Integrating LGBTQIA+ Health Education into the Curricula of Professional Healthcare Students

by K. R. Fairley, Doctor of Pharmacy student, University of Mississippi School of Pharmacy

Summary and Analysis of: Kelley L, Chou CL, Dibble SL, and Robertson PA. A Critical Intervention in Lesbian, Gay, Bisexual, and Transgender Health: Knowledge and Attitude Outcomes Among Second-Year Medical Students, Teaching and Learning in Medicine 2008; 20:3: 248-253.

It is estimated that up to 4.5% of the U.S. population actively identifies themselves as a member of the LGBTQIA+ community.¹  When broken down, this equates to nearly 15 million Americans, being found across all major racial, ethnic, religious, and age-based groups.² Despite these staggering figures, however, the LGBTQIA+ community remains one of the most underserved populations in the United States when it comes to healthcare.³  The reasons for this disparity are multi-factorial, ranging from a lack of trust in providers due to previous discriminatory experiences in the healthcare system to issues with accessing insurance coverage based on name changes or sex and gender differences.  While not the only cause of these disparities, the lack of provider knowledge and competence to furnish the appropriate care to this diverse group of individuals is a contributing factor. 

As a third-year pharmacy student, the topic of LGBTQIA+ health has long been of importance to me.  I think that, over the course of this past year, that importance has only grown, especially after witnessing some of the disparities play out first-hand during my clinical rotations. The discrimination faced by members of the LGBTQIA+ community in the healthcare system, including pharmacies, is just as prevalent now as ever. I knew immediately when the topic of this essay was announced that I wanted to use this time and space to talk about a learning intervention for professional healthcare students to educate them about the needs of LGBTQIA+ patients, as well as to discuss why learning interventions such as this one are so important.

Image credit: Discoversociety. “Focus: Looking Critically at Gender and Sexuality.” Discover Society, 5 Dec. 2016, discoversociety.org/2016/12/06/focus-critical-perspectives-in-gender-and-sexuality/.

Originally published in 2008, the study by Leah Kelley and colleagues describes one of the very first interventions of its kind to incorporate LGBT health education into the curriculum.  This educational event was part of the second year Doctor of Medicine program at the University of California San Francisco.  The goals of the intervention were three-fold: (1) To increase the students’ awareness and address existing assumptions about LGBT people, (2) To highlight disparities in health care delivery to which LGBT patients, and (3) To underscore the important role that physicians can play in dispelling these disparities to optimize LGBT health care.³  In order to achieve these goals, the directors of the course developed a three-pronged intervention, consisting of a syllabus, a 1-hour patient panel, and a 1-hour small group session. The syllabus was distributed to the students prior to class and served as a brief introduction to the educational event, while also emphasizing basic definitions and health hazards associated with homophobia.  The 1-hour patient panel was organized based on prior studies that indicated direct contact between students and patients helped medical students form more positive impressions of marginalized populations. The panel consisted of three voluntary participants: an older gay man, a middle-aged lesbian, and a young transgender man.  Each participant gave a short presentation, which was then followed by an interactive Q+A session with the students.  The 1-hour small group sessions focused on working through three case studies designed to highlight several LGBT health issues.  Additionally, a pre-and post-class survey was created to assess if student attitudes had changed as a result of the intervention.

At the conclusion of the two-hour course, more than 90% of students agreed that the combination of the syllabus, patient panel, and small-group cases helped to educate them about relevant LGBT issues. The majority of student comments left on the surveys were overwhelmingly positive, with most of the students indicating that hearing about personal experiences of the LGBTQIA+ panel members was most helpful in terms of identifying and addressing unconscious biases toward the LGBT community.  The results of the pre- and post-class surveys indicated that the students experienced a significant increase in their general knowledge of the challenges that LGBT individuals face in the healthcare system. They also showed an increased level of awareness about sexual orientation, gender identity, and other related attributes relevant to clinical practice.¹

A couple of the strengths of this study included (1) the integration of three different but cohesive teaching interventions to achieve the stated goal and (2) the inclusion of face-to-face contact between the medical students and members of the LGBTQIA+ community.  A few limitations were: (1) the short-term follow-up period, (2) the ability to measure a change of attitude as an outcome, and (3) the limited definitions of sexual orientation, attraction, and identity when describing the LGBTQIA+ population.  The authors in this paper continually made references to the LGBT community as “homosexual”, which is not true for every self-identified LGBTQIA+ individual.  I think the study could have been more comprehensive/ inclusive had the researchers also addressed the problems of transphobia and biphobia, as well as some of the more common issues faced by non-binary and asexual individuals in the healthcare system.  In terms of the outcome measures for this study, I believe that the investigators measured them in the best way available, given that a change in attitude is difficult to measure and prone to social desirability bias. I would have liked to have seen a longer follow-up period to this study to evaluate just how much the intervention affected the students during clinical rotations and, ultimately, their practice habits as healthcare providers.

Regardless of its limitations, this study truly has made waves in the medical education community since it was first published. I found over 200 articles citing this paper as well as two books. I believe that educators should take this study as an outline when developing courses to educate healthcare students about the challenges faced by minority groups, including but not limited to the LGBTQIA+ community.  Integrating a working knowledge about the causes and consequences of health disparities, discrimination, and unconscious bias into the professional curriculum can help increase access to healthcare and trust in providers.⁴ 

The authors state:  “It is essential for students to understand that a common causative factor in these health risks is not necessarily in merely being lesbian, gay, bisexual, or transgender: it is living as a LGBT person in a homophobic society.”³ Or, more generally, in a LGBTQ-phobic society.  This remark, I think, is the central message that educators should take away from this paper and it states clearly why educational interventions are so crucial.  More schools (including schools of medicine, pharmacy, and nursing) should consider adding similar interventions to their curriculums.

References

1. Newport F. In U.S., Estimate of LGBT Population Rises to 4.5%. com, Gallup, 29 Oct. 2020,  Accessed November 5, 2020.
2. Macapagel K, Bhatia R, Greene GJ. Differences in Healthcare Access, Use and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual, Transgender and Questioning Emerging Adults, LGBT Health 2016; 3 (6): 434-442.
3. Kelley l , Chou CL, Dibble SL, and Robertson PA. A Critical Intervention in Lesbian, Gay, Bisexual, and Transgender Health: Knowledge and Attitude Outcomes Among Second-Year Medical Students, Teaching and Learning in Medicine 2008; 20 (3): 248-253.
4. Rowe d, Ng YC, O’Keefe L, Crawford D. Providers’ Attitudes and Knowledge of Lesbian, Gay, Bisexual and Transgender Health, Federal Practitioner 2007; 34(11): 28–34.