Currently submitted to: Journal of Medical Internet Research
Date Submitted: Feb 1, 2026
Open Peer Review Period: Feb 2, 2026 - Mar 30, 2026
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Web-based, open-source LGBTQ+ Affirming Care Education for Primary Healthcare Providers: A Descriptive Analysis
ABSTRACT
Background:
Affirming Care for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) populations refers to culturally and clinically competent healthcare that recognizes specific health needs and provides respectful, inclusive, equitable, and non-discriminatory services that are supportive of diverse identities. LGBTQ+ populations face greater discrimination in healthcare, leading to higher levels of unmet health needs than the general population. Very few primary care practices in the United States have training for staff and clinicians on LGBTQ+ healthcare needs. Despite the growing needs for LGBTQ+ affirming care, there are no national standards or requirements for LGBTQ+ cultural competence training for primary-care healthcare providers in the United States.
Objective:
This study explores the accessibility and quality of online ‘grey literature’ providing LGBTQ+ affirming and culturally competent care information for primary care providers in the United States. Grey literature is produced by government, academic, business, and industry sources in formats not controlled by commercial publishing.
Methods:
We conducted a Google search of grey literature to identify readily available resources and training materials. Two thousand websites were screened. Those published in a language other than English before January 1, 2014, as well as those that were peer-reviewed literature or behind a paywall, were excluded. Fifty-four websites met the inclusion criteria for a full-text review.
Results:
We identified six themes from the existing academic literature: (1) affirming physical and visual environments, (2) sexual orientation and gender identity (SOGI) data collections, (3) training on LGBTQ+ health needs, (4) anti-discrimination policies, (5) appropriate, relevant services for LGBTQ+ patients, and (6) use of inclusive language. We then applied these themes as a deductive coding framework to the web-based sources and, during analysis, two additional sub-themes emerged: (1) staff diversity, (2) health inequalities and inequities. Findings revealed that not every web-based source addressed all themes. This unequal distribution of coverage across these themes means that providers must consult multiple web-based sources to obtain a comprehensive understanding. Additionally, existing grey literature resources often lacked depth, technical detail, and practical guidance, making it difficult for primary care providers to access actionable information on LGBTQ+ affirming care. ‘Training on LGBTQ+ health needs’ was the most frequently covered theme, and ‘SOGI data collection’ was the least addressed. Study limitations included geolocation biases and embedded advertisements in the Google search results.
Conclusions:
The study highlights that grey literature is insufficient for self-guided training. We recommend integrating formal LGBTQ+ affirming care training into medical and nursing curricula, as well as professional associations and continuing education, particularly amid growing federal and state-level restrictions on LGBTQ+ healthcare.
Citation
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