Despite increased attention to “culturally competent” practice with diverse populations, lesbian, gay, bisexual, transgender, and queer (LGBTQ) people remain relatively invisible within medicine and other health professions. Health care providers (HCPs) frequently dismiss sexual and gender identity as irrelevant to care. This study uses interviews with 24 physicians and 38 LGBTQ-identified women to explore how routine practices in health care can perpetuate or challenge the marginalization of LGBTQ women. While physicians avoid making assumptions to reduce judgment, a “neutral” stance reinforces the hetero- and gender normative status quo. Cultural competence with LGBTQ patients requires learning with, rather than learning about, LGBTQ people’s particular health care concerns as well as paying explicit attention to pervasive power relations and normative contexts.