Addressing the healthcare needs of older Lesbian, Gay, Bisexual, and Transgender patients in medical school curricula: a call to action

Sexual and gender minority content in undergraduate medical education in the United States and Canada: current state and changes since 2011

PURPOSE

To characterize current lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI +) health-related undergraduate medical education (UME) curricular content and associated changes since a 2011 study and to determine the frequency and extent of institutional instruction in 17 LGBTQI + health-related topics, strategies for increasing LGBTQI + health-related content, and faculty development opportunities.

METHOD

Deans of medical education (or equivalent) at 214 allopathic or osteopathic medical schools in Canada and the United States were invited to complete a 36-question, Web-based questionnaire between June 2021 and September 2022. The main outcome measured was reported hours of LGBTQI + health-related curricular content.

RESULTS

Of 214 schools, 100 (46.7%) responded, of which 85 (85.0%) fully completed the questionnaire. Compared to 5 median hours dedicated to LGBTQI + health-related in a 2011 study, the 2022 median reported time was 11 h (interquartile range [IQR], 6-16 h, p < 0.0001). Two UME institutions (2.4%; 95% CI, 0.0%-5.8%) reported 0 h during the pre-clerkship phase; 21 institutions (24.7%; CI, 15.5%-33.9%) reported 0 h during the clerkship phase; and 1 institution (1.2%; CI, 0%-3.5%) reported 0 h across the curriculum. Median US allopathic clerkship hours were significantly different from US osteopathic clerkship hours (4 h [IQR, 1-6 h] versus 0 h [IQR, 0-0 h]; p = 0.01). Suggested strategies to increase content included more curricular material focusing on LGBTQI + health and health disparities at 55 schools (64.7%; CI, 54.6%-74.9%), more faculty willing and able to teach LGBTQI + -related content at 49 schools (57.7%; CI, 47.1%-68.2%), and more evidence-based research on LGBTQI + health and health disparities at 24 schools (28.2%; CI, 18.7%-37.8%).

CONCLUSION

Compared to a 2011 study, the median reported time dedicated to LGBTQI + health-related topics in 2022 increased across US and Canadian UME institutions, but the breadth, efficacy, or quality of instruction continued to vary substantially. Despite the increased hours, this still falls short of the number of hours based on recommended LGBTQI + health competencies from the Association of American Medical Colleges. While most deans of medical education reported their institutions' coverage of LGBTQI + health as 'fair,' 'good,' or 'very good,' there continues to be a call from UME leadership to increase curricular content. This requires dedicated training for faculty and students.

Sexual and gender minority health-related content in geriatric fellowships

INTRODUCTION

Despite a growing number of older lesbian, gay, bisexual transgender, and queer (LGBTQ) adults in the United States, education on care for this vulnerable population has historically been inadequate across all levels of training. This research assessed the extent of LGBTQ education in geriatric medicine fellowship curricula across the United States.

METHODS

We designed a survey to anonymously collect information from geriatric medicine fellowship programs on LGBTQ curricular content. Eligible participants included all 160 fellowship directors on record with the American Geriatrics Society. The survey addressed demographics of the fellowship program, current state of inclusion of LGBTQ content in didactic curricula and in clinical settings, and other available training opportunities.

RESULTS

Out of those contacted, 80 (50%) completed the survey. Of the programs surveyed, 60 (75%) were housed in internal medicine, 19 (24%) were in family medicine, and one was in their own department. Forty-seven fellowships (59%) reported some formal didactic session (e.g., lecture or case based), with the majority of these programs (72%) featuring 1-2 h of formal instruction. Forty-five programs (56%) reported offering no formal clinical experiences. There was less than 50% coverage for all surveyed topics in the required curriculum (range 46% for discrimination to 9% for gender affirming care). Time and lack of expertise were cited as the main barriers to content inclusion.

CONCLUSIONS

Curricular content regarding care for LGBTQ older adults is inadequate in geriatric medicine fellowships. Faculty development of current educators and providing standardized guidelines and curricula are steps toward addressing this deficit.

Characterization of content associated with lesbian, gay, bisexual, transgender, intersex, and queer individuals in Chilean medical schools: a cross-sectional survey

BACKGROUND

Lesbian, gay, bisexual, transgender, intersex, queer, and other sexual and gender identities (LGBTIQ+) individuals face health inequities. Additionally, medical students report a lack of confidence in providing specific health care to LGBTIQ + individuals, and medical schools do not offer the breadth and depth of coverage needed to fully prepare and make them comfortable in caring for these individuals. This study aims to characterize the teaching of curricular content related to LGBTIQ + health issues in medical schools in Chile.

METHODS

This was a cross-sectional descriptive mixed-methods study based on a 15-question survey sent to school directors of the 24 medical schools in Chile, conducted between October 2020 and July 2021. The questions included in the study were mostly based on two pre-existing questionnaires covering content, assessment methods, and identification of barriers to teaching this content.

RESULTS

The validated questionnaire was answered by 14 of 24 Chilean medical schools, with 11 schools (78.9%) declaring that they included some training in their curriculum. The predominant range of time allocated to LGBTIQ + training in medical programs was between 1 and 5 h. The most addressed topics were HIV (92.85%), sexual orientation (78.57%), and chronic disease risk in LGBTIQ + populations (78.57%). Most schools, accounting for 71.5%, considered the content they delivered to be "moderately insufficient" or "insufficient". Regarding the teaching methodologies, the most used were lectures (92.8%), clinical cases (42.9%), and clinical simulation (28.6%).

CONCLUSION

Most surveyed medical schools reported curricular spaces dedicated to teaching health issues of LGBTIQ + individuals, primarily during the pre-internship training period. However, the time allocated is insufficient, and there is little approach to topics beyond the patient's sexual history or sexual orientation. Given the crucial role of medical schools, they must adopt both local and national strategies to enrich training focused on the care of LGBTIQ + patients.

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.

Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Nonbinary Adults 50 Years Old and Older in the United States

Purpose: The purpose of this study was to examine health disparities among LGBT and nonbinary adult subgroups of those 50 years old and older. Methods: This was a cross-sectional analysis of data from the 2019 Behavioral Risk Factor Surveillance System survey. Access to health care, disabilities, health risk and healthy behaviors, and general health and chronic diseases and conditions were compared between gay men, bisexual men, lesbian/gay women, bisexual women, transgender women, transgender men, and nonbinary adults 50 years old and older. Rao-Scott corrected chi-square tests were utilized to determine significant differences between subgroups using weighted data. Multiple comparisons adjusted p values (Bonferroni) analyses were conducted when chi-square tests were significant. Results: Health disparities were identified among subgroups of LGBT and nonbinary older adults, with those who identified as nonbinary or as transgender women being the most vulnerable. Older nonbinary adults, transgender women, and bisexual men were more likely to not have a personal doctor or to not have had a medical checkup in the past 2 years, and nonbinary older adults were more likely to report disabilities, poor mental and physical health, depression, and asthma. Conclusion: Public health professionals and health care providers can use this information to target interventions to specific groups. Subgroup analyses of LGBT and nonbinary adults who are 50 years old and older need to continue with a focus on the most vulnerable groups. In addition, more research is needed that disaggregates transgender and nonbinary older adults to identify the unique health concerns of each group.

Propensity Score Analysis Assessing the Burden of Non-Communicable Diseases among the Transgender Population in the United States Using the Behavioral Risk Factor Surveillance System (2017-2019)

Research to assess the burden of non-communicable diseases (NCDs) among the transgender population needs to be prioritized given the high prevalence of chronic conditions and associated risk factors in this group. Previous cross-sectional studies utilized unmatched samples with a significant covariate imbalance resulting in a selection bias. Therefore, this cross-sectional study attempts to assess and compare the burden of NCDs among propensity score-matched transgender and cisgender population groups. This study analyzed Behavioral Risk Factor Surveillance System data (2017–2019) using complex weighting procedures to generate nationally representative samples. Logistic regression was fit to estimate propensity scores. Transgender and cisgender groups were matched by sociodemographic variables using a 1:1 nearest neighbor matching algorithm. McNemar, univariate, and multivariate logistic regression analyses were conducted among matched cohorts using R and SPSS version 26 software. Compared with the cisgender group, the transgender group was significantly more likely to have hypertension (31.3% vs. 27.6%), hypercholesteremia (30.8% vs. 23.7%), prediabetes (17.3% vs. 10.3%), and were heavy drinkers (6.7% vs. 6.0%) and smokers (22.4% vs. 20.0%). Moreover, the transgender group was more than twice as likely to have depression (aOR: 2.70, 95% CI 2.62–2.72), stroke (aOR: 2.52 95% CI 2.50–2.55), coronary heart disease (aOR: 2.77, 95% CI 2.74–2.81), and heart attack (aOR: 2.90, 95% CI 2.87–2.94). Additionally, the transgender group was 1.2–1.7 times more likely to have metabolic and malignant disorders. Differences were also found between transgender subgroups compared with the cisgender group. This study provides a clear picture of the NCD burden among the transgender population. These findings offer an evidence base to build health equity models to reduce disparities among transgender groups.

Educating health and social care practitioners on the experiences and needs of older LGBT+ adults: Findings from a systematic review

AIM(S)

To report review findings into interventions used to educate the health and social care workforce on the experiences and needs of LGBT+ older adults.

BACKGROUND

Research demonstrates that inequalities in outcomes on health and social well-being for LGBT+ older adults are perpetuated by the cumulative disadvantages from discrimination and social exclusion throughout the life course and a lack of culturally competent workforce.

METHODS

A systematic search of peer-reviewed papers published before February 2020 was conducted in electronic databases. The search resulted in a screening of 2,509 papers with nine matching the inclusion criteria, which were rated using the MERSQI quality measure.

RESULTS

Studies demonstrated some positive outcomes of interventions, especially an increase in knowledge, but less so in skills and attitudes.

DISCUSSION

More robust designs such as randomized controlled trials, the use of standardized measures and a focus more on the longitudinal impact of educational interventions could improve the quality of study designs.

CONCLUSION(S)

Diversification of intervention content and patient and public involvement in the design, delivery and evaluation of educational interventions could improve efforts and have a more sustained impact on LGBT+ ageing inequalities.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers have important roles in supporting staff education and ensuring LGBT+ inclusive practice.

Transgender Health Care Curriculum Development: A Dual-Site Medical School Campus Pilot

Purpose: Lack of physician training contributes to health care disparities for transgender people. The limited generalizability and feasibility of published training approaches lessen their utility in lowering barriers for other institutions to adopt similar training. Methods: All first-year medical students at the Mayo Clinic Alix School of Medicine (MCASOM) in Minnesota and Arizona received a 1-h lecture introducing key concepts related to transgender people and their health disparities. Students completed a 21-question survey before and after the lecture, and 1 year later. Chi-square likelihood coefficients were used to compare responses between the three time points. Results: Eighty-six of 100 students answered the prelecture survey (86% response rate); 70 the postlecture survey; and 44 the 1-year follow-up survey. Twenty-five (29%) students had prior education in any lesbian, gay, bisexual, and transgender (LGBT+) health disparities, but this did not correlate with more favorable attitudes or knowledge. LGBT+ students and those with close LGBT+ friends had the most favorable attitudes and knowledge. The proportion of students comfortable with caring for transgender people changed significantly (76% self-reported very comfortable prelecture vs. 91% postlecture, p=0.0073) and remained at 89% 1 year later. The proportion of students comfortable with a transgender patient scenario significantly increased (67% self-reported very comfortable prelecture vs. 87% postlecture, p=0.032) even when surveyed 1 year later (95% very comfortable, p<0.0001). Conclusion: This study demonstrates that a 1-h lecture can increase the proportion of medical students who demonstrate positive attitudes and correct knowledge on transgender patient care for at least a year, and how a survey can gather essential information on student learning needs to guide training development.

Are all LGBTQI+ patients white and male? Good practices and curriculum gaps in sexual and gender minority health issues in a Dutch medical curriculum

Objectives: People marginalized based on their sexual and gender identity face specific health risks and experience barriers to culturally competent care. Insight into how Dutch medical schools address LGBTQI+ health-related learning objectives is scarce. We therefore examined how LGBTQI+ health issues are integrated in the Amsterdam UMC-VUmc medical curriculum by evaluating the year-two course 'Sex, Sexuality and Relationships' for LGBTQI+ content. Methods/Design: We examined written course content (course syllabus, lecture notes, and course literature) of the 2016-2017 course. We used a framework for essential LGBTQI+ content in medical education and an intersectional approach to examine which LGBTQI+ themes and subthemes were addressed. Results: Several essential LGBTQI+ health issues were adequately addressed and integrated into the Amsterdam UMC-VUmc curriculum, but we also identified curriculum gaps. The needs of patients with lesbian, bisexual, or gender non-conforming identities were marginally addressed, and issues related to intersections of minoritized sexual and gender identities with other aspects of diversity such as ethnicity, age and class remained unexplored. The course discussed gender and sexuality as fixed and mainly binary constructs, and only addressed biomedical explanatory models of sex, gender and sexuality. Discussion and conclusion: The absence of complex patient identities in relation to sex, gender and sexuality does not adequately prepare students to provide LGBTQI+ responsive care. If not designed and taught competently, LGBTQI+-related curriculum content may reproduce bias and stereotypes, and contribute to a medical climate where both LGBTQI+ patients, students, and doctors conceal their identities. Further implementation of LGBTQI+ health issues is required in (continuing) medical education to secure culturally competent clinical environments. Educational research is needed to understand how medical education contributes to marginalization of LGBTQI+ identities and thus, to health disparities.

Strategies for inclusion of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) education throughout pharmacy school curricula

Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others (LGBTQIA+) patients face stigma and barriers to health care, including a lack of health care professionals' knowledge and confidence in treating this patient population. Pharmacists are in prime position to decrease this health disparity. United States pharmacy schools have limited LGBTQIA+ content, continuing the concern of recent graduates without knowledge and confidence. This commentary discusses potential barriers to introducing LGBTQIA+ content into school of pharmacy curricula and presents five strategies currently in use by nursing, medical, and pharmacy schools. Schools of Pharmacy should consider proactive incorporation of this content to graduate practitioners able to provide quality care to LGBTQIA+ patients.

Physical and mental health inequalities among aging lesbian, gay, and bisexual Canadians: cross-sectional results from the Canadian Longitudinal Study on Aging (CLSA)

OBJECTIVE

International estimates suggest the presence of health inequalities among older sexual minorities (i.e., individuals who identify as lesbian, gay, or bisexual and are 65 years old or above). In this study, we investigated the presence of health inequalities among aging lesbian and bisexual females, as well as aging gay and bisexual males in Canada.

METHODS

We used baseline data from the Canadian Longitudinal Study on Aging (CLSA) Tracking and Comprehensive cohorts to cross-sectionally compare self-reported physical and mental health indicators by sex and sexual orientation. Within our analysis sample of 51,208 Canadians 45 years old and over, 2% (n = 1057) of respondents identified as lesbian, gay, or bisexual.

RESULTS

Compared to heterosexual female peers, lesbian and bisexual females had greater odds of heavy drinking (AOR = 1.8, 95% CI = 1.3-2.4) and being a former smoker (AOR = 1.5, 95% CI = 1.2-1.9). Gay and bisexual males had greater odds of reporting a diagnosis of cancer (AOR = 1.5, 95% CI = 1.0-1.9) and currently smoking (AOR = 1.5, 95% CI = 1.1-2.0), compared to heterosexual males. Female and male sexual minorities had greater odds of reporting mood disorders (including depression) and anxiety disorders relative to heterosexual peers of the same sex.

CONCLUSION

These findings highlight the importance of considering both sex and sexual orientation when developing approaches to support the physical and mental health of a diverse aging population in Canada.