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Knowledge, Attitudes, and Practices of Healthcare Providers in Addressing the Care Needs of Individuals who identify as LGBTQIA+ in Türkiye : Evidence from Implicit and Explicit Measures

This study of 278 Turkish healthcare providers reveals that while higher education, less experience, and personal contact with LGBTQIA+ individuals correlate with better self-reported knowledge and practices, a disconnect exists between these favorable explicit reports and underlying implicit biases favoring heterosexual and cisgender individuals, highlighting the need for comprehensive interventions to address both dimensions of bias.

Original authors: Seda Karakaya Çataldaşᵃ, Joanna Anneke Rummensᵇ, Erin Zieglerᶜ, Esra Ummakᵈ, Cemile Hürrem Ayhanᵉ, Fahriye Oflazᶠ

Published 2026-07-01

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Seda Karakaya Çataldaşᵃ, Joanna Anneke Rummensᵇ, Erin Zieglerᶜ, Esra Ummakᵈ, Cemile Hürrem Ayhanᵉ, Fahriye Oflazᶠ

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine the healthcare system as a massive, busy airport. The doctors and nurses are the air traffic controllers and gate agents, and the LGBTQIA+ community represents a specific group of travelers who have historically faced extra turbulence, delays, and sometimes even being turned away at the gate.

This study, conducted in Türkiye, is like a "pre-flight check" on the controllers themselves. The researchers wanted to know: Do these healthcare workers actually know how to help these travelers? Do they say they are friendly? And, perhaps most importantly, what are their unconscious feelings when they aren't thinking about it?

Here is the breakdown of what the study found, using simple analogies:

1. The Two Different "Brains" (Explicit vs. Implicit)

The researchers looked at the healthcare workers using two different lenses:

The "Polite Guest" Lens (Explicit): They asked the workers directly, "Do you know how to care for LGBTQIA+ people? Do you treat them well?" This is like asking a guest at a dinner party, "Do you like everyone here?" Most guests will say "Yes, of course!" because it's the polite thing to do.
The "Reflex Test" Lens (Implicit): They used a computer game called an Implicit Association Test (IAT). This is like a speed test where you have to sort words into "Good" or "Bad" buckets as fast as possible. You can't think about your answer; you just react. This reveals what your brain does on "autopilot."

The Finding: The healthcare workers were great "Polite Guests." They reported high levels of knowledge and said they treated everyone fairly. However, on the "Reflex Test," their autopilot showed a slight, automatic preference for straight and cisgender people (people whose gender matches their birth sex).

The Analogy: Imagine a driver who says, "I always drive safely!" (Explicit). But when you test their reflexes in a sudden emergency, they instinctively swerve toward the familiar lane and away from the unfamiliar one (Implicit). The study found that while these doctors and nurses say they are inclusive, their unconscious brains still hold onto old, subtle habits of preferring the "standard" norm.

2. The "Fresh Grad" vs. The "Veteran"

The study looked at how experience and education changed the results.

Education: Workers with higher degrees (like a Master's or PhD) were like students who had just read the latest, most up-to-date travel guide. They knew more about the specific needs of LGBTQIA+ travelers and practiced better inclusive habits.
Experience: Surprisingly, the workers with less experience (under 5 years) actually scored higher on knowledge and inclusive practices than the veterans with 10+ years.
- The Analogy: Think of it like a video game. The newer players (less experience) are playing on the "New Version" of the game, which has updated rules about diversity and inclusion built right into the code. The veteran players have been playing the "Old Version" for so long that the old rules are deeply ingrained in their muscle memory, making it harder to switch to the new, inclusive way of playing.

3. The "Friendship" Factor

The researchers checked if knowing LGBTQIA+ people personally made a difference.

The Finding: Healthcare workers who had LGBTQIA+ friends or family members generally knew more and practiced better care.
The Analogy: It's like having a local guide. If you are visiting a new city and you have a friend who lives there, you learn the shortcuts, the hidden gems, and the local customs much faster than someone who only reads a map. Personal contact helped the healthcare workers understand the "territory" better.

4. The "Disconnect"

The most interesting part of the study is the gap between what the workers said and what their reflexes showed.

The Finding: There was no link between the "Polite Guest" answers and the "Reflex Test" results. A worker could say, "I treat everyone equally," while their reflex test showed a slight bias.
The Analogy: This is like a person who genuinely believes they are not prejudiced (their conscious mind) but still flinches slightly when a stranger of a different background walks by (their unconscious mind). The study suggests that the workers' positive answers might be because they want to be good, or because society expects them to be good, rather than because their unconscious biases have disappeared.

5. What the Study Says Needs to Happen

The paper concludes that just telling healthcare workers to "be nice" or giving them a basic pamphlet isn't enough to fix the "autopilot" bias.

The Solution: They need a "system update." This means:
- New Training: More education, especially for those who have been in the field a long time, to update their "software."
- Real Contact: Creating safe spaces for healthcare workers to actually meet and interact with LGBTQIA+ people (the "local guide" effect).
- Policy Changes: Changing the rules of the airport (the hospital) to make sure the environment itself is welcoming, not just relying on the individual workers to be perfect.

In a Nutshell:
The healthcare workers in Türkiye are trying hard and say they are inclusive, but their unconscious minds still carry some old baggage. To truly fix the "turbulence" for LGBTQIA+ patients, the system needs to update its training and create environments where these unconscious biases can be recognized and smoothed out, not just ignored.

Technical Summary: Knowledge, Attitudes, and Practices of Healthcare Providers in Addressing LGBTQIA+ Care Needs in Türkiye

Problem Statement
Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender minority (LGBTQIA+) individuals experience significant health disparities compared to their heterosexual and cisgender counterparts, including higher rates of chronic conditions and psychosocial stressors. A primary driver of these inequities is the perceived or experienced hostility and bias from healthcare providers (HCPs), which leads to delayed care, underutilization of services, and suboptimal health outcomes. While explicit attitudes (consciously controlled) have been studied, there is a critical gap in understanding the implicit attitudes (unconscious, automatic associations) of HCPs, particularly in Türkiye. In the Turkish context, characterized by a blend of European and Asian cultures and recent increases in anti-LGBTQIA+ rhetoric, the interplay between HCPs' knowledge, self-reported practices, and unconscious biases remains uninvestigated. This study addresses this gap by examining the knowledge, implicit attitudes, and clinical practices of HCPs in Türkiye.

Methodology
This study employed a descriptive cross-sectional quantitative design, adhering to STROBE guidelines. The sample consisted of 278 nurses and physicians working across diverse healthcare settings in Türkiye (public, private, university, and primary care).

Instruments:
- Sociodemographic Form: Collected data on age, gender, education, profession, experience, and personal contact with LGBTQIA+ individuals.
- Knowledge and Practices Questionnaire: A 43-item, researcher-developed instrument based on the Education, Training and Research (ETR) Health Equity Framework. It measured four domains: Physiological Pathways (Knowledge), Relationship and Network (Practice), Systems of Power (Practice), and Individual Factors (Practice). The tool demonstrated high internal consistency (Cronbach's $\alpha$ = .932).
- Implicit Association Tests (IATs): Two web-based IATs were administered to assess unconscious biases: the Sexuality IAT (measuring associations between gay/lesbian vs. heterosexual) and the Transpictures IAT (measuring associations between cisgender vs. transgender).
Procedure: Data were collected via an online platform using convenience sampling. Participants completed the questionnaire followed by the IATs. A 5 USD incentive was provided for completion.
Analysis: Descriptive statistics, Independent Samples T-tests, One-Way ANOVA, and Pearson Correlation analyses were performed using SPSS 25.0.

Key Results

Sample Demographics: The majority of participants were female (78.4%), nurses (89.2%), aged 20–29 (52.9%), and held a bachelor's degree (51.8%). Most identified as heterosexual (85.3%) and reported no LGBTQIA+ family members (93.5%).
Implicit Attitudes: Participants demonstrated slight implicit attitudes favoring heterosexual and cisgender individuals (Sexuality IAT mean $D$ = 0.26; Transpictures IAT mean $D$ = 0.17).
Knowledge and Practices: Self-reported scores indicated moderate levels of knowledge and inclusive practices.
- Education: Higher educational attainment (Bachelor's, Master's, PhD/Specialty) was significantly associated with higher scores in knowledge (Physiological Pathways) and practices (Relationship and Networks, Individual Factors).
- Experience: Counter-intuitively, providers with fewer than five years of experience scored significantly higher in knowledge and most practice domains compared to those with over 10 years of experience.
- Personal Contact: Having an LGBTQIA+ friend was associated with significantly higher knowledge and practice scores, though it showed a complex relationship with Systems of Power scores. Having an LGBTQIA+ family member was linked to lower Systems of Power scores.
The Dissociation: Crucially, no significant association was found between implicit attitudes (IAT scores) and self-reported knowledge or practices.
Correlations: Significant positive correlations existed among the questionnaire domains (e.g., Knowledge correlated with Practice), and between the two IATs, but neither IAT correlated with the self-reported measures.

Key Contributions

First Empirical Evidence in Türkiye: This study provides the first quantitative data on the implicit attitudes of Turkish healthcare providers toward LGBTQIA+ individuals, a population previously unstudied in this context.
Explicit-Explicit Dissociation: The research highlights a significant divergence between what HCPs report (inclusive practices) and their unconscious biases (favoring heteronormativity/cisnormativity). This suggests that self-reported inclusivity may reflect social desirability rather than the absence of underlying bias.
Predictive Factors: The study identifies education level and years of experience as significant predictors of LGBTQIA+-competent care, suggesting that recent curricular reforms and generational shifts may be driving improvements in knowledge and practice.
Methodological Application: It successfully integrates the ETR Health Equity Framework with psychometric tools (IATs) to operationalize complex constructs of health equity in a non-Western context.

Significance and Claims
The authors claim that the findings underscore the complexity of addressing health inequities in Türkiye. The persistence of subtle implicit biases, despite favorable self-reported practices, indicates that traditional knowledge-based training alone is insufficient. The study argues that achieving health equity requires interventions that target both explicit and implicit dimensions of bias.

Specifically, the paper posits that:

Educational Interventions must be expanded at undergraduate and postgraduate levels to sustain the positive trends seen in younger, more educated providers.
Intergroup Contact opportunities are vital, as personal relationships with LGBTQIA+ individuals correlate with better knowledge and practices.
Institutional Policies must evolve to create inclusive environments (e.g., gender-neutral forms, visible diversity symbols) that mitigate the impact of unconscious bias on patient care.

The authors conclude that while HCPs in Türkiye may be reporting inclusive behaviors, the underlying implicit biases remain a barrier to truly equitable care. Therefore, a multifaceted approach involving cultural humility training, bias mitigation strategies, and systemic policy reform is necessary to improve health outcomes for LGBTQIA+ individuals in Türkiye. The paper maintains a modest tone, acknowledging limitations such as the cross-sectional design, the predominance of nurses in the sample, and the potential for selection bias due to technical difficulties with the IATs.