The field of clinical neuropsychology has increasingly recognized the importance of cultural and identity factors through the development of clinical, research, and educational initiatives. Only within the last 10 years have guidelines for psychological practice with lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people included recommendations for neuropsychological assessment. However, it remains unclear to what extent neuropsychologists have acquired the knowledge and skills necessary to implement these recommendations. It is also unknown whether they engage in LGBTQ+ inclusive neuropsychological assessment. In this study, we surveyed the LGBTQ+ related education, training, and clinical practice of independently licensed neuropsychologists in the United States. We sought to understand the implementation of inclusive guidelines, including factors that predict affirmative neuropsychological assessment. We hypothesized that sexual/gender identities, female identity, recency of training, and LGBTQ+ related education would be associated with use of recommended practices.

A workgroup of clinical psychologists with experience in LGBTQ+ psychology and neuropsychology developed a survey to identify personal and professional factors that predict LGBTQ+ affirmative neuropsychological assessment practices. The survey was distributed through professional organizations and listservs between August and September 2021 with 118 responses meeting inclusionary criteria. We used logistic, multinomial logistic, and ordinal logit regressions to examine unadjusted, univariate effects. Predictors included in the final, adjusted, univariate and multivariate models were those for which we had specific hypotheses and variables that predicted more than two affirming practice behaviors.

The majority of participants identified as heterosexual (70.3%), cisgender (97.5%), and female (66.1%). Participants reported obtaining their highest degree between 1977 and 2019. Most obtained a Ph.D. (73.7%), were not board-certified (69.5%), and worked primarily with adults (54.2%). Generally, participants reported having little experience working with LGBTQ+ patients. However, they reported greater exposure to lesbian, gay, and bisexual identities as compared to transgender and queer identities. Most (48-63%) received LGBTQ+ training post-licensure. Between 19% and 32% of participants reported never completing LGBTQ+ specific education. Participants described using affirmative clinical practice behaviors either “always/often” or “never/rarely.” Factors predicting those practice behaviors were LGBTQ+ education/training, prior experience with LGBTQ+ patients, primary patient population (child vs. adult), and personal background (sexual minority status, female gender, and years since degree). When in need of consultation, the current sample consulted with their colleagues most often (n = 95) followed by academic literature (n = 90) and professional organizations (n = 80). Qualitative responses indicated varying attitudes and knowledge regarding collection of LGBTQ+ information and modification of clinical practice.

Consistent with the broader clinical psychology literature, neuropsychologists have limited education/training on LGBTQ+ concepts. Neuropsychologists underutilize affirming practices as evidenced by low rates of querying pronouns, knowing whether LGBTQ+ health information is available at their institutions, and adjusting evaluation and feedback approaches. Our findings imply a great need to expand continuing education trainings to address providers’ gaps and limitations, including opportunities for inclusive neuropsychological services throughout the assessment process (interview, testing, feedback). We present additional recommendations for future research as well as resources.