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Abstract

It has been well established that those identifying as a member of the sexual and gender minority (SGM) have difficulties accessing health care services. This is strongly associated with the desire to avoid discriminatory health care practices and prejudicial providers that many SGM individuals have encountered. Implementation of specific welcoming clinic space indicators (WCSIs) has been recommended to mitigate prior health care alienation experienced by SGM individuals. The project supported three HIV clinical care sites in Louisiana to implement and maintain identified SGM WCSIs as one of its interventions to improve sexually transmitted infection screening, testing, and treatment in people with and at-risk of HIV. This project found that SGM WCSIs had a positive impact on SGM individuals and were predominately unnoticed by those that were non-SGM–identifying individuals. Further, across the entire sample, the SGM WCSIs had an extremely low (<1%) level of negative impact, eliminating the misconception that SGW WCSI implementation may offend non-SGM individuals. There were differences in the implementation of the SGM WCSIs across the three sites associated with their governance structure and priority community. Implementation of SGM WCSIs should be considered as an important component of assuring culturally competent health care for SGM individuals.

Introduction

It has been well established that those identifying as a member of the sexual and gender minority (SGM) population (including those who identify as, but not limited to, lesbian, gay, bisexual, transgender, pansexual, intersex, queer, nonbinary, two-spirited, and asexual) have difficulties accessing health care services.^1,2 Barriers to accessing health care services are a result of a pervasive cisgender-heteronormative attitude predominating the health care system.^1,3 Further, the prevalence of anti-SGM attitudes in the general society permeates into the health care system.^1,4 The SGM population reports discrimination widely across health care and other domains, especially among racial/ethnic minorities.⁵ The traditional structure of hospitals, clinics, and academic medical centers can often create unintentional barriers to the care and may be perceived by the SGM community as inaccessible, unwelcoming, and even unsafe.⁶ Prior exposure to discriminatory health care practices and prejudicial providers discourage many SGM individuals from accessing health care for treatment or preventive services.⁷ This results in an increased rate of many morbidities in the SGM population compared with the non-SGM (nSGM) population.^8,9

In 2011, The Joint Commission (TJC) published a Field Guide providing health care organizations recommendations to alleviate health care services barriers experienced by the SGM community.¹⁰ This document had far-reaching ramifications, as TJC bases its recommendations on those established by the US Department of Health and Human Services and reflects the clinical standards of Centers of Medicare and Medicaid, the largest funders of health care in the United States.^10,11 TJC developed the Field Guide in response to its 2011 standard revisions requiring health care systems to assure no discrimination in services based on sexual orientation, gender identity, or gender expression as legislated in section 1557 of the Affordable Care Act.¹⁰ Via the convening of an expert advisory panel, TJC amended their previously published tool: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals, providing guidance to advance effective communication and cultural competence as a means to assure health care equity to SGM persons.¹⁰ As the expert advisory panel comprised of professional associations, key stakeholders, and advocacy groups in the area of SGM persons' health care, the Field Guide reflects recommendations similar to many other organizations that aim to assure the care of SGM populations.¹⁰

The TJC Field Guide, as other guidelines published by organizations with expertise in SGM population health, recommends health care organizations alleviate significant barriers SGM people may experience in accessing quality health by assuring a culturally competent care.¹² Overarching in these guidelines is acknowledging that prior health care alienation experienced by SGM people can be mitigated by assuring the health care system provides a “welcoming environment.”¹⁰ A “welcoming environment” is one that communicates to those that enter a sense of inclusiveness and safety, encourages self-expression of individual distinctiveness, and that the individual will be respected as the staff strives to understand and address the individual's unique needs.^{3,10,12

–15} An environment can communicate that it is “welcoming” through visual, written, verbal, and nonverbal cues. These cues are intended to make an impression on the individual who must receive (notice) the cue that is then assessed (Positive impact → Negative impact). By assuring the presence of specific cues, a health care clinic can communicate to SGM people that the clinic services are prepared to respond to the unique health needs of the SGM community through culturally competent care. Through the literature, the following have been identified as SGM welcoming clinic space indicators (WCSIs)^10,12

–15:

Adequate staff training on sexual and gender diversity

Inclusion of SGM persons in organization policy-making or governances

Prominently displayed organization's established gender identity, gender expression, and sexual orientation nondiscrimination policy

Inclusion of SGM people in the organization's workforce

Use of gender-neutral language in all aspects of clinical care, data collection, and information exchange

Demographic data that allows self-identification of gender identity, chosen names, and pronouns

Individual assessment that includes noting assigned and identified gender, and sexual orientation including those that are nonbinary

Gender-neutral bathroom(s)

Readily available information regarding SGM community resources

Education material designed to appeal to SGM individuals and include appropriate SGM messaging

Visible displays of SGM community support [lesbian gay bisexual transgender queer/questioning and others (LGBTQ+) flag, Pride insignia]

Visible SGM people inclusiveness in waiting room materials (magazines, flyers) and décor (imagery)

Advertising of services in SGM community media

Acknowledging, collaborating, supporting, advertising SGM community functions, awareness, celebrations or events (e.g., National Coming Out Day, Transgender Day of Remembrance, LGBTQ+ Pride)

Implementation of SGM WCSIs is recommended for all types of health care systems as SGM individuals have similar health needs as non-SGM–identifying individuals. However, the ability to implement welcoming measures can vary based on the specific health care system. Data have shown that the successful implementation of any health care associated change (transformation) will be impacted by the system's governance (regulatory body, public, nonpublic, academic, private, faith based), structure (large/small, multi-site, multi-providers, multi-specialty) funding (federal or state supported, profit, nonprofit), priority community (urban, rural, maternal child, geriatric pediatric, homeless) as well as is the specific services provided (diagnostic services, behavioral health, skilled nursing, urgent care, home health, ambulatory surgery).¹⁶ Thus, implementation of SGM WCSIs would be expected to vary based on the targeted health care system. Various types of health care organizations have attempted to transform their clinical practices to improve the quality of care available to the SGM community, including implementing SGM WCSI.^17

–20 Unfortunately; there are limited data that compares the implementation of SGM WCSIs across various health care settings.

Owing to its design, the sexually transmitted infection (STI) Special Project of National Significance (SPNS) was able to provide data to assess the impact of SGM WCSIs on SGM and nSGM populations as well as determine if the implementation of SGM WCSIs differs in various distinct health care environments. As described elsewhere, the STI SPNS was developed to test the effectiveness of four distinct evidenced-based interventions designed to improve clinical demonstration sites' capacity to screen, test, and treat STIs in PWH within a variety of health care systems across the United States. As the persons with HIV (PWH) and SGM populations intersect, the project predicted that improving the SGM community's access to health care would also improve a large portion of PWHs' access to care including STI care. It was further recognized that providing a culturally affirming care environment with the implementation of SGM WCSIs, STI testing increased in SGM patients.¹⁸ Thus, one of the SPNS STI four interventions to improve STI care was designed to support the maintenance or implementation of 12 specific SGM WCSIs.

As described elsewhere, sites chosen to participate in the STI SPNS project were located in regions that had high rates of STI and HIV infections. As Louisiana has higher STI and HIV rates than most other US regions,^21
–23 three sites within the state were included in this SPNS project. Although not a consideration in choosing sites for the project, recognizing that Louisiana has been identified as one of the most “unfriendly” US states to SGM community,²⁴ resources to counter this perception and increase an SGM individual willingness to engage in health care are crucial. Although all sites were funded to provide HIV specialized medical care to PWH, each site varied in governance, scope of services, and structure. The three STI SPNS sites in Louisiana included an HIV Care Program at a Health Resources and Services Administration Funded Healthcare Center (HCPC), a specialty clinic in a large academic health center (AHC), and an independent community HIV health center (CHC).

Over the course of 18 months (April 2020 through August 2021), each site in Louisiana was supported to maintain or implement 12 specific SGM WCSIs.

As given in Table 1, >40% of the indicators were in place before the start of the project and 95% were present by the end. Using the data collected through the STI SPNS project, the impact of SGM WCSIs implemented in the three Louisiana sites was analysis to identify if there is a difference between SGM and nSGM groups, as well as identify any difference in the implementation of SGM WCSIs across various distinct health care environments.

Table 1.

Louisiana Sexually Transmitted Infection Special Project of National Significance Project Clinic Sites Descriptions

Clinic description	HCPC	AHC	CHC
Total participants	221	42	249
Days in project	499	427	499
Number of completed satisfaction survey
1	144	41	75
2	69	1	83
>2	8	0	91

SGM WCSI	Days to implementation
All staff trained on gender identity and sexual orientation diversity^a	X	68	X
Visible SGM inclusiveness in waiting room materials (magazines, posters, fliers)^a	X	219	X
Gender-neutral bathroom(s)^a	386	X	X
SGM inclusive educational materials (gender diverse persons and same-gender couples)^a	X	219	X
A gender identity/expression, and sexual orientation non-discrimination policy clearly displayed^a	455	X	1
Clinic registration/intake form includes patient's preferred name/pronoun (in addition to legal/birth name as required for documentation/billing)^a	X	X	X
Affiliations with SGM supportive community-based organizations with information of same available^a	N/A	X	X
SGM member(s) on advisory board	X	X	X
History taking includes assigned gender and current gender identity inclusive of nonbinary identities	X	X	X
LGBTQ+ flag (red, orange, yellow, green, blue, purple) or symbol displayed^a	365	N/A	1
Transgender flag (blue, pink, white, pink, blue) or symbol displayed^a	365	N/A	1
Acknowledgment of LGBTQ+ awareness and recognition days/events (e.g., Transgender Day of Remembrance, LGBTQ+ Pride)^a	364	X	1
Prior SGM WCSI	6	7	8
Total number implemented at project end	11	10	12
Average days to implementation	387	169	1

Impact of SGM WCSI was measured via the Satisfaction Survey.

AHC, academic health center; CHC, community HIV health center; HCPC, HIV Care Program at a Health Resources and Services Administration Funded Healthcare Center; LGBTQ+, lesbian gay bisexual transgender queer/questioning and others; N/A, site did not apply/implement SGM WCSI during study; SGM, sexual and gender minority; WCSIs, Welcoming Clinic Space Indicators; X, SGM WCSI was in place before the project starting.

Methods

As described elsewhere, all PWH who sought care at one of the three Louisiana STI SPNS project sites were recruited to participate in this project. For those who consented, demographic and health care service data were collected from each visit during the study period. For the length of the project, every 3 months after each clinic visit, participants were asked to complete an Audio Computer-Assisted Self Interview (ACASI)-based Patient Satisfaction Survey (satisfaction survey). In addition to assessing participants' satisfaction regarding interventions intended to improve the site's capacity for STI care, this survey asked participants their impression of 10 of the 12 SGM WCSIs that could be easily assessed in the clinic environment. Impact of the SGM WCSIs regarding provider training was assessed by asking the participants' impression of: “The clinic staff and providers treated me with respect.” Participants were also asked to provide an overall assessment of their clinic visit via their degree of agreement regarding comfort “….discussing sexual health with clinic staff.”

Based on an ACASI-based sexual health history collected at each visit along with the satisfaction survey, each participant was identified as an SGM individual (those who reported an identified gender that differed from the assigned gender at birth, or any who reported a sexual orientation that was not “heterosexual”) or nSGM individual (all others unless there were insufficient data to determine gender identity or sexual orientation). Of the 573 who consented to participate, 512 had sufficient data to be identified as an SGM individual or nSGM individual, accounting for 903 clinic interactions, all with a completed satisfaction survey.

Demographic and STI test results were provided from each clinic and used to describe the sample (Tables 2 –4). Using the sexual health history data, the project was also able to determine if a participant had an STI risk factors or STI symptoms at that clinic visit. As participants were able to complete a sexual health history multiple times over the course of the project, the presence of an STI risk or symptoms could vary. As a means to better describe the samples, each participant was identified as “Ever” reporting an STI symptom or “Ever” reporting an STI risk factor.

Table 2.

Louisiana Sexually Transmitted Infection Special Project of National Significance Project Sites Demographics

Characteristic (frequency %)	SGM (N = 197)	nSGM (N = 315)	p
Age, mean (SD)	37.0 (11.9)	46.2 (11.2)	<0.001^a
Assigned birth gender
Male	179 (90.9)	132 (41.9)	<0.001^b
Female	18 (9.1)	183 (58.1)	<0.001^b
Race
Black	127 (65.8)	264 (86.6)	<0.001^b
White	64 (33.2)	40 (13.1)
Other	2 (1.0)	1 (0.3)
Missing	4	10
Insurance
Commercial	61 (31.6)	70 (22.9)	0.081^b
Medicaid	106 (54.9)	202 (66.2)
Medicare	15 (7.8)	21 (6.9)
No/unknown	11 (5.7)	12 (52.2)
Missing	4	10
Ethnicity
Hispanic/Latino	4 (2.1)	0	0.022^c
Non-Hispanic/Latino	189 (97.9)	305 (100)
Missing	4	10
Satisfaction survey frequency
1	100 (50.8)	160 (50.8)	0.882^b
2	57 (28.9)	96 (30.5)
>2	40 (20.3)	59 (18.7)
Young adult (<30 years old)
Yes	60 (31.1)	27 (8.8)	<0.001^b
No	133 (68.9)	278 (91.2)
Missing	4	10
At-risk for STI
Ever	113 (57.4)	89 (28.2)	<0.001^b
Never	84 (43.6)	220 (69.8)	<0.001^b
Report STI symptoms
Ever	87 (44.2)	117 (37.1)	0.115^b
Never	110 (55.8)	198 (62.9)	0.115^b

Including only those that could be identified as SGM or nSGM.

p-Value from t-test.

p-Value from chi-square test.

p-Value from Fisher-exact test (due to the small numbers).

nSGM, non sexual and gender minority; SD, standard deviation; SGM, sexual and gender minority; STI, sexually transmitted infection.

Table 3.

Sexually Transmitted Infection Tests and Rates

STI test	SGM (N = 349)	nSGM (N = 554)	p ^a
Chlamydia
Pharyngeal
Positive	5 (2.4)	0	0.085^b
Nonpositive	202 (97.6)	139 (100)	0.085^b
Urine
Positive	7 (3.0)	5 (1.4)	0.179^a
Nonpositive	228 (97.0)	354 (98.6)	0.179^a
Rectal
Positive	12 (6.5)	5 (5.0)	0.592^a
Nonpositive	172 (93.5)	96 (95.0)	0.592^a
Gonorrhea
Pharyngeal
Positive	13 (6.3)	2 (1.4)	0.030^a
Nonpositive	194 (93.7)	137 (96.6)	0.030^a
Urine
Positive	4 (1.7)	3 (0.8)	0.336^b
Nonpositive	230 (98.3)	356 (99.2)	0.336^b
Rectal
Positive	13 (7.1)	1 (1.0)	0.023^b
Nonpositive	171 (92.9)	100 (99.0)	0.023^b
Syphilis
New infection^c	18 (7.6)	7 (1.8)	<0.001^a
Reactive	96 (40.3)	49 (12.7)	<0.001^a
Nonreactive	142 (59.7)	337 (87.3)	<0.001^a

p-Value from chi-square test.

p-Value from Fisher-exact test (owing to the small numbers).

Percentage of all tests (reactive and nonreactive).

nSGM, non sexual and gender minority; SGM, sexual and gender minority; STI, sexually transmitted infection.

Table 4.

Demographics of Sexual and Gender Minority Population Per Site

Characteristics, frequency (%)	HCPC	AHC	CHC	p ^a
SGM sample/total sample (%)	62/221 (28.1)	20/42 (47.6)	115/249 (46.2)	<0.001
Age, mean (SD)	37.4 (11.9)	32.2 (10.9)	37.6 (11.9)	0.167^b
Identified gender
Male	49 (79.0)	15 (75)	101 (87.8)	0.056
Female	6 (9.7)	1 (5)	11 (9.6)
Transgender male	1 (1.6)	0	0
Transgender female	6 (9.7)	4 (20)	3 (2.6)
Assigned gender
Male	56 (90.3)	19 (95)	104 (90.4)
Female	6 (9.7)	1 (5)	11 (9.6)	0.795
Sexual orientations
Heterosexual	1 (1.6)	1 (5.0)	2 (1.7)
Same gender loving	51 (82.3)	14 (70)	82 (71.3)	0.392
Bisexual/pansexual	8 (12.9)	4 (20)	29 (25.2)
Something else/DNK	0	0	2 (1.8)
Not disclosed	2 (3.2)	1 (5)	0
Race
Black	49 (84.5)	17 (85.0)	61 (53.0)
White	8 (13.8)	3 (15.0)	53 (46.1)	<0.001
Other	1 (1.7)	0	1 (0.9)
Insurance
Commercial	25 (43.1)	0	36 (31.3)
Medicaid	31 (53.3)	13 (65.0)	62 (53.9)	<0.001
Medicare	1 (1.7)	0	14 (12.2)
No/unknown	1 (1.7)	7 (35.0)	3 (27.3)
Ethnicity
Hispanic/Latino	0	0	4 (3.5)
Non-Hispanic/Latino	58 (100)	20 (100)	111 (96.5)	0.250
Satisfaction survey frequency
1	39 (67.2)	20 (100)	37 (32.2)
2	17 (29.3)	0	40 (34.8)	<0.001
>2	2 (3.5)	0	38 (33.0)
Young adult (<30 years old)
Yes	17 (29.3)	9 (45.0)	34 (29.6)
No	41 (70.7)	11 (55.0)	81 (70.4)	0.365
At-risk for STI
Ever	45 (54.2)	9 (45.0)	127 (51.6)
Never	38 (45.8)	11 (55.0)	119 (48.4)	<0.001
Report STI symptoms
Ever	23 (27.7)	7 (35.0)	84 (34.2)
Never	60 (72.3)	13 (65.0)	162 (65.8)	0.543

p-Value from chi-square test except where noted.

p-Value from t-test.

AHC, academic health center; CHC, community HIV health center; DNK, do not know; HCPC, HIV Program at a Health Resources and Services Administration Health Center Program-Funded Clinic; SD, standard deviation; SGM, sexual and gender minority; STI, sexually transmitted infection.

Tables 5 and 6 present the data regarding analysis of the impact of 10 of the 12 SGM WCSIs. To measure the impact of the implemented SGM WCSI, the satisfaction survey asked participants to indicate if the indicator had a positive impact: “I noticed and liked it,” a negative impact “I noticed it but disliked it”; a neutral impact “I noticed it but neither like or dislike it” or if it was not noticed “I didn't notice it.” The impact of two implemented SGM WCSIs was not measured as they could not be easily assessed during a clinic visit (see notation in Table 1). As the extent of clinic staff's sexual and gender diversity provider training could not be easily assessed during a clinic visit, the impact of this SGM WCSI was measured by asking the participants if they noticed “The clinic staff and providers treated me with respect.” As the same satisfaction survey was used throughout the study, but SGM WCSIs were introduced into a clinic at different points, only responses after introduction of a specific SGM WCSI at a specific site were considered in the analysis (labeled “valid responses”), accounting for the variation in Total Valid Responses reported for each indicator. Recognizing the small sample size and the risk to significance, the 10 studied SGM WCSIs were clustered into communication types (visual, written, verbal/nonverbal) based on the primary means that the cue would be transmitted for further analysis. To assess for potential bias owing to violation to sample independence (high frequency of multiple visits for the same patients) data were also examined based on unique individual (N = 512), considering only the first valid response for each participant and limiting the bias that could be presented by those who had multiple entries.

Table 5.

Impact of Sexual and Gender Minority Welcoming Clinic Space Indicator on PWH in Louisiana

SGM WCSI (total valid responses)	Cluster	Impact	Responses (total sample size ^a )
SGM WCSI (total valid responses)	Cluster	Impact	SGM (349)	nSGM (554)	p ^b
All staff trained on gender identity/sexual orientation diversity (903)	Verbal	Positive	339 (97.1)	512 (92.4)	0.003
		Other	10 (2.9)	42 (7.3)
		Negative	2 (20.0)	3 (7.1)
		Neutral	0	11 (26.2)
		Not noticed	8 (80.0)	28 (66.7)
Visible SGM inclusiveness in waiting room materials (870)	Visible	Positive	190 (57.1)	118 (22.0)	0.003
		Other	143 (42.9)	419 (88.0)
		Negative	2 (1.4)	8 (1.9)
		Neutral	37 (25.9)	72 (17.2)
		Not noticed	104 (72.7)	339 (80.9)
Gender-neutral bathroom(s) (710)	Visible	Positive	159 (53.4)	150 (36.4)	<0.001
		Other	139 (46.6)	262 (63.6)
		Negative	3 (2.1)	6 (2.3)
		Neutral	25 (18.0)	48 (18.4)
		Not noticed	111 (79.9)	208 (79.4)
SGM inclusive educational materials (870)	Written	Positive	195 (58.6)	123 (22.9)	<0.001
		Other	138 (41.4)	414 (77.1)
		Negative	4 (2.9)	8 (1.9)
		Neutral	30 (21.7)	63 (15.2)
		Not noticed	104 (75.4)	343 (82.9)
A gender identity/expression and sexual orientation NDP clearly displayed (632)	Written	Positive	167 (59.6)	118 (33.5)	<0.001
		Other	113 (40.4)	234 (66.5)
		Negative	2 (1.8)	8 (3.4)
		Neutral	25 (22.1)	50 (21.3)
		Not noticed	86 (76.1)	176 (75.2)
Clinic registration/intake form includes patient's preferred name/pronoun (903)	Verbal	Positive	200 (57.3)	199 (35.9)	<0.001
		Other	149 (42.7)	355 (64.1)
		Negative	3 (2.0)	2 (0.6)
		Neutral	17 (11.4)	35 (9.9)
		Not noticed	129 (86.6)	318 (89.6)
Affiliations with SGM supportive CBO with information of same available (596)	Written	Positive	169 (65.5)	122 (37.0)	<0.001
		Other	97 (36.5)	208 (67.0)
		Negative	2 (2.1)	6 (2.9)
		Neutral	14 (14.4)	42 (20.2)
		Not noticed	81 (83.5)	160 (76.9)
LGBTQ+ flag or symbol displayed (860)	Visible	Positive	193 (58.7)	161 (30.3)	<0.001
		Other	136 (41.3)	370 (69.7)
		Negative	1 (0.7)	4 (1.1)
		Neutral	33 (24.3)	64 (17.3)
		Not noticed	102 (75.0)	302 (81.6)
Transgender flag or symbol displayed (860)	Visible	Positive	184 (55.9)	136 (25.6)	<0.001
		Other	145 (44.1)	395 (74.4)
		Negative	1 (0.7)	5 (1.3)
		Neutral	31 (21.4)	66 (16.7)
		Not noticed	113 (77.9)	324 (82.0)
Acknowledgment of LGBTQ+ awareness/recognition days/events (728)	Verbal	Positive	153 (50.7)	106 (24.9)	<0.001
		Other	149 (49.3)	320 (75.1)
		Negative	1 (0.7)	4 (1.2)
		Neutral	24 (16.1)	48 (15.0)
		Not noticed	124 (83.2)	268 (83.7)
Comfortable discussing sexual health with clinic staff (903)^c		Agree	326 (93.4)	466 (84.1)	<0.001
		Other	23 (6.6)	88 (15.9)
		Disagree	11 (48)	37 (40)
		No talk/refuse	12 (52)	51 (60)
Visual indicators (3300)		Positive	726 (56.3)	565 (28.1)	<0.001
		Other	563 (43.7)	1446 (71.9)
		Negative	7 (1.2)	23 (1.6)
		Neutral	126 (22.4)	250 (17.3)
		Not noticed	430 (76.4)	1173 (81.1)
Verbal indicators (2534)		Positive	692 (69.2)	817 (53.3)	<0.001
		Other	308 (30.8)	717 (46.7)
		Negative	6 (1.9)	9 (1.3)
		Neutral	41 (13.3)	94 (13.1)
		Not noticed	261 (84.7)	614 (85.6)
Written indicators (3078)		Positive	531 (60.4)	363 (29.8)	<0.001
		Other	348 (39.6)	856 (70.2)
		Negative	8 (2.3)	22 (2.6)
		Neutral	69 (19.8)	155 (18.1)
		Not noticed	271 (77.9)	679 (79.3)

The total sample size but not all provided valid responses for all indicators.

p-Values from chi-square tests.

In addition to Agree or Disagree, potential responses included “I have never talked to staff about my sexual health” or “Refused to answer.”

CBO, community-based organization; LGBTQ+, lesbian gay bisexual transgender queer/questioning and others; NDP, nondiscrimination policy; nSGM, non sexual and gender minority; SGM, sexual and gender minority; WCSIs, Welcoming Clinic Space Indicators.

Table 6.

Analysis of Sexual and Gender Minority (SGM) Welcoming Clinic Space Indicator Impact on SGM Individuals Across Three Louisiana Sites

SGM WCSI (total valid responses)	Cluster	Impact	SGM responses (total sample size ^a )
SGM WCSI (total valid responses)	Cluster	Impact	HCPC (83)	AHC (20)	CHC (246)	p ^b
All staff trained on gender identity/sexual orientation diversity (349)	Verbal	Positive	80 (96.4)	20 (100)	239 (97.1)	0.685
		Other	3 (3.6)	0	7 (2.9)
		Negative	0	0	0
		Neutral	0	0	2 (28.6)
		Not noticed	3 (100)	0	5 (71.4)
Visible SGM inclusiveness in waiting room materials (333)	Visible	Positive	32 (38.6)	20 (50.0)	156 (63.4)	<0.001
		Other	51 (61.4)	2 (50.0)	90 (36.6)
		Negative	0	0	2 (2.2)
		Neutral	4 (7.8)	0	33 (36.7)
		Not noticed	47 (92.2)	2 (100)	55 (61.1)
Gender-neutral bathroom(s) (298)	Visible	Positive	13 (40.6)	11 (55.0)	135 (54.9)	0.311
		Other	19 (59.4)	9 (45.0)	111 (45.1)
		Negative	1 (5.3)	0	2 (1.8)
		Neutral	0	1 (11.1)	24 (21.6)
		Not noticed	18 (94.7)	8 (88.9)	85 (76.6)
SGM inclusive educational materials (333)	Written	Positive	31 (37.4)	3 (75.0)	161 (65.5)	<0.001
		Other	52 (62.6)	1 (25.0)	85 (34.5)
		Negative	0	0	4 (4.7)
		Neutral	5 (9.6)	0	25 (29.4)
		Not noticed	47 (90.4)	1 (100)	56 (65.9)
A gender identity/expression and sexual orientation NDP clearly displayed (280)	Written	Positive	6 (42.9)	9 (45.0)	152 (61.8)	0.143
		Other	8 (57.1)	11 (55.0)	94 (38.2)
		Negative	0	0	2 (2.1)
		Neutral	1 (12.5)	0	24 (25.5)
		Not noticed	7 (87.5)	11 (100)	68 (72.3)
Clinic registration/intake form includes patient's preferred name/pronoun (349)	Verbal	Positive	46 (55.4)	13 (65.0)	141 (57.3)	0.739
		Other	37 (44.6)	7 (35.0)	105 (42.7)
		Negative	0	1 (14.3)	2 (1.9)
		Neutral	3 (8.1)	1 (14.3)	13 (12.4)
		Not noticed	34 (91.9)	5 (71.4)	90 (85.7)
Affiliations with SGM supportive CBO with information of same available (266)	Written	Positive	N/A	9 (45.0)	160 (65.0)	0.091
		Other		11 (55.0)	86 (35.0)
		Negative		0	2 (2.3)
		Neutral		0	14 (16.3)
		Not noticed		11 (100)	70 (81.4)
LGBTQ+ flag or symbol displayed (329)	Visible	Positive	23 (27.7)	N/A	170 (69.1)	<0.001
		Other	60 (72.3)		76 (30.9)
		Negative	0		1 (1.3)
		Neutral	6 (10.0)		27 (35.5)
		Not noticed	54 (90.0)		48 (63.2)
Transgender flag or symbol displayed (329)	Visible	Positive	19 (22.9)	N/A	165 (67.1)	<0.001
		Other	64 (77.1)		81 (32.9)
		Negative	0		1 (1.2)
		Neutral	4 (6.3)		27 (33.3)
		Not noticed	60 (93.7)		53 (65.4)
Acknowledgment of LGBTQ+ awareness/recognition days/events (302)	Verbal	Positive	10 (27.8)	7 (35.0)	136 (55.3)	0.003
		Other	26 (72.2)	13 (65.0)	110 (44.7)
		Negative	0	0	1 (0.9)
		Neutral	3 (11.5)	0	21 (19.1)
		Not noticed	23 (88.5)	13 (100)	88 (80.0)
Comfortable discussing sexual health with clinic staff (349)^c		Agree	78 (94.0)	19 (95.0)	229 (93.1)	0.885
		Other	5 (6.0)	1 (5.0)	17 (6.9)
		Disagree	2 (40.0)	0	9 (52.9)
		No	3 (60.0)	1 (100)	8 (47.1)
		Talk/refuse
Visual indicators (1289)		Positive	87 (31.0)	13 (54.2)	626 (63.6)	<0.001
		Other	194 (69.0)	11 (45.8)	358 (36.4)
		Negative	1 (0.5)	0	6 (1.7)
		Neutral	14 (7.2)	1 (9.1)	111 (31.0)
		Not noticed	179 (92.3)	10 (90.9)	241 (67.3)
Verbal indicators (1000)		Positive	136 (67.3)	40 (66.7)	516 (69.9)	0.707
		Other	66 (32.7)	20 (33.3)	222 (30.1)
		Negative	0	1 (5.0)	5 (2.3)
		Neutral	6 (9.1)	1 (5.0)	34 (15.3)
		Not noticed	60 (90.9)	18 (90.0)	183 (82.4)
Written indicators (879)		Positive	37 (38.1)	21 (47.7)	473 (64.1)	<0.001
		Other	60 (61.9)	23 (52.3)	265 (35.9)
		Negative	0	0	8 (3.0)
		Neutral	6 (10.0)	0	63 (23.8)
		Not noticed	54 (90.0)	23 (100)	194 (73.2)

The total sample size of SGM individuals that provided a valid responses to at least one indicator from each site. Not all provided valid responses for all indicators.

p-Values from chi-square tests.

In addition to Agree or Disagree, potential responses included “I have never talked to staff about my sexual health” or “Refused to answer.”

AHC, academic health center; CBO, community-based organization; CHC, community HIV health center; HCPC, HIV Care Program at a Health Resources and Services Administration Funded Healthcare Center; LGBTQ+, lesbian gay bisexual transgender queer/questioning and others; N/A, site did not apply/implement SGM WCSI during study; NDP, nondiscrimination policy; SGM, sexual and gender minority; WCSIs, Welcoming Clinic Space Indicators.

Statistical methods

The satisfaction survey's SGM WCSI impact data were compared between the SGM sample and nSGM sample from all three clinical sites. To determine the difference between clinic sites, only the data from SGM individuals were considered. To account for the risk of response bias, the satisfaction survey results were quantified by both entries and by unique study ID for separate analysis. The t-test and ANOVA test were used to evaluate the difference in average age between SGM sample and nSGM sample and the SGM samples across the three clinics. Chi-square tests and Fisher's exact tests were used to test the homogeneity across different populations regarding categorical demographic data and satisfaction survey data. The satisfaction survey's SGM WCSI data were dichotomized into two groups: positive with all other responses (negative, neutral, not noticed) categorized as other. As the distribution of other responses was of interest, the frequency of negative, neutral, and not noticed responses are provided.

Results

In this sample of 512 PWH (Table 2) receiving clinical services at 3 sites throughout Louisiana, 38.5% were identified as SGM individuals. The SGM group had a significantly higher percentage identified as young adults compared with the nSGM group, but the nSGM had a much higher percentage of persons that reported Black race. There was a significantly higher percentage of persons who were assigned male gender at birth in the SGM population. SGM participants had a higher rate of reported STI risk behavior compared with nSGM participants.

Of all CT/GC NAATs and syphilis tests, the SGM sample had an average of 2.5 STI tests per person and the nSGM sample had an average of 1.7 STI tests per person (Table 3). There was a significantly higher number of throat and anal swab STI tests in the SGM population. Further, the rate of pharyngeal and rectal gonorrhea and new syphilis infections was significantly higher in the SGM sample compared with nSGM sample (Table 3).

Comparing just the SGM sample across the three sites, there was a higher number of SGM individuals receiving care at the CHC, but the AHC had the highest percentage (Table 4). The HCPC and AHC had significant higher percentages of SGM individuals that identified the race as Black compared with the CHC. It was also noted that the CHC had more SGM participants returning to the clinic multiple times than the other sites.

Overall, the SGM WCSIs had a predominantly positive impact on SGM individuals. For the nSGM individuals, most often the SGM WCSIs were not noticed (Table 5). Although the impact of being treated with respect was highly positive for the entire population, the SGM individuals had a higher level of agreement regarding comfort in talking to the staff about sexual health than the nSGM individuals. When the SGM WCSIs were clustered, the SGM individuals reported the highest positive impact from the verbal cues, with the nSGM individuals, again, reporting most often that the SGM WCSIs were not noticed. There were very few instances that an SGM WCSIs had a negative impact for either the SGM or nSGM individuals. For the SGM individuals, the highest rate of negative impact (1.2%) was associated with SGM-inclusive educational materials, whereas for the nSGM individuals the highest rate of negative impact (2.3%) associated with gender identity, gender expression, and sexual orientation nondiscrimination policy were clearly displayed. Considering the possible response bias owing to a participant's multiple visits, analyses were performed using only the initial valid SGM WCSI impact response for each participant (Appendix Table A1). Similar results were derived concluding that response bias did not affect the results.

When the SGM sample data were examined across the three sites, the extent of an SGM WCSI positive impact is not as clear. In general, the SGM sample seemed to have a positive clinical experience at all sites based on a high level of agreement regarding comfort in talking to the staff about sexual health and high positive impact of being treated with respect by the staff (Table 6). However, SGM individuals at the HCPC reported 7/9 SGM WCSIs and at the AHC 3/8 SGM WCSIs as not having a predominantly positive impact as they mostly were not noticed (Table 6). Only at the CHC had all SGM WCSIs predominantly reported as having a positive impact. In comparing the sites, there were significantly higher rates of positive impression toward five SGM WCSIs at the CHC compared with the other sites with visual and written cues having a significant difference in their impact. Analyses were performed using only the initial valid SGM WCSI impact response for each participant (Appendix Table A2). Except the recognizing of LGBT days had a lower positive impact at the CHC, similar results were derived, concluding that the impression of participants who had frequent visits did not affect the analysis.

Recognizing the small sample size of the AHC participants and its potential impact on the site analysis, a separate analysis of the nine SGM WCSIs that was implemented at both the CHC and HCPC was conducted (Table 7). There were five SGM WCSIs that had significantly higher positive impressions at the CHC compared with the HCPC, demonstrating the small sample size of the AHC did not bias the cross site analysis. An analysis conducted on only the initial valid visits resulted in similar findings (Appendix Table A3). Thus, the impression of participants who had frequent visits did not affect conclusions derived from overall analysis comparing these two sites.

Table 7.

Site Analysis of Sexual and Gender Minority (SGM) Welcoming Clinic Space Indicator Impact on SGM to Address Sample Size Bias

SGM WCSI (total valid responses)^a	Cluster	Impact	SGM responses (total sample size ^b )
SGM WCSI (total valid responses)^a	Cluster	Impact	HCPC (83)	CHC (246)	p ^c
All staff trained on gender identity/sexual orientation diversity (329)	Verbal	Positive	80 (96.4)	239 (97.1)	0.724
	Verbal	Other	3 (3.6)	7 (2.9)	0.724
Visible SGM inclusiveness in waiting room materials (329)	Visible	Positive	32 (38.6)	156 (63.4)	<0.001
Visible SGM inclusiveness in waiting room materials (329)	Visible	Other	51 (61.4)	90 (36.6)	<0.001
Gender-neutral bathroom(s) (278)	Visible	Positive	13 (40.6)	135 (54.9)	0.129
Gender-neutral bathroom(s) (278)	Visible	Other	19 (59.4)	111 (45.1)	0.129
SGM inclusive educational materials (328)	Written	Positive	31 (37.4)	161 (65.5)	<0.001
SGM inclusive educational materials (328)	Written	Other	52 (62.6)	85 (34.5)	<0.001
A gender identity/expression and sexual orientation NDP clearly displayed (260)	Written	Positive	6 (42.9)	152 (61.8)	0.171
	Written	Other	8 (57.1)	94 (38.2)	0.171
Clinic registration/intake form includes patient's preferred name/pronoun (329)	Verbal	Positive	46 (55.4)	141 (57.3)	0.763
	Verbal	Other	37 (44.6)	105 (42.7)	0.763
LGBTQ+ flag or symbol displayed (329)	Visible	Positive	23 (27.7)	170 (69.1)	<0.001
LGBTQ+ flag or symbol displayed (329)	Visible	Other	60 (72.3)	76 (30.9)	<0.001
Transgender flag or symbol displayed (329)	Visible	Positive	19 (22.9)	165 (67.1)	<0.001
Transgender flag or symbol displayed (329)	Visible	Other	64 (77.1)	81 (32.9)	<0.001
Acknowledgment of LGBTQ+ awareness/recognition days/events (282)	Verbal	Positive	10 (27.8)	136 (55.3)	0.002
	Verbal	Other	26 (72.2)	110 (44.7)	0.002
Comfortable discussing sexual health with clinic staff (329)		Agree	78 (94.0)	229 (93.1)	0.853
		Other	5 (6.0)	17 (6.9)	0.853
Visual indicators (1265)		Positive	87 (31.0)	626 (63.6)	<0.001
Visual indicators (1265)		Other	194 (69.0)	358 (36.4)	<0.001
Verbal indicators (940)		Positive	136 (67.3)	516 (69.9)	0.501
Verbal indicators (940)		Other	66 (32.7)	222 (30.1)	0.501
Written indicators (835)		Positive	37 (38.1)	473 (64.1)	<0.001
Written indicators (835)		Other	60 (61.9)	265 (35.9)	<0.001
At-risk for STI (329)		Ever	45 (54.2)	127 (51.6)	0.683
At-risk for STI (329)		Never	38 (45.8)	119 (48.4)	0.683
Report STI symptoms (329)		Ever	23 (27.7)	84 (34.2)	0.343
Report STI symptoms (329)		Never	60 (72.3)	162 (65.8)	0.343

Indicator regarding affiliations with SGM supportive CBO is not included as it was not implemented at the HCPC.

The total sample size of SGM individuals that provided a valid responses to at least one indicator from each site. Not all provided valid responses for all indicators.

p-Values from chi-square tests.

CHC, community HIV health center; HCPC, HIV Care Program at a Health Resources and Services Administration Funded Healthcare Center; LGBTQ+, lesbian gay bisexual transgender queer/questioning and others; NDP, nondiscrimination policy; SGM, sexual and gender minority; STI, sexually transmitted infection; WCSIs, Welcoming Clinic Space Indicators.

Discussion

These data demonstrate that implementing specific SGM WCSI had a positive impact on SGM individuals while not being noticed by the nSGM population, in general. Based on the Minority Stress Theory, minority populations such as SGM individuals will have a high level of vigilance and greater assessment intensity when entering an environment.²⁵ It is common for SGM individuals to look for environmental cues that would signal that a health care organization is “welcoming”²⁶ Thus, unlike the nSGM group, the SGM WCSIs were noticed more by SGM individuals and predominately, had a positive impact.

Of importance, these data are a valuable resource to counter resistance by some health care systems to incorporating SGM WCSI. Organizations may claim that the time and resources needed to implement SGM WCSI is unjustified because of the size of the SGM population or may oppose implementation based on concerns of offending patients.^6,27
–29 This resistance is a form of microaggression, specifically microinvalidation, that devaluates, negates, or nullifies the experiential reality of the SGM.³⁰ Health care–associated SGM microinvalidation can include: minimizing the importance or avoiding assessment of an individual's sexual orientation or gender identity, endorsing a heteronormative or gender normative culture while denying the extent of cis-heterosexism, or a genderist, homophobic/transphobic propensity of the health care system.^31,32 Microaggressions provide cover and support for established systems to ignore the health care needs of SGM.³³ These data demonstrate SGM WCSI had an extremely low level of negative impact on participants (0.95%), whether SGM (0.57%) or nSGM sample (1.3%), and were reported as not noticed in 43% of satisfaction surveys (SGM 30.4%; nSGM 51.8%). Thus, health care systems do not need to be concerned regarding the risk of offending patients by implementing SGM WCSI.

These data demonstrate that implementation of SGM WCSIs will vary based on the health care organization's governance and prioritized community: the more complex a health care organization's governance and/or the extensive its targeted community, the higher the potential for obstacles to transformation. As all three sites in this project provided services to PWH, of which many were also members of the SGM population, and had many SGM WCSIs in place before the project, only the CHC was able to implement all 12 WCSIs. The CHC, which was developed specifically to attract the PWH in their region (many of whom are also SGM individuals), and had a limited governance bureaucracy, implementation of the SGM WCSIs was met with few obstacles and staff were able to implement the changes quickly (all SGM WCSIs implemented in the shortest period). Although the specialty clinic in the AHC was specifically designed to care for PWH, and thus many SGM individuals, its position in a system consisting of a highly complex administration (answering various accrediting bodies and funders) presented more obstacles in implementing all the SGM WCSIs (i.e., TJC standard LS.03.01.70 prohibits all combustible decorations unless they meet the criteria of NFPA 101-2012: 20/21.7.5.4 such as flags).³⁴ Although HCPC clinics are designed to provide culturally competent care through governance by community members, they must meet the needs of the most vulnerable populations and allocate limited resources across completing demands, for which the SGM community may not be easily recognized.³⁵ Although more complex organizations may provide a larger variety of services to a more diverse community, the specific needs of a particular community, such as the SGM community, may not easily be addressed.

The data also demonstrate that the impact of SGM WCSIs will vary based on the extent of services provided in a health care system. Although there was a very low level of negative impact regarding SGM WCSIs at any site, the degree in which the SGM WCSIs was noticed varied greatly. The SGM WCSIs were noticed at a far greater rate at the CHC that was specifically designed to care for PWH, many of whom are also SGM persons. However, the HIV programs, that had a specific interest in meeting the needs of SGM individuals, at the HCPC and the AHC were only one of many programs or services offered in these organizations.³⁵ At the HCPC there are numerous environmental cues targeting various vulnerable populations, thus the SGM WCSIs could have been easily missed. The AHC is located in a larger institution; to access one would need to traverse environments that may not have been specifically welcoming to the SGM community. Thus, the impact of SGM WCSIs is greatly influenced by the diversity of the health care system.¹⁶

Limitations

Initially one of the limitations of the study is the accuracy in identifying all those who are members of the SGM population, thus appropriately analyzing the SGM WCSI impact difference. It is well known that research that assesses sensitive topics such as sexual orientation is threatened by respondent bias.^36,37 Even collecting sensitive data via an ACASI system, deemed to provide a higher degree of perceived privacy over other data collection, does not guarantee participants will answer honestly.³⁸ Further, as there is increased acknowledgment of its fluidity, there should be a degree of speculation regarding the precision of a single-moment assessment to accurately measure a person's gender identity or sexual orientation.³⁹

Although the SGM WCSIs were found to have a positive impact, we do not know what effect they had on the actual care of the SGM individuals or if they increased SGM individuals' access to health care. Although a prior study did show increase in SGM populations' services after implementing SGM WCSI, it is unclear if that increase was because of the addition of new patients or simply improved identification of existing SGM patients brought about by the implementation of SGM WCSI.²¹

Although they may make intuitive sense, there are minimal empirical data to support or clear theoretical underpinnings for which to base many of the specific SGM WCSIs that have been recommended to create an SGM “welcoming environment.”²⁶ Only two studies provide data that indicate the importance of SGM WCSI. A qualitative interview-based study of 30 SGMs concluded with a list of potential SGM WCSIs.⁴⁰ A quantitative study of SGM (n = 327) found significantly less importance given to environmental cues compared with the practitioner's behaviors.²⁶ Many SGM WCSI recommendations are not based on established theories and limit understanding of what may influence or explain their impact, greatly hampering their successful implementation.^41,42 Although incorporating any of the SGM WCSIs listed previously into a clinic's environment will most likely assist in mitigating some of the prior negative health care experiences of SGMs, the topic requires additional study.

Although this project intended to measure the impact of SGM WCSIs on the entire spectrum of the SGM population, there were only a few participants identifying as gender minority. Across Louisiana, only 14 PWH who identified as transgender had data included in this analysis. This accounts for only 7% of the entire SGM sample of the study, a sample size inadequate from which to draw valid conclusions regarding the impact of these SGM WCSIs on transgender individuals. This limitation is magnified as transgender person may encounter more severe discriminatory health care practices than lesbian/bisexual/queer (LBQ) cis gender women or gay/bisexual/queer (GBQ) cis gender men. Within the prior year, nearly 50% of transgender persons reported mistreatment by a health care provider, including being verbally or physically abused or having health care services withheld.⁴³ Transgender persons reported fearing a negative encounter with a health care provider nearly two times more often than LBQ cis gender women or GBQ cis gender men (62.2% vs. 32.2% vs. 36.5%).⁴⁴ Recognizing the severity of prior transphobic health care experiences and the potential difference in health care needs compared with the other SGM populations, additional focused attention is needed to identify specific WCSI that can have a positive impact on transgender person.⁴⁵

It should also be noted that the data collection for this project started soon after the onset of the public health emergency (PHE) because of the SARS-CoV-2 pandemic. The PHE greatly affected health care services and patients' access to services. For instance, services at the AHC were suspended and staff were redeploying to other sectors, thus decreasing the time the site could work to implement SGM WCSI. The PHE impacted the CHC by causing clinic closure after staff infections, quarantine closures, and limited staffing. Although the HCPC was never closed, as they were an essential provider during the PHE, staff attention was diverted to address SARS-CoV-2 screening, testing, and treatment, limiting capacity to recruit all potentially eligible participants. Finally, as clinic care delivery experiences were diverted at all sites to reduce nosocomial exposure, the ability for a participant to accurately assess the SGM WCSIs in the clinical environment was most likely altered, if not hindered.

Implementation of SGM WCSIs is recognized as a means to mitigate health care alienation experienced by SGM individuals. SGM WCSIs were found to have a positive impact on SGM individuals and rarely had a negative impact on SGM or nSGM populations. The ability to implement SGM WCSIs will vary based on the specific health care system characteristics. Although implementing SGM WCSIs are important, it should be recognized as only one component of providing high-quality, culturally complement care to SGM individuals: displaying a rainbow flag in a clinic may cue the SGM population the site is welcoming but is insufficient on its own.^46
–48 Considering the root cause of SGM community barriers to health care, far more than changing a clinical environment or training staff is required. There must be a biopsychosocial change to health care systems from a predominately pervasive cis-heteronormative attitude.⁴⁹ Finally, it is essential that a health care system continually monitors its ability to provide quality health care for SGM individuals, assuring the appropriateness and desired impact of any intervention.

Ethical Approval

The study protocol was approved by the Institutional Review Boards of Louisiana State University and Rutgers University.

Consent

Informed consent was obtained from all participants.

Footnotes

Author Disclosure Statement

No competing monetary interests exist.

Funding Information

This program is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) (grant no. 4U90HA32147-03-04) as part of an award totaling $11,251,973 with 0% financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US Government. For more information, please visit HRSA.gov

Appendix

Appendix Table A3.

Test for Response Bias on Analysis of Site Sexual and Gender Minority Welcoming Clinic Space Indicator Impact That Address Sample Size Bias

SGM WCSI (total valid responses)^a	Cluster	Impact	Responses (total sample size ^b )
SGM WCSI (total valid responses)^a	Cluster	Impact	HCPC (62)	CHC (115)	p ^c
All staff trained on gender identity/sexual orientation diversity (177)	Verbal	Positive	62 (100)	114 (99.1)	1.000^d
	Verbal	Other	0	1 (0.9)	1.000^d
Visible SGM inclusiveness in waiting room materials (161)	Visible	Positive	23 (37.1)	66 (57.4)	0.010
Visible SGM inclusiveness in waiting room materials (161)	Visible	Other	39 (62.9)	49 (42.6)	0.010
Gender-neutral bathroom(s) (166)	Visible	Positive	12 (38.7)	56 (48.7)	0.323
Gender-neutral bathroom(s) (166)	Visible	Other	19 (61.3)	59 (51.3)	0.323
SGM inclusive educational materials (161)	Written	Positive	23 (37.1)	73 (63.5)	0.001
SGM inclusive educational materials (161)	Written	Other	39 (62.9)	42 (36.5)	0.001
A gender identity/expression and sexual orientation NDP clearly displayed (129)	Written	Positive	6 (42.9)	67 (58.3)	0.393
	Written	Other	8 (57.1)	48 (41.7)	0.393
Clinic registration/intake form includes patient's preferred name/pronoun (177)	Verbal	Positive	38 (61.3)	58 (50.4)	0.167
	Verbal	Other	24 (38.7)	57 (49.6)	0.167
LGBTQ+ flag or symbol displayed (157)	Visible	Positive	16 (25.8)	80 (69.6)	<0.001
LGBTQ+ flag or symbol displayed (157)	Visible	Other	46 (74.2)	35 (30.4)	<0.001
Transgender flag or symbol displayed (157)	Visible	Positive	13 (21.0)	75 (65.2)	<0.001
Transgender flag or symbol displayed (157)	Visible	Other	49 (79.0)	40 (33.8)	<0.001
Acknowledgment of LGBTQ+ awareness/recognition days/events (150)	Verbal	Positive	9 (25.7)	56 (48.7)	0.016
	Verbal	Other	26 (74.3)	59 (51.3)	0.016
Comfortable discussing sexual health with clinic staff (677)		Agree	58 (92.6)	104 (90.4)	0.723
		Other	4 (6.2)	11 (9.6)	0.723
Visual indicators (677)		Positive	64 (29.5)	277 (60.2)	<0.001
Visual indicators (677)		Other	153 (70.5)	183 (39.8)	<0.001
Verbal indicators (504)		Positive	109 (68.6)	228 (66.1)	<0.585
Verbal indicators (504)		Other	50 (31.4)	117 (33.9)	<0.585
Written indicators (421)		Positive	29 (38.2)	210 (60.9)	<0.001
Written indicators (421)		Other	47 (61.8)	135 (39.1)	<0.001
At-risk for STI (177)		Ever	36 (58.1)	68 (59.1)	0.891
At-risk for STI (177)		Never	26 (41.9)	47 (40.9)	0.891
Report STI symptoms (177)		Ever	19 (30.6)	61 (53.0)	0.004
Report STI symptoms (177)		Never	43 (69.4)	54 (47.0)	0.004

Indicator regarding affiliations with SGM supportive CBO is not included as it was not implemented at the HCPC.

The total sample size of SGM individuals that provided a valid responses to at least one indicator from each site. Only the first valid response from each is considered in this analysis. Not all provided valid responses for all indicators.

p-Values from chi-square tests unless otherwise noted.

p-Value from Fisher-exact test (due to the small numbers).

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Impact of Implementing Welcoming Clinic Space Indicators on Sexual and Gender Minority Patients' Health Care Experience

Abstract

Introduction

Methods

Statistical methods

Results

Discussion

Limitations

Ethical Approval

Consent

Footnotes

Author Disclosure Statement

Funding Information

Appendix

References