Keywords: LGBTQI+ health, Cis-heteronormativity, Inclusive primary healthcare

Background:

LGBTQI+ individuals face well-documented disparities in access to healthcare, contributing to increased vulnerability to a range of diseases. Primary care, as the first point of contact for most patients, has the potential to either mitigate or reinforce these disparities. This study investigates how cis-heteronormative assumptions, that patients are cisgender and heterosexual, embedded in biomedical discourse and clinical practice result in discrimination against LGBTQI+ individuals.

Research questions:

How does cis-heteronormativity manifest in healthcare practices, and how does it affect LGBTQI+ patients’ access to and quality of primary care?

Method:

A qualitative study was conducted using 42 semi-structured interviews across three groups (n=14 each): LGBTQI+ patients, LGBTQI+ healthcare professionals, and non-LGBTQI+ providers. Supplementary field observations were carried out in three outpatient clinics of public hospitals in Thessaloniki. Data were analyzed using critical discourse analysis, informed by queer theory and the social determinants of health framework.

Results:

Non-cisgender and non-heterosexual identities are often pathologized or rendered invisible in the discourse and practices of psychiatry, gynecology, endocrinology, and infectiology. Lesbian and gay patients frequently receive reproduction-focused sexual health advice irrelevant to their needs. Trans individuals often avoid Pap tests due to non-inclusive procedures and must undergo psychiatric evaluation to access hormone therapy, reinforcing binary gender norms. LGBTQI+ individuals may be referred to exploratory or corrective mental health interventions. Such practices either pathologize or dismiss LGBTQI+ health needs in core areas of primary care, such as sexual and reproductive health, mental health, and hormone-related treatment (initiation, follow-up, or referral).

Conclusions:

Cis-heteronormativity acts as a structural barrier to equitable care within healthcare settings, reinforcing discrimination against LGBTQI+ patients. Inclusive sexual histories, gender-neutral forms, organ-based screening, accessible gender-affirming care, and welcoming environments are essential changes. With its holistic and patient-centered approach, primary care can play a critical role in promoting inclusivity and reducing health disparities.

Points for discussion:

What everyday clinical practices in primary care reflect cis-heteronormative assumptions, and how do they limit access to care for LGBTQI+ patients?

How can inclusive practices of care in sexual and reproductive health, mental health, and hormone treatment be integrated into PHC to address LGBTQI+ health needs?

Beyond individual clinician attitudes, what changes in healthcare training, organizational structures, and clinical protocols (e.g., intake forms, pronoun use) are needed to create inclusive and affirming primary care environments?