Esteban et al.

BMC Public Health (2023) 23:857 BMC Public Health

https://doi.org/10.1186/s12889-023-15811-8

RESEARCH Open Access

Sexual orientation knowledge and attitudes

and its association with therapy satisfaction
among lesbian, gay, and bisexual + Hispanic
Puerto Ricans
Caleb Esteban1*, Margarita Francia‑Martínez2, Miguel Vázquez‑Rivera3, Frances Crespo4, Taysha Bruno‑Ortiz5,
Aquiria M. Santiago‑Ortiz5 and Alfonso Martínez‑Taboas6

Abstract
This study aimed to examine the difference in therapy satisfaction between lesbian, gay, and bisexual + (LGB +) indi‑
viduals and heterosexual individuals, and to identify the association between therapy satisfaction and the perception
of knowledge and attitudes of their last therapist among the LGB + participants. Through an exploratory design with
a comparative group, 125 LGB + and 75 heterosexual participants were recruited online by availability. Results indicate
that the participants’ sexual orientation has no significant relation on therapy satisfaction. However, there was a signifi‑
cant positive association between satisfaction with therapy and the LGB + participants’ perception that their therapist
demonstrated knowledge and positive attitudes. This research highlights the importance for continuous education
and curriculum efforts on LGB + issues.
Keywords LGB/LGBT Health, Therapy, Knowledge, Attitudes, Mental health, Sexual minorities health, Stigma

Stigma, exclusion, and discrimination toward non-het-
erosexual persons has been maintained by social, reli-
gious, and legal institutions throughout many cultures
around the world [1, 2]. Stigma and its related seque-
lae are observed in many instances of everyday life and
social institutions, such as cultural scripts, legal systems,
*Correspondence:
Caleb Esteban
cesteban@psm.edu
1
Clinical Psychology Program, School of Behavioral and Brain Sciences,
Ponce Health Sciences University, PO BOX 7004, 00732‑7004 Ponce,
Puerto Rico
2
Carlos Albizu University, San Juan, Puerto Rico
3
Ana G. Méndez University System, San Juan, Puerto Rico
4
Instituto de Investigación y Desarrollo para Estudiantes Dotados, San
Juan, Puerto Rico
5
University of Puerto Rico, Río Piedras Campus, Puerto Rico
6
InterAmerican University of Puerto Rico, San Juan, Puerto Rico
public and private institutions, and in different religious
groups [3]. These become more prominent as negative
attitudes and prejudice toward lesbian, gay, and bisexual
umbrella identities [e.g., bisexual, pansexual] (LGB +)
are legitimized [4]. Mental health professionals are not
exempt from promoting discrimination. The American
Psychiatric Association [APA] maintained that homo-
sexuality was a psychiatric diagnosis until 1973, when the
diagnosis was excluded from the Diagnostic and Statisti-
cal Manual of Mental Disorders (DSM) [5]. Despite the
political movements for the equal rights of sexual minor-
ities, it is still a challenge to avoid the damage caused by
the stigma that some therapists perpetuate when provid-
ing services to Hispanic LGB + individuals.
There is considerable agreement, among therapy
researchers and practitioners, that the therapist-client/
patient relationship plays a crucial role in the thera-
peutic process and outcome [6]. On the other hand, it

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Esteban et al. BMC Public Health (2023) 23:857
is not uncommon for LGB + clients/patients to experi-
ence unhelpful therapy practices such as heterosexism,
lack of knowledge about issues unique to being a sexual
minority, and the dismissal of sexual orientation on psy-
chological functioning [3, 7]. To promote more com-
petent, sensible, and adequate therapeutic services for
LGB + individuals, it is important to expand the knowl-
edge on affirmative model services. The affirmative
model is a concept in which therapists are aware of their
own attitudes and beliefs and understand the impact of
their own biases and the dynamics of discrimination, ste-
reotypes, power, privilege, and oppression when working
with LGBTQ + individuals [3].
Research in Puerto Rico
In Puerto Rico, as a Hispanic culture, several studies
have found that certain therapists exhibit stigma toward
LGB + individuals, affecting bisexual individuals the most
[8, 9]. These findings about the general concern of bias
toward LGB + individuals have provided useful guidance
for a more informed psychology practice such as the cre-
ation of the Standards to Work and Intervene with the
Lesbian, Gay, Bisexual and Trans Identities Community
of the Puerto Rico Psychological Association [PRPA] [10,
11].
Although there is ample literature on LGB + issues in
other parts of the world, this is still an underdeveloped
field in Puerto Rico and other Hispanic countries. In a
recent literature review, Martínez-Taboas [11] stated
that the first professional publication in Puerto Rico on
LGBT + issues was published in 2003. Since then, sev-
eral journal articles and dissertations have been added to
the field. In a recent publication, Esteban [12] reviewed
investigations related to gay men’s issues in Puerto Rico
from 2000 to 2019. They found that 41% of the publica-
tions were related to stigma, prejudice, and social dis-
tance toward gay men. Other themes were sexual identity
development, religion/spirituality violence, and alcohol
and substance use. Notably, there is an absence of studies
on positive factors and aspects related to the best prac-
tice and services with LGB + clients/patients, which can
help eliminate health disparities.
In studies regarding the attitudes of mental health pro-
fessionals, specifically in Puerto Rico, it has been found
that around 16% of psychology graduate students show
anxiety during therapeutic encounters with gay and les-
bian persons, 13% choose to refer lesbian and gay clients/
patients cases before offering them therapeutic services,
and 16% negatively self-evaluate their clinical skills with
gay and lesbian clients/patients [13, 14]. These numbers
warn us of a group of therapists in Puerto Rico that may
lack skills, competence, and knowledge to work with
LGB + clients/patients; therefore, increasing the risk of
Page 2 of 8
harm, revictimization, and contribute to mental health
disparities.
Health disparities among LGB +
Abundant research suggests that LGB + individuals suffer
from psychological symptoms such as depression, anxi-
ety, suicide, sexual, physical, and verbal abuse, and prob-
lematic use of alcohol, drugs, and tobacco [4, 15–17].
Some of these symptoms have been related to minority
stress [18]. Meyer proposed the minority stress theory,
which mainly advances the idea that health disparities
among minorities can be largely explained t by stressors
induced by a hostile, harassing, and discriminating cul-
ture and environment [11]. This model has been widely
used to explain the higher rates of mental health issues
and disparities shown by LGB + individuals [19].
Meyer [20] proposed that the minority stress concept
can be described along a distal to proximal continuum.
Distal stressors refer to external events that impacted the
individual (e.g., negative life events, microaggressions,
social stigma, discrimination, and victimization). Proxi-
mal stressors are related to the personal appraisal of the
LGB + individual, specifically the fear of revealing their
identity, the inability to confront different types of rejec-
tions, and the internalization of LGB + phobias.
In addition, a study conducted by Vázquez-Rivera
[13], found that, in their sample of 220 Hispanic gradu-
ate psychology students, 70% reported not receiving any
formal education nor graduate courses on topics related
to sexual minority issues. Similar findings were reported
by Esteban years later [21]. Lack of knowledge and com-
petencies regarding sexual minority issues has been
associated with increased risks of unhelpful therapeu-
tic practices and negative perceptions of the therapeutic
process by LGB + clients/patients [3].
Therapeutic experiences of LGB + Clients/Patients
Therapy should not become a source of oppression for
disadvantaged populations such as LGB + individuals. A
person receiving therapy from a professional that perpet-
uates societal myths and stigma can develop iatrogenic
harm and worsen their symptoms. Some investigations
support the view that most LGB + individuals evaluate
therapists during their first appointment in order to ver-
ify that they show affirmative attitudes about their sexual
orientation and will be responsive to their needs [2].
Several studies have confirmed the negative experi-
ences of LGB + people in therapy. McCann and Sharek
[2] found that, of the sample that disclosed their sexual
orientation to their therapists, 64% felt that their thera-
pists lacked knowledge in LGB + issues, and 43% felt that
the professionals did not meet their needs. Another 17%
said that they would not disclose their LGB + identity to
Esteban et al. BMC Public Health (2023) 23:857
mental health professionals for fear of a negative reac-
tion. Other studies have found that 25% of their samples
perceived a lack of knowledge regarding LGB + issues
from their therapists, and 21% reported that their thera-
pists ignored their sexual orientation and/or viewed it as
problematic [22].
On the other hand, studies have found that some
basic therapeutic skills, the therapeutic relationship, the
professional background, and the therapist’s attitudes
towards their client/patient’ sexual orientation influenced
whether the service was a positive or negative experience
[23]. Farmer [24] and Graham [25] found that the more
competent therapists with the LGB + population (using
self-reported competence measures) were those that had
more exposure to LGB + clients/patients in their training
and clinical practices, and those who had greater attend-
ance to professional and continued education activities
on LGB + matters.
It is necessary to evaluate the perception of satisfaction
that LGB + individuals have about their therapeutic ser-
vices, especially due to psychology’s own historical role
in considering homosexuality and bisexuality as patholo-
gies. Although there is a strong trend of professionals
and therapists who have adopted affirmative models for
working with the LGB + community, this minority’s expe-
rience regarding mental health services in Puerto Rico’s
particular cultural context should be researched.
Aims
This project draws upon the minority stress model. This
model explains how socially minoritized groups, such
as sexual minorities, are more likely to experience con-
stant stress due to experiences of bias, discrimination,
and marginalization. The model highlights the impor-
tance of addressing the stigma and barriers for essential
services that could originate health disparities [26]. The
study’s specific aims were: (1) to examine if there is a sig-
nificant difference in therapy satisfaction levels between
LGB + and heterosexual individuals, and (2) to identify
if there is an association between therapy satisfaction
and the perception of knowledge and positive attitudes
of their last therapist among the LGB + participants. We
hypothesized that there would be a significant difference
in therapy satisfaction levels between the samples, and
that there would be an association between therapy sat-
isfaction and the perception of knowledge and positive
attitudes of the LGB + participants’ last therapist.
Method
Design and procedure
The study had a quantitative method with a transver-
sal exploratory design. This study was approved by the
IRB of Albizu University (Sum16-05). Participants were
Page 3 of 8
recruited online by availability, using a flyer primarily
promoted on Facebook Ads (targeting LGBT + interests
such as pride, rainbow flag, LGBT news, and others).
The flyer was also mailed to different LGBT + community
organizations on the island for promotion. The Survey-
Monkey platform was used to collect the data, including
the informed consent and to complete the study’s instru-
ments. A total of 125 LGB + individuals finalized the
study. Participants who did not complete the study were
removed from the database. Participants had to meet
the following inclusion criteria: (1) self-identify as gay,
lesbian, or bisexual + (e.g., bisexual, pansexual); (2) be
21 or over; (3) be a resident of Puerto Rico; and (4) have
received therapy services at any time. All inclusion crite-
ria were verified and confirmed with a sociodemographic
questionnaire.
To answer Aim 1, a comparative group of heterosexual
individuals was recruited. This group was recruited via
Facebook Ads with a different, untargeted flyer. The Sur-
veyMonkey platform was likewise used for the informed
consent and to complete the study. Overall, 75 partici-
pants completed the instruments. Participants for this
group had to meet similar inclusion criteria: (1) self-iden-
tify as heterosexual, (2) be 21 or over, (3) be a resident of
Puerto Rico, and (4) have received therapy services.
Instruments
Four Spanish language instruments were used to obtain
the data of the LGB + sample. The instruments were: 1)
Sociodemographic Questionnaire, 2) MHSIP Consumer
Survey—Spanish version, 3) Therapy Experience Ques-
tionnaire, and 4) the Perceived Attitudes in Therapy
toward Lesbian, Gay, and Bisexual Scale. The compara-
tive group (heterosexual individuals) only completed the
first two instruments (1 and 2), as the latter two (3 and 4)
only catered to LGB + individuals.
Sociodemographic questionnaire
This questionnaire was created by the researchers, and
collected information such as sex, gender, sexual orien-
tation, marital status, age, income, education, religious/
spiritual affiliation, and clinical information.
MHSIP adult consumer survey – Spanish version
(MHSIP‑CS)
This instrument was originally created in English and
validated by the Mental Health Statistical Improvement
Program (MHSIP) in 2006 [27]. The 35-item instrument
addressed adult and senior populations and measured
satisfaction with the therapeutic process. The instrument
included access to services, quality and appropriateness
of the services, effectiveness, participation in treatment
planning, social connection, and functioning. In 2014,
Esteban et al. BMC Public Health (2023) 23:857
the survey was translated to Spanish and adapted and
validated to the Puerto Rican population by the PIT-
IRRE Community Initiative Program. Answers stand
on a 5-point Likert scale (1 = totally agree to 5 = totally
disagree). Its various subscales have the following Cron-
bach alphas: General Satisfaction (α = 0.87), Quality of
Appropriateness (α = 0.87), Participation in the Treat-
ment Targets (α = 0.56), Perceived Outcomes (α = 0.91),
Services Access (α = 0.82), Functionality (α = 0.87), Social
Connectivity (α = 0.79), and Stigma (α = 0.86). For the
purpose of this research, the items were adapted to an
individual therapy service and the subscales of Function-
ality and Social Connection were eliminated, resulting
in 11 items. Some examples of the items are: I liked the
mental health services I received, I would recommend
my therapist to friends or family members, I felt comfort-
able asking questions about my treatment. Total scores
ranged from 11 to 55. Lower scores indicated greater ser-
vice satisfaction.
Therapy experience questionnaire
This descriptive instrument, created by the researchers,
consisted of 10 Spanish-language questions regarding the
therapy experience. The questionnaire examined the fol-
lowing aspects of therapy and the therapist: sex, approxi-
mate age, office location (town), therapist’s profession,
modality of therapy, disclosure of the therapist’s own
sexual orientation and religious/spirituality affiliation,
number of negative and positive experiences in therapy,
disclosure of sexual orientation to the therapist, having
worked on issues of sexual orientation in therapy, and
having been referred to another therapist because of the
participant’s sexual orientation.
Perceived attitudes in therapy toward lesbian, gay,
and bisexual scale
This scale was constructed in Spanish and validated for
this study [28]. This instrument consists of 36 items and
two subscales: 1) the perceived LGB + knowledge of their
therapist and 2) the perceived attitudes of their thera-
pist toward LGB + individuals. For content validity, 12
evaluators with expertise in LGBT + studies assessed the
items. Only two items were eliminated for being under
the Lawshe’s Content Validity Radio (CVR) adequacy.
Answers stand on a 5-point Likert scale (1 = totally agree
to 5 = totally disagree). Total scores ranged from 34 to
170. Lower scores indicated greater positive attitudes
perceived by the therapist. This scale presented accept-
able coefficients with a Cronbach alfa of 0.84.
Data analysis
A total of 107 subjects were required to achieve a statis-
tical power of 95% to determine a correlation between
Page 4 of 8
predictors (knowledge and attitudes) and outcomes
(therapy satisfaction), assuming an effect size f2 of 0.15
(medium effect size) and an alpha of 0.05 using a Bon-
ferroni adjustment and assuming a correlation between
predictors of 0.50. Each sexual orientation strata included
a minimum of 35 subjects. Sample size was estimated
using Linear Multiple Regression (F-test) with G*Power.
Data were analyzed using IBM SPSS Statistics Pro-
gram (28.0v). The study team calculated the Cronbach’s
Alpha and McDonald’s Omega as internal consistency
indexes and obtained the means and standard devia-
tions of the measurements (see Table 2). To verify inter-
nal consistency, values ​​were supposed to be greater than
0.70 [29]. Correlation analyzes were performed between
the dependent and independent variables using Pearson’s
Product-Moment Coefficient (r). To interpret the asso-
ciations, the team used Taylor’s [30] classification where
correlations are considered low (0.01 to 0.35), moderate
(0.36 and 0.67), high (0.68 and 0.89), or very high (0.90 <).
Linear multiple regression was performed. Only depend-
ent variables (knowledge and attitudes) were included in
the model as possible predictors. Sociodemographic vari-
ables were not included in the model for being nominal
variables. The effect size of the predictor on the predicted
variable was established through the standardized regres-
sion coefficient (β). The values of​​ β as trivial effect size
(> 0.09) were classified as: small (0.10 and 0.29), medium
(0.30 and 0.49), large (0.50 and 0.69), and very large
(0.70 <) [31]. All results were considered significant for p
values ​​ < 0.05. Linear regression analysis was performed
considering only the LGB + sample.
Results
Participants
A total of 35 lesbian women, 52 gay men, 25 bisex-
ual + women, and 8 bisexual + men completed the study.
In this group, the majority (93.6%) identified their gen-
der as cisgender. Ages ranged from 19 to 59 (M = 28.86,
SD = 8.30). Almost half of the sample (48.4%) were sin-
gle, and 68% percent had an annual salary of $12,000 or
below, although 50.4% had a bachelor’s degree. Finally,
44.3% informed to have a religious affiliation (see
Table 1).
Regarding therapy experience, 92% of the sample
received services from a clinical psychologist, 8.3% from
a psychiatrist, 9.9% a counseling psychologist, 4.1% a
clinical social worker, and 1.7% did not know. Only 32%
of the therapists disclosed their sexual orientation, 14%
disclosed their religion, and 7.4% used religion and reli-
gious text as part of the therapy process. Almost three
quarters of participants came out to their therapist dur-
ing the initial appointment, 16.5% waited some sessions,
Esteban et al. BMC Public Health (2023) 23:857 Page 5 of 8

Table 1 Demographic Characteristics of the Sample reported option. Only 43.4% of participants had an
Variables
annual salary of $12,000 or below, and the majority also
had a bachelor’s degree (35.5%). Lastly, 65.8% informed
LGB + Hetero p1 to have a religious affiliation (see Table 1).
n = 125 n = 75
f (%) f (%) Analysis showed that all scales obtained acceptable
values ​​of internal consistency higher than 0.80. As the
Gender Identity 0.001* team had a non-probabilistic sample, a Levene’s test was
Men 61 (48.8) 9 (12.0) performed to test the homogeneity of variances. The test
Women 64 (51.2) 66 (88.0) indicated unequal variances (F = 845, p = 0.359); there-
Gender Expression 0.001* fore, a parametric test was executed (see Table 2).
Masculinity 58 (46.4) 66 (88.0) A one-way ANOVA between groups (heterosexual vs
Femininity 59 (47.2) 8 (10.7) LGB +) was conducted to compare sexual orientations
Transgender 1 (0.8) 1 (1.3) in therapy satisfaction. Sexual orientation did not sub-
Non-binary 7 (5.6) 0 (0.0) stantially impact therapy satisfaction (F (1, 198) = 0.004,
Sexual Orientation - p = 0.953). Tukey’s HSD Test for multiple comparisons
Heterosexual - 75 (100) found that the mean value of therapy satisfaction was
Lesbian or Gay 87 (69.6) - not significantly different between the stratified groups:
Bisexual/Pansexual 38 (30.4) - heterosexual orientation and homosexual orientation
Partner/s 0.371 (p = 0.98, 95% C.I. = -3.55, 4.23) or bisexual/pansexual
Yes 63 (50.8) 43 (42.6) orientation (p = 0.86, 95% C.I. = -6.00, 3.83).
No 61 (49.2) 32 (57.4) Results of the Pearson Correlation indicated that there
Individual Income 0.422 was a considerable positive association between ther-
None 28 (22.4) 12 (16.0) apy satisfaction and the perception that the therapists
  < $12,000 48 (38.4) 21 (28.0) possess adequate LGB + knowledge and positive atti-
$12,001—$30,000 28 (22.4) 22 (29.3) tudes (r = 0.72, p < 0.001). Subscales were also tested and
$32,001—$50,000 12 (9.6) 11 (14.7) revealed an important positive association between ther-
$52,001—$72,000 6 (4.8) 7 (9.3) apy satisfaction and the client/patient’s perception that
$72,001—$92,000 1 (0.8) 1 (1.3) the therapist has adequate LGB + knowledge (r = 0.66,
  > $92,001 2 (1.6) 1 (1.3) p < 0.001) and positive attitudes (r = 0.71, p < 0.001).
Education Completed 0.047 A multiple linear regression analysis showed that the
Hight School 11 (8.8) 4 (5.3) perception of the therapist’s LGB + knowledge and posi-
Undergraduate degree 71 (56.8) 32 (42.7) tive attitudes toward this community were significant
Graduate degree 43 (34.4) 39 (52) predictor variables for therapy satisfaction. The results
Religious Affiliation 0.008* of the multiple regression indicated that these two pre-
No 66 (54.1) 26 (34.7) dictors explained 52% of the variance (R2 = 0.519, F(2,
Yes 59 (45.9) 49 (65.3) 95) = 1.173, p < 0.001). In this model, it was found that
Age 0.001* LGB + knowledge did not significantly predict therapy
19—28 82 (65.6) 27 (37.0) satisfaction (β = 0.213, p < 0.116), but positive LGB + atti-
29—38 30 (24.0) 20 (27.3) tudes did (β = 0.329, p < 0.001) (see Table 3).
39—48 4 (3.2) 13 (17.9)
48—58 8 (6.4) 9 (12.4)
Discussion
59—68 1 (0.8) 4 (5.3)
This research has shed light on an unexposed topic in
1
p-values were obtained using Pearson Chi Square Test. Puerto Rican sexual minorities research. Even though
*Statistically significant values (p < 0.01) the attitudes of therapists and LGB + persons have been
researched in the past, there has not been research
regarding therapy satisfaction in Puerto Rico. Interna-
and 9.1% never did. In addition, 43.8% of the therapists
tional literature has shown the importance of therapists
did not explore sexual orientation in the process.
having affirmative knowledge and awareness towards
The comparative sample consisted of 75 participants,
LGB + clients/patients and culture [32, 33].
with the majority being women (64%) who identified as
More than half of the LGB + sample of this study has
cisgender (98%) were women Ages ranged from 19 to 63
been treated by two or more therapists, which is impor-
(M = 34.82, DS = 12.38). Compared to the LGB + sam-
tant data that validates previous research stating that
ple, just 28.9% were single; however, it was also the most
LGB + people access mental health providers at a higher
Esteban et al. BMC Public Health (2023) 23:857 Page 6 of 8

Table 2 Cronbach’s Alpha, McDonald’s Omega Coefficient, Means, Standard Deviations, and Correlations Between the Variables
Instruments α Ω M SD 1 2 3

MHSIP-CS1 .94 .94 22.48 10.39 –-

APTLGBS2 .96 .95 73.70 27.64 .72** –-
3
LGB ­Knowledge .89 .90 31.50 11.52 .66** .95** –-
LGB ­Attitudes4 .94 .93 44.31 17.68 .71** .97** .86**
MHSIP-CS = MHSIP Adult Consumer Survey, APTLGBS = Attitudes Perceived in Therapy toward Lesbian, Gay and Bisexual Scale, SO = Sexual Orientation
** = p < .01
α = Cronbach’s Alpha; Ω = McDonald’s Omega Coefficient (n1 = 200; n2,3,4 = 125)

Table 3 Regression Coefficients and Associations Between Therapy Satisfaction and the Perception of Therapists’ Sexual Orientation
Knowledge and Attitudes
Variables B SE β t p 95% CI

Therapy ­Satisfaction [R = .721; R = .519; F = 51.281]

α 2

Constant 1.173 2.293 .511 .610 [-3.380, 5.726]

LGB knowledge .213 .135 .224 1.585 .116 [-.054, .481]
LGB attitudes .329 .090 .519 3.678 .001 [.152, .507]
(n = 125)

rate than heterosexual peers [34]. In both instances, ther-
apists did not openly express their sexual orientation, yet
some did express their religious beliefs. Most participants
did not initially reveal their sexual orientation.
On the other hand, therapists explore if disclosing their
sexual orientation might be an ethical decision that ben-
efits the client/patient [35]. In this study, some therapists
appeared to evade important, reported therapeutic rec-
ommendations for LGB + clients/patients such as asking
sexual orientation and disclosing their own sexual orien-
tation when needed. LGB + patients/clients who believed
or knew that their therapist identifies as gay, lesbian, or
bisexual + perceived them as being more helpful. A quote
from a participant from the Kelley [36] study may exem-
plify this point: “Working with a gay/lesbian therapist
was the smartest move. A heterosexual therapist is unable
to grasp the psychic, interior, cultural dynamics of being
gay and growing up in a heterosexual society.” Regarding
the present study, it is possible that the small number of
clients/patients who chose not to reveal their sexual ori-
entation in therapy demonstrate the difficulty and fear
that some clients/patients can experiment towards com-
ing out, even in a therapeutic setting.
The results obtained in this study reveal that sexual
orientation has no significant association with the par-
ticipants’ therapy satisfaction, contradicting the first
hypothesis developed by the investigators. LGB + clients/
patients can go to therapy for many reasons, not all of
which are inherently sexual orientation issues. For exam-
ple, clients/patients may be somewhat satisfied with ther-
apeutic interventions related to a grief process or a social
skills intervention, if the therapy is limited to that event.
Nevertheless, the second hypothesis about the relation
between therapy satisfaction levels and the perception of
knowledge and attitudes has been sustained.
The results of this study suggest that it is important for
therapists to show openness, competence, and knowl-
edge towards LGB + culture. These results also show that
treating a person without considering LGB + culture is a
disservice to this population. As therapists, it is impor-
tant to understand the differences of the people being
assisted and the intersections of those differences in a
sensible and affirmative manner, especially when working
with the LGB + community. While therapists approach
how to treat minority populations, they must start look-
ing at models of cultural humility [37]. Therapists need
to be educated on LGB + topics and continue to learn
about cultural shifts and social changes that affect this
community.
This research adds to the literature review that stresses
the importance of including sexual orientation education
in therapist curriculums as core content [20]. Regard-
ing cultural standards, continuous education efforts on
LGB + issues should be supported to add to the forma-
tion of affirmative model professionals. Unsolicited refer-
rals, maltreatment, and conversion efforts can have a
negative effect on a person’s mental well-being [38]. Pub-
lic policy on LGB + treatments should be stated in every
service location. Therapists should be informed on what
to expect and what to avoid regarding professional ser-
vices, to prevent offering therapies that may jeopardize
their patients/clients’ mental health.
Esteban et al. BMC Public Health (2023) 23:857
The study’s strengths and limitations must be acknowl-
edged. Some of the strengths were: 1) we have a statisti-
cally representative sample of lesbian, gay, and bisexual/
pansexual individuals, 2) the study ensured a compara-
tive group of heterosexual individuals that allows group
comparisons, and 3) internal consistency of the instru-
ments were all adequate. Study limitations must be also
considered when interpreting these findings: 1) all data
were cross-sectional; therefore, conclusions about cau-
sality cannot be drawn (for example, we cannot conclude
that knowledge about LGB + topics causes a greater sat-
isfaction in therapy), 2) all data were collected through
self-reports and could be influenced by social desirability,
minimization, or over-reporting (however, some research
suggests that self-reported data of sensitive issues col-
lected via technology devices may reduce reporting bias
[39]), and 3) samples, although showing unequal vari-
ances, were significantly different by gender identity, gen-
der expression, religious affiliation, and age; yet, studies
with LGB + samples in Puerto Rico tend to have higher
participation of gay men, gender diverse individuals, and
report less religious affiliations [18]. Still, we recommend
ensuring a higher participation of heterosexual men for
future research studies, or even stratified samples.
Another limitation of the study is related to how the
concept of minority stress was understood and applied.
Meyer [20] highlighted that minority stress has distal and
proximal components. The proximal is related to internal
cognitive processes, which likely include the individual
perceptions, expectations, and internalized conflicts
regarding their LGB + identity. It could be possible that
LGB + participants perceived negative attitudes towards
them from their therapists when that was not the case.
It could be suggested that some LGB + individuals, by
virtue of proximal stress processes, distorted or misin-
terpreted their interactions with their therapists. Our
study cannot answer in a definite way if there is a deficit
or problem with the therapist’s knowledge or attitudes, as
we did not study, asked, or observed their behavior. The
data point to the fact that some LGB + participants per-
ceived such negative attitudes.
Other research efforts should be made to continue
highlighting the importance of affirmative psychological
therapy services, especially being aware of our own bias,
knowledge, and competences. Other variables concern-
ing the affirmative model should be addressed in future
studies, for example, examining the perception of power
dynamics, discrimination, micro/meso/macro-aggres-
sions, stereotype beliefs, and privilege awareness. Quali-
tative or mixed methods research should also be done to
examine in-depth the barriers and positive experiences
for therapy services in Puerto Rico among lesbian, gay,
and bisexual/pansexual individuals. Similar research
Page 7 of 8
including or specifically aimed at gender minorities are
also encouraged.
Acknowledgements
We want to acknowledge the recruitment and distributing collaboration of
other members of the Sex, Gender, and Sexual Orientation Diversity Commit‑
tee of the Puerto Rican Psychological Association [SGSODC-PRPA], especially,
to the Research Subcommittee of SGSODC-PRPA who made this project and
article possible. In addition, special thanks to The Hispanic Alliance for Clinical
and Translational Research [Alliance] (supported by the National Institute of
General Medical Sciences, National Institutes of Health, under the Award Num‑
ber U54GM133807) for their financial support for the PI and the publication of
this article (https://​allia​nce.​rcm.​upr.​edu/). Finally, our gratitude for the Ponce
Research Institute and the Office of Research and Development of the Ponce
Health Sciences University for the editing and revision of the manuscript.
Authors’ contributions
CE: conceptualization, research design, collection of the data, preparation of
the data, statistical analyses, drafting manuscript, editing manuscript; MFM:
conceptualization, research design, drafting manuscript, editing manu‑
script; MVR: conceptualization, research design, drafting manuscript, editing
manuscript; FC: conceptualization, research design, editing manuscript; TBO:
literature search, collection of the data, editing manuscript; ASO: literature
search, collection of the data, editing manuscript; & AMT: editing manuscript.
All authors read and approved the final manuscript.
Funding
The project described was supported by Sex, Gender, and Sexual Orientation
Diversity Committee of the Puerto Rican Psychological Association.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Institutional Review Board (IRB) of the Albizu
University (Sum16-05). All methods were carried out in accordance with
relevant guidelines and regulations. Informed consent was obtained from all
the subjects.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 9 January 2023 Accepted: 4 May 2023
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