Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study

A Mixed Methods Evaluation of an Inclusive Sexual History Taking and HIV Prevention Curriculum for Trainees

BACKGROUND

Health disparities exist in HIV risk in the USA among the lesbian-gay-bisexual-transgender-queer (LGBTQ) community. There is also scarce literature on curricula for HIV prevention and pre-exposure prophylaxis (PrEP) for trainees.

AIM

To create a curriculum to train residents to perform inclusive sexual history taking and HIV prevention care. The curriculum covers sexual history, LGBTQ health, sexually transmitted infections, and HIV risk assessment and risk reduction counseling including use of PrEP.

SETTING

A dedicated PrEP Clinic was created within an Academic Medical Center Outpatient HIV Clinic. Patients were primarily LGBTQ identified, but also included HIV sero-discordant couples, cisgender individuals, heterosexual invididuals, and those with experience of homelessness, sex work, and substance abuse.

PARTICIPANTS

Thirty-four internal medicine residents completed the course between November 2017 and May 2018.

PROGRAM DESCRIPTION

The curriculum was delivered as Just in Time Teaching (JiTT) via online virtual patient cases followed by directly observed clinical care at a large urban PrEP clinic.

PROGRAM EVALUATION AND RESULTS

The effectiveness of the curriculum was assessed through paired pre/post-self-assessment surveys (n = 19), additional post-surveys on the online modules (n = 22), and interviews (n = 9). Many respondents reported no prior training or inadequate prior training in the course content. As a result of the course, participants reported statistically significant increased confidence and comfort in all seven HIV prevention topic areas, with the greatest gains in safe sex counseling for LGBTQ patients and in discussing PrEP (mean changes of 1.21, 1.58 on 5-point Likert scale, respectively, p < 0.0001). Six of nine interviewees post-course had applied what they learned to patient care; five indicated their learning would benefit patients.

DISCUSSION

An HIV prevention curriculum focused on cultural humility in care can improve trainee's skills in HIV risk reduction counseling, including PrEP, among all patients including those identifying as LGBTQ.

LGBT+ Health Teaching within the Undergraduate Medical Curriculum

Introduction: The lesbian, gay, bisexual, and transgender (LGBT+) population experience health and social inequalities, including discrimination within healthcare services. There is a growing international awareness of the importance of providing healthcare professionals and students with dedicated training on LGBT+ health. Methods: We introduced a compulsory teaching programme in a large London-based medical school, including a visit from a transgender patient. Feedback was collected across four years, before (n = 433) and after (n = 541) the session. Student confidence in using appropriate terminology and performing a clinical assessment on LGBT+ people was assessed with five-point Likert scales. Fisher exact tests were used to compare the proportion responding “agree” or “strongly agree”. Results: Of the students, 95% (CI 93–97%) found the teaching useful with 97% (96–99%) finding the visitor’s input helpful. Confidence using appropriate terminology to describe sexual orientation increased from 62% (58–67%) to 93% (91–95%) (Fisher p < 0.001) and gender identity from 41% (36–46%) to 91% (88–93%) (p < 0.001). Confidence in the clinical assessment of a lesbian, gay or bisexual patient increased from 75% (71–79%) to 93% (90–95%) (p < 0.001), and of a transgender patient from 35% (31–40%) to 84% (80–87%) (p < 0.001). Discussion: This teaching programme, written and delivered in collaboration with the LGBT+ community, increases students’ confidence in using appropriate language related to sexual orientation and gender identity, and in the clinical assessment of LGBT+ patients.

A writing assignment to address gaps in the nursing curriculum regarding health issues of LGBT+ populations

BACKGROUND

Lesbian, gay, bisexual, and transgender (LGBT+) populations account for 4% of the US population, yet health disparities persist, which are considered a priority in health care systems. In nursing education programs, the allotment in time to cover LGBT+ health content is not mandated thus ranges from zero to several hours total in nursing curricula. Therefore, nursing students' education regarding LGBT+ health issues remains minimal and inconsistent throughout the nation's nursing programs.

AIM

To provide associate degree nursing students with exposure to the health disparities in LGBT+ populations through a reflective writing assignment.

METHODS

The essays were culled from both sections of an established core course in the nursing curriculum, which was taught by both faculty. Using a retrospective content analysis approach, the essays from 61 associate degree nursing students were read and reread by both authors. Similar statements were grouped together and themes emerged for both authors.

RESULTS

The content analysis from the students' essays, which exposed the students to LGBT+ health issues, yielded intriguing and encouraging data. Four themes regarding LGBT+ health emerged from the students' essays: (1) communication, (2) advocacy, (3) increased knowledge and awareness, and (4) empathy development.

CONCLUSIONS

Such results suggested that a reflective writing assignment was beneficial for nursing students and exposed and familiarized them with the disparities of LGBT+ populations. Through an analysis of the students' essay contents, the two faculty researchers were able to identify improved knowledge and awareness from the writing assignment.

Transphobia rather than education predicts provider knowledge of transgender health care

PURPOSE

Transgender and gender diverse (TGD) patients face significant hurdles in accessing affirming, knowledgeable care. Lack of provider knowledge presents a substantial barrier to both primary and transition-related care and may deter patients from seeking health care. Little is known about factors that affect provider knowledge or whether exposure to TGD health content during training is associated with improved knowledge among providers. Using the TGD Healthcare Knowledge Scale, this study aimed to determine whether prior education on TGD health predicts clinicians' current knowledge regarding health care for TGD patients.

METHODS

An online survey examining exposure to TGD content and knowledge of TGD health care was distributed to all primary care providers in an integrated health care system in the Midwestern United States. Multivariable linear regression was used to predict provider knowledge, controlling for demographics, transphobia and other potential confounders.

RESULTS

The response rate was 57.3% (n = 223). The mean knowledge score was 7.41 (SD = 1.31) on a 10-point scale. Almost half (48.4%, n = 108) had no formal education on TGD health care, yet half (49.7%, n = 111) of providers reported previously caring for at least one transgender patient. In regression analysis, provider knowledge of TGD health care was associated with transphobia (β = -0.377, 95% CI = -0.559 to -0.194, p < 0.001), but not with hours of formal education (β = -0.027, 95% CI = -0.077 to 0.023, p = 0.292) or informal education (β = -0.012, 95% CI = -0.033 to 0.009, p = 0.259).

CONCLUSIONS

Increasing hours of education related to TGD health care may not be sufficient to improve providers' competence in care for TGD individuals. Transphobia may be a barrier to learning that needs to be addressed. Broader efforts to address transphobia in society in general, and in medical education in particular, may be required to improve the quality of medical care for TGD patients.

Implicit bias toward cervical cancer: Provider and training differences

OBJECTIVE

Implicit prejudice and stereotyping may exist in health care providers automatically without their awareness. These biases can correlate with outcomes that are consequential for the patient. This study examined gynecologic oncology care providers' implicit prejudice and stereotyping toward cervical cancer.

METHODS

Members of professional gynecologic oncology organizations were asked to complete two Implicit Association Tests to determine if they implicitly associate cervical cancer with feelings of anger (prejudice) and beliefs about culpability for the disease (stereotypes), compared to ovarian cancer. Linear models and Student t-tests examined average levels of implicit bias and moderators of the implicit bias effects.

RESULTS

One-hundred seventy-six (132 female, 43 male, 1 nonresponse; X¯_age = 39.18 years, SD_age = 10.58 years) providers were recruited and the final sample included 151 participants (93 physicians and 58 nurses, X¯_age = 38.93, SD_age = 10.59). Gynecologic oncology providers showed significant levels of implicit prejudice, X¯ = 0.17, SD = 0.47, 95% CI: (0.10, 0.25), toward cervical cancer patients. They also showed significant levels of implicit stereotyping of cervical cancer patients, X¯ = 0.15, SD = 0.42, 95% CI: (0.08, 0.21). Whereas physicians did not demonstrate significant levels of implicit bias, nurses demonstrated greater levels of implicit prejudice and implicit stereotyping. Providers without cultural competency/implicit bias training demonstrated greater bias than those who had completed such training (p < .05).

CONCLUSIONS

This study provides the first evidence that gynecologic oncology providers hold implicit biases related to cervical cancer. Interventions may be designed to target specific groups in gynecologic oncology to improve interactions with patients.

Genetic Counselors' and Genetic Counseling Students' Implicit and Explicit Attitudes toward Homosexuality

Members of the lesbian, gay, and bisexual (LGB) community experience significant health disparities. Widespread preferences for heterosexual over homosexual people among healthcare providers are believed to contribute to this inequity, making recognition (and ultimately reduction) of healthcare providers' sexual prejudices of import. The present study sought to characterize North American genetic counselors' and genetic counseling students' implicit and explicit attitudes toward homosexuality. During January 2017, 575 participants completed a Web-based survey and Sexuality Implicit Association Test (SIAT). A majority of participants (60.2%) harbored implicit preferences for heterosexual over homosexual people. Mean implicit attitude score (0.24) indicated a slight automatic preference for heterosexual over homosexual people, while mean explicit attitude score (0.033) indicated no preference for either group. Although participants' implicit and explicit attitudes were positively correlated (p < 0.001), there was greater implicit bias for heterosexual over homosexual people than suggested by explicit attitude scores (p < 0.001). Implicit attitudes differed across self-reported sexual orientation (p < 0.001), but not across gender, race, or genetic counseling specialty. Education has been demonstrated to be moderately effective at reducing sexual prejudices, and almost all participants (95.8%) indicated that they would support the implementation of genetic counseling curricula addressing lesbian, gay, bisexual, and transgender (LGBT) issues. The study's combined findings suggest that North American genetic counselors and genetic counseling students support, and may benefit from, the implementation of genetic counseling curricula addressing LGBT issues.

Explicit bias among fourth-year medical students

The aim of this study was to analyze themes related to explicit bias in patient-doctor relationships among fourth-year medical students. Class cohorts between 2013 and 2016 taking an online elective, "Self and Culture," submitted reflections about explicit bias. Thematic analysis was conducted on 283 student submissions totaling 849 entries until saturation. Themes included explicit bias toward patients with obesity, those who smoked, those from low-socioeconomic conditions, and, to a lesser extent, race/ethnicity. Themes related to the patient-doctor relationship included a negative impact on the relationship itself, trust, treatment of the patient, and patient experience. Themes related to making a positive impact included seeking positive treatment of the patient, understanding patients' circumstances rather than making assumptions, partnering with the patient, and education. Furthermore, researchers noted external versus internal attribution of the bias. Some students used neutral language to explain explicit biases, whereas fewer used internal attribution language. Results demonstrated that this type of reflection promoted personal insight, and faculty members should be trained to ensure successful crucial conversations about the impact of assumptions and biases on patient treatment, care plans, and health disparities. Finally, the curriculum should be intentional, providing experiences with marginalized populations to develop cultural humility and empathy.

Predictors of correspondence between self-reported substance use and urinalysis screening among a racially diverse cohort of young men who have sex with men and transgender women

It is unknown if estimates of illicit drug use among young men who have sex with men and transgender women (YMSM/TW) may be biased due to historical distrust of research or reliable due to more accepting norms for use. Research is needed to examine the validity of drug use self-reports among YMSM/TW. Data came from an ongoing longitudinal study of YMSM/TW aged 16-29 living in Chicago (analytic N = 1029). Baseline urinalysis screens for marijuana, ecstasy, amphetamine, methamphetamine, cocaine, benzodiazepine, and opiate metabolites were compared to self-reported use within different recall periods using measures of concordance. Generalized estimating equations logistic regressions were conducted on three waves of data to identify predictors of disclosing past-6-month use of marijuana and non-marijuana drugs. Past-6-month self-reported use of all non-marijuana substances was <15%. There was excellent agreement between self-reported and drug-tested marijuana use. For other substances, sensitivities within the urinalysis detection window were <0.5 but increased with longer recall periods. Black participants had lower odds of disclosing non-marijuana drug use. Gender minority participants had lower odds of disclosing marijuana use. Participants with a history of arrest had higher odds of disclosing both marijuana and non-marijuana drug use. Wave and year of first research participation were non-significant, suggesting no systematic bias or increasing honesty associated with longer research participation. Programs that rely on self-identification of non-marijuana illicit substance use may be missing a substantial portion of drug-using YMSM/TW. Future epidemiological studies should work to reduce social desirability biases and include biomarker-based drug screenings to increase validity.

Sexual and gender minority health in medical curricula in new England: a pilot study of medical student comfort, competence and perception of curricula

BACKGROUND

Sexual and gender minority (SGM) individuals experience high rates of harassment and discrimination when seeking healthcare, which contributes to substantial healthcare disparities. Improving physician training about gender identity, sexual orientation, and the healthcare needs of SGM patients has been identified as a critical strategy for mitigating these disparities. In 2014, the Association of American Medical Colleges (AAMC) published medical education competencies to guide undergraduate medical education on SGM topics.

OBJECTIVE

Conduct pilot study to investigate medical student comfort and competence about SGM health competencies outlined by the AAMC and evaluate curricular coverage of SGM topics.

DESIGN

Six-hundred and fifty-eight students at New England allopathic medical schools (response rate 21.2%) completed an anonymous, online survey evaluating self-reported comfort and competence regarding SGM health competencies, and coverage of SGM health in the medical curriculum.

RESULTS

92.7% of students felt somewhat or very comfortable treating sexual minorities; 68.4% felt comfortable treating gender minorities. Most respondents felt not competent or somewhat not competent with medical treatment of gender minority patients (76.7%) and patients with a difference of sex development (81%). At seven schools, more than 50% of students indicated that the curriculum neither adequately covers SGM-specific topics nor adequately prepares students to serve SGM patients.

CONCLUSIONS

The prevalence of self-reported comfort is greater than that of self-reported competence serving SGM patients in a convenience sample of New England allopathic medical students. The majority of participants reported insufficient curricular preparation to achieve the competencies necessary to care for SGM patients. This multi-institution pilot study provides preliminary evidence that further curriculum development may be needed to enable medical students to achieve core competencies in SGM health, as defined by AAMC. Further mixed methods research is necessary to substantiate and expand upon the findings of this pilot study. This pilot study also demonstrates the importance of creating specific evaluation tools to assess medical student achievement of competencies established by the AAMC.

Primary Care Providers' Attitudes, Practices, and Knowledge in Treating LGBTQ Communities

Cultural competency in lesbian, gay, bisexual, transgender, and queer (LGBTQ) health care has been found to be lacking within various medical specialties, but no studies have compared competency among primary care providers. The authors compared 127 primary care providers' cultural competency regarding LGBTQ health using a survey that assessed providers' attitudes, practices, and knowledge. Overall, 78.0% of respondents agreed that they were comfortable treating LGBTQ patients. Yet many providers did not feel well informed on specific LGBTQ health needs (70.1%), on clinical management of LGBTQ care (74.8%), nor on referring patients with LGBTQ issues (78.7%). Overall accuracy on LGBTQ knowledge questions was 51.0%. This study revealed a lack of cultural competency and much need for improvement as primary care providers endorsed negative attitudes, biases, inconsistencies in clinical practice, and deficiencies in medical knowledge in specialty-specific ways. There is a need for greater LGBTQ-specific education to increase providers' comfortability and competency in the needs, management, and referrals within LGBTQ health care.

Comparing medical, dental, and nursing students' preparedness to address lesbian, gay, bisexual, transgender, and queer health

Background

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations face multiple health disparities including barriers to healthcare. Few studies have examined healthcare trainees’ perceptions of their preparedness to care for LGBTQ populations and none have compared perceptions of training across medicine, dental medicine, and nursing. We aimed to understand variations across disciplines in LGBTQ health by assessing medical, dental, and nursing students’ perceptions of preparedness across three domains: comfort levels, attitudes, and formal training.

Methods

We developed a 12-item survey with an interprofessional panel of LGBTQ students from the schools of medicine, dental medicine, and nursing at a top-tier private university in the United States. Any student enrolled full time in any of the three schools were eligible to respond. We performed descriptive statistical analyses and examined patterns in responses using Kruskal-Wallis tests and an ordered logistic regression model.

Results

1,010 students from the Schools of Medicine, Dental Medicine, and Nursing responded to the survey for an overall response rate of 43%. While 70–74% of all student respondents felt comfortable treating LGBTQ patients, fewer than 50% agreed that their formal training had prepared them to do so. Overall, 71–81% of students reported interest in receiving formal LGBTQ health education, though dental students were significantly less likely than medical students to report this interest (OR 0.53, p<0.01). Respondents who identified as LGBQ were significantly less likely than heterosexual students to agree that training was effective (OR 0.55, p<0.01) and that their instructors were competent in LGBTQ health (OR 0.56, p<0.01).

Conclusion

Despite high comfort levels and positive attitudes towards LGBTQ health, most student respondents did not report adequate formal preparation. There were some significant differences between disciplines, but significant gaps in training exist across disciplines. Health professional schools should develop formal content on LGBTQ health and utilize this content as an opportunity for interprofessional training.

Welcoming Deaf Students into STEM: Recommendations for University Science Education

Scientists are shaped by their unique life experiences and bring these perspectives to their research. Diversity in life and cultural experiences among scientists, therefore, broadens research directions and, ultimately, scientific discoveries. Deaf individuals, for example, have successfully contributed their unique perspectives to scientific inquiry. However, deaf individuals still face challenges in university science education. Most deaf students in science, technology, engineering, and mathematics (STEM) disciplines interact with faculty who have little to no experience working with deaf individuals and who often have preconceptions or simply a lack of knowledge about deaf individuals. In addition to a lack of communication access, deaf students may also feel unwelcome in STEM, as do other underrepresented groups. In this essay, we review evidence from the literature and, where data are lacking, contribute the expert opinions of the authors, most of whom are deaf scientists themselves, to identify strategies to best support deaf students in university STEM education. We describe the journey of a hypothetical deaf student and methods for faculty to create a welcoming environment. We describe and provide recommendations for classroom seating and layout, accommodations, teaching strategies, and research mentoring. We also discuss the importance of including deaf scientists in research about deaf individuals.

Affective Responses to Gay Men Using Facial Electromyography: Is There a Psychophysiological "Look" of Anti-Gay Bias

Despite a wealth of attitudinal studies that elucidate the psychological correlates of anti-gay bias, studies that provide evidence of the physiological correlates of anti-gay bias remain relatively scarce. The present study addresses the under-representation of physiological research in the area of homonegativity by examining psychophysiological markers, namely the affective manifestations of anti-gay prejudice, and their correspondence with anti-gay behavior. Facial electromyography (EMG) was the technique used to acquire the psychophysiological markers via recordings from two facial muscle sites. Whether heterosexual men's implicit affective reactions to gay male couples best predicted their overt and covert discriminatory behavior toward a presumed gay male confederate was determined. The strength of the implicit affective reactions to predict anti-gay discrimination was then tested against the strength of participants' implicit cognitive reactions acquired via the Implicit Association Test (IAT). Results indicated that the affective reactions recorded via facial EMG emerged as the strongest predictor of discrimination toward gay men compared to the cognitive reactions recorded using the IAT. Findings support the contention that emotional reactions to gay men using implicit techniques such as facial EMG are potentially valuable pathways toward understanding the nature and sequelae of anti-gay behavior.

Predicting Trans-Inclusive Attitudes of Undergraduate Nursing Students

BACKGROUND

Research informs that transgender individuals experience harsh and negative experiences when accessing medical care. As a person of contact, nurses serve a key role in providing a sense of emotional safety for transgender patients.

METHOD

Undergraduate nursing students (N = 265) completed an online survey assessing transprejudice attitudes and other individual-difference variables (e.g., openness to experience, attribution of cause for being transgender, and empathic concern).

RESULTS

Confidence in providing culturally competent and affirming health care to diverse populations was associated with having received educational information on transgender issues and personally knowing a transgender individual. A significant positive correlation was found between beliefs that being transgender is due to genetics and holding more accepting attitudes toward transgender individuals.

CONCLUSION

Nursing education that addresses gender identity and provides an opportunity for student health professionals to interact with transgender individuals may help promote affirming heath care practices and reduce prejudice toward transgender people. [J Nurs Educ. 2017;56(11):660-669.].

Engaging the Transgender Community to Improve Medical Education and Prioritize Healthcare Initiatives

Phenomenon: Transgender patients experience discrimination, limited access to care, and inadequate provider knowledge in healthcare settings. Medical education to address transgender-specific disparities is lacking. Research that engages transgender community members may help address health disparities by empowering patients, increasing trust, and informing medical curricula to increase competence.

APPROACH

A 2015 Community Forum on Transgender Health Care was hosted at the University of Louisville School of Medicine, which included healthcare professionals and transgender community members to facilitate dialogue among mixed-participant groups using a World Café model. Fifty-nine participants discussed the status of transgender healthcare and made recommendations for local improvements. A follow-up survey was administered to 100 individuals, including forum participants and their referrals. The forum discussion and survey responses were analyzed to determine common perceptions of transgender healthcare, priorities for improvement interventions, and themes to inform curriculum.

FINDINGS

The community forum discussion showed that local transgender care is overwhelmingly underdeveloped and unresponsive to the needs of the transgender community. The follow-up survey revealed that priorities to improve transgender care included a multidisciplinary clinic for lesbian, gay, bisexual, and transgender (LGBT) patients, an LGBT-friendly network of physicians, and more training for providers and support staff. This mutually constructive engagement experience influenced reform in undergraduate curricula and continuing education opportunities. Insights: Community engagement in healthcare disparities research can cultivate improbable discussions, yield innovative insight from marginalized populations, and build relationships with community members for future collaborations and interventions. Societal acceptance of transgender identities, which could be promoted through healthcare providers, could stimulate significant progress in transgender healthcare. Supplemental educational interventions for practicing physicians will improve the current conditions of transgender healthcare, but a comprehensive medical school curriculum specifically for transgender health that includes interactions between the transgender community and medical students could be particularly impactful.

Changes in medical student implicit attitudes following a health equity curricular intervention

PURPOSE

This study assessed the: (1) effect of an LGBTQI + health equity curriculum (eQuality) on implicit attitudes among first (M1) and second year (M2) medical students and (2) utility of dedicated time to explore implicit bias.

METHOD

Implicit biases were assessed at baseline using implicit association tests (IAT) for all M2s and a random sample of first years (M1A). These students were then debriefed on strategies to mitigate bias. Following eQuality, all M1 and M2s completed post-intervention IATs. The remaining first years (M1B) were then debriefed. Paired sample t-tests assessed differences between pre/post. Independent sample t-tests assessed differences in post-IATs between M1 groups.

RESULTS

IATs indicated preferences for "Straight," "White," and "Thin" at both pre and post. M2s demonstrated statistically significant improvements pre to post for sexuality (p = 0.01) and race (p = 0.03). There were significant differences in post-intervention IAT scores between M1As who received the IAT and debriefing prior to eQuality and M1Bs for sexuality (p = 0.002) and race (p = 0.046). There were no significant changes for weight.

CONCLUSION

eQuality reduced implicit preference for "Straight" and "White." Differences in M1 post-intervention IAT scores between groups suggest dedicating time to debrief implicit attitudes enhances bias mitigation.

Palliative and End-of-Life Care for Lesbian, Gay, Bisexual, and Transgender (LGBT) Cancer Patients and Their Caregivers

OBJECTIVE

To identify the unique needs of lesbian, gay, bisexual, and transgender (LGBT) cancer patients and caregivers, and review recommendations supporting more effective and inclusive palliative and end-of-life care.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Transitions in care raise particular challenges for LGBT patients, including provider communication, perceptions of safety and acceptance, and assessing and respecting patients' definitions of family and spirituality.

IMPLICATIONS FOR NURSING PRACTICE

LGBT patients and their caregivers need competent nurses to support them, especially during transitions. Implementing LGBT-inclusive education, training, and practice will improve outcomes for LGBT cancer patients and their caregivers - and potentially all patients.

LGBT Cultural Competence and Interventions to Help Oncology Nurses and Other Health Care Providers

OBJECTIVES

To define and give an overview of the importance of lesbian, gay, bisexual, and transgender (LGBT) cultural competency and offer some initial steps on how to improve the quality of care provided by oncology nurses and other health care professionals.

DATA SOURCES

A review of the existing literature on cultural competency.

CONCLUSION

LGBT patients experience cancer and several other diseases at higher rates than the rest of the population. The reasons for these health care disparities are complex and include minority stress, fear of discrimination, lower rates of insurance, and lack of access to quality, culturally competent care. Addressing the health care disparities experienced by LGBT individuals and families requires attention to the actual needs, language, and support networks used by patients in these communities. Training on how to provide quality care in a welcoming and non-judgmental way is available and can improve health equity.

IMPLICATIONS FOR NURSING PRACTICE

Health care professionals and institutions that acquire cultural competency training can improve the overall health of LGBT patients who currently experience significant health care disparities.

Transgender health care: improving medical students' and residents' training and awareness

BACKGROUND

A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care.

METHODS

We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017.

RESULTS

Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients.

CONCLUSION

Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.

A Framework for Integrating Implicit Bias Recognition Into Health Professions Education

Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula-such as individual and contextual variables, as well as formal and informal cultural influences-are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.

Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students

BACKGROUND

Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students.

OBJECTIVE

To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people.

DESIGN

Prospective cohort study.

PARTICIPANTS

A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014).

MAIN MEASURES

Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1.

KEY RESULTS

In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004).

CONCLUSIONS

Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.

Beyond Generalized Sexual Prejudice: Need for Closure Predicts Negative Attitudes Toward Bisexual People Relative to Gay/Lesbian People

Increasing evidence suggests that bisexual people are sometimes evaluated more negatively than heterosexual and gay/lesbian people. A common theoretical account for this discrepancy argues that bisexuality is perceived by some as introducing ambiguity into a binary model of sexuality. The present brief report tests a single key prediction of this theory, that evaluations of bisexual people have a unique relationship with Need for Closure (NFC), a dispositional preference for simple ways of structuring information. Participants (n=3406) were heterosexual medical students from a stratified random sample of 49 U.S. medical schools. As in prior research, bisexual targets were evaluated slightly more negatively than gay/lesbian targets overall. More importantly for the present investigation, higher levels of NFC predicted negative evaluations of bisexual people after accounting for negative evaluations of gay/lesbian people, and higher levels of NFC also predicted an explicit evaluative preference for gay/lesbian people over bisexual people. These results suggest that differences in evaluations of sexual minority groups partially reflect different psychological processes, and that NFC may have a special relevance for bisexual targets even beyond its general association with prejudice. The practical value of testing this theory on new physicians is also discussed.

Inclusion of Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Health in Australian and New Zealand Medical Education

PURPOSE

This study aims at establishing the scope of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) health in Australian and New Zealand medical curricula.

METHODS

We sent medical school curriculum administrators an online cross-sectional survey.

RESULTS

The response rate was 15 medical schools (71%): 14 Australian schools and 1 New Zealand school. Respondents included program directors (n = 5; 33%), course coordinators (n = 4; 27%), Heads of School (n = 2; 13%), one Dean (7%), and three others (20%). Most schools (n = 9; 60%) reported 0-5 hours dedicated to teaching LGBTQI content during the required pre-clinical phase; nine schools (60%) reported access to a clinical rotation site where LGBTQI patient care is common. In most schools (n = 9; 60%), LGBTQI-specific content is interspersed throughout the curriculum, but five schools (33%) have dedicated modules. The most commonly used teaching modalities include lectures (n = 12; 80%) and small-group sessions (n = 9; 60%). LGBTQI content covered in curricula is varied, with the most common topics being how to obtain information about same-sex sexual activity (80%) and the difference between sexual behavior and identity (67%). Teaching about gender and gender identity is more varied across schools, with seven respondents (47%) unsure about what is taught. Eight respondents (53%) described the coverage of LGBTQI content at their institution as "fair," two (13%) as "good," and two (13%) as "poor," with one respondent (7%) describing the coverage as "very poor." None of the respondents described the coverage as "very good."

CONCLUSIONS

Currently, medical schools include limited content on LGBTQI health, most of which focuses on sexuality. There is a need for further inclusion of curriculum related to transgender, gender diverse, and intersex people.

Sexual orientation differences in treatment expectation, alliance, and outcome among patients at risk for suicide in a public psychiatric hospital

BACKGROUND

Sexual minority (SM) individuals (gay, lesbian, bisexual, or otherwise nonheterosexual) are at increased risk for mental disorders and suicide and adequate mental healthcare may be life-saving. However, SM patients experience barriers in mental healthcare that have been attributed to the lack of SM-specific competencies and heterosexist attitudes and behaviors on the part of mental health professionals. Such barriers could have a negative impact on common treatment factors such as treatment expectancy or therapeutic alliance, culminating in poorer treatment outcomes for SM versus heterosexual patients. Actual empirical data from general psychiatric settings is lacking, however. Thus, comparing the treatment outcome of heterosexual and SM patients at risk for suicide was the primary aim of this study. The secondary aim was to compare treatment expectation and working alliance as two common factors.

METHODS

We report on 633 patients from a suicide prevention inpatient department within a public psychiatric hospital. Most patients were at risk for suicide due to a recent suicide attempt or warning signs for suicide, usually in the context of a severe psychiatric disorder. At least one indicator of SM status was reported by 21% of patients. We assessed the treatment outcome by calculating the quantitative change in suicide ideation, hopelessness, and depression. We also ran related treatment responder analyses. Treatment expectation and working alliance were the assessed common factors.

RESULTS

Contrary to the primary hypothesis, SM and heterosexual patients were comparable in their improvement in suicide ideation, hopelessness, or depression, both quantitatively and in treatment responder analysis. Contrary to the secondary hypothesis, there were no significant sexual orientation differences in treatment expectation and working alliance. When adjusting for sociodemographics, diagnosis, and length of stay, some sexual orientation differences became significant, indicating that SM patients have better outcomes.

CONCLUSIONS

These unexpected but positive findings may be due to common factors of therapy compensating for SM-specific competencies. It may also be due to actual presence of SM competencies - though unmeasured - in the department. Replication in other treatment settings and assessment of SM-specific competencies are needed, especially in the field of suicide prevention, before these findings can be generalized.

Empathy in Medical Students Is Moderated by Openness to Spirituality

THEORY

Empathy is one component of medical student education that may be important to nurture, but there are many potential psychological barriers to empathy, such as student depression, burnout, and low quality of life or wellness behaviors. However, few studies have addressed how positive behaviors such as wellness and spirituality, in combination with these barriers, might affect empathy.

HYPOTHESES

We hypothesized a negative relationship between psychological distress and empathy, and a positive relationship between empathy and wellness behaviors. We also hypothesized that openness to others' spirituality would moderate the effects of psychological distress on empathy in medical students.

METHOD

This cross-sectional study included 106 medical students in a public medical school in the U.S. Midwest. Mailed questionnaires collected student information on specialty choice and sociodemographics, empathy, spirituality openness, religiosity, wellness, burnout, depression, anxiety, and stress. Hierarchical multiple regression analysis was conducted, with empathy as the dependent variable, psychological distress and all wellness behaviors as predictors, and spirituality openness as a moderator.

RESULTS

Specialty choice, burnout, wellness behaviors, spirituality openness, and religiosity were significant independent predictors of empathy. In addition, when added singly, one interaction was significant: Spirituality Openness × Depression. Spirituality openness was related to empathy only in nondepressed students. Empathy of students with higher levels of depression was generally lower and not affected by spirituality openness.

CONCLUSIONS

Nondepressed students who reported lower openness to spirituality might benefit most from empathy training, because these students reported the lowest empathy. Highly depressed or disengaged students may require interventions before empathy can be addressed. In addition, burnout was related to lower levels of empathy and wellness was related to higher levels. These provide potential points of intervention for medical schools developing tools to increase medical trainees' empathy levels.

Informal Training Experiences and Explicit Bias Against African Americans among Medical Students

Despite the widespread inclusion of diversity-related curricula in US medical training, racial disparities in the quality of care and physician bias in medical treatment persist. The present study examined the effects of both formal and informal experiences on non-African American medical students' (N=2922) attitudes toward African Americans in a longitudinal study of 49 randomly selected US medical schools. We assessed the effects experiences related to medical training, accounting for prior experiences and attitudes. Contact with African Americans predicted positive attitudes toward African Americans relative to White people, even beyond the effects of prior attitudes. Furthermore, students who reported witnessing instructors making negative racial comments or jokes were significantly more willing to express racial bias themselves, even after accounting for the effects of contact. Examining the effects of informal experiences on racial attitudes may help develop a more effective medical training environment and reduce racial disparities in healthcare.

The Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS): Establishing a New Interdisciplinary Self-Assessment for Health Providers

These three studies provide initial evidence for the development, factor structure, reliability, and validity of the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS), a new interdisciplinary LGBT clinical self-assessment for health and mental health providers. Research participants were voluntarily recruited in the United States and United Kingdom and included trainees, clinicians, and educators from applied psychology, counseling, psychotherapy, and primary care medicine. Study 1 (N = 602) used exploratory and confirmatory factor analytic techniques, revealing an 18-item three-factor structure (Clinical Preparedness, Attitudinal Awareness, and Basic Knowledge). Study 2 established internal consistency for the overall LGBT-DOCSS (α = .86) and for each of the three subscales (Clinical Preparedness = .88, Attitudinal Awareness = .80, and Basic Knowledge = .83) and 2-week test-retest reliability (.87). In study 3 (N = 564), participant criteria (sexual orientation and education level) and four established scales that measured LGBT prejudice, assessment skills, and social desirability were used to support initial content and discriminant validity. Psychometric properties, limitations, and recommendations are discussed.

An Interdisciplinary Approach to Lesbian, Gay, Bisexual, and Transgender Clinical Competence, Professional Training, and Ethical Care: Introduction to the Special Issue

There are exigent reasons to foster lesbian, gay, bisexual, and transgender (LGBT) competence, training, and ethical care for health professionals within an interdisciplinary paradigm. LGBT individuals experience serious health and psychosocial disparities; moreover, these inequalities can be amplified when other aspects of diversity such as race, ethnicity, age, gender, religion, disability, and socioeconomic status intersect with sexual orientation and gender identity (Institute of Medicine [IOM], 2011). While the origins of LGBT health and psychosocial disparities are manifold, deficiencies in professional training, ethical care, and clinical competence are underlying contributors (IOM, 2011). In addition, LGBT clinical competency advancements are often siloed within the various health care disciplines-thus advances by one group of health professionals often have limited impact for those practicing in different health and human service fields. This special issue explores LGBT clinical competence, professional training, and ethical care within an interdisciplinary context and, to our knowledge, represents the first attempt to address LGBT clinical competence from a multidisciplinary health care perspective.

Specialty Choice Among Sexual and Gender Minorities in Medicine: The Role of Specialty Prestige, Perceived Inclusion, and Medical School Climate

PURPOSE

Sexual and gender minorities (SGMs) in medicine experience unique stressors in training. However, little is known about SGM specialty choice. This study examined predictors of SGM specialty choice, associations between specialty prestige and perceived SGM inclusion, and self-reported influences on specialty choice.

METHODS

Medical trainees and practitioners (358 SGM, 1528 non-SGM) were surveyed online. We operationalized specialty choice at the individual level as respondents' specialty of practice; at the specialty level, as a percentage of SGM respondents in each specialty. We examined specialty prestige, perceived SGM inclusivity, and medical school climate as predictors of SGM specialty choice, and we compared additional influences on specialty choice between SGM and non-SGM.

RESULTS

The percentage of SGM in each specialty was inversely related to specialty prestige (P = 0.001) and positively related to perceived SGM inclusivity (P = 0.01). Prestigious specialties were perceived as less SGM inclusive (P < 0.001). Medical school climate did not predict specialty prestige (P = 0.82). SGM were more likely than non-SGM to indicate that sexual and gender identity strongly influenced specialty choice (P < 0.01). SGM most frequently rated personality fit, specialty content, role models, and work-life balance as strong influences on specialty choice. Exposure as a medical student to SGM faculty did not predict specialty prestige among SGM.

CONCLUSION

Specialty prestige and perceived inclusivity predict SGM specialty choice. SGM diversity initiatives in prestigious specialties may be particularly effective by addressing SGM inclusion directly. Further research is needed to inform effective mentorship for SGM medical students. Exposure to SGM in medical training reduces anti-SGM bias among medical professionals, and SGM in medicine often assume leadership roles in clinical care, education, and research regarding SGM health. Supporting and promoting SGM diversity across the spectrum of medical specialties, therefore, represents a critical avenue to improve the care delivered to SGM populations and addresses the role of providers in the health disparities experienced by SGM.

Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review

Recent evidence suggests that one possible cause of disparities in health outcomes for stigmatized groups is the implicit biases held by health care providers. In response, several health care organizations have called for, and developed, new training in implicit bias for their providers. This review examines current evidence on the role that provider implicit bias may play in health disparities, and whether training in implicit bias can effectively reduce the biases that providers exhibit. Directions for future research on the presence and consequences of provider implicit bias, and best practices for training to reduce such bias, will be discussed.

Giving Context to the Physician Competency Reference Set: Adapting to the Needs of Diverse Populations

Delineating the requisite competencies of a 21st-century physician is the first step in the paradigm shift to competency-based medical education. Over the past two decades, more than 150 lists of competencies have emerged. In a synthesis of these lists, the Physician Competency Reference Set (PCRS) provided a unifying framework of competencies that define the general physician. The PCRS is not context or population specific; however, competently caring for certain underrepresented populations or specific medical conditions can require more specific context. Previously developed competency lists describing care for these populations have been disconnected from an overarching competency framework, limiting their uptake. To address this gap, the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development adapted the PCRS by adding context- and content-specific qualifying statements to existing PCRS competencies to better meet the needs of diverse patient populations. This Article describes the committee's process in developing these qualifiers of competence. To facilitate widespread adoption of the contextualized competencies in U.S. medical schools, the committee used an established competency framework to develop qualifiers of competence to improve the health of individuals who are lesbian, gay, bisexual, transgender; gender nonconforming; or born with differences in sexual development. This process can be applied to other underrepresented populations or medical conditions, ensuring that relevant topics are included in medical education and, ultimately, health care outcomes are improved for all patients inclusive of diversity, background, and ability.

Microaggressions Toward Lesbian, Gay, Bisexual, Transgender, Queer, and Genderqueer People: A Review of the Literature

Microaggressions are subtle forms of discrimination, often unconscious or unintentional, that communicate hostile or derogatory messages, particularly to and about members of historically marginalized social groups. While Sue's (2010a, 2010b) microaggression theory formed its foundation in studies based on racial microaggressions, the following review summarizes microaggression literature to date, as it pertains to the lesbian, gay, bisexual, transgender, queer, and genderqueer (LGBTQ) people. Searching PsycINFO and other databases between 2010 and 2015, we found 35 peer-reviewed papers or dissertations that concentrate on the negative impact microaggressions have on LGBTQ people. A comprehensive overview of the experiences of individual LGBTQ subgroups (e.g., lesbian women, gay men, bisexual people, transgender people, and genderqueer people) is included, as well as microaggressions based on intersectional identities (e.g., experiences of LGBTQ people of color). The significance of this review is that it is the only known article to comprehensively analyze the literature on LGBTQ people and microaggressions, examining the strengths and weaknesses of past literature while encouraging future areas of theory, research, and practice.

Considering Research Outcomes as Essential Tools for Medical Education Decision Making

As medical educators face the challenge of incorporating new content, learning methods, and assessment techniques into the curriculum, the need for rigorous medical education research to guide efficient and effective instructional planning increases. When done properly, well-designed education research can provide guidance for complex education decision making. In this Commentary, the authors consider the 2015 Research in Medical Education (RIME) research and review articles in terms of the critical areas in teaching and learning that they address. The broad categories include (1) assessment (the largest collection of RIME articles, including both feedback from learners and instructors and the reliability of learner assessment), (2) the institution's impact on the learning environment, (3) what can be learned from program evaluation, and (4) emerging issues in faculty development. While the articles in this issue are broad in scope and potential impact, the RIME committee noted few studies of sufficient rigor focusing on areas of diversity and diverse learners. Although challenging to investigate, the authors encourage continuing innovation in research focused on these important areas.

Implicit bias against sexual minorities in medicine: cycles of professional influence and the role of the hidden curriculum

Despite many recent advances in rights for sexual and gender minorities in the United States, bias against lesbian, gay, bisexual, and transgender (LGBT) people still exists. In this Commentary, the author briefly reviews disparities with regard to LGBT health, in both health care and medical education, and discusses the implications of Burke and colleagues’ study of implicit and explicit biases against lesbian and gay people among heterosexual first-year medical students, published in this issue of Academic Medicine. Emphasis is placed on the ways in which physicians’ implicit bias against LGBT people can create a cycle that perpetuates a professional climate reinforcing the bias. The hidden curriculum in academic health centers is discussed as both a cause of this cycle and as a starting point for a research and intervention agenda. The findings from Burke and colleagues’ study, as well as other evidence, support raising awareness of LGBT discrimination, increasing exposure to LGBT individuals as colleagues and role models in academic health centers, and modifying medical education curricula as methods to break the cycle of implicit bias in medicine.

A Comparison of the Mental Health and Well-Being of Sexual Minority and Heterosexual First-Year Medical Students: A Report From the Medical Student CHANGE Study

PURPOSE

Research is lacking on psychological distress and disorder among sexual minority medical students (students who identify as nonheterosexual). If left unaddressed, distress may result in academic and professional difficulties and undermine workforce diversity goals. The authors compared depression, anxiety, and self-rated health among sexual minority and heterosexual medical students.

METHOD

This study included 4,673 first-year students who self-reported sexual orientation in the fall 2010 baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, a national longitudinal cohort study. The authors used items from published scales to measure depression, anxiety, self-rated health, and social stressors. They conducted bivariate and multivariate analyses to estimate the association between sexual identity and depression, anxiety, and self-rated health.

RESULTS

Of 4,673 students, 232 (5.0%) identified as a sexual minority. Compared with heterosexual students, after adjusting for relevant covariates, sexual minority students had greater risk of depressive symptoms (adjusted relative risk [ARR] = 1.59 [95% confidence interval, 1.24-2.04]), anxiety symptoms (ARR = 1.64 [1.08-2.49]), and low self-rated health (ARR = 1.77 [1.15-2.60]). Sexual minority students were more likely to report social stressors, including harassment (22.7% versus 12.7%, P < .001) and isolation (53.7% versus 42.8%, P = .001). Exposure to social stressors attenuated but did not eliminate the observed associations between minority sexual identity and mental and self-reported health measures.

CONCLUSIONS

First-year sexual minority students experience significantly greater risk of depression, anxiety, and low self-rated health than heterosexual students. Targeted interventions are needed to improve mental health and well-being.