Sexual and Gender Minority Health Care Issues Related Competence and Preparedness Among the Health Care Professionals and Trainees in India: A Comparative Study

Abstract

Background:

The Lesbian, Gay, Bisexual, Transgender and additional Queer, Intersex, asexual and agender (LGBTQIAA+) community is roughly 3.8% of the population of India. However, the services in terms of availability and competence are currently limited in the Indian healthcare system.

Aim:

To assess self-reported competence and preparedness of primary healthcare individuals and trainees in India (primarily Delhi) and compare the findings with Western studies.

Setting and design:

A cross-sectional study was designed to study sexual and gender minority (SGM) healthcare issues related to the competence and preparedness among the primary healthcare individuals and trainees at a tertiary healthcare centre. The study population included: Faculty members, Residents, Postgraduate trainees, Undergraduate trainees and Nursing staff. The study was conducted using an online Google survey after ethical clearance.

Method and material:

A cross-sectional Web-based survey was conducted for the medical and nursing healthcare professionals and trainees at a tertiary healthcare centre to assess competence and preparedness to deal with SGM healthcare issues using a questionnaire for the assessment of self-reported competence, comfort and preparedness for sexual orientation, gender identity and sex development health issues based on competencies outlined by the AAMC (Association of American Medical Colleges). A minimum of 25 participants in each of the four equally stratified groups were recruited using purposive sampling over 3 months.

Statistical analysis used:

The data was analysed using Epicollect software.

Results:

Satisfactory comfort and competence among the study groups are in line with the available Western literature though contrary to findings of Indian studies where inadequacy of knowledge regarding homosexuality was a major finding. A majority of positive responses in comfort, competency and knowledge are reflective of the change in attitude and culture among the modern society and effectiveness of awareness and support groups in government colleges of Delhi which was comparable with the available Indian and Western literature.

Conclusion:

Our study is a pioneer work to assess the healthcare workers’ skills in the assessment approach for the SGM population. The findings of our study may be useful further to develop objective measures to evaluate the competency and knowledge of healthcare providers.

Keywords

Competency healthcare professionals knowledge preparedness sexual minority

Abbreviations

AAMC: Association of American Medical Colleges

LGBTQIAA+: Lesbian, Gay, Bisexual, Transgender and additional Queer, Intersex, asexual and agender

SGM: Sexual and gender minority

Introduction

The Lesbian, Gay, Bisexual, Transgender and additional Queer, Intersex, asexual and agender (LGBTQIAA+) community is roughly around 3.8% population of India.¹ The sexual and gender minority (SGM) includes a myriad of sexual and gender identities including LGBTQIAA+.

Despite being a significant existence the community has so far been unable to access sexual and gender-specific healthcare due to stigma, discrimination and marginalisation by society. Several studies conducted both in the West and India itself show higher rates of suicide, depression (including a spectrum of mental health disorders), substance abuse, obesity, AIDS, cancer, and homelessness.²

An Indian study conducted in Maharashtra to study hazardous drinking amongst men who have sex with men was found to be 23.1% which was four to five times higher than the estimated general population.³ The exceptional increase in the prevalence of illicit drug use, substance use and poly-substance use also suggested a high number of participants self-reporting HIV testing. Shaw et al. (2012) found a prevalence rate of 18% of MSM and transgender persons in India experiencing some kind of sexual violence.³

The recent overturning of section 377 by the Supreme Court on 6 September 2018 has opened doors for the long-marginalised and criminalised SGM community. Proper healthcare procreates healthcare and burgeons the need for better healthcare provisions in the context of the Indian primary healthcare sector.

Treatment of such patients requires a collaboration of different schools of medicine including endocrinology, surgery, psychiatry and further as per the requirement speech and language therapists, which require a high level of expertise.⁴

Previous studies conducted within India and outside suggest not-so-positive attitudes and knowledge of healthcare providers toward sexual and gender minorities.^5-8

However, the current scenario of Indian healthcare in treating such patients and the competency of primary healthcare has only been assessed by medical students and interns.

Our study aims to assess the self-reported competency and training of various parts of the medical community including medical health professionals and trainees as well as nursing professionals and trainees.

Aims and Objectives

To assess self-reported competence and preparedness of primary healthcare individuals and trainees in India (primarily Delhi) and compare the findings with Western studies.

Methodology and Material

A cross-sectional study was designed to study SGM healthcare issues related to competence and preparedness among primary healthcare individuals and trainees at a tertiary healthcare centre. The study population included: Faculty members, Residents, Postgraduate trainees, Undergraduate trainees and Nursing staff. Following the COVID-19 precautions (social distancing and minimal contact) and ensuring confidentiality, the study was conducted using an online Google survey after ethical clearance.

An online Google form was formulated comprising two subsets. Consent of the subject was taken at the beginning of the survey along with a thorough explanation of the contents, parameters assessed and consequences of the survey. The subjects were also made aware of the complete anonymity of the survey. The participants were free to skip any question they wished to and could stop taking the survey anytime.

Further care was taken if any participant was feeling distressed about their sexual and gender concerns by providing the contact information of an experienced mental health professional at the end of the survey.

The two subsets of the survey included semi-structured Performa for assessing the socio-demographic details of the participants like- age, place of origin, religiosity, sexual and gender orientation and history along with their perceived ideas about the orientation of family and friends; followed by assessment of self-reported competence and preparedness. A self-reporting questionnaire assessing the comfort, competency and knowledge of sexual orientation, gender identity and sex development health issues as outlined by the AAMC (Association of American Medical Colleges) was used.

The outcomes were spread across three domains, that is, 1- comfort, 2- competency (in treating patients of SGM) and 3- curriculum assessment comprised of 6, 14 and 6 questions, respectively.

The index for healthcare practitioner’s comfort in treating SGM patients was calculated as the mean of 6 four-point Likert items (where 1 = not comfortable and 4 = very comfortable). The index for a health professional’s competence in treating SGM patients was calculated as the mean of 14 four-point Likert items (where 1 = not competent and 4 = very competent). The self-reported assessment of curriculum was calculated as the mean of 6 four-point Likert items (where 1 = strongly disagree and 4 = strongly agree) where students and healthcare professionals describe their curriculum and their perceived notion of its effectiveness in the care of SGM patients.

A short questionnaire of nine items was also presented to the respondents to get a rough idea about the basic knowledge of health concerns and screening methods employed in the care of the SGM population.

The results obtained were further analysed using the Epicollect software.

Results

The cross-sectional Google survey showed total participation of 235 participants including healthcare professionals and trainees. The majority of the study population was female sex 210 (89.40%), while 10.60% (n = 25) were male sex. A predominant proportion of the participants were from the nursing staff (45.70%, n = 107) and undergraduate trainees (39.70%, n = 93); while the least participation was from the faculty of health professionals (0.40%, n = 1). The study group majorly was found to have a moderate (35.80%) and quiet (22.40%) religiosity (Table 1).

Table 1.

Socio-demographic Profile of the Study Population.

Demographics	N = 235 (%)	Percentage
Sex assigned at birth
Female	210	89.4
Male	25	10.6
Intersex	0	0
Designation
Resident	13	5.6
PG Student	20	8.5
UG Student	93	39.7
Nursing Department	107	45.7
Religiosity
Not at all	33	14.2
Slightly	30	12.9
Moderately	83	35.8
Quite	52	22.4
A whole lot	34	14.7
Gender identity
Female	207	89.2
Male	24	10.3
Trans woman	–	–
Trans man	1	0.4
Gender queer	–	–
Not answered	3	1.28
Sexual orientation
Lesbian	–	–
Bisexual	6	2.8
Gay	–	–
Queer	3	1.4
Heterosexual	209	95.9
Not answered	17	7.2
Professional/Trainee
Medical trainee	70	29.8
Medical professional	58	24.7
Nursing trainee	57	24.3
Nursing professional	50	21.3

Among 235 medical healthcare professionals and trainees, 89% (n = 207) subjects identified self as female 10% (n = 24) identified as male gender whereas 0.4% (n = 1) identified as transgender men. A total of 209 (95%) individuals were reported to be heterosexual in orientation whereas 4.2% belonged to LGBTQ comprising 6 (2.80%) bisexual and 3 (1.4%) queer groups.

The composite mode of healthcare professional’s “comfort” in treating SGM patients was calculated to be 4.0 ± 0.6 (Table 3), which corresponds to feeling ‘very comfortable’ in the treatment of SGM patients. Majority of respondents (approximately 84%) felt comfortable in treating SGM patients almost equally 87% and 85%, respectively. The respondents felt least comfortable in discussing sexual practices among the SGM patients (62%) (Table 2, Figure 1).

Table 2.

Comfort, Competency and Curriculum Among the Healthcare Professionals.

Outcome	Overall Composite Mode (n = 168)	Standard Deviation
Comfort	4.0	0.66
Competency	4.0	0.70
Curriculum	1.0	0.85

Figure 1.

Healthcare Professional’s “comfort” in Treating SGM Patients.

The composite mode of healthcare professional’s “competency” in treating SGM patients was calculated to be 4.0 ± 0.7 (Table 3), which corresponds to feeling ‘very competent’ in the treatment of SGM patients. The respondents felt most competent (75%) in interviewing patients about their sexual identity, sexual history and sexual practices followed closely by interviewing transgender and GNC patients about their gender identities, health and risk behaviours and physical anatomy (73%) and employing appropriate consent and assent practices for disclosure of gender, sexuality and sex issues in a clinical setting (77%). The respondents felt least competent in describing legal and policy issues that affect LGBTQ patients, GNC patients and patients born with DSD (60%) (Table 4, Figure 2).

Table 3.

Self-reported Healthcare Professional’s “comfort” in Treating SGM Patients.

Comfort Items	Number of Respondents N(%)
Comfort Items	Not Comfortable	Somewhat Not Comfortable	Somewhat Comfortable	Very Comfortable
1. Treating sexual minority (e.g., queer, bisexual, lesbian, gay) patients	6	24	94	111
(percentage)	(2.6)	(10.2)	(40.0)	(47.2)
2. Treating gender minority (e.g., transmasculine, transfeminine, genderqueer) patients	8	26	101	100
(percentage)	(3.4)	(11.1)	(43.0)	(42.6)
3. Discussing sexual orientation (i.e., an individual’s sexual attraction, sexual partners, and sexual orientation identity, such as LGBQ) with patients	10	49	76	100
(percentage)	(4.3)	(20.9)	(32.3)	(42.6)
4. Discussing sexual practices with sexual and gender minority patients (e.g., bottom/top, sex toy use, dental dam use)	29	60	91	55
(percentage)	(12.3)	(25.5)	(38.7)	(23.4)
5. Discussing gender identity (i.e., individuals’ internal perception or sense of their own gender) with patients	5	44	88	98
(percentage)	(2.1)	(18.7)	(37.4)	(41.7)
6. Discussing sexual and gender minority-specific health topics (e.g., hormone therapy, reciprocal in vitro fertilisation, safe sex practices for sexual minority women etc.)	2	36	70	127
(percentage)	(.9)	(15.3)	(29.8)	(54.0)

Table 4.

Health Professionals and Trainees’ Self-reported Competency in Treating SGM Patients.

Competency Items	Number of Respondents N(%)
Competency Items	Not Competent	Somewhat Not Competent	Somewhat Competent	Very Competent
1. Sensitively interview patients about sexual orientation identity, sexual history and sexual practices	10	43	122	58
(percentage)	(4.3)	(18.5)	(52.4)	(24.9)
2. Sensitively interview transgender and GNC patients about their gender identities, health and risk behaviours, and physical anatomy	11	51	115	56
(percentage)	(4.7)	(21.9)	(49.4)	(24.0)
3. Describe the treatment options for transgender patients, including pre-pubertal hormone block, hormone therapy and surgeries	22	64	86	62
(percentage)	(9.4)	(27.4)	(36.8)	(26.5)
4. Describe the treatment options for patients born with DSD, differentiating between elective and non-elective therapies and surgeries for the most common DSD conditions.	27	57	88	61
(percentage)	(11.6)	(24.5)	(37.8)	(26.2)
5. Describe key screening recommendations for sexual and gender minorities.	15	64	88	63
(percentage)	(6.5)	(27.8)	(38.3)	(27.4)
6. Define and describe the differences between the following: sex and gender; gender expression and gender identity; and gender discordance, gender nonconformity, and gender dysphoria.	13	63	81	75
(percentage)	(5.6)	(27.2)	(34.9)	(32.3)
7. Describe the main aetiologies of atypical sex development	19	50	91	73
(percentage)	(8.2)	(21.5)	(39.1)	(31.3)
8. Describe the historical, political, socio-cultural and institutional factors that contribute to the development and maintenance of health disparities among LGBTQ patients, GNC patients, and patients born with DSD, including historical and current provider practices (e.g., reparative therapy)	15	52	98	68
(percentage)	(6.4)	(22.3)	(42.1)	(29.2)
9. Describe how patients’ and families’ healing traditions and beliefs might shape reactions to diverse forms of sexuality, sexual behaviour, sexual orientation, gender identity, gender expression, and sex development.	9	51	91	81
(percentage)	(3.9)	(22.0)	(39.2)	(34.9)
10. Employ appropriate consent and assent practices for disclosure of gender, sexuality and sex issues in a clinical setting.	17	39	90	85
(percentage)	(7.4)	(16.9)	(39.0)	(36.8)
11. Describe the special challenges faced by health professionals who identify with one or more of the following populations: LGBTQ, GNC, DSD	16	58	82	71
(percentage)	(7.0)	(25.6)	(36.1)	(31.3)
12. Describe strategies that can be used to enact reform within existing healthcare institutions to improve care for LGBTQ patients, GNC patients, and patients born with DSD.	16	44	67	41
(percentage)	(7.0)	(21.8)	(41.5)	(29.7)
13. Describe the special legal and policy issues (e.g., insurance limitations, lack of partner benefits, visitation and nondiscrimination policies) that affect LGBTQ patients, GNC patients, and patients born with DSD.	27	62	80	57
(percentage)	(11.9)	(27.4)	(35.4)	(25.2)
14. Identify your own implicit biases which impact the care delivered to LGBTQ patients, GNC patients, and patients born with DSD, and develop strategies to mitigate the impact of these biases	12	52	94	68
(percentage)	(5.3)	(23.0)	(41.6)	(30.1)

Figure 2.

Healthcare Professional’s “self-reported competency” in Treating SGM Patients.

The composite mode of healthcare professionals’ “self-reported assessment of their curricula” was calculated to be 1.0 ± 0.8 (Table 3) which corresponds to ‘strongly disagree’ on the competency of the curricula involved in their educational setting. A majority of respondents (62%) did not have the opportunity to practice interacting with SGM patients in the course of their medical education. An overwhelming number of respondents felt that their curricula did not prepare them for the treatment of SGM patients (Table 5, Figure 3).

Table 5.

Healthcare Professional’s “self-reported assessment of their curricula” in Treating SGM Patients.

Formal Curricula Items	Number of Respondents N(%)
Formal Curricula Items	Strongly Disagree	Somewhat Disagree	Somewhat Agree	Strongly Agree
1. The formal curriculum at my college has adequately prepared me to comfortably and competently serve sexual and gender minority patients	66	55	83	25
(percentage)	(28.8)	(24.0)	(36.2)	(10.9)
2. The formal curriculum at my college adequately covers sexual orientation diversity	60	59	80	30
(percentage)	(26.2)	(25.8)	(34.9)	(13.1)
3. The formal curriculum at my college adequately covers gender diversity	57	74	66	31
(percentage)	(25.0)	(32.5)	(28.9)	(13.6)
4. The formal curriculum at my college adequately covers health disparities among sexual and gender minorities	52	80	67	30
(percentage)	(22.7)	(34.9)	(29.3)	(13.1)
5. The formal curriculum at my college adequately covers sexual and gender minority-specific health topics	52	80	66	31
(percentage)	(22.7)	(34.9)	(28.8)	(13.5)
6. Over the course of my medical education, I have had the opportunity to practice interacting with sexual and gender minority patients	68	73	59	25
(percentage)	(30.2)	(32.4)	(26.2)	(11.1)

Figure 3.

Healthcare Professional’s “self-reported assessment of their curricula” in Treating SGM Patients.

A mixed response was seen under the domain of questions that seek to evaluate the respondents’ knowledge on health care of SGM population where only 30% of the individuals responded correctly about suicidal ideation and attempted suicides being high in the SGM population and only 32% of individuals thought that transgender men may need pap smears (Table 6, Figure 4).

Figure 4.

Healthcare Professional’s “knowledge” in Treating SGM Patients.

Table 6.

Healthcare Professional’s “knowledge” in Treating SGM Patients.

Knowledge items	Number of Respondents N(%)
Knowledge items	True	False	I Do Not Know	Correct Answer
1. LGBTQ people mostly only experience sexual health-related disparities (e.g., HIV/AIDS)	66	132	33	False
(percentage)	28.6	57.1	14.3
2. Transgender men may need pap smears.	75	53	103	True
(percentage)	32.5	22.9	44.6
3. LGBTQ individuals are more likely to report mental health problems (such as anxiety and depression).	162	34	33	True
(percentage)	70.7	14.8	14.4
4. Smoking is more prevalent among sexual minority women, putting them at greater risk for certain respiratory diseases.	84	53	92	True
(percentage)	36.7	23.1	40.2
5. All men who have sex with men are gay	72	140	19	False
(percentage)	31.2	60.6	8.2
6. Suicidal ideation and attempted suicide are just as common among heterosexual, cisgender individuals as among LGBT individuals.	88	71	72	False
(percentage)	38.1	30.7	31.2
7. LGBTQ people experience a wide variety of disparities in risk and disease compared to their non-LGBTQ peers.	136	42	52	True
(percentage)	59.1	18.3	22.6
8. Some individuals exhibit genetic, hormonal or physiological phenotypes that do not fit into a strict sex binary (i.e., male and female).	159	13	58	True
(percentage)	69.1	5.7	25.2
9. Lesbians do not need routine pap smears, since they do not have sexual relations with men.	22	138	71	False
(percentage)	9.5	59.7	30.7

The domains were further analysed for association using the Pearson chi-square test. A significant strong association was found between healthcare workers’ perception and self-assessment of their curriculum (chi-square = 135.74, p < .001) and their competency (chi-square = 185.00, p < .01) (Table 7).

Table 7.

Association of Comfort, Competency and Curriculum Among the Professional/Trainee.

	Medical Trainee	Medical Professional	Nursing Trainee	Nursing Professional	Chi-square	p Value
Comfort	70	58	57	50	62.42	.08
Competency	70	57	57	50	185.00	.01
Curriculum	67	57	57	49	135.74	<.001

Note: p < .05 is significant.

Discussion

This study was designed as a cross-sectional survey to evaluate self-reported competencies, comfort and perception of curricula among healthcare professionals, where faculty members, Residents, Postgraduate trainees, Undergraduate trainees and Nursing staff were included in the study. A majority of the study population was from nursing staff and undergraduate trainees and female gender (89.40%).

Among the study population, majority identified themselves as heterosexual, while 4.2% belonged to LGBTQIAA+. This was comparable with the current proportion of roughly around 3.8% LGBTQIAA+ population of India.¹

Though, the majority of respondents (84%) felt comfortable in treating SGM patients, more than half (62%) respondents felt least comfortable in discussing sexual practices among the SGM group. Considering the recent cultural shift into positive attitudes towards the SGM population, the overwhelming response of the healthcare providers in their self-reported comfort and competency towards treating this particular population as evident in a study by Kohut A et al. (2011) is in line with our study.⁸ However, this positive response in comfort and competency is starkly opposite to the perception of individuals belonging to the SGM population in the United States that identified the need for greater sensitivity from healthcare professionals.^10,11

Some studies done in United States also concluded that the LGBTQIAA+ population experiences difficulties in communicating with health professionals including assumptions about sexual orientation and embarrassing situations that stem from homophobia.^13,15 This overwhelming response in comfort and competency can also be due to respondents primarily consisting of females who according to previous studies have shown to be less likely to have implicit preferences or biases towards the LGBTQIAA+ community.¹²

The presence of inadequate knowledge about the mental health scenario of the SGM population in the previous studies conducted in India explains that transgender individuals tend to avoid free government healthcare services and prefer self-medication or private healthcare and were found to be not taking any treatment during the study period.¹³ In our study, 2/3^rd of the population was found to have difficulty in talking about sexual practices which could be an indirect reflection of the difficulty of communication by both health-care providers and seeker part. These findings support the results of an Indian study conducted by Banwari G et al. (2015), and further solidify the previous survey-based Indian study indicating the inadequacy of knowledge regarding homosexuality.¹⁴

The study also showed that a majority of respondents did not have the course of their medical education where formal training for an approach to interaction with SGM patients was provided. An overwhelming number of respondents felt that their curricular did not prepare them for the treatment of SGM patients. Similar findings were evident from a recent study by Arthur et al., 2021 in a survey including 252 medical students. This survey reported a positive attitude towards LGBT patients but a majority had presence of lack of confidence discussing sexual orientation and specific training in the same.⁸

Recently, with almost every major government college from Delhi having clubs specially assigned to advocate for LGBTQIAA+ rights and healthcare that routinely conduct webinars with professionals from psychiatric and paediatric backgrounds discussing sensitive ways to handle SGM care can be concluded to be implicit in the excellent self-reported comfort and competency in the respondents.

However personal positive bias and social desirability factors should not be exempted from being taken into account as much as the notion that the healthcare providers may overestimate their competence in serving SGM patients.

Conclusion

The study is one of the pioneering work in assessing the pragmatic approach for the LGBTQIAA+ group among the health-care workers. This can be used as preliminary data to develop a comprehensive curriculum for the undergraduate medical and nursing programmes across all over India that cater to the specific and sensitive care that is required to treat SGM patients and to increase the exposure of trainees as well as professionals to SGM patients and clinical topics that impact the health of marginalised communities. Taking into account the subjectivity of this study, the findings of this study should be used to further develop objective measures to further evaluate the competency and knowledge of healthcare providers. Comprehensive education transformation, the introduction of basics like familiarity with relevant terminology and skill building at the preliminary level could lead to positive attitudes and outcomes in health-care delivery to the LGBT population.

Footnotes

Acknowledgements

This study is a part of ICMR STS (Short Term Studentship) research project approved in year 2020 (reference no.: 2020-01575). We are thankful to ICMR (Indian Council Medical Research) for approving this project for STS. The content of the project is solely responsibility of authors and does not represent official view of ICMR. ICMR has no role in design and conduct of study or manuscript preparation.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval

The study was conducted after ethical approval from the IEC (LHMC/IEC/2020/52).

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Informed Consent

Not applicable

References

Kealy-Bateman

The possible role of the psychiatrist: the lesbian, gay, bisexual, and transgender population in India. Indian J Psychiatry. 2018;60:489–493.

Meyer

. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697. doi: 10.1037/0033-2909.129.5.674

Wilkerson

, Di Paola

, Rawat

, Patankar

, Rosser

BRS

, Ekstrand

. Substance use, mental health, HIV testing, and sexual risk behavior among men who have sex with men in the state of Maharashtra, India. AIDS Educ Prev. 2018;30(2): 96-107. doi: 10.1521/aeap.2018.30.2.96. PMID: 29688773; PMCID: PMC6214349.

Joseph

, Cliffe

, Hillyard

, Majeed

. Gender identity and the management of the transgender patient: a guide for non-specialists. J R Soc Med. 2017;110(4):144-152. doi: 10.1177/0141076817696054. Epub 2017 Apr 6. PMID: 28382847; PMCID: PMC5407520.

Rowe

, Ng

, O’Keefe

, Crawford

. Providers’ attitudes and knowledge of lesbian, gay, bisexual, and transgender health. Fed Pract. 2017;34(11):28–34.

Henry

, Perrin

, Sawyer

, Pugh

M Jr

. Health conditions, access to care, mental health, and wellness behaviors in lesbian, gay, bisexual, and transgender adults. Int J Chronic Dis. 2020;2020:9094047. doi: 10.1155/2020/9094047. PMID: 32206669; PMCID: PMC7079213.

Alencar

Albuquerque G

, de Lima Garcia

, da Silva Quirino

, . Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC Int Health Hum Rights. 2016;16:2. doi: 10.1186/s12914-015-0072-9. PMID: 26769484; PMCID: PMC4714514.

Arthur

, Jamieson

, Cross

, Nambiar

, Llewellyn

. Medical students’ awareness of health issues, attitudes, and confidence about caring for lesbian, gay, bisexual and transgender patients: a cross-sectional survey. BMC Med Educ. 2021;21(1):56. doi: 10.1186/s12909-020-02409-6. PMID: 33446197; PMCID: PMC7809852.

Kohut

, Wike

, Horowitz

, . The American-Western European Values Gap. Pew Research Center’s Global Attitudes Project, November. 2011:1–24.

10.

Hoffman

, Freeman

, Swann

. Healthcare preferences of lesbian, gay, bisexual, transgender and questioning youth. J Adolesc Health. 2009;45(3):222-229. doi: 10.1016/j.jadohealth.2009.01.009

11.

Willging

, Gunderson

, Shattuck

, Sturm

, Lawyer

, Crandall

. Structural competency in emergency medicine services for transgender and gender non-conforming patients. Soc Sci Med. 2019;222:67–75. doi: 10.1016/j.socscimed.2018.12.031. Epub 2018 Dec 24. PMID: 30605801.

12.

Sabin

, Riskind

, Nosek

. Health care providers’ implicit and explicit attitudes toward lesbian women and gay men. Am J Public Health. 2015;105(9):1831-1841. doi: 10.2105/AJPH.2015.302631

13.

Wandrekar

, Nigudkar

. What do we know about LGBTQIA+ mental health in India? A review of research from 2009 to 2019. J Psychosexual Health. 2020;2(1):26-36. doi: 10.1177/2631831820918129

14.

Banwari

, Mistry

, Soni

, Parikh

, Gandhi

. Medical students and interns’ knowledge about and attitude towards homosexuality. J Postgrad Med. 2015;61(2):95-100. doi: 10.4103/0022-3859.153103. PMID: 25766341; PMCID: PMC4943442.