LGBT+ Health Teaching within the Undergraduate Medical Curriculum

Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Health Disparities: A Position Paper From the American College of Physicians

Lesbian, gay, bisexual, transgender, queer, or other sexual and gender minorities (LGBTQ+) populations in the United States continue to experience disparities in health and health care. Discrimination in both health care and society at large negatively affects LGBTQ+ health. Although progress has been made in addressing health disparities and reducing social inequality for these populations, new challenges have emerged. There is a pressing need for physicians and other health professionals to take a stance against discriminatory policies as renewed federal and state public policy efforts increasingly impose medically unnecessary restrictions on the provision of gender-affirming care. In this position paper, the American College of Physicians (ACP) reaffirms and updates much of its long-standing policy on LGBTQ+ health to strongly support access to evidence-based, clinically indicated gender-affirming care and oppose political efforts to interfere in the patient-physician relationship. Furthermore, ACP opposes institutional and legal restrictions on undergraduate, graduate, and continuing medical education and training on gender-affirming care and LGBTQ+ health issues. This paper also offers policy recommendations to protect the right of all people to participate in public life free from discrimination on the basis of their gender identity or sexual orientation and encourages the deployment of inclusive, nondiscriminatory, and evidence-based blood donation policies for members of LGBTQ+ communities. Underlying these beliefs is a reaffirmed commitment to promoting equitable access to quality care for all people regardless of their sexual orientation and gender identity.

Measures of Health Care Providers' Knowledge, Clinical Skills, or Prejudice Toward Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Other Sexual and Gender Minority Populations: A Scoping Review

Purpose: Assessing health care providers' knowledge, clinical skills, and prejudice toward lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender minority populations (LGBTQIA+) can help identify areas for improvement in health care provider training. The aim of this study was to map the range of studies that report measures of health care providers' knowledge, clinical skills, or prejudice toward LGBTQIA+ populations. Methods: A scoping review adopting the Joanna Briggs Institute methodology was conducted. Electronic database searches were conducted in CINAHL via EBSCO Host, Epistemonikos, LILACS via Virtual Health Library Regional Portal, PubMed, Scopus, and Web of Sciences. The samples of other reviews were screened. Studies that validated, translated, and/or cross-culturally adapted measures of the knowledge, clinical skills, and prejudice of health care providers and students toward LGBTQIA+ individuals were selected. Scholars were consulted to ensure that no relevant studies were missing. Data were extracted by two independent reviewers and presented in tabular form along with narrative summaries. Results: This scoping review identified 27 measures that have been validated, translated, and/or adapted with health care providers or students as the target population, distributed across 33 studies. Conclusions: Psychometric studies involving LGBTQIA+ patients and health care professionals have increased in recent years, with North American countries being the most frequent location. However, a growing number of studies are being conducted in Latin American countries such as Brazil and Colombia.

Sexual and gender minority health: a roadmap for developing evidence-based medical school curricula

Background

Educating future physicians about sexual and gender minority (SGM) patients and their health care needs is an important way to mitigate discrimination and health disparities faced by this community. Canada, across its 17 medical schools, lacks a national standard for teaching this essential topic. This paper aims to review the best practices for teaching an SGM curriculum in undergraduate medical education and synthesize this information into actionable propositions for curriculum development.

Methods

A scoping literature review was conducted to identify best practices for SGM teaching. The review elicited peer-reviewed and grey literature on best practices for SGM teaching, policy documents, and opinion pieces from medical education authorities and SGM advocacy groups. Through an iterative process with all authors, the Canadian Queer Medical Students Association (CQMSA), and the Association of Faculties of Medicine of Canada (AFMC), a set of propositions was developed.

Results

The search yielded 1347 papers, of which 89 were kept for data extraction. The main outcomes of these papers were sorted along five repeating themes, which formed the basis for six propositions; two more propositions were then added after discussion with all authors.

Conclusion

We present eight propositions for the development of a national standard for SGM education at the undergraduate medical level. These include standardizing learning objectives across all schools, using established curricular models to guide curriculum development, interweaving concepts across all levels of training, diversifying teaching modalities, providing faculty training, ensuring a safe space for SGM students and faculty, using OSCEs as a teaching tool, and involving the local SGM community in curriculum development and delivery.

Addressing the Health Needs of LGBTQ Persons in Medical Curricula: A Review of Educational Programs

OBJECTIVE

Given the vulnerability of and the importance of caring for the specific health care needs of the growing lesbian, gay, bisexual, transgender, and queer (LGBTQ) population, the authors attempted to identify all educational interventions in psychiatric settings with quantitative outcomes targeting medical students, residents, and physicians in postgraduate settings. To gain insight from other disciplines that have published research in this area, a second objective was to review studies in teaching in those other disciplines. The authors sought to describe the methods of selected studies.

METHODS

The authors searched the published English-language literature indexed in PubMed, EMBASE, and PsycINFO using key terms for health care education concerning LGBTQ populations. The authors described and critically appraised studies with quantitative outcomes designed to enhance knowledge, skills, and attitudes in treating the LGBTQ community.

RESULTS

Of the 15 trials identified, 10 included medical students, 4 included internal medicine residents or medical school faculty, and 1 included oncologists. We did not find any randomized controlled trials or controlled nonrandomized trials of curricula dedicated to teaching learners in psychiatry. All of the studies included a presurvey, followed by an educational intervention and then a postsurvey assessment. The educational interventions, outcome measures, and quality of studies varied widely. Four studies enrolled self-identified members of the LGBTQ community as trainers and facilitators of the educational interventions.

CONCLUSIONS

The lack of high-quality controlled studies indicates the need to develop evidence-based curricula to support the education of the psychiatric workforce to provide for the special needs of LGBTQ persons.

Lesbian, gay, bisexual, transgender, and queer health-related educational experiences in undergraduate medical curricula among Thai medical schools (LEAD-IN)

PURPOSE

In Thailand, Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) individuals face significant health disparities and discrimination in healthcare. A primary cause is the lack of knowledge among doctors and their negative attitudes towards LGBTQ people. The purpose of this study was to explore the current undergraduate medical curricula of medical schools in Thailand concerning learning outcomes, contents, teaching and learning methods, and assessment methods in the field of LGBTQ health. It also sought to gather opinions from principal stakeholders in curriculum development.

METHODS

The authors employed a mixed-methods approach with a convergent design to conduct the research. Quantitative data were collected from 23 deputy deans of educational affairs using a standardized interview form, and qualitative data were obtained through in-depth interviews with key stakeholders including 16 LGBTQ healthcare receivers, 22 medical students, and three medical teachers. Both datasets were analyzed simultaneously to ensure consistency.

RESULTS

The findings indicate that none of the medical schools had established learning objectives related to LGBTQ healthcare within their curricula. Of the institutions surveyed, 8 out of 15 (53.3%) offered some form of teaching on this topic, aligning with the qualitative data which showed 7 out of 17 institutions (41.2%) provided such education. The most frequently covered topics were gender identity and sexual orientation. Lectures were the predominant teaching method, while multiple-choice questions were the most common assessment format. There was a unanimous agreement among all principal stakeholders on the necessity of integrating LGBTQ healthcare into the M.D. program and the professional standards governed by the Thai Medical Council.

CONCLUSIONS

Although some Thai medical schools have begun to incorporate LGBTQ health into their curricula, the approach does not fully address the actual health issues faced by LGBTQ individuals. Future teaching should emphasize fostering positive attitudes towards LGBTQ people and enhancing communication skills, rather than focusing solely on the cognitive aspects of terminology. Importantly, medical educators should serve as role models in providing competent and compassionate care for LGBTQ patients.

Investigating the Needs and Concerns of Lesbian, Gay, Bisexual, Transgender, Queer, or Questioning Cancer Patients

The needs and concerns of lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) patients with cancer remain poorly understood. This is important as LGBTQ+ patients have an elevated risk of developing certain cancers and have poorer oncologic outcomes compared to non-LGBTQ+ patients. The lack of research may be linked to the complexity of studying the needs and concerns of this patient population. This review aimed to describe the evidence that sought to identify the needs and concerns of LGBTQ+ cancer patients. Studies were extracted using keywords such as "LGBTQ" and "Oncology." Patient participants were excluded if they did not identify as LGBTQ+ and if they did not have cancer or were not cancer survivors. Healthcare professionals were excluded if they were not oncology specific. A total of 22 studies met our inclusion criteria. LGBTQ+ cancer patients expressed concerns surrounding heteronormative assumptions made by healthcare professionals, a lack of LGBTQ±specific cancer support groups, and psychosexual concerns such as erectile dysfunction following cancer treatment. Oncology healthcare professionals lacked the knowledge and education that are required to manage this patient cohort. Further research is required to investigate the needs and concerns of LGBTQ+ cancer patients specifically in the radiation oncology setting.

Gaps in sexual health content of healthcare professional curriculum: a systematic review of educational interventions

BACKGROUND

Sexual health care, including assessment and patient teaching, is part of comprehensive patient care. Health professional (medical and nursing) students' education in sexual health lacks uniformity in content and assessment skills.

OBJECTIVES

The current systematic review aimed to assess sexual health educational curriculum for health professional students regarding the educational content, duration, and evaluation of these educational interventions.

METHODS

This systematic review followed the preferred reporting guidelines for systematic reviews. A comprehensive search was conducted between May-August, 2023 across four databases (PubMed, Scopus, CINAHL, EMBASE), outlining 614 sources. Following the screening process, 36 educational intervention studies were deemed eligible for inclusion. The quality assessment of these studies was conducted using The Effective Public Health Project tool, which was found appropriate for evaluating this type of research.

RESULTS

The studies had a global representation, with most studies conducted in the US. Limited nursing educational interventions were found. Three main categories emerged from the analysis of the educational interventions: one-time interventions, workshops, and semester courses. These categories differed in terms of their duration. Upon evaluating the educational intervention programs, it was found that the majority relied on participant self-reporting, while only a few included objective evaluations.

CONCLUSIONS

This review revealed inconsistencies in educational content for healthcare professional students and may impact their clinical skills, particularly in sexual health. The variation in content, duration, and evaluation methods created challenges in assessing the interventions. The lack of standardized sexual health education highlighted a significant gap, raising concerns about students' ultimate proficiency in this area. Bridging this divide is essential by integrating comprehensive sexual health content and assessment skills into the health professional curriculum.

A Cross-Sectional Survey Study on Homophobia Among Medical, Nursing, Pharmacy, and Other Health Sciences Students

Since the lesbian, gay, bisexual, transgender, and intersex (LGBTI) community may be exposed to violence, discrimination, stigma, exclusion, and maltreatment due to their sexual orientation while accessing healthcare services, understanding, and improving the attitudes of future's health care professionals toward LGBTI individuals seem essential. This descriptive and cross-sectional study aimed to investigate the homophobia among medical, nursing, pharmacy, and healthcare sciences students and examine the related factors. The study included 2,531 students from medicine, nursing, pharmacy, and other health sciences (midwifery, nutrition and dietetics, physiotherapy, management of healthcare facilities) disciplines. Homophobia was measured with the Hudson and Ricketts Homophobia Scale. After getting ethical and institutional approvals, data were collected and analyzed using descriptive and inferential statistical tests. Medical students had the lowest homophobia score, and their mean score was significantly lower than other students. There was a significant difference between students' scores according to years of study, age, sex, acquaintance with LGBTI individuals, providing healthcare services to an LGBTI person, and opinions on providing care. Although homophobia scores of nursing, pharmacy, and other health sciences students were lower than the medical students', policies and expansive content regarding LGBTI should be in place in all health science educational institutes, including medical schools, to prevent students from holding homophobic and prejudicial attitudes against LGBTI individuals.

The power to help or harm: student perceptions of transgender health education using a qualitative approach

BACKGROUND

Lack of transgender health education among health professional education programs is a limitation to providing gender-affirming care. Educational interventions have advanced in the past decade using a variety of pedagogical approaches. Although evidence supports that educational interventions can significantly improve student knowledge, comfort levels, preparedness, and clinical skills, few studies have addressed student perceptions of or receptiveness towards transgender health education. The study purpose was to explore student perceptions of transgender health education using a qualitative approach.

METHODS

We utilized a basic qualitative design to explore student perceptions of transgender health education at a Catholic, Jesuit institution. Participants were medical students (n = 182), medical family therapy students (n = 8), speech, language and hearing sciences students (n = 44), and dietetic interns (n = 30) who participated in an Interprofessional Transgender Health Education Day (ITHED) in partnership with transgender educators and activists. Participants completed an online discussion assignment using eight discussion prompts specific to the ITHED sessions. Data were analyzed using the constant comparative method and triangulated across four medical and allied health programs.

RESULTS

A total of 263 participants provided 362 responses across eight discussion prompts. Three major themes resulted: (1) The Power to Help or Harm, (2) The Responsibility to Provide Health Care, and (3) A Posture of Humility: Listen and Learn. Each theme was supported by three to four subthemes.

CONCLUSIONS

Health professional students were highly receptive towards transgender health education delivered by transgender community members. First-person accounts from session facilitators of both positive and negative experiences in healthcare were particularly effective at illustrating the power of providers to help or harm transgender patients. Reflection and constructive dialogue offers students an opportunity to better understand the lived experiences of transgender patients and explore their identities as healthcare providers at the intersection of their religious and cultural beliefs.

A Qualitative Study on the Experiences of Preclinical Students in Learning Clinical and Communication Skills at a Simulation Centre

Introduction

Simulation centres (SC) and its learning resources are now firmly established as part of medical education. In SC, medical students obtain both knowledge and skills based on a combination of theory and practice using provided resources. This study aims to explore medical students' use of SC learning resources to learn clinical and communication skills based on Kolb's experiential learning cycle. This is based on the research question 'How are the SC resources useful in supporting preclinical medical students' clinical and communication skills learning?' The findings of the study can make a case for further enhancement of SC design and resources for medical students in the preclinical phase.

Methods

A qualitative study involving 20 preclinical medical students with learning experiences in SC was conducted between December 2019 and 2020 at a medical school in Malaysia. Semi-structured interview questions were developed based on Kolb's learning cycle. The data were thematically analysed using the six phases of Braun and Clarke's thematic analysis.

Results

Three main themes were identified based on preclinical medical students' experiences in SC; they were 'preparation for authentic clinical experience', 'accessibility of multiple resources for learning and support' and 'opportunities to learn and improve'.

Conclusions

The SC's resources have a significant and positive role in supporting preclinical medical students learn clinical and communication skills. The SC resources prepared them for authentic clinical experiences with a patient-centred care approach and self-directed learning opportunities. Social support from peers, peer tutors and academics emerged as a key finding and resource of the SC as they help preclinical students learn and improve.

When Health Intersects with Gender and Sexual Diversity: Medical Students' Attitudes Towards LGBTQ Patients

A central tenet of the health professions is that of equitable access to health care. However, disparities in equitable healthcare provision continues to be a challenge in many societies due to prejudices against the LGBTQ community. This study was aimed at exploring the attitudes of medical students toward LGBTQ patients in Malaysia. A qualitative approach was adopted to seek depth of understanding of clinical year medical students' perceptions and attitudes toward LGBTQ patients. Data were collected in 2018 through individual interviews and focus group discussions with a total of 29 participants, using a semi-structured question guideline. Purposive sampling comprised representation from the three major ethnic groups in Malaysia. Thematic analysis using NVivo highlighted three main themes i.e., neutrality, in compliance with the Professional Code of Conduct; implicit biases and tolerance of an Odd Identity; explicit biases with prejudices and stereotyping. The lack of knowledge and understanding of the nature and issues of sexuality is problematic as found in this study. They are primarily biases and prejudices projected onto marginalized LGBTQ patients who must contend with multiple jeopardies in conservative societies such as in Malaysia. With some state policies framed around Islam the concern is with the belief among Malay/Islamic students for LGBTQ individuals to go through conversion 'therapies' to become cisgender and heterosexual.

Communication about sexual orientation and gender between clinicians, LGBT+ people facing serious illness and their significant others: a qualitative interview study of experiences, preferences and recommendations

BACKGROUND

Healthcare organisations have legal and ethical duties to reduce inequalities in access to healthcare services and related outcomes. However, lesbian, gay, bisexual and/or transgender (LGBT+) people continue to experience and anticipate discrimination in health and social care. Skilled communication is vital for quality person-centred care, but there is inconsistent provision of evidence-based clinician education on health needs and experiences of LGBT+ people to support this. This study aimed to identify key stakeholders' experiences, preferences and best practices for communication regarding sexual orientation, gender identity and gender history in order to reduce inequalities in healthcare.

METHODS

Semistructured qualitative interviews with LGBT+ patients with serious illness, significant others and clinicians, recruited via UK-wide LGBT+ groups, two hospitals and one hospice in England. We analysed the interview data using reflexive thematic analysis.

RESULTS

74 stakeholders participated: 34 LGBT+ patients with serious illness, 13 significant others and 27 multiprofessional clinicians. Participants described key communication strategies to promote inclusive practice across three domains: (1) 'Creating positive first impressions and building rapport' were central to relationship building and enacted through routine use of inclusive language, avoiding potentially negative non-verbal signals and echoing terminology used by patients and caregivers; (2) 'Enhancing care by actively exploring and explaining the relevance of sexual orientation and gender identity', participants described the benefits of clinicians initiating these discussions, pursuing topics guided by the patient's response or expressed preferences for disclosure. Active involvement of significant others was encouraged to demonstrate recognition of the relationship; these individual level actions are underpinned by a foundation of (3) 'visible and consistent LGBT+ inclusiveness in care systems'. Although participants expressed hesitance talking about LGBT+ identities with individuals from some sociocultural and religious backgrounds, there was widespread support for institutions to adopt a standardised, LGBT+ inclusive, visibly supportive approach.

CONCLUSIONS

Person-centred care can be enhanced by incorporating discussions about sexual orientation and gender identity into routine clinical practice. Inclusive language and sensitive exploration of relationships and identities are core activities. Institutions need to support clinicians through provision of adequate training, resources, inclusive monitoring systems, policies and structures. Ten inclusive communication recommendations are made based on the data.

LGBTQ+ Healthcare Teaching in UK Medical Schools: An Investigation into Medical Students' Understanding and Preparedness for Practice

OBJECTIVES

Lesbian, gay, bisexual, trans* and queer/questioning + (LGBTQ+) healthcare teaching within UK medical schools is currently lacking, potentially impacting on patients' confidence in health services and ability to access care. The current study conducted a multi-site analysis aiming to investigate medical students' perceptions towards the teaching of LGBTQ+ healthcare in UK medical schools, as well as to gain a greater understanding of medical students' level of knowledge of LGBTQ+ healthcare, and preparedness for working with LGBTQ+ patients.

METHODS

Medical students (N = 296) from 28 UK institutions responded to a 15-question online survey distributed via course leads and social media. Thematic analysis of qualitative data was conducted, as well as statistical analysis of quantitative data using SPSS.

RESULTS

Only 40.9% of students reported having any teaching on LGBTQ+ healthcare, 96.6% of whom said this was one-off or very irregular sessions. Only 1 in 8 felt their knowledge and skills on LGBTQ+ healthcare was sufficient. 97.2% of students questioned wanted more knowledge on LGBTQ+ healthcare.

CONCLUSION

The current study highlighted that UK medical students felt underprepared for working with LGBTQ+ patients due to insufficient education. Given that teaching on LGBTQ+ healthcare is often optional and extra-curricular, it may not be reaching those who need it most. The authors are calling for the mandatory inclusion of LGBTQ+ healthcare in the teaching of all UK medical schools, within their individual curriculum frameworks, and with regulatory support from the General Medical Council. This will ensure a wider understanding among medical students, and subsequently qualified doctors, of the health inequities and unique health issues LGBTQ+ people face, which will better equip them to provide high-quality care to LGBTQ+ patients, and start to tackle the inequities they face.

Classroom Instruction: Medical Students' Attitudes Toward LGBTQI+ Patients

The Association of American Medical Colleges declared it essential that medical students receive instruction on the health needs of lesbian, gay, bisexual, transgender, questioning, and intersex (LGBTQI⁺) individuals. The integration of LGBTQI⁺ health and instruction in medical curricula, however, is scant. A pre-post confidential survey study was completed by first-year medical students (N = 103; 85% response rate) in the context of classroom instruction. The California State University Northbridge instrument assessed students' perspectives on LGBTQI⁺ Patient-Care, Comfort with LGBTQI⁺ Patient Interactions, Gender and Sexuality, Civil Rights, and LGBTQI⁺ Education. Post-instruction, students reported a significant increase in understanding of bisexuality (p = .02), being transgender (p = .006), and LGBTQI⁺ couples' adoption rights (p = .003). The findings support the incorporation of LGBTQI⁺ instruction into medical curricula and suggest that educators may consider consulting pre-intervention data before teaching LGBTQI⁺ health content, which would allow material to be tailored toward learner-specific needs.

Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators

Health disparities faced by transgender people are partly explained by barriers to trans-inclusive healthcare, which in turn are linked to a lack of transgender health education in medical school curricula. We carried out a theory-driven systematic review with the aim to (1) provide an overview of key characteristics of training initiatives and pedagogical features, and (2) analyze barriers and facilitators to implementing this training in medical education. We used queer theory to contextualize our findings. We searched the PubMed/Ovid MEDLINE database (October 2009 to December 2021) for original studies that reported on transgender content within medical schools and residency programs (N = 46). We performed a thematic analysis to identify training characteristics, pedagogical features, barriers and facilitators. Most training consisted of single-session interventions, with varying modes of delivery. Most interventions were facilitated by instructors with a range of professional experience and half covered general LGBT+-content. Thematic analysis highlighted barriers including lack of educational materials, lack of faculty expertise, time/costs constraints, and challenges in recruiting and compensating transgender guest speakers. Facilitators included scaffolding learning throughout the curriculum, drawing on expertise of transgender people and engaging learners in skills-based training. Sustainable implementation of transgender-health objectives in medical education faces persistent institutional barriers. These barriers are rooted in normative biases inherent to biomedical knowledge production, and an understanding of categories of sex and gender as uncomplicated. Medical schools should facilitate trans-inclusive educational strategies to combat transgender-health inequities, which should include a critical stance toward binary conceptualizations of sex and gender throughout the curriculum.

Knowing to Ask and Feeling Safe to Tell - Understanding the Influences of HCP-Patient Interactions in Cancer Care for LGBTQ+ Children and Young People

Background

Lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) people experience healthcare inequalities in cancer care. Previous studies have focused on knowledge, attitudes and behaviours of healthcare professionals (HCPs) treating adults with cancer and how these contribute to inequalities. To date, no research has focused on HCPs treating LGBTQ+ children and adolescents with cancer in the UK. This is important given that this group may be at a critical time for exploring their gender identity and sexual orientation, whilst also facing a cancer diagnosis. We aimed to explore the knowledge, attitudes and behaviours of paediatric, teenage and young adult oncology HCPs treating LGBTQ+ patients in the UK.

Methods

We carried out semi-structured interviews with 8 HCPs in paediatric, teenage and young adult (TYA) oncology from the Royal Marsden NHS Foundation Trust. Eight questions were asked, which centred around participants' knowledge, attitudes and behaviours regarding management of LGBTQ+ patients in oncology. Interview transcripts were analysed by inductive thematic analysis.

Results

We identified 10 themes, including novel themes (how HCPs acquire knowledge and expectations of a 'third party' to be the expert) which may underlie previously observed trends in knowledge, attitudes and behaviours of HCPs. We highlight other themes and HCP concerns specific to care of LGBTQ+ patients in paediatrics (influence of the parental-carer dynamic, concerns around patient age and development as a barrier to disclosure) which require further research. We found evidence of the interrelatedness of HCP knowledge, attitudes and behaviours and the ability of these elements to positively influence each other. We mapped our themes across these elements to form a new suggested framework for improving HCP-patient interactions in LGBTQ+ Cancer Care. We found a need both for individual HCP education and organisational change, with creation of a culture of psychological safety to improve patient care.

Conclusion

Knowledge, attitudes and behaviours of HCPs are closely interdependent when providing care to young LGBTQ+ patients with cancer. The authors suggest that future efforts to improve care of these patients address this complexity by spanning the domains of our suggested framework. Whilst HCP education is essential, change must also occur at an organisational level.

Validity and reliability of the gender equity scale in nursing education

Equity is an emerging issue across all sectors of society, and one of the frequently raised concerns in nursing education is gender inequity. An accurate assessment appears to be a key component in creating an environment of gender equity in nursing education. This study aimed to develop a scale of gender equity in nursing education and establish its validity and reliability. In total, 341 senior nursing students participated in the psychometric evaluation of the Gender Equity Scale in Nursing Education. This psychometric evaluation revealed that the 4-subdomain (personal experience of gender inequity, perceptions of gender roles, gender discrimination, and gender biases in class), 23-item measure possesses both good reliability and validity, as well as a good level of internal consistency. The Gender Equity Scale in Nursing Education was developed as a self-report questionnaire for both female and male students and considers gender role stereotypes, gender-biased educational climates, gender discrimination, and gender inequity in nursing education.

Affirming and Inclusive Care Training for Medical Students and Residents to Reducing Health Disparities Experienced by Sexual and Gender Minorities: A Systematic Review

Purpose

Providing inclusive and comprehensive gender-affirming care is critical to reducing health disparities (gaps in care) experienced by sexual and gender minorities (SGM). Currently, little is known about how medical students and residents are being trained to address the health needs of SGM persons or of the most effective methods.

Methods

We conducted a systematic review of the research literature from 2000 to 2020 on the effectiveness of teaching medical students and residents on knowledge, attitudes, and skills in addressing the health of SGM persons and the strength of the research sample, design, and methods used.

Results

We identified a total of 36 articles that assessed the impact of medical student and resident education on knowledge, comfort, attitudes, confidence, and skills in working with SGM patients. All studies utilized quasi-experimental designs, and found efficacious results. No study examined the impact of training on patient outcomes.

Conclusion

Future studies will need to be powered and designed to assess the impact of training on patient outcomes.

Sexual and gender minority identity in undergraduate medical education: Impact on experience and career trajectory

INTRODUCTION

The wellbeing of sexual and gender minority (SGM) medical students and the impact of their experiences on career trajectory remain poorly understood. The present study aimed to characterize the incidence of mistreatment in SGM trainees as well as general perspectives on the acceptance of SGM individuals across medical and surgical specialties.

METHODS

This was a cross sectional survey study of all actively enrolled medical students within the six University of California campuses conducted in March 2021. An online, survey tool captured incidence of bullying, discrimination, and suicidal ideation as well as perceived acceptance of SGM identities across specialties measured by slider scale. Differences between SGM and non-SGM respondents were assessed with two-tailed and chi-square tests. Qualitative responses were evaluated utilizing a multi-stage, cutting-and-sorting technique.

RESULTS

Of approximately 3,205 students eligible for participation, 383 submitted completed surveys, representing a response rate of 12.0%. Of these respondents, 26.9% (n = 103) identified as a sexual or gender minority. Overall, SGM trainees reported higher slider scale scores when asked about being bullied by other students (20.0 vs. 13.9, P = 0.012) and contemplating suicide (14.8 vs. 8.8, P = 0.005). Compared to all other specialties, general surgery and surgical subspecialties had the lowest mean slider scale score (52.8) in perceived acceptance of SGM identities (All P < 0.001). In qualitative responses, students frequently cited lack of diversity as contributing to this perception. Additionally, 67.0% of SGM students had concerns that disclosure of identity would affect their future career with 18.5% planning to not disclose during the residency application process.

CONCLUSIONS

Overall, SGM respondents reported higher incidences of bullying and suicidal ideation as well as increased self-censorship stemming from concerns regarding career advancement, most prominently in surgery. To address such barriers, institutions must actively promote diversity in sexual preference and gender identity regardless of specialty.

Attitudes and Knowledge of Medical Students Towards Healthcare for Lesbian, Gay, Bisexual, and Transgender Seniors: Impact of a Case-Based Discussion With Facilitators From the Community

Background: Lesbian, gay, bisexual, and transgender (LGBT) seniors are generally a medically underserved population that faces unique healthcare challenges. When compared to younger patients, LGBT seniors are at a greater risk for social isolation and have higher rates of smoking, disability, physical and mental distress, and lack of access to healthcare services. They are often reluctant to discuss their sexual orientations and gender identities with healthcare providers due to fear of discrimination and receiving inferior care based on prior unsatisfactory experiences with untrained or insensitive healthcare providers. Furthermore, recent research has revealed that only about 50% of primary care providers indicated confidence in providing culturally competent LGBT healthcare, highlighting the need for more LGBT proficiency training in medical school curricula.

Objectives: The aim of this study was to provide early intervention training to first-year medical students regarding best practices for equitable healthcare for LGBT seniors through integrative, small group, case-based discussions. The impact of this activity on the knowledge and attitudes of medical students regarding LGBT healthcare was also assessed.

Methods: First-year medical students participated in a two-hour small group, case-based discussion. Each group consisted of seven to eight students with one of seven facilitators who were invited members of the LGBT community. Students were provided with two clinical case scenarios related to treatment of LGBT senior patients. Students were given a pre/post-session knowledge and attitude survey to assess the impact of the session on their attitudes and understanding of the importance of providing equitable healthcare to LGBT patients. A rubric was also used by facilitators to evaluate level of student engagement and professionalism.

Results: A total of 51 first-year medical students attended the session and 38 (74.5%) completed the pre/post surveys. There was diverse representation in our student demographic with 5.2% of respondents identifying as LGBT. Survey results showed a significant increase in knowledge confidence and attitudes following the session. Students’ attitudes regarding determinants of health status changed significantly for nine of the 13 (69%) survey items. In addition, their confidence in knowledge regarding healthcare barriers, health issues, and practices for LGBT culturally competent care significantly increased post-session. Data from our assessment rubrics also show that students were highly professional and engaged with the LGBT facilitators.

Conclusion: Our study provides some evidence that case-based training of medical students regarding issues that affect health of LGBT seniors can improve attitudes and sensitize them to the unique needs of this population. Through this activity, the students indicated their desire to learn more about the topics covered and to receive further training in this field of study. While the study was somewhat limited by a small participant number, the significance of the data demonstrates the effectiveness of the approach involving members of the LGBT community as facilitators. Future work with these students as part of a longitudinal curriculum will include additional LGBT proficiency training to be offered in the subsequent blocks of instruction. Additionally, this intervention could potentially be adapted by other medical schools.

Increasing medical student confidence in gender and sexual health through a student-initiated lecture series

INTRODUCTION

Medical students self-report insufficient training in topics of gender and sexuality in medicine, which may ultimately lead to negative health outcomes in patients for whom they will provide care. This study aims to identify whether a student-initiated lecture series on topics related to gender and sexual health leads to greater student comfort with discussing topics related to diverse sexual content.

METHODS

Medical students matriculated during two consecutive academic years were invited to participate in the lecture series. Investigators administered anonymous pre- and post-series surveys (n=152 and 105 respondents, respectively) using google forms. Respondents rated their comfort levels discussing relevant topics and provided narrative feedback concerning strengths and areas for improvement of the lecture series. Overlaps between the 95% confidence intervals around pre- and post-series percentage of students comfortable/very comfortable discussing each topic were examined to compare pre- vs post-series comfort ratings. Narrative comments were reviewed for thematic feedback.

RESULTS

105 medical students completed the lecture series, with 80% identifying as female. Self-assessed comfort levels across all seminar topics were greater in post- versus pre-lecture series surveys with the following topics showing the biggest differences (percentage of students "somewhat" or "very" comfortable [95% confidence intervals]: discussing sexuality with gender (68%[59-77] vs. 29%[22-36]) and sexual minority patients (84%[77-91] vs. 49%[41-57]), HIV prevention counseling (70%[61-78] vs. 20% [20-34]), identifying female genital cutting (44% [34-53] vs. 11%[6-16]), and discussing intimate partner violence (65%[55-74] vs. 33%[25-40]). Qualitative analysis indicated respondents found the lectures to be effective and believed they should be integrated into the required medical school curriculum.

CONCLUSION

Our student-initiated lecture series was associated with greater student comfort discussing topics related to gender and sexuality with patients. This framework represents a useful method to address gaps in medical education and has the potential to improve health outcomes in multiple populations.

Teaching LGBT+ Health and Gender Education to Future Doctors: Implementation of Case-Based Teaching

Improving the education of medical students and physicians can address the disparities in LGBT+ (lesbian, gay, bisexual, transgender, and others) health care. This study explored how teachers used case-based teaching to teach medical students about gender and LGBT+ health care and discussed the implementation and effectiveness of case-based teaching from the perspective of the teachers and students. This study employed the case study method and collected data through semi-structured interviews. This study used two gender courses in clinical psychiatric education as case studies. Two teachers and 19 medical students were recruited as participants. The findings of this study were as follows: (1) effective cases links theory to clinical practice and competency learning; (2) experience sharing by LGBT+ is highly effective; (3) discussions promote the effectiveness of case-based teaching; and (4) the challenges of case-based teaching included time limitations, the multiplexity of the cases, and multilevel learning. This study also found that using narrative cases is a form of narrative pedagogy, which can help students to integrate medicine, gender, and LGBT+ competency education. A successful narrative case–based teaching strategy involves teachers integrating knowledge related to gender, guiding students through the cases to understand the importance of these cases, and reflecting on the medical profession to make improvements. However, teachers face challenges in this approach, such as changes in the school’s teaching culture and a lack of institutional support.

Que(e) rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education

BACKGROUND

Lesbian, Gay, Bisexual, and Transgender (LGBT) individuals are more likely to have negative healthcare experiences and worse health outcomes when compared with their heterosexual and cisgender counterparts. A key recommendation of the 2018 Stonewall-commissioned "LGBT in Britain" report was that the curricula, standards, and training provided by medical schools should be reviewed in order to encompass mandatory teaching about LGBT health inequalities and discrimination, LGBT-inclusive care and the use of appropriate language. The aim of our study was to conduct an in-depth national review of the content of LGBT teaching within the curricula of UK Medical Schools.

METHODS

Course leads at all 37 UK Medical Schools with students currently enrolled in a primary undergraduate medical training course were asked between December 2019-March 2020 to complete a cross-sectional online survey comprised of 30 questions; divided into three sections relating to the current LGBT teaching (Part 1), any planned or future LGBT teaching (Part 2), and the opinions of the survey respondent about the coverage of LGBT topics (Part 3) at their institution. Responses were analysed using descriptive statistics.

RESULTS

Questionnaires were received from 19/37 institutions (response rate: 51%). The median estimated number of hours of LGBT-teaching across the entire undergraduate course was 11.0 (IQR: 12.25). Teaching on LGBT mental health, gender identity, sexual orientation, awareness of LGBT-health inequalities, and LGBT discrimination in healthcare were reported by almost all respondents, whilst maternity and childbirth, chronic disease and LGBT adolescent health were least represented within the curriculum. Almost all (18 medical schools; 95%) responding institutions were considering implementing new LGBT teaching within the next three academic years. A lack of space within the curriculum is a universally reported barrier to the implementation of LGBT teaching. Only 5 (26%) survey respondents consider their institution's current coverage of LGBT topics to be "Good" or "Very good".

CONCLUSION

Our study demonstrates a significant variation in the amount and breadth of content within the undergraduate curricula of UK medical schools. Recommendations for increasing the quantity and quality of LGBT content are provided, based upon areas of good practice.

How much is needed? Patient exposure and curricular education on medical students' LGBT cultural competency

BACKGROUND

For medical students, providing exposure to and education about the lesbian, gay, bisexual, and transgender (LGBT) patient population are effective methods to increase comfort, knowledge, and confidence in caring for LGBT people. However, specific recommendations on the number of patient exposures and educational hours that relate to high LGBT cultural competency are lacking.

METHODS

Medical students (N = 940) at three universities across the United States completed a survey consisting of demographics, experiential variables (i.e., number of LGBT patients and LGBT hours), and the 7-point Likert LGBT-Development of Clinical Skills Scale (LGBT-DOCSS). LGBT-DOCSS scores were stratified by 1-point increments, and experiential variable means were computed per each stratification to characterize the mean LGBT patients and hours of medical students with higher scores and those with lower scores.

RESULTS

Medical students reported caring for some LGBT patients annually (M = 6.02, SD = 20.33) and receiving a low number of annual LGBT curricular hours (M = 2.22, SD = 2.85) and moderate number of annual LGBT extracurricular hours (M = 6.93, SD = 24.97). They also reported very high attitudinal awareness (M = 6.54, SD = 0.86), moderate knowledge (M = 5.73, SD = 1.01), and low clinical preparedness (M = 3.82, SD = 1.25). Medical students who cared for 35 or more LGBT patients and received 35 or more LGBT total hours reported significantly higher preparedness and knowledge.

CONCLUSIONS

Medical students have shortcomings in LGBT cultural competency and limited LGBT patient exposure and education. To improve LGBT cultural competency, medical schools and accrediting bodies should consider providing medical students with at least a total of 35 LGBT patient contacts and 35 LGBT education hours (10 h of required curricular education and 25 h of supplemental education).

Prevalence and curriculum of sexual and gender minority education in Japanese medical school and future direction

Background: In Japan, sexual and gender minorities (SGM) remain stigmatized, provoking hospital access barriers and health disparities from judgmental care. Japan's Western-influenced introduction of SGM course content into medical education for future physicians addresses these disparities, although often perfunctorily and inconsistently.Objective: To examine the prevalence and characteristics of medical education curriculum with respect to SGM patients, we surveyed medical schools.Methods: A medical education faculty member from each of 80 Japanese medical schools received double postcards to identify relevant SGM coursework. Upon acknowledgement, 43 schools received seven-item anonymous questionnaires in March 2018. Survey results were analyzed from the perspective of three of the qualities and abilities required of a physician - Patient Care, Knowledge for Practice, and Professionalism from Japan's Medical Core Curriculum - to develop recommendations for outcomes-based SGM curriculum through the lens of Van Melle's medical education framework.Results: The response rate was 46%, with 22 schools providing SGM lectures mostly to first- and third-year students. Obstetrics and Gynecology, Neuropsychiatry, and Introduction to Medicine lectures were the top three subjects offering SGM lectures, primarily consisting of basic knowledge of SGM and Differences in Sex Development. Several lectures addressed the health challenges of SGM. Primary reasons for not offering SGM lectures were lack of suitable instructors or no school policies.Conclusions: Students can best experience the humanity of SGM patients and employ more appropriate diagnostic practices and modes of treatment with targeted curriculum to address SGM health disparities and inclusion of SGM patients in clinical practice training. To disseminate SGM education in Japanese medical schools, development of qualified instructors and policies is essential, employing currently active experts. The Van Melle reforms framework can guide in the development of recommended tailored learning experiences and lectures for improved and expanded SGM education, integrating appropriate coursework within current medical core curriculum structure.

Cervical cancer prevention in transgender men: a review

There is increased awareness of transgender physical and mental health widely and in academic research. A significant proportion of transgender men will retain their cervix with an increased risk of cervical cancer. In this review of cervical cancer screening among transgender men, we try to estimate how many transgender men still have a cervix, understand to identify challenges and barriers to cervical screening and propose possible solutions. Organised cervical screening programmes need to consider the needs of this population, in particular the provision of HPV self-sampling. TWEETABLE ABSTRACT: Transgender men need access to cervical screening.

Education First: Promoting LGBT+ Friendly Healthcare with a Competency-Based Course and Game-Based Teaching

How, apart from by conveying professional knowledge, can university medical education nurture and improve the gender competency of medical students and thereby create an LGBT+ friendly healthcare environment? This study explored the use of game-based teaching activities in competency-based teaching from the perspective of competency-based medical education (CBME) and employed a qualitative case-study methodology. We designed an LGBT+ Health and Medical Care course in a medical school. Feedback was collected from two teachers and 19 medical students using in-depth interviews and thematic analysis was used to analyze the collected data. The findings of this study were as follows: (1) Games encouraged student participation and benefited gender knowledge transmission and transformation through competency learning, and (2) games embodied the idea of assessment as learning. The enjoyable feeling of pressure from playing games motivated students to learn. Using games as both a teaching activity and an assessment tool provided the assessment and instant feedback required in the CBME learning process. Game-based teaching successfully guided medical students to learn about gender and achieve the learning goals of integrating knowledge, attitudes, and skills. To fully implement CBME using games as teaching methods, teaching activities, learning tasks, and assessment tools, teachers must improve their teaching competency. This study revealed that leading discussions and designing curricula are key in the implementation of gender competency-based education; in particular, the ability to lead discussions is the core factor. Game-based gender competency education for medical students can be facilitated with discussions that reinforce learning outcomes to achieve the objectives of gender equality education and LGBT+ friendly healthcare. The results of this study indicated that game-based CBME with specific teaching strategies was an effective method of nurturing the gender competency of medical students. The consequent integration of gender competency into medical education could achieve the goal of LGBT+ friendly healthcare.