Sexual Orientation– and Gender Identity–Affirming Activities Provided in Primary Care
Authors: Ellesse-Roselee L. Akre, Ching-Wen Wendy Yang, Greta R. Bauer, Matthew Brian Mackwood, A. James O’Malley, Elliott S. Fisher, Karen E. Schifferdecker
Journal: JAMA Network Open (2025)

Importance Addressing health disparities in lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities has been a significant policy focus for more than a decade. Ensuring access to safe, respectful primary health care from knowledgeable clinicians is crucial for reducing health inequalities. Objective To assess the engagement of primary care practices in LGBTQ+ affirming care activities and identify practice characteristics associated with increased engagement. Design, Setting, and Participants This cross-sectional study used data from the National Survey of Healthcare Organizations and Systems II, which focused on primary care practices in the US and was administered between June 2022 through February 2023. Participants were primary care physicians and practice managers. Percentages were weighted for national representation. Data were analyzed from November 2023 to December 2024. Exposure Practice characteristics including practice size, ownership, federally qualified health center (FQHC) designation; percentage of patients enrolled in Medicare; percentage of patients enrolled in Medicaid; having accountable care organization (ACO) contracts for Medicare, Medicaid, or commercial insurance; rurality; census region; and LGBTQ+ Equality Score by state policy. Main Outcomes and Measures Sexual orientation– and gender identity– (SOGI) affirming activities, a composite variable reflecting activity specific to SOGI patients. Results Among 1245 practices in the sample (38.4% response rate), 923 (77.40%) collected data on gender identity, 921 (75.62%) on sexual orientation, and 742 (65.83%) on patients’ pronouns. Only 412 practices (34.42%) provided LGBTQ+ training for clinicians and 480 practices (39.20%) provided training for staff. Practices designated as FQHCs had 3.16 (95% CI, 4.60 to 19.73) percentage points higher probability of engaging in all SOGI-affirming activities) compared with non-FQHCs ( P = .001). Practices with a Medicaid payer mix at least 50% had 3.28 (95% CI, 1.19 to 5.36) percentage points higher probability than practices with less than 50% Medicaid payer mix ( P = .002), and participation in a Medicaid ACO was associated with 4.26 (95% CI, 0.78 to 7.73) percentage points increased probability compared with nonparticipants ( P = .02). Each 1-unit increase in the state-level LGBTQ+ Equality Score was associated with 1.07 (95% CI, 0.28 to 1.85) percentage points higher probability of engaging in all SOGI-affirming activities ( P = .02). High performance was negatively associated with practice rurality (average marginal effect, −16.00 [95% CI, −29.72 to −2.28]; P = .02), and rural practices were less likely to provide appropriate referrals (average marginal effect, −15.47 [95% CI, −29.22 to −1.72]; P = .03). Conclusions and Relevance These findings suggest there is a need for federal and state mandates to require LGBTQ+ health care and competency training for health professionals and standardized data collection on SOGI, and these may be particularly important in rural regions. These measures are essential to evaluate practice performance and address health disparities effectively.