Evaluation of the four national lesbian, gay, bisexual, transgender, and queer (LGBTQ)-competent provider directories in the United States

Background: Postponement and avoidance of healthcare by lesbian, gay, bisexual, transgender, and queer (LGBTQ) people can be attributed to various individual and systemic barriers. National directories of culturally-competent providers may serve as a bridge solution until LGBTQ health education becomes a requisite within standard medical education. This study seeks to evaluate these directories. Methods: In this qualitative study, characteristics such as populations served, number of providers, provider-specific feedback, and searchable criteria of the four national LGBTQ-competent provider directories in the United States, i.e., the Gay and Lesbian Medical Association (GLMA) Provider Directory, OutCare Health OutList, Referral Aggregator Database (RAD), and World Professional Association for Transgender Health (WPATH) Member Directory, were evaluated. Results: The GLMA Provider Directory and OutCare Health OutList both served the LGBTQ community while the RAD and WPATH Member Directory served the transgender community. The directories enumerated many providers: GLMA Provider Directory (n = 3961), OutCare Health OutList (n = 1900), RAD (n = 4051), and WPATH Member Directory (n = 1573). Only the OutCare Health OutList and RAD allowed provider-specific feedback. All directories provided nine fundamental searchable criteria (including provider name, location, specialty, population identity, service type, payment types, gender identity, and languages spoken) except the WPATH Member Directory which offered three criteria. Conclusion: The four national directories of LGBTQ-competent providers help address an essential need within the LGBTQ population by promoting equitable healthcare access. Provider-specific feedback and searchable criteria are important key characteristics to ensure cultural competency. By implementing these features, existing and future directories could better provide for the LGBTQ population.

3 more likely to endure poor physical health, activity limitations, chronic disease, obesity, and mental health conditions (including mood disorders, anxiety disorders, substance use disorders, and suicidality) [3][4][5][6][7]. The etiology of such LGBTQ disparities is multifaceted and appreciably a function of insufficient provider cultural competency. For example, both students and providers have been shown to harbor biases [8,9] and negative attitudes [1,2,10], infrequently inquire about sexual orientation and gender identity [11][12][13], and demonstrate shortcomings in education [12][13][14][15][16]. In addition, many LGBTQ patients encounter high rates of refusal of care and exposure to verbal and physical violence during healthcare physical examinations, which can subsequently lead to postponement of healthcare needs, delay in receiving medication, and avoidance of obtaining routine and urgent healthcare services altogether [1,17].
Finding concrete solutions for LGBTQ healthcare disparities is challenging. Identifying avenues that can decrease poor healthcare encounters may lead to better health outcomes for a substantial number of LGBTQ patients. Institutional endeavors such as increasing formal LGBTQ education and curricular reform have shown promising benefits for provider preparedness, knowledge, and attitudinal awareness [18]; however, these educational initiatives, at this time, are locally concentrated and are not standardized nor universal. Such shortfall highlights the need for platforms that enable patients to find LGBTQ-competent healthcare providers. When considering a national solution for LGBTQ health equity, national directories of culturally-competent providers may serve as a bridge until LGBTQ health education becomes a requisite within standard medical education.
Nonetheless, a paucity of such directories exists. To address the current gaps in medical literature, this study sought to evaluate the key characteristics of the four national LGBTQ-competent provider directories in the United States and thereby recommend important features for existing and future resources of this kind.

Methods
The four national directories were analyzed qualitatively from their respective websites: the Gay and Lesbian Medical Association (GLMA) Provider Directory [19], OutCare Health OutList [20], Referral Aggregator Database (RAD) [21], and World Professional Association for Transgender Health (WPATH) Member Directory [22]. The populations served and total number of providers enumerated on each directory were examined. Additionally, several characteristics were identified in each directory, including provider-specific feedback and searchable criteria (i.e., provider name, location, specialty, population identity, service type, payment types, gender identity, and languages spoken).

Results
The GLMA Provider Directory and OutCare Health OutList both served the LGBTQ community, while the RAD and WPATH Member Directory served the transgender community ( Table 1). The directories enumerated many providers: GLMA Provider Directory (n = 3961), OutCare Health OutList (n = 1900), RAD (n = 4051), and WPATH Member Directory (n = 1573). Regarding individual provider feedback, only the OutCare Health OutList and RAD provided patients with a means of reviewing providers. With respect to searchable criteria, the GLMA Provider Directory and OutCare Health OutList each provided nine searchable criteria, i.e., name, location, specialty, population identity, service types (i.e., medical and complementary/alternative entities), payment types, gender identity, and languages spoken. RAD provided nine searchable fields, i.e., name, location, specialty, population identity, service types (i.e., medical, social, legal, and complementary/alternative entities), and payment types. The WPATH Member Directory offered three searchable criteria, i.e., name, location, and specialty.

Discussion
These four directories represent the most widely accessed and available means of identifying LGBTQcompetent healthcare providers in the United States. The analysis of these directories reveals several areas for improvement in the optimization of the existing directories as well as the creation of future directories. Specifically, focus was given to populations served, total number of providers, providerspecific feedback, and searchable criteria, i.e., provider name, location, specialty, population identity, service type, payment types, gender identity, and languages spoken.
Of the directories, two (i.e., the GLMA Provider Directory and OutCare Health OutList) provided valuable information for the LGBTQ population as a whole and two (i.e., the RAD and WPATH Member Directory) were specific for the transgender population. There were a considerable number of providers listed on each directory. Of note, on all directories, providers self-registered and self-5 asserted that they met the cultural competency standards set forth by each directory. None of these directories except the OutCare Health OutList showcased organizational-specific cultural competency certifications; for example, providers on the OutCare Health OutList have the opportunity to participate in training and become certified by the organization OutCare Health. This lack of organizational evaluation of cultural competency among the other three directories may generate apprehension for some LGBTQ people, especially if self-registered providers only have competency in one specific subpopulation of the LGBTQ community. For instance, the transgender population has unique healthcare needs, such as high rates of certain health conditions and less health insurance coverage [3] and specific preventive services and treatments (such as gender-affirming hormones and surgeries) [23]. On both the GLMA Provider Directory and OutCare Health OutList, which serve the general LGBTQ population, providers may list their particular subspecialties, e.g., having the ability to specify transgender expertise. Given that past research has shown that providers' funds of knowledge differ between general LGBTQ education and population-specific proficiency (e.g., the transgender population) [12], it is paramount that provider directories specify LGBTQ education, Provider-specific feedback is very important for the LGBTQ population, yet only the OutCare Health OutList and RAD allowed this feature. More than half of LGBTQ people endure interpersonal discrimination including slurs, microaggressions, sexual harassment, and violence. Likewise, as many as one in five suffer from discrimination in healthcare environments [2]. The public's ability to review specific providers not only illustrates firsthand patient perspectives on provider care but may also foster reassurance to LGBTQ people and increase their willingness to seek care. Implementation of this feature across existing and future directories may promote increased utilization of these 6 directories by the LGBTQ community. Furthermore, future research should consider the impact that provider review has on LGBTQ people's avoidance of care.
Similarly, searchable criteria are essential for the LGBTQ population to ensure cultural competency.
The GLMA Provider Directory, OutCare Health OutList, and RAD provided various fundamental searchable fields, while the WPATH Member Directory only provided three criteria. Notably, transgender people of color often experience more challenging healthcare experiences because of both transphobia and racism, and many prefer providers of color and/or LGBTQ-competent providers in order to avoid discrimination [24]. In addition, much of the LGBTQ population confronts significant financial barriers to healthcare [25,26]. As such, these visible attributes allow providers to build trust with the LGBTQ population by showcasing their quality care, attitudinal awareness, and cultural competence concerning the intersections of sexual orientation, gender identity, race, ethnicity, and socioeconomic status. For current and future directories, offering these features would be very valuable to reach and provide care to diverse, non-English speaking subpopulations of the general LGBTQ population.

Conclusion
Postponement and avoidance of healthcare by LGBTQ people can be attributed to various individual and systemic barriers. The four national directories of LGBTQ-competent providers help address an essential need within the LGBTQ population. By facilitating the identification of LGBTQ-competent providers, these directories promote equitable healthcare access. Nonetheless, there are several key characteristics that are lacking among certain directories. Provider-specific feedback and searchable criteria are important characteristics to ensure cultural competency. By implementing these features, existing and future directories could better provide for this diverse population with diverse needs. In addition to optimization of provider directories, healthcare providers, academic medical institutions, and accrediting organizations must continue to push for standardized, universal LGBTQ cultural competency for the next generation of providers.

Abbreviations
LGBTQ Lesbian, Gay, Bisexual, Transgender, and Queer 7 Declarations Ethics approval and consent to participate: Not applicable

Availability of data and materials: Not applicable
Competing interests: DZN is the co-founder and president of an organization referenced in this paper, OutCare Health, which is a nonprofit, 501(c)(3) organization and as such no financial interests exist.
Funding: Not applicable Table 1 Due to technical limitations, Table 1 is provided in the Supplementary Files section.

Supplementary Files
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