The lesbian, gay, bisexual, and transgender (LGBT) community is characterized by significant racial, ethnic, and socioeconomic diversity, yet collectively faces a barrier to accessing appropriate health care (1). The challenges they face include not only issues of access to health services and culturally competent care, but also the impact of national policies that often exacerbate social stigma, marginalization, or discrimination (2). Recent years have seen advances in the accurate collection of data, research, and a deeper understanding of the healthcare needs of the LGBT community and the challenges related to access to care (3–5). Although significant steps have been taken to reduce health disparities among LGBT individuals, further action is needed to achieve full equality in the healthcare system, especially in Poland. Poland currently has a high rate of discrimination based on sexual orientation (6), and both conscious and unconscious homophobia in society often stem from the activities of right-wing politicians, for whom the LGBT community is a convenient target for criticizing nationalist values (7).

The existence of non-heteronormative individuals in Polish society has been and is evident, but for years this topic has been treated as taboo and not discussed in family or public relations (8). The discourse constructing homosexuality as a threat to the nation has been used for many years by both general members of Polish society and politicians in Poland to legitimize homophobic rhetoric and behaviors, causing prejudices against LGBT people at the level of individual citizens' beliefs (9). Political and partly social opposition to the rights of sexual minorities in Poland is among the highest in the EU. In the research conducted by ILGA-Europe in 2023 (10), 2 Poland scored only 15% in respecting human rights in the area of equality, ranking close to Belarus (12%) and Russia (8%). Countries with the highest rates in Europe have been for many years Malta (89%), Denmark (76%), and Spain (74%) (10).

For these reasons, quality measurement of medical care in the context of affirming practices toward LGBT individuals has not been conducted in Poland, which seems necessary given the evidence demonstrated in the literature. Given such an unfavorable environment for the LGBT community in Poland, and simultaneously recognizing that the healthcare needs of LGBT individuals are often different from those of the heterosexual majority (11), there may be exclusion of gays, lesbians, bisexuals, and transgender individuals in terms of access to proper medical care, particularly in the sense of health services that recognize the patient as a non-heteronormative individual. In the latest report by the KPH (Campaign Against Homophobia) organization on the situation of LGBT people in Poland, it was shown that when sexual orientation was known to healthcare workers, they were provided with poorer quality care and received overall worse treatment, with this discriminatory behavior most often being directed toward transgender individuals (48%). Surveyed individuals described incidents such as refusal to perform a procedure, inappropriate jokes, or entering information about sexual orientation into medical documentation (12).

An important phenomenon in the experience of treating people from the LGBT community in health care is minority stress (13), which has been widely described in the literature, including the identification of the impact of this stress on health, mainly in mental and emotional disorders, with minority stress being seen and treated as a stressor in this case (14). One type of proximal stressor directly related to the person providing the health service may be the attitude of a doctor, nurse, or other medical professional, whose affirmative or stigmatizing attitude may translate not only into the experience of the health service itself, but also into the patient's eventual refusal to use the service, which is known as the self-exclusion phenomenon. Minority stressors therefore have a unique impact on health as they add up to the effect of general stressors (15). A study of minority stress levels of the LGBT community conducted in Poland showed that minority stress is not only noticeably present, but is significantly higher than stress due to other health determinants (15).

This collectively highlights the reasons why it is important to assess and improve the clinical skills, attitudes, beliefs, and cultural understanding of healthcare providers, especially medical doctors, nurses, paramedics, and other allied healthcare professionals. This is essential to enable them to effectively meet the diverse needs of LGBT patients, and not further contribute to feelings of stigma, shame, and other health disparities that result from a lack of competence (16).

Various scales are available worldwide to measure acceptance or affirmation toward the LGBTQ community, including those focusing on people living with HIV, gay men, lesbians, same-sex families, and individuals receiving pre-exposure prophylaxis (PrEP) (17–20). In the context of the Health Exclusion Research in Europe (HERE) project, Poland has made strides by developing a tool focused on enhancing clinical skills in LGBT care (21). Despite this progress, there is still a notable lack of instruments assessing affirmation toward homosexual individuals specifically. This gap highlights the need for new methodologies that allow a more comprehensive and inclusive approach within the Polish healthcare system. In choosing the GAP questionnaire for our study, we aimed to address this gap.

Therefore, the purpose of this study is to evaluate the psychometric properties (internal consistency, reliability, and factor structure) of the Polish-language version of the Gay Affirmative Practice Scale (GAP-PL).

The specific psychometric properties examined in the study of the Polish-language version of the Gay Affirmative Practice Scale (GAP-PL) were internal consistency, reliability, and factor structure. Results indicate that the psychometric properties and cultural adaptation of the GAP-PL were carried out successfully. This is the first study adapting the GAP Scale into the Polish language in order to improve our understanding of the dimensions measured by the GAP (Beliefs and Behaviors). This achievement enables the creation of an assessment scale that is culturally equivalent for evaluating clinical skills in the context of Polish-speaking healthcare professionals. The process of cross-cultural adaptation went smoothly, with no language challenges, and only a few expressions were adjusted slightly to ensure their cultural relevance. The internal consistency of the GAP Scale of each of the two domains contained within the assessment scale were high, with values very close to those found in the original version of the GAP Scale. The Cronbach's alpha for the two subscales of the GAP-PL was 0.95 for the belief domain and 0.94 for the behavior domain. Similar alpha values were reported by the Crips of the original questionnaire, with 0.93 for the belief domain and 0.94 for the behavior domain (24).

The scale has important implications for patient care practice, education, and health care research. By identifying areas of competency deficits or inappropriate behavior toward LGBT patients, it helps to develop the awareness and skills needed to effectively support LGBT identifying clients. The GAP-PL is an example of a scale that contributes to promoting equality and understanding of LGBT people that can be used in the fields of public health and clinical medical care. Developed by C. Crisp in 2006, the Gay Affirmative Practice Scale (GAP) is established in the field LGBT health research; however, its adaptation into the Polish language represents a new application, as it has not been previously tailored for use in the Polish language despite a substantial body of literature that underscores its effectiveness and importance (24).

In the literature, the GAP Scale is used both to engage social work therapists in gay and lesbian affirmative practice (32), determining health professionals' attitudes toward gay and lesbian, bisexual and transgender people seeking health care for their children in family-centered pediatric hospitals (33), or as a scale to support psychotherapeutic work in identifying factors that may influence the extent to which LGBT affirmative practice would be positively related to psychological wellbeing and assessing levels of internalized homophobia (34). The aspect of medical professionals' attitudes toward affirmative care for children from LGBT backgrounds is not isolated as it is also receiving attention at the level of academic nursing education (24). All of these studies used the GAP Scale questionnaire and found it to be of high research quality.

Numerous examples of the application of the GAP questionnaire can be found in the literature, not only for social workers, psychologists, and students, but also for practicing nurses (35). In this study, the authors point out that although Italian nurses showed moderately positive attitudes and affirmative behavior, there is a need to increase their cultural competence in relation to sexual minorities.

Authors using the GAP Scale questionnaire in a number of countries around the world argue that increasing cultural competence includes, among other things, using inclusive language, increasing knowledge about sexual minorities, using educational resources such as cultural competency workshops, experiential stories, and seeking mentoring from people with experience of working with sexual minorities (36). The GAP Scale is also applicable to assess the attitudes, beliefs, and intentions of medical and social professionals toward older people from the LGBT community. Indeed, lifelong stigma can affect barriers to care, social isolation, and accompanying health disparities (37). As the literature shows, the GAP Scale, despite its short history, is a widely used research scale with proven effectiveness in assessing the affirmative competence of health professionals. Therefore, there is scientific evidence for its use also in Polish speaking communities and populations to assess the competence of service providers. Although our study was conducted on a group of health professionals and medical students (which is in line with previous use of the GAP Scale in other publications), further research could be extended to include social service professionals, as encouraged by other publications.

The results of this study of translation and cultural adaptation the Polish Version of the Gay Affirmative Practice Scale (GAP-PL) show that the internal consistency, reliability, and factor structure of the scale are excellent. The GAP-PL will be useful, inter alia, for research purposes in the healthcare field. Compared to the original instrument, the psychometric tests and the results of the transcultural adaptation were similar to the original English-language validated version of the GAP Scale.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Bioethics Committee of Wrocław Medical University in Poland (No. KB 976/2022). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and institutional requirements.

PK: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. AD: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. RJ-V: Formal analysis, Writing – original draft, Writing – review & editing. IS-A: Writing – original draft, Writing – review & editing. TS-S: Writing – original draft, Writing – review & editing. MG-C: Writing – original draft, Writing – review & editing. MC: Conceptualization, Formal analysis, Supervision, Writing – original draft, Writing – review & editing.