research and Quality released a systematic review examining collaborative care outcomes and found that the integration of behavioral health services in primary care achieves positive clinical outcomes.
32
Second, of the 33 studies included, none reported outcomes categorized by SOGIE characteristics. Overall, primary care stakeholders are unable to conclude how the integration of behavioral health services in primary care has an impact on outcomes for LGBTQ people, the amount of attention paid to LGBTQ-affirmative communication strategies, or the impact of environmental affirmation strategies in primary care (eg, inclusive imagery and advisory boards). More research is needed to determine what models of collaborative care and which affirming treatment strategies are associated with improved outcomes for LGBTQ patients. To increase understanding, systematized SOGIE screening, implementation of LGBTQ-affirmative communication strategies, and the continued integration of behavioral health providers in primary care settings will be critical.Of the various models of collaborative care, the primary care behavioral health (PCBH) model has been used most widely.
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The PCBH model can be implemented effectively in most primary care settings and is designed to facilitate the delivery of various evidence-based psychological interventions and can include both prevention and treatment as primary aims. This approach to collaborative care serves as a pathway for addressing behavioral health needs in settings where patients already receive care. Over time, this approach can both normalize and reduce the stigma associated with engagement in behavioral health services. To date, most behavioral health providers are trained in a specialty mental health care model characterized by patient self-referrals, either brief or long-term psychotherapy, and weekly or biweekly sessions lasting 50 minutes. This approach can be challenging to sustain in primary care settings where behavioral health providers must be readily available to contribute to a patient’s care before, during, or after their appointment with a primary care provider. To be successful in a primary care setting, and to best meet the needs of LGBTQ patients, behavioral health providers must redefine their approach to assessment and intervention to the primary care environment.To adapt LGBTQ-affirmative behavioral health approaches from specialty mental health settings, providers can seek continuous professional development courses that address relevant terminology, health disparities, and brief behavioral and cognitive interventions. Additionally, the 5As model of assessment and intervention provides a useful structure for guiding discussions about sexual and gender diversity. The 5 As model is a flexible and patient-centered approach consisting of 5 primary domains: assess, advise, agree, assist, and arrange.
34
Specific tasks within each domain vary on the nature of the presenting concern as well as its severity and complexity. A review of the literature revealed no published studies on the use of the 5As model among LGBTQ patients within primary care settings. Based on the authors’ clinical experiences, expanding the model to include a sixth A, for affirm, is proposed, which explicitly describes affirmation of identity and is most consistent with an LGBTQ-affirming model of care.Affirm
To demonstrate inclusivity and increase patient comfort, behavioral health providers can wear lapel pins that depict LGBTQ flags or their own affirmed pronouns. For telemental health sessions, providers can list their pronouns next to their display name. For in-person sessions, pronouns can be stated verbally at the start of the session. The American Psychological Association provides additional practice guidelines for working with LGBTQ patients here: https://www.apa.org/pi/lgbt/resources.
To avoid misgendering or deadnaming patients, providers can ask, “What name would you like me to use during our visits together?” and “What pronouns would you like me to use?” The patient’s affirmed name and pronouns then should be used throughout the visit and reflected in clinical documentation. Together, these behaviors promote psychological safety and can help build trust between the provider and patient.
Assess
Following a review of the EHR, a functional assessment of behavioral health concerns should include questions regarding factors relevant to the etiology or treatment of the presenting concern and an assessment of the effect of the presenting problem on functioning and quality of life. The following questions can assist providers in assessing if the presenting concerns are related to minority stress and provide useful information for treatment planning personalization:
- •In your lifetime, in family or social situations, have you been rejected or distanced because of your identity or expression?
- •In your lifetime, have you ever been discriminated against, harassed, or physically/sexually assaulted because of your identity or expression?
- •Who currently knows you, accepts you, and respects you as you in your life? They can be family, friends, community centers, or others.
A review of the patient’s EHR for past discussions on sexual and gender diversity (eg, coming out and initiation of gender-affirming medical care) can yield more detailed information than SOGIE questionnaire responses alone. Behavioral health providers also can consult a patient’s primary care provider to gather additional information about psychosocial and medical factors related to a patient’s presenting concerns.
Advise
Based on information gathered during the assessment phase, advise the patient on potentially effective intervention approaches. Patients struggling with increased homonegativity or transnegativity may inquire about treatments intended to suppress same-sex attraction or gender expansiveness (ie, conversion therapies). Existing literature indicates that conversion therapies are not evidence based or effective for resolving distress related to sexual or gender minority stress. Rather, conversion therapies have been shown to exacerbate distress
35
,36
and are banned for minors in 20 US states and the District of Columbia.37
Instead, providers can recommend brief cognitive and behavior interventions that promote self-exploration and resilience building. Providers also can state that although it can be helpful to involve family, romantic partners, or friends in subsequent visits, this will not be explored until it is determined that disclosure of LGBTQ identities will not leave the patient vulnerable to victimization. For gender diverse patients in need of transition-related services (eg, behavioral, medical, or surgical interventions), recommend a referral to specialty gender-focused care if these services are not available at the provider’s clinic.Agree
Medical mistrust and health care discrimination can decrease a patient’s willingness to discuss sexual or gender diversity (eg, the role of minority stress on psychological functioning) in clinical encounters. As such, some patients may prioritize a medical management approach to their presenting concerns. Sharing with patients a bio-psycho-sociocultural conceptualization of their distress, highlighting relevant minority stress and resilience factors, prior to introducing the cognitive behavior model may help decrease mistrust and reluctance to engage in behavioral health treatment in conjunction with medical management.
Assist
Table 1 describes interventions that can be used to assist LGBTQ patients presenting with behavioral health concerns in primary care. As previously stated, integration of family, romantic partners, or friends in psychotherapy should be done only when the behavioral health provider and patient collaboratively determine it is safe.
Table 1Evidence-based LGBTQ-affirming behavioral health interventions
| Intervention | Reference |
|---|---|
| Affirmative Dialectical Behavior Therapy (DBT): An adapted DBT protocol for emotion dysregulation that acknowledges minority stress among LGBTQ individuals | Cohen, J. M., Norona, J. C., Yadavia, J. E., & Borsari, B. (2020). Affirmative Dialectical Behavioral Therapy Skills Training with Sexual Minority Veterans. Cognitive and Behavioral Practice. https://doi.org/10.1016/j.cbpra.2020.05.008 |
| AWARENESS: A 9-session cognitive–behavioral intervention targeting minority stress as a driver of greater substance use and poorer mental and physical health | Flentje, A. (2020). AWARENESS: Development of a cognitive–behavioral intervention to address intersectional minority stress for sexual minority men living with HIV who use substances. Psychotherapy, 57(1), 35–49. https://doi.org/10.1037/pst0000243 |
| ESTEEM (Effective Skills to Empower Effective Men): A 10-session cognitive-behavioral intervention aimed to reduce young gay and bisexual men’s co-occurring health risks | Burton, C. L., Wang, K., & Pachankis, J. E. (2019). Psychotherapy for the spectrum of sexual minority stress: Application and technique of the ESTEEM treatment model. Cognitive and Behavioral Practice, 26(2), 285-299. https://doi.org/10.1016/j.cbpra.2017.05.001 |
| EQuIP (Empowering Queer Identities in Psychotherapy): An adapted transdiagnostic cognitive–behavioral treatment for sexual minority women | Pachankis, J. E., McConocha, E. M., Clark, K. A., Wang, K., Behari, K., Fetzner, B. K., Brisbin, C. D., Scheer, J. R., & Lehavot, K. (2020). A transdiagnostic minority stress intervention for gender diverse sexual minority women’s depression, anxiety, and unhealthy alcohol use: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 88(7), 613–630. https://doi.org/10.1037/ccp0000508 |
| TA-CBT (Transgender-Affirmative Cognitive Behavior Therapy): Adapted CBT that includes gender-affirming practices, minority stress, and trauma-informed frameworks | Austin, A., Craig, S. L., & Alessi, E. J. (2017). Affirmative cognitive behavior therapy with transgender and gender nonconforming adults. Psychiatric Clinics, 40(1), 141-156. https://doi.org/10.1016/j.psc.2016.10.003 |
Arrange
LGBTQ patients with significant socio-environmental needs or significant psychological distress may not experience improvement from brief PCBH interventions. Affirming behavioral health providers can assist in linking patients to specialty or intensive outpatient mental health services for continued care. LGBTQ patients with less complex presentations may desire to address their behavioral, sexual, or gender health concerns through the use of self-help materials or LGBTQ community groups. The resources described in Table 2 can be used to connect LGBTQ patients to these and other supports. For patients who show improvement in PCBH intervention, consider arranging 1 to 2 relapse-prevention appointments within 1 year of their last appointment to help minimize the recurrence of moderate to severe psychological distress.
Table 2Resources for LGBTQ patients with behavioral health concerns
| Name | Description |
|---|---|
| Amaze www.amaze.org | LGBTQ-affirming and age-appropriate information about puberty, relationships, and sexual health |
| CenterLink www.lgbtcenters.org | Directory of LGBTQ community centers across the U.S. |
| Family Acceptance Project www.familyproject.sfsu.edu | Resources for families and parents of LGBTQ children and adolescents |
| Gay and Lesbian Medical Association www.glma.org | U.S. organization for LGBTQ-affirming professionals. Includes an LGBTQ-affirming directory of providers across specialties |
| HIV PrEP Locator www.preplocator.org | U.S. directory of providers of HIV Pre-Exposure Prophylaxis |
| Human Rights Campaign www.hrc.org/resources | LGBTQ-affirming resources across range of LGBTQ topics |
| It Gets Better Project www.itgetsbetter.org | LGBTQ stories of coming out and resilience |
| The National LGBTQIA+ Health Education Center www.lgbtqiahealtheducation.org | Educational resources for providers on LGBTQ health topics |
| Trans Lifeline www.translifeline.org | Crisis management hotline for the trans community |
| Trevor Project www.thetrevorproject.org | Crisis management hotline and chat for LGBTQ youth |
| National Center for Transgender Equality www.transequality.org | Educational resources related to legal protections for transgender individuals living in the U.S. |
| National LGBT Cancer Network www.cancer-network.org | Resources for providers and patients focused on cancer and cancer survivorship among LGBTQ individuals |
| World Professional Association for Transgender Health www.wpath.org | International professional organization focused on transgender health. Includes a trans-affirming provider directory |
Tracking Behavioral Health Outcomes
In addition to systematized SOGIE screening, enhanced implementation of a PCBH model of integrated care for LGBTQ patients can be accomplished when behavioral health providers use measurement-based care (MBC) to support early identification of behavioral health concerns and monitor progress over time. MBC is defined as the practice of basing clinical care on client data collected throughout treatment.
38
This care strategy facilitates improved patient outcomes and reduced care costs by generating data that help providers monitor treatment progress, assess outcomes, and guide treatment decisions from initial screening to completion of care.39
For LGBTQ patients in primary care, the standardization and implementation of MBC are crucial next steps for evaluating the feasibility, usability, and acceptability of LGBTQ-affirmative care initiatives and monitoring how these initiatives have an impact on patient responses to behavioral health treatment. MBC protocols for patient screening and outcome monitoring also can provide actionable information to primary care stakeholders, including patients, medical colleagues, community partners, and clinic administrators.38
At the population level, patient-reported outcomes can be leveraged to develop shared decision-making tools, to monitor population status, and to assess program efficacy.
40
With regard to LGBTQ population health, aggregation of data on sexual and gender diversity allows primary care stakeholders to assess providers’ use of affirming communication strategies following participation in LGBTQ-focused education and training. It also allows for the monitoring of treatment-as-usual, when applied to LGBTQ patients, and can help evaluate the effect of newly implemented LGBTQ-affirming practice changes. For instance, if a primary care system were to implement a multisite mood management group adapted to LGBTQ patients (ie, describing the application of cognitive behavior skills to distress related to minority stress), stakeholders then could evaluate the treatment based on patient reported outcomes. If providers were to identify that patients with mild to moderate depression and anxiety scores at admission responded well, but patients with severe scores showed an unreliable improvement, clinical practices could be adapted to include discussion of the benefits of advancing to a higher level of care to further remediate symptom severity. In contrast, patients with scores in the mild to moderate range could be offered the choice between either type of treatment. In doing so, the primary care system’s approach to shared decision making would be informed by data collected from LGBTQ patients receiving care within the health care system. This patient-centered practice not only can help patients navigate the health care system more effectively but also can allow providers to connect LGBTQ patients to the specialty care services they need (eg, specialty gender-focused care) more efficiently.Integrating Community Partners and Providers with Lived Experience
Community-engaged approaches to research and service delivery have been emphasized as a means for improving health outcomes through community, provider, and systems relationships that build trust and community capacity.
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Often, communities that are the focus of population health initiatives lack the opportunity to participate actively in the development, evaluation, and dissemination of the services they receive. One means of addressing this deficit is to integrate community partners and practitioners who are members of the target community to bridge gaps in the provision of culturally responsive care. Community-engaged approaches have been utilized to address research and practice gaps through the inclusion of critical stakeholders, such as peer advocates, community health workers, and community advisory boards. Community-engaged practices are consistent with health equity efforts and are used among LGBTQ communities at risk of HIV.42
Although collaborative partnerships with LGBTQ community members and LGBTQ-identified providers hold great promise within primary care settings where health care discrimination is common, no published studies have described the core processes and roles that define such partnerships. Table 3 describes the authors’ approach to integrating LGBTQ community partners and LGBTQ-identified providers in primary care settings.Table 3Community partner and provider roles in LGBTQ-affirmative integrated behavioral health care
Adapted from Thielke, S, Vannoy, S, and Unützer, J. Integrating mental health and primary care. Prim. Care 2007; 34(3), 571-592; with permission.
| Process | Roles | ||||
|---|---|---|---|---|---|
| Care Manager | Behavioral Health Specialist | Primary Care Provider | LGBTQ Community Partners and Providers | Information Tracking and Exchange | |
| Systematic identification of LGBTQ patients, diagnosis of behavioral health concerns, and tracking of behavioral health outcomes |
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a Note: Patient information is anonymized as appropriate in line with confidentiality mandates.
Integrated care, as described in this article, differs from common collaborative care approaches prioritizing communication between primary care and behavioral health providers. The authors extended existing models by emphasizing communication between the integrated behavioral health delivery system, LGBTQ community partners, and LGBTQ-identified providers. This approach allows for the development of community partnerships wherein participants work together to optimize behavioral health services. In the area of LGBTQ-affirmative integrated behavioral health, the primary contributions of LGBTQ community partners and LGBTQ-identified providers include (1) guiding practice improvement efforts, (2) highlighting patient and provider experiences, (3) encouraging change-making, (4) communicating practice improvements and outcomes to the greater LGBTQ community, (5) educating team members about the LGBTQ patient perspective and strategies for facilitating referral to affirming specialty services, (6) increasing the greater LGBTQ community’s awareness of self-help programs and organizations that can help maintain treatment outcomes, and (7) assisting in the development of opportunities for social connection.
A community-engaged approach to LGBTQ-affirmative integrated behavioral health care differs from traditional models in 3 primary ways. First, the primary care service delivery system actively works to build sustainable and long-term partnerships with LGBTQ communities. Second, LGBTQ community partners and LGBTQ-identified providers experience tangible improvements from their collaborative efforts (eg, uptake of affirming practices and increased opportunities for social connection) and work together to disseminate results to the community. Lastly, LGBTQ-affirming behavioral health providers cultivate collaborative partnerships between the primary care delivery system and LGBTQ people, thus ensuring that practice improvements address the needs of LGBTQ patients receiving care within their system. Integrating community voices into integrated behavioral health care offers real and obtainable solutions for advancing LGBTQ population health.
Summary
Behavioral health concerns related to sexual and gender minority stress impair functioning and limit the quality of life of LGBTQ people. Behavioral health and medical providers may not feel adequately prepared to address the biological, psychological, social, and cultural minority stress factors that have an impact on LGBTQ patients. LGBTQ-affirmative behavioral health providers in primary care can offer a unique service by conducting tailored evaluations and individualized interventions targeting the multifactorial influences that cause and perpetuate psychological distress in LGBTQ patients. As outlined in this review, evidence-based specialty behavioral health treatments can be tailored to adequately meet the needs of LGBTQ patients while also adhering to the brief, structured PCBH model. Furthermore, establishing collaborative partnerships with LGBTQ people and ensuring that their perspectives are reflected in practice improvement initiatives can result in innovative and obtainable solutions for advancing LGBTQ population health. A continued focus on building LGBTQ community partnerships and examining outcome data is needed to empirically demonstrate that integrated behavioral health treatments adapted for LGBTQ patients lead to improvements in overall health, functioning, and quality of life.
Clinics care points
- •To establish welcoming primary care environments, display nondiscrimination policies that include statements prohibiting discrimination based on gender identity, gender expression, and sexual orientation; display LGBTQ-themed artwork, posters, and reading materials in public spaces, such as waiting areas and hallways; and systematize SOGIE screening to identify LGBTQ patients earlier.
- •When delivering care to LGBTQ patients, assess and utilize a patient’s affirmed name and pronouns in clinical work, provider meetings, and documentation; determine if presenting concerns are influenced by minority stress factors (eg, rejection, discrimination, and internalized stigma); and connect patients to brief psychological treatments that are tailored to assist LGBTQ patients presenting with behavioral health concerns in primary care.
Disclosure
All authors have nothing to disclose.
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