It is estimated that at least 7.1% of the US population identifies as lesbian, gay, bisexual, transgender, or queer (LGBTQ).¹ Despite growing acceptance of this population, there is evidence to suggest that LGBTQ people remain medically underserved.^2,3 Reasons for health care disparities in this population are multifactorial and include perceived discrimination, patients’ expectations of rejection, and physicians’ lack of awareness and responsiveness to cultural factors specific to LGBTQ patients.^3,5

The Office of Disease Prevention and Health Promotion has included LGBTQ health in the Healthy People 2030 initiative,⁶ which aims to eliminate disparities and improve the health of all groups. A shortage of culturally competent physicians in LGBTQ health was identified as one of the social determinants impacting the health of LGBTQ individuals.⁶

There is some formal guidance from the AUA on how to care for transgender patients.⁷ However, outside of a document outlining differences in sexual health care for gay and bisexual men after treatment for prostate cancer (PCa), resources to guide clinicians remain limited.⁸

We constructed a 35-question survey to assess urologists’ contemporary attitudes and practices toward sexual minority patients, and we surveyed urologists across the United States about knowledge, comfort, and practice patterns when treating LGBTQ patients and men who have sex with men (MSM). In addition to performing whole-cohort analysis, we also examined responses by various demographic subgroups.

One hundred fifty-four responses met inclusion criteria. Compared to the demographic of practicing US urologists as reported in the 2021 AUA Census,⁹ our cohort tended to skew younger, included more female-identifying and gay-identifying providers, and a greater proportion of academic urologists.

The first section sought to garner a sense of respondents’ views toward LGBTQ care in urology. While the majority (88%) of responding practitioners feel comfortable discussing sexual health with LGBTQ-identifying patients (Figure 1) and they do not assume patients are heterosexual (54.2%), the majority do not elicit this information via intake forms (57.8%) or during history-taking (60.7%; Table 1), believing that this information may come up in a more organic manner should it relate directly to the patient’s clinical problem. This practice puts the onus on the patient to bring up his or her sexual orientation and begs the question whether patients feel comfortable bringing up a potentially sensitive topic when there are no standardized structures in place for sharing this information.

Table 1. Responses of the Entire Cohort on Beliefs and Practices Surrounding Sexual History Taking

Figure 1. Responses of the entire cohort regarding comfort when discussing sexual health with patients stratified by sexual orientation of the patient (heterosexual vs lesbian, gay, bisexual, transgender, or queer [LGBTQ]).

This practice pattern seems to suggest that physicians believe that identifying as LGBTQ is only important in certain circumstances. Interestingly, this view appears to also be shared by some patients, who felt that their sexual orientation was not important or relevant to their cancer care or perceived their sexual orientation to be private.¹⁰ Both of these attitudes assume that provider and patient alike are actively considering whether identifying as LGBTQ applies to a given clinical presentation and will broach the topic if necessary, which may not represent a best practice.

The second section of the survey focused on respondents’ feelings toward LGBTQ health disparities education. A majority (32.7%) reported 1-5 hours of LGBTQ health training, 74.3% believe more training is needed (Figure 2), 74.5% agreed to being listed as an LGBTQ-friendly provider currently, and 65.8% felt they needed additional training.

Figure 2. Estimated number of hours spent on lesbian, gay, bisexual, transgender, or queer (LGBTQ) health during training (defined as professional school and continuing education training; A). Responses to whether there ought to be increased educational events on LGBTQ health in urology (B).

Respondents were largely open to ongoing professional education on the care of LGBTQ patients. Academic urologists reportedly spent more time on LGBTQ health during professional school and continued training. This may be attributed to some degree of recall bias as academic urologists by definition engage in more didactic events during the course of their careers. Alternatively, academic urologists may more readily have access to LGBTQ-focused continuing education at their institutions.

The final section of the survey included both subjective and objective questions which focused on specific details of urological care for LGBTQ/MSM patients. While a significant percentage of physicians reportedly understand that the prostate may be a source of sexual pleasure (63.6%) and that MSM patients may have different health concerns related to prostate cancer, fewer implement this understanding during patient encounters. This is evidenced by lower reported rates of evaluating sexual satisfaction after PCa treatment, a lack of knowledge in some specifics, and the tendency to avoid explicitly acknowledging that the prostate may be stimulated when counseling patients prior to testing (Table 2). This may in part be due to the fact that “PCa treatment” is a vague term and encompasses a growing number of modalities including radiation and focal therapy in addition to radical prostatectomy. It would have been helpful to understand how respondents might change counseling in response to the sexual orientation.

Table 2. Practice Trends of Respondents Regarding Gay/Bisexual Men and Men Who Engage in Receptive Anal Intercourse When Discussing Prostate Cancer Diagnosis and Treatment

The results of our study demonstrate that urologists across subgroups are aware that LGBTQ patients may require variation of care from heterosexual patients. However, younger urologists engaged in academic practice appear better equipped to implement these beliefs into everyday practice. They are more likely to inquire about sexual orientation both in written and verbal form, agree to more formal education on LGBTQ care, and to be listed publicly as LGBTQ-friendly providers. Furthermore, when asked specific questions pertaining to LGBTQ patient care such as anal stimulation of the prostate or assessing sexual function of men who engage in receptive anal intercourse after PCa treatment, younger physicians appear to be more familiar with such scenarios.

While it is reassuring that there is overall a strong desire from practicing urologists to be educated and to create a safe space for their LGBTQ patients, ongoing education remains necessary. This education no longer needs to focus on the fact that differences exist between LGBTQ and heterosexual patients but on the specifics of these differences and how to apply this knowledge in order to implement LGBTQ-friendly best practices which are effective in addressing the needs of a rapidly aging LGBTQ population.