Canadian Medical Education Journal Major Contributions Improving the LGBTQ2S+ cultural competency of healthcare trainees: advancing health professional education Améliorer la compétence culturelle des stagiaires en soins de santé auprès de personnes LGBTQ2S+ : un pas en avant pour la formation des professionnels de la santé Matthew Lee,1 Elisabet Tasa-Vinyals,2 Jacqueline Gahagan1 1Gender and Health Promotion Studies Unit, School of Health and Human Performance, Dalhousie University, Nova Scotia, Canada; 2Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Catalonia, Spain; 3Department of Psychiatry and Mental Health. Osona Salut Mental. Consorci Hospitalari de Vic, Catalonia, Spain Correspondence to: Dr. Matthew Lee; 507-3020 Monaghan Drive, Halifax NS B3K 0G3; e-mail: Lee.Matthew@dal.ca Published ahead of issue: December 6, 2020; published: February 26, 2021. CMEJ 2021; 12(1). Available at http://www.cmej.ca © 2021 Lee, Tasa-Vinyals, Gahagan; licensee Synergies Partners https://doi.org/10.36834/cmej.67870. This is an Open Journal Systems article distributed under the terms of the Creative Commons Attribution License. (https://creativecommons.org/licenses/by-nc-nd/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is cited. Abstract Résumé Background: Lesbian, Gay, Bisexual, Trans, Queer, and Two-spirit Contexte : Les populations lesbiennes, gaies, bisexuelles, transgenres, (LGBTQ2S+) populations experience worse health outcomes queers et bispirituelles (LGBTQ2S+) présentent de moins bons résultats de compared to age-matched heterosexual and cisgender peers. Health santé que leurs homologues hétérosexuelles et cisgenres. Le manque de professionals’ deficient knowledge and negative attitudes can connaissances et les attitudes négatives des professionnels de la santé contribute to these inequities. Healthcare trainees report insufficient peuvent contribuer à ces inégalités. Les stagiaires en soins de santé LGBTQS2+ cultural competence training. estiment leur formation en matière de compétence culturelle insuffisante en ce qui a trait aux personnes LGBTQS2+. Methods: In this prospective, mixed-methods pre-post design, Méthodes : Dans cette étude prospective pré-post, utilisant une Atlantic Canadian health students were tested on knowledge, méthodologie mixte, des étudiants en soins de santé du Canada atlantique attitudes and self-reported behaviours towards LGBTQ2S+ ont été testés sur leurs connaissances, leurs attitudes et leurs populations in healthcare settings. Assessment included comportements autodéclarés à l'égard des populations LGBTQ2S+ en psychometric measurements and clinical cases involving normative contexte de soins de santé. L'évaluation comprenait des mesures and non-normative fictional patients. Participants were randomised psychométriques et des cas cliniques impliquant des patients fictifs to intervention or control groups. The intervention consisted of three normatifs et non normatifs. Les participants étaient répartis training sessions lead by LGBTQ2S+ experts and elders from the aléatoirement entre le groupe d’intervention et le groupe témoin. community. The control group continued with usual training. Full L'intervention consistait en trois séances de formation dirigées par des assessment was repeated after training. We also held focus group experts en LGBTQ2S+ et des patients formateurs de la communauté. Le discussions with students and faculty. groupe témoin a poursuivi la formation habituelle. L'évaluation complète Results: The intervention group significantly improved attitudes a été répétée après la formation. Nous avons également organisé des toward and knowledge of LGBTQ2S+ populations and changed discussions de groupe avec les étudiants et le corps professoral. relevant aspects of their performance in the simulated clinical Résultats : Les stagiaires du groupe d'intervention ont considérablement situations. Focus groups identified key gaps in current local training. amélioré leurs connaissances sur les populations LGBTQ2S+ et leurs attitudes envers elles, et ils ont modifié des aspects pertinents de leur Conclusions: Integrating specific training related to LGBTQ2S+ health performance dans les situations cliniques simulées. Les groupes de within health professions programs is an important step toward discussion ont permis d'identifier les principales lacunes de la formation improving these populations’ accessibility to a competent, exhaustive locale actuelle. and nurturing healthcare. Additional research on innovative means to Conclusions: L'intégration d'un volet portant spécifiquement sur la santé expand and broaden the scope of our training is warranted. des personnes LGBTQ2S+ dans les programmes de formation en santé est un élément important de l’amélioration de l’accès de ces populations à des soins de santé appropriés, complets et bénéfiques. Des recherches plus poussées sur les moyens innovants d'élargir la portée de nos formations sont de mise. e7 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) of different health-related occupations and stages of Introduction training, signifying a need for providers to gain these crucial Lesbian, Gay, Bisexual, Trans, Queer, Two-spirit and other skills. For example, transgender patients struggle with sexual and gender minority (LGBTQ2S+) populations finding healthcare providers with sufficient knowledge to experience worse health outcomes in many distinct health address their health needs. Moreover, some healthcare domains as compared to their heterosexual and cisgender providers argue that sexual orientation and gender identity peers.1,2 Research indicates many poor health outcomes do not matter in the health care context and by focusing on amongst LGBTQ2S+ Canadians, including higher rates of sexual orientation and gender identity, we may in fact suicide, cigarette smoking, alcohol and other forms of drug contribute to worse healthcare provision and poor health abuse, depression, and HIV/AIDS,3,4 and avoiding health outcomes in LGBTQ2S+ populations.16 services when needed.5,6 These longstanding health disparities represent an important public health issue. Several published studies evaluate healthcare provider From an intersectional perspective, it is important to note training programs for LGBTQ2S+-specific content. For that populations with multiple axes of marginalisation example, a survey of undergraduate medical education (race, education, income, age, among others) within the programs in the US and Canada shows a median time in the broader LGBTQ2S+ population experience further risks to total curriculum of five hours with high variability in their health.7 content, quality, and instruction.17 Trans health is a particular area of concern in this and other studies, as some Several theories are used to help explain these striking studies have found that less than 10% of surveyed health disparities and are described in the health literature. Canadian medical students feel knowledgeable about trans Minority stress theory, for example, is a conceptual health issues and suggests a continued deficit in clinical framework used to help illuminate health disparities in competence within medical and nursing education.18,19 LGBTQ2S+ communities.8 Social determinants of health, including social exclusion, housing, employment, income, Other opportunities to improve access to healthcare and early childhood development, intersect and contribute involve structural, policy, and institutional changes. For to poor health outcomes among LGBTQ2S+ individuals.9 example, the misgendering of patients by staff in electronic Internalized homophobia is another mechanism medical records and in legal documentation can heighten contributing to poor health outcomes among LGBTQ2S+ gender dysphoria among transgender and gender non- populations.10 conforming individuals, while heteronormative assumptions can lead to discomfort among sexual minority Inequalities in cancer screening and care amongst patients. These negative experiences may contribute to LGBTQ2S+ populations exist, and as such, overall cancer patients abandoning health care seeking behaviours and screening rates remain low.11,12 The case of breast cancer thus dissuade future care.5 among lesbians is perhaps one of the most researched, with clear evidence of homophobia (e.g. discriminating However, LGBTQ2S+ healthcare training interventions are against the patient and/or her female partner because of implemented in many training and research settings across their sexual orientation and heterosexism (e.g. assuming the globe.20,21 At the Boston University School of Medicine, the existence of a male sexual and/or affective partner for Park and Safer demonstrate that early clinical exposure to the patient) shaping the experiences of lesbian women transgender patients improves comfort and knowledge with the disease.13,14 A number of patient factors by which regarding trans health issues,22 while Taylor et al. integrate screening may be different in LGBTQ2S+ populations role-play scenarios into training for medicine, dentistry, include family structure, social isolation, and cultural and nursing students, although only focusing on a myths. However, LGBTQ2S+ individuals also report lack of particular mental health issue (gender dysphoria).23 knowledge among healthcare providers as a key barrier to Further, a review from Sekoni et al. encompassing 15 health care and describe receiving substandard care.15 studies on methodologically diverse medical educational interventions seeking to improve knowledge, attitudes, In fact, previous research suggests that many healthcare and practice with LGBTQ2S+ patients report a significant providers themselves do not feel comfortable or increase in knowledge after specific training on LGBTQ2S+ knowledgeable enough to address the unique health needs populations regardless of the particular educational of LGBTQ2S+ individuals and are frustrated by the lack of methodology used.24 Notably, transgender content was specific training they receive. This is observed in a variety absent from the studies in the review, and 12 of the 15 e8 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) studies took place in the USA, with two from the UK and Directly after inclusion and before randomisation (pre- one from Kenya. As well, the studies represent a mix of test), each participant completed an online survey both healthcare profession student trainees and practicing delivered using free online survey software (Opinio). The healthcare professionals. survey consisted of two validated psychometric tools available in the existing literature and three fictional clinical Taken together, existing research findings clearly suggest a cases involving gender normative and non-normative role for a case-based training in working toward addressing patients. (Please see the following subsection on Materials LGBTQ2S+ health disparities. In addition, there is also clear for further details). Participants also provided basic opportunity to improve patient-provider therapeutic demographic data in order to check for potential effects of relationships through the increased knowledge, skills, and factors that could arguably be relevant in terms of power attitudes—leading to greater competence—that asymmetry, i.e. race, gender identity, or sexual orientation. LGBTQ2S+-specific training can offer. After completing the pre-test survey, participants were On a local level, we found very little content regarding randomised to the intervention or control groups using LGBTQ2S+ health within the required curriculum for health internet-based randomisation software. After the professional trainees at Dalhousie University (Halifax, NS), intervention group had finished the training, we invited all though LGBTQ2S+ patients in the local area arguably participants to complete an identical online survey (post- experience the same disparities reported in other test) and to provide feedback on the content and quality of jurisdictions.25 The goal of our study was to test the the workshops. effectiveness of a pilot intervention consisting of a short- term training session lead by LGBTQ2S+ experts and elders In addition, after the training period concluded, we held a from our local community. We were particularly interested total of three focus groups to seek feedback about the pilot in finding out whether our intervention was capable of training program and discuss its perceived connection with changing the attitudes, knowledge, and clinical decisions broader conceptual frameworks related to LGBTQ2S+ on case-based discussions of future healthcare cultural competence. The principal investigator conducted professionals, in the understanding that answers given by a facilitated discussion and audio recorded all three focus students could arguably be in line with those eventually groups with permission from participants. Focus group displayed in real-life clinical settings in the future. sessions lasted approximately one hour each. The full text of the predetermined questions that we used to guide Methods facilitated discussion can be provided by contacting the Research ethics authors. The Health Sciences Research Ethics Board (REB) at Participants Dalhousie University approved this study. We obtained For the training portion of the study, we recruited 50 informed consent from participants through an online students using snowball convenience sampling from the acceptance process before completing our online survey. School of Nursing and the Faculty of Medicine at Dalhousie We used written consent forms for the in-person focus University via e-mail and promotional posters. groups. Participation was entirely voluntary and obtained data could not be matched to specific participants. For the focus groups, we recruited 15 participants in total Participants did not receive any financial compensation for via e-mail. Focus groups were open to both students and participation and were free to withdraw from the study at faculty members in any Faculty of Health program or any time without penalty. Medicine. Therefore, participants in the focus groups were not necessarily the same people as had participated in the Study design and protocol training or been part of the control group, and they can be Our prospective, mixed-methods, randomised pre-post considered a more diverse group insofar they were not study design was comprised of an educational intervention only nursing and medicine students. Participants were not and a series of focus groups which took place during asked to state their study program in focus groups, though November 2016 in Halifax, Nova Scotia, Canada. Since this they were required to provide information on whether project was designed as a pilot study, no determination they were undergraduate students, postgraduate students, was made prior to starting the study of the number of or staff. subjects needed to expect a given effect size in the data. e9 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) Materials hypogastric pain as a single symptom. Case design was built Lesbian, Gay, and Bisexual Knowledge and Attitudes Scale for the specific purposes of this study on the basis of for Heterosexuals (LGB-KASH):26 The LGB-KASH scores authors’ previous work, which was in turn informed by reflect attitudes toward and knowledge about LGB existing literature.29,30 We consecutively presented three populations, and is scored in 5 domains named Hate, clinical cases to participants, followed by a series of Knowledge, Civil Rights, Religious Conflict, and attitudinal and clinical reasoning questions. For the Affirmativeness. As suggested by its name, it was originally purpose of this study, we used a hypothetical scenario in developed for heterosexual populations whereby which screening for all listed medical conditions was participants are presented with 28 items and self-identify actually available (e.g. screening for all STIs or for ovarian in a Likert scale (1-7) according to the degree upon which cancer). We used a Likert scale (1-5) for attitudinal they identify with each of the statements. The scores given questions, and dichotomous answers for questions to the items corresponding to each of the five domains are regarding self-reported clinical behaviour and performance then added up separately and divided by the number of (e.g. ordering specific medical testing or use of pronouns). items that integrate each domain in such a way as to allow For further details on the clinical cases used, along with the for individual scores to be interpreted against the backdrop complete list of questions that followed each of them, of a minimum-maximum score range for each domain that please refer to Appendix A. depends on the number of items that integrate it. (For Intervention complete notes on item content and scoring, please Participants in the intervention group were invited to contact the authors. attend a three-session 90-minute training intervention lead The Riddle Scale: Attitudes towards Gay, Lesbian, by LGBTQ2S+ experts and elders from the community Bisexual, and Trans (GLBT) people purvey:27,28 The Riddle (instructors) over a period of one month. Instructors were Scale scores participants along a dimensional spectrum contacted via LGBTQ2S+ communities in Nova Scotia. All ranging from Repulsion (category 1) to Nurturance sessions took place within university facilities outside of (category 8) of GLBT populations. Though not explicitly regular academic schedule (evenings), and were audio stated in the instruments’ denomination, its item recorded with permission of all instructors and formulation seems to imply that the scale is aimed to participants. Each session focused on a particular normative (heterosexual and cisgender) population. It healthcare challenge identified by instructors and presents participants with 16 statements on GLBT researchers: 1) Introduction of LGBTQ2S+ healthcare, 2) populations in order, from the most hateful (1) to the most Lesbian and bisexual women and breast cancer, and 3) nurturing (16) views. Subjects self-identify in a Likert scale Medical care and access to treatment for transgender and (1-5) in each of the statements. A final score is obtained by gender non-conforming individuals. Sessions were combining scores in each statement, which is then organized with some information giving along with videos converted into a categorical result (1-8). (For complete and stories of lived experiences followed by a facilitated notes on item content and scoring, please refer to contact discussion the authors. Over the study period, the control group continued Model clinical cases: We constructed three model clinical receiving the usual training provided by their healthcare cases involving demographically and clinically identical educational program. For ethical reasons, at the end of the patients presenting as LGBTQ2S+ or as study period–after all participants had completed the post- cisgender/heterosexual. Cases consisted of three test survey–participants in the control group were given independent everyday-life clinical scenarios suitable for a online access to training materials, including presentations standard general medical and nursing practitioner and and audio recordings. included: 1) A person with no significant clinical records consulting with signs of Sexually Transmitted Infection Data analysis For analysis of data obtained from psychometric (STI), 2) A person within breast cancer screening age range measurements and model clinical cases, we exported presenting asymptomatic to a medical routine visit with no survey results from Opinio for each experimental group records of previous screening breast exams available (training, control) for statistical analysis. We used IBM SPSS (clinical, analytic, nor radiological), and 3) A person with a Statistics software version 25.0 for univariate and bivariate family history of cervical cancer presenting with e10 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) analysis. We used paired Student t-test and Wilcoxon negative attitudes toward LGB populations. No other signed rank tests to analyse change between pre- and post- domains showed significant changes in the intervention test quantitative and ordinal measurements. Cohen's d test group. The control group did not show any remarkable nor for effect sizes were calculated for the purpose of statistically significant changes in any domain. Of particular identifying practically important findings deserving further note, our sample (both control and intervention groups) study, a point that we considered particularly important showed baseline high scores in the domains of Internalized since this is a pilot study. For relationships between Affirmativeness (mean score=26.4 for the intervention categorical variables, we used Chi-square test, along with group and mean score=24.8 for the control group; possible its Yates correction if necessary. Statistical significance was score range 5-35), and Support of LGB Civil Rights (mean set at p < 0.05 for two-tailed p value. Non-parametric score=34.1 for the intervention group and mean equivalents were considered when required by sample score=34.2 for the control group; possible score range 5- distribution. 35). Similarly, they obtained relatively low baseline scores in domains such as Hate (mean score=7.9 for the For data obtained from the focus groups, two members of intervention group and mean score=7.5 for the control the research team independently analysed the group; possible score range 6-42) and Religious Conflict transcriptions of the recordings to ensure agreement (mean score=15.9 for the intervention group and mean between themes, which we arranged into major and minor score=15.4 for the control group; possible score range 7- themes. 49). This arguably left little room for improvement, as we Results will discuss in the following section. Demographic data Table 1. Participant demographics: Descriptive statistics regarding study population collected with the initial survey. We collected and compiled demographic data about our Participants self-identified. participants in Table 1 “Participant demographics.” In total, Participant demographics 50 participants enrolled in the study. Of these, 13 were Intervention Control Total students in Dalhousie University Faculty of Nursing, and the (n = 18) (n = 32) (n = 50) remaining 37 were students in the Faculty of Medicine. It Gender Identity should be noted that a total of 13 participants (three from Female 14 21 35 the intervention group and 10 from the control group) did Male 4 11 15 not complete the second survey after the study period and Trans* 0 0 0 Other 0 0 0 were considered withdrawn. Sexual Orientation Component 1: Lesbian, Gay, and Bisexual Knowledge and Heterosexual 16 24 40 Attitudes Scale for Heterosexuals (LGB-KASH). Results are Gay 1 3 4 shown in Table 2 “LGB-KASH pooled results.” The most Lesbian 0 0 0 Bisexual 0 0 0 striking change within the intervention group is the mean Asexual 0 5 5 increase in scoring within the Knowledge domain from 11.5 Other 1 1 2 to 20.5 (score range 5-35; p = 0.0004; Cohen’s d = 1.38), Race / Ethnicity compared to the control group which only minimally White 16 26 42 changed from 12.0 to 13.6. Given the nature of the Black 0 1 1 Knowledge domain items, this shows that participants in Indigenous 0 3 3 the intervention group significantly improved their Asian 1 3 4 perceived knowledge of LGB issues and history compared Hispanic 0 0 0 to the control group, though it is not possible to conclude Arab 0 2 2 Other 1 1 2 that there was an actual improvement in measurable Faculty knowledge. There was also a statistically significant Nursing 6 7 13 decrease in mean scoring in the intervention group along Medicine 12 25 37 the Hate domain from 7.94 to 6.07 (score range 6-42; p = 0.032; Cohen’s d = 0.82), demonstrating decreased e11 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) Table 2. LGB-KASH pooled results. Pre- and post-training comparison of mean results between intervention and control groups Pre-Training Post-Training ∆ (Mean) Cohen’s d p Intervention: Mean, (SD) N = 18 N = 15 Hate 7.94 (3.2) 6.07 (.3) -1.87 0.82 0.0318 Knowledge 11.53 (5.4) 20.47 (7.4) 8.94 1.38 0.0004 Civil Rights 34.06 (1.7) 33.93 (2.3) -0.13 NS Religious Conflict 15.94 (8.0) 13.13 (7.1) -2.81 NS Affirmativeness 26.44 (5.5) 28.43 (4.2) 1.99 NS Control: Mean, (SD) n = 32 n = 22 Hate 7.50 (2.8) 7.76 (5.3) 0.26 NS Knowledge 12.03 (7.3) 13.59 (8) 1.56 NS Civil Rights 34.16 (2.1) 33.95 (2.5) -0.21 NS Religious Conflict 15.43 (8.4) 16.79 (7.8) 1.36 NS Affirmativeness 24.84 (6.6) 25.9 (5.3) 1.06 NS Component 2: The Riddle Scale: Attitudes Towards GLBT changes were statistically significant. Overall, our People Survey. Results are fully detailed in Table 3 “Riddle participants had very positive pre-test scores on the scales Scale pooled results.” The total percentage of participants Appreciation and Nurturance with 93.8% (n = 30/32) of the scoring in the most positive category (Nurturance) control group and 94.4% (n = 17/18) of the intervention increased in the intervention group from 83.3% (pre-test) group scoring in the most positive categories. Similar to to 93.3% (post-test). In contrast, those in our control group what occurred with Component 1, this probably created a remained relatively static (71.9% and 68.2% in the pre- and ceiling effect. post-test assessments, respectively). However, none of the Table 3.Riddle Scale pooled results. Results showing number and percentage of participants scoring in each domain of the scale before and after the intervention. Riddle Scale pooled results Pre-Training Post-Training ∆ (%) p Intervention: Count, (%) n = 18 n = 15 Repulsion 0 0 0 NS Pity 0 0 0 Tolerance 0 0 0 Acceptance 0 0 0 Support 1 (5.6) 0 -5.6 Admiration 0 0 0 Appreciation 2 (11.1) 1 (6.7) -4.4 Nurturance 15 (83.3) 14 (93.3) 10.0 Control: Count, (%) n = 32 n = 22 Repulsion 0 0 0 NS Pity 0 0 0 Tolerance 0 0 0 Acceptance 0 0 0 Support 1 (3.1) 0 -3.1 Admiration 1 (3.1) 2 (9.1) 6.0 Appreciation 7 (21.9) 5 (22.7) 0.8 Nurturance 23 (71.9) 15 (68.2) -3.7 Component 3: Model clinical cases. Selected results are In the first clinical scenario–describing a man presenting to shown in “Model Clinical Cases” (Appendix B). There were a clinic with symptoms of STI–participants indicated that no significant differences between pre- and post-test they felt it more necessary after training to perform a scores in the control group. Conversely, we observed a few physical exam of the heterosexual-identified man (4.67 significant differences within the intervention group. e12 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) versus 5.00, p = 0.04) compared to one with a same-gender LGBTQ2S+ individuals, and the needs of aging LGBTQ2S+ partner. individuals were key aspects commonly perceived as lacking. Participants also stated that they felt a need for Similarly, in the second clinical scenario – describing an additional training in core counselling topics including, but asymptomatic woman with criteria for primary prevention not limited to, coming out, parenting, relationships, and (screening) of breast cancer, participants were more likely interpersonal violence. The inclusion of these concepts as after training to take a sexual history of the woman with a core or mandatory curriculum, rather than as an elective male partner compared to the one with a female partner extracurricular option, was regarded as crucial. (3.67 versus 4.53, p = 0.012), in addition to feeling more Nonetheless, participants’ discourse emphasised a motivated toward providing help to the LGBTQ2S+ woman preference towards encouraging self-directed learning (3.90 versus 4.53, p = 0.013) and perceiving that she had related to LGBTQ2S+ health rather than arbitrarily increased need for a hypothetical ovarian cancer screening incorporating such contents as part of the formal curricula. (55.6% would order such screening versus 93.3% after This apparent contradiction between two perceived training, p = 0.015). needs–a need for mainstreaming and standardisation In the third clinical scenario–the one comparing a cisgender along with a need to emphasize the intrinsic motivational woman and a transgender man with no surgical history part of self-directed and enthusiastic learning–might be presenting with hypogastric pain–participants in the feasible by engaging in active learning in regular intervention group compared to the control group were classrooms while at the same time providing valid and significantly more likely after training to order breast authoritative resources for students to use in their self- cancer screening for the transgender man (22.2% versus directed learning. Moreover, participants stressed the 73.3%, p = 0.033 and 46.9% versus 40.9% respectively). importance of materials being clinically relevant in order to Participants in the intervention group compared to the prevent poor levels of student engagement. Despite the control group also elected to screen the transgender man stress that the majority of the participants put on the at higher rates after training for cervical cancer (77.8% importance of the training encouraging self-directed versus 93.3% compared to 68.8% versus 54.5% learning, some people reckoned that specific LGBTQ2S+ respectively); and were more likely to order a hypothetical health contents should be formally incorporated to their ovarian cancer screening (72.2% versus 93.3% compared to curricula: 62.5% versus 45.5, though these observed changes may I wish this was something that we learned in the have been due to chance. In the cisgender paired clinical classroom and not just something that I can seek out case, rates of screening for breast cancer increased on my own because the people who seek it out, are the significantly in the intervention group (38.9% versus 80%, p people who are either part of the community or who = 0.017) compared to the control group (50% versus are allied and who already have an open mind and 63.6%). All of the participants (100%) in both groups open heart to these issues. – Faculty of Health elected to screen for cervical cancer at pre-test. Regarding Undergraduate Student pronoun use, we detected an increase in the use of masculine pronouns to refer to the transgender man in the Theme 2: Multiple barriers must be addressed while intervention group after the training (50% versus 66.7%), integrating LGBTQ2S+ content into health training control group (50% versus 59.1%). However, this did not programs. Participants saw the level of comfort of reach statistical significance. students, facilitators, and instructors as critical in advancing LGBTQ2S+ health. There is a wide breadth of LGBTQ2S+ health training: qualitative data analysis background knowledge amongst health professions We conducted thematic analysis from the focus group students, which may contribute to difficulties in engaging discussion data which yielded four major emergent themes in healthy discussion, especially with cultural differences as well as 17 minor themes or subthemes. Each major between students. Faculty members who are not members theme is briefly described in the following subsections. of the LGBTQ2S+ community may feel they are not experts Theme 1: Current curriculum is lacking in LGBTQ2S+ health or even comfortable with this content; and may fear information. As indicated by our participants, a number of repercussions from student evaluations if it is perceived to key gaps in training programs were identified. In particular, be poorly taught, leading some to forgo teaching it transgender health, mental health and sexual health of altogether. Compounding this problem, the changes in best e13 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) practices and related information creates challenges in I agree that there should definitely be some keeping content up-to-date and relevant. One solution mandatory [content] for everyone, just to open offered was to build community responsiveness by people’s eyes because sometimes people don’t even harnessing community-based LGBTQ2S+ organizations to realize that this is something they need to learn about. help offer input into LGBTQ2S+ curricular content. Another And I also think it’s really important that they was to use pre-designed modules for non-expert incorporate that in a way that doesn’t shame people instructors. Perceived lack of time or access to content in who don’t know things. You know often times people already busy programs was flagged as yet another barrier. when they feel maybe a little under-educated on a Since opportunities for enriching already existing courses certain topic, kind of shy away from it altogether with more content are limited, such content could end up because they don’t want to ask the wrong questions. included in non-credit activities or occur outside regular –Faculty of Health Graduate Student program hours, thus making high levels of attendance less Theme 4: There are multiple benefits to improving likely. Conversely, integration within existing lectures or LGBTQ2S+ cultural competency. Both student and faculty learning experiences instead of addition of new contents member participants identified many benefits to improving was regarded as a particularly interesting option: LGBTQ2S+ health content in training programs. Patient Normalize it more within the curriculum. So, when I care was seen as paramount, with participants offering that approach my teaching which is around teaching and it would improve quality of care, increase provider learning, I don’t necessarily give case studies confidence and comfort, and reduce barriers to access the specifically on LGBTQ issues, [but] I will integrate them healthcare system. Building connections with community into case studies on other topics. So that it’s not a case organizations could improve student exposure and study about this issue, it’s a case study about learning opportunities, as well as accessing community- something else, but this is who we’re focusing on, sourced knowledge to ensure congruence with evolving these are the characters in it. And I think it gets LGBTQ2S+ healthcare information and healthcare [students] to do two things. Think about that topic but practices: also think about it from a different perspective. It I have a number of friends who won’t go, who identify makes it more normal for them to think about this as LGBTQ+, they avoid going to the doctor at all cost population, these issues, integrate into their own just because it’s uncomfortable. Not because they teaching and learning. –Faculty of Health Faculty don’t want to get their issues addressed but because Member they fundamentally find it so harmful for their well- Theme 3: Teaching environment and teaching style is being overall, just to even walk into that office. So variable and impacts delivery of LGBTQ2S+ content. As that’s very disheartening for me as someone who’s stated before, the participants in the focus groups were going into this field. So, I think that we definitely want enrolled in several health professions programs including [to learn]; that would benefit the population as a medicine, social work, occupational therapy, and nursing. whole from students being enriched. –Health These programs all presented LGBTQ2S+ content Professions Undergraduate Student differently, including dedicated, standalone courses, simulated patient encounters, and extracurricular Discussion interprofessional experiences. In most cases, these This study supports the existing research literature in the learning experiences were optional and not part of field of medical education in that students in health and mandatory curriculum, leading only interested students to medical professions currently perceive a lack of LGBTQ2S+ seek them out. Content delivery was a key component of health content in their curricula, and consequently do not discussion, as participants pointed out that effective always feel comfortable nor knowledgeable enough to learning requires a safe classroom climate where questions ensure delivery of quality healthcare to patients identifying can be openly shared and healthy discussion is promoted. as LGBTQ2S+. Faculty participants felt that an identified faculty member Our results also support the existing literature on the idea or “LGBTQ2S+ health champion” equipped with teaching that particular populations such as LGBTQ2S+ populations resources would be helpful in further integrating content have unique healthcare needs and require specific research and increasing comfort with material: attention. In our study, as in most of the current literature e14 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) available, this was particularly the case for transgender her hypothetical need for ovarian cancer screening. A health. Our study designed training content and included variety of factors might help explain these results. First, the evaluation measures specific to transgender health, in greater extent to which STIs are linked to heterosexual sex accordance with the gaps identified in the literature. than to female homosexual sex may have contributed to this response. The deeper understanding of sexual Further, our study demonstrates the efficacy of a brief orientation as something complex, dynamic and evolving LGBTQ2S+ health training program for medicine and through time rather than as a fixed characteristic of an nursing trainees with measurable changes in knowledge individual could also account for the increased interest of and attitudes towards the LGBTQ2S+ population. participants in taking a complete sexual history of the Moreover, our intervention demonstrated the ability to patient, both in terms of learning whether a past history of change clinical decisions in paper-based clinical scenarios male sexual partners existed and in terms of characterising involving patients identifying as LGBTQ2S+ and her current sexual situation (e.g. whether she was in a transgender. After receiving the training, our participants monogamous relationship with the female partner that made different decisions regarding approach to patients walked into the medical office with her or in a polyamorous (e.g. pronoun use) and their bodies (e.g. performing union involving sex with other people of different genders, complete physical examinations, ordering specific medical or other arrangement). We believe the change in testing). motivation towards the LGBTQ2S+ clinical case can be seen The use of simulated written clinical scenarios involving as a direct result of attitudinal change achieved by the LGBTQ2S+ patients and matched normative comparators training. offer an innovative approach and allowed our study to Regarding ovarian cancer screening, medical and nursing draw particular conclusions that connect more directly to students were likely aware that obstetric history the reality of everyday clinical practice. In fact, our findings significantly affects the incidence of this type of neoplasia. revealed some surprising results regarding changes in A clinical scenario with a woman presenting with a female perceived need to perform particular clinical actions, such sexual partner might have encouraged particular as a physical exam or cancer screening tests, that we feel assumptions about her obstetric history, for example that require further discussion. she had not been pregnant or given birth. Though this Our participants were presented with a fictional clinical reasoning is not actually correct in the absence of further scenario describing a young man without remarkable information on the woman’s full history, it is a possible medical records presenting with signs of STI (penile rash). consequence of the intersection between participants’ After completing the training, those in the intervention conventional curricular training and the new- group perceived an increased need for physical exam in the understandings from our pilot intervention on LGBTQ2S+ case of the heterosexual-identified man, but not in the case experiences. of the gay-identified one. The reasons for this change The last clinical situation presented a patient identified as remain unclear. We speculate that this may be that the female at birth with hypogastric pain in the presence of result of the stereotypical belief that gay men are more family history of cervical cancer and no other remarkable promiscuous or use less protection for risky sex and medical records. After the training, participants in the therefore more likely to contract STIs. intervention group were more prone to order breast Another of the simulated clinical situations provided cancer screening for both the transgender man and the described a woman without a history of breast cancer but cisgender woman. Though not statistically significant, they falling within screening age range for this pathology also showed an increase in the likelihood of ordering presenting to a routine visit, where the clinician was to screening tests for cervical cancer and a hypothetical note that she had never undergone screening. Participants ovarian cancer for the transgender man. Participants’ who had taken our training stated an increased likelihood clinical decisions made before the training are in line with of taking a complete sexual history of the woman with a conventional medical training and popular beliefs about male partner compared to the one with a female partner. these kinds of gynecological neoplasia, and as such not We observed elevated motivation to address this clinical surprising. However, changes observed after training may situation properly when the woman was presented having reflect increased understanding of how knowledge of a lesbian relationship, and also an increased perception of cisgender and transgender anatomy are important in e15 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) determining proper healthcare screening for transgender populations at baseline, which arguably decreased our patients. In our opinion, the content of our module on study’s capacity to effect change over time and between breast cancer in lesbian-identifying women could also have intervention and control groups, and as our data was not played a role in responses given to this clinical case, since paired, it limits our ability to analyze changes with ANOVA. it was mostly focused on cisgender women. There is Our qualitative data also reflects this, where participants arguably an interaction between the content of two of the voiced that learning experiences were often sought by training modules, a problem that should be taken into students that already identified as LGBTQ2S+ or allies, account when designing future similar training. In addition especially when opportunities were extra-curricular. to clinical decisions, as previously stated, we observed a remarkable change in pronoun use after the training with Future directions Although we gathered both quantitative and qualitative increased likelihood of changing female to male pronouns data, more research is needed to fully evaluate the impacts in the case of a transgender man when participants were of our pilot LGBTQ2S+ health training program on real-life not provided with information on the pronoun preferred clinical practice following graduation. Follow-up studies are by the particular trans man in the clinical scenario. also warranted in an effort to investigate the potential Conclusion long-term impacts of our training. Inclusion of other health professional programs such as pharmacy, dentistry, Result outlines psychology or social work is also encouraged. Offering the Our study demonstrates measurable and relevant changes training as a part of the required curricular activities would in health care students’ perceived knowledge, attitudes, help align this program with existing institutional aims, and clinical behaviour regarding LGBTQ2S+ populations as reduce schedule conflicts and further incentivize a result of our short training intervention. Overall, students participation. rated the training highly and reported in their feedback that it was valuable and relevant. Our model using a clinical On a local level, our research project adds more context to case approach was also positively rated, as participants Atlantic Canadian background on healthcare needs of reported that they felt more motivated when presented LGBTQ2S+ populations and provides a detailed analysis of with a LGBTQ2S+ simulated patient than when presented barriers to inclusion of LGBTQ2S+ health content in current with abstract contents alone. training programs. This is relevant since it provides useful guidance regarding eventual curricular improvements Study limitations towards inclusive healthcare education on a local and There are a number of limitations to this pilot study which provincial level. Participants in our study actually provided should be noted and addressed before scaling up this some useful insights on concrete actions to be taken in intervention more broadly. Given the relatively small order to improve the training of future healthcare sample size of 50 participants, we were not powered for professionals in our area. According to our results, further robust statistical analysis of our educational intervention, understanding of LGBTQ2S+ health inequities through which limits the generalizability of our findings. This was current frameworks or innovative strengths-based further compounded by participants being lost to follow- approaches are warranted to inform best practices. up, particularly those in the intervention group, who Longitudinal studies may contribute to moving Canadian sometimes had scheduling conflicts between their usual health care education towards a more competent, academic routines and our training dates and times. There accessible and nurturing system. was potential for self-selection bias in that those who participated likely had an existing interest in LGBTQ2S+ health, and therefore our sample may not be Conflicts of Interest: There are no conflicts of interest to representative of the general population of health declare. professions students. It is remarkable, then, that so much Funding: Funding for researcher summer salaries was change was noted in the intervention group in the regards provided by the Dalhousie Faculty of Medicine Research in to knowledge, attitudes and clinical behaviour with our Medicine (RIM) program and the Maritime Strategy for training. As well, our participants scored very highly on our Patient-Oriented Research (SPOR) unit. Additional research pretest survey toward LGBTQ2S+ nurturance on the Riddle funding was provided through the office of the Associate Scale, indicating very positive attitudes toward LGBTQ2S+ Vice-President Academic at Dalhousie University. Dr. E. e16 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) Tasa-Vinyals participated thanks to predoctoral 2013;8(5):521–48. scholarships awarded by: a) ERASMUS-Mundus Action 2, https://doi.org/10.1177/1745691613497965 Strand 2, Lot 1 Project: Nova Domus-CHEMEDPHO, 9. Meyer IH. 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J Women at: Health Gend Based Med. 2002;11(7):653–66. https://www.researchgate.net/publication/292970429 https://doi.org/10.1089/152460902760360595 [Accessed September 4, 2019]. e18 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) Appendix A: Model clinical cases and full question list Model clinical case 1 summary: 18-year-old gay (version A) / heterosexual (version B) man presenting with an acute-onset penis rash. Model clinical case 2 summary: Asymptomatic 55-year-old woman with a female (version A) / male (version B) partner who does not undergo regular medical check-ups. Model clinical case 3 summary: 45-year-old transgender man (version A) / cisgender woman (version B) presenting with hypogastric pain as leading symptom, with a family history of gynaecological cancer and no other remarkable findings in the anamnesis. Full question list about clinical cases For each of the cases (1A, 1B, 2A, 2B, 3A, 3B) participants were presented with the following questions: 1. How do you feel about this patient? 2. How competent do you feel to deal with this situation? 3. How necessary do you think it would be to take a sexual history of this patient? 4. If available, do you think this patient would need screening for: a. Metabolic diseases b. Breast cancer c. Cervical cancer d. Ovarian cancer e. STI f. Other 5. Which pronoun would you use to refer to this patient? a. She/her b. He/him c. They/them d. Unsure e. Other 6. How necessary do you consider it to be to perform a physical examination of the patient?* 7. How likely are you to take a sexual history of this patient?* 8. How likely are you to refer this patient to another medical specialist?* 9. As part of an interprofessional health team, how likely are you to refer this patient to a physician?** 10. As part of an interprofessional health team, how urgently would you refer this patient to a physician?** * = Question was only for respondents in the Faculty of Medicine** = Question was only for respondents in the Faculty of Nursing e19 CANADIAN MEDICAL EDUCATION JOURNAL 2021, 12(1) Appendix B. Select results of responses to three clinical cases. Select results of responses to three clinical cases. Only question sets with statistically significant results included for space. * = Question was only for respondents in the Faculty of Medicine Clinical Case 1 18-year-old gay man 18-year-old heterosexual man How necessary do you consider it to be to perform a physical examination of the patient?* Pre-Training Post-Training ∆ p Pre-Training Post-Training ∆ d p Intervention; mean (SD) 4.92 (0.3) 4.91 (0.3) -0.01 NS 4.67 (0.5) 5.00 (0.0) 0.33 1.38 0.04 Control; mean (SD) 4.83 (0.5) 4.65 (0.6) -0.18 NS 4.76 (0.5) 4.65 (0.6) -0.11 NS d = effect size calculated by Cohen’s Clinical Case 2 55-year-old woman with female partner 55-year-old woman with male partner How [motivated] do you feel about this patient? Pre-Training Post-Training ∆ d p Pre-Training Post-Training ∆ p Intervention; mean (SD) 3.90 (0.8) 4.53 (0.5) 0.63 0.94 0.013 4.44 (0.6) 4.40 (0.7) -0.04 NS Control; mean (SD) 4.32 (0.7) 4.24 (0.7) -0.08 NS 4.13 (0.9) 4.19 (0.8) 0.06 NS How necessary do you think it would be to take a sexual history of this patient?* Pre-Training Post-Training ∆ p Pre-Training Post-Training ∆ d p Intervention; mean (SD) 3.89 (1.0) 4.27 (0.9) 0.38 NS 3.67 (1.0) 4.53 (0.8) 0.86 0.95 0.012 Control; mean (SD) 4.06 (1.0) 4.14 (0.9) 0.08 NS 3.63 (0.8) 4.05 (1.0) 0.42 NS If available, you think this patient would need screening (Y/N) for: Pre-Training Post-Training ∆ (%) p OR Pre-Training Post-Training ∆ (%) p Ovarian cancer Intervention; count = Y, (%) 10 (55.6) 14 (93.3) 37.7 0.015 10.0 10 (55.6) 12 (80) 24.4 NS Control; count = Y, (%) 22 (68.8) 15 (68.2) -0.6 NS 20 (62.5) 15 (68.2) 5.7 NS OR = Odds ratio calculated by McNemar’s Clinical Case 3 45-year-old transgender man 45-year-old cisgender woman Do you think this patient needs screening (Y/N) for: Pre-Training Post-Training ∆ (%) p OR Pre-Training Post-Training ∆ (%) p OR Breast cancer Intervention; count = Y, (%) 4 (22.2) 11 (73.3) 51.1 0.033 1 7 (38.9) 12 (80) 41.1 0.017 2.33 Control; count = Y, (%) 15 (46.9) 9 (40.9) -6 NS 16 (50) 14 (63.6) 13.6 NS Do you think this patient needs screening (Y/N) for: Pre-Training Post-Training ∆ (%) p Pre-Training Post-Training ∆ (%) p Cervical cancer Intervention; count = Y, (%) 14 (77.8) 14 (93.3) 15.5 NS 18 (100) 15 (100) 0 NS Control; count = Y, (%) 22 (68.8) 12 (54.5) -14.3 NS 31 (96.9) 20 (90.0) -6.9 NS If available, you think this patient would need screening (Y/N) for: Pre-Training Post-Training ∆ (%) p Pre-Training Post-Training ∆ (%) p Ovarian cancer Intervention; count = Y, (%) 13 (72.2) 14 (93.3) 21.1 NS 17 (94.4) 15 (100) 5.6 NS Control; count = Y, (%) 20 (62.5) 10 (45.5) -17 NS 31 (96.9) 19 (86.4) -10.5 NS Which pronoun would you use to refer to this patient? Pre-Training Post-Training ∆ (%) p She/Her Intervention; count, (%) 3 (16.7) 2 (13.3) -3.4 NS Control; count, (%) 8 (25) 5 (22.7) -2.3 NS He/Him Intervention; count, (%) 9 (50) 10 (66.7) 16.7 NS Control; count, (%) 16 (50) 13 (59.1) 9.1 NS They/Them Intervention; count, (%) 5 (27.8) 3 (20.0) -7.8 NS Control; count, (%) 9 (28.1) 6 (27.3) -0.8 NS Unsure Intervention; count, (%) 5 (27.8) 3 (20.0) -7.8 NS Control; count, (%) 9 (28.1) 4 (18.2) -9.9 NS Other Intervention; count, (%) 2 (11.1) 1 (6.7) -4.4 NS Control; count, (%) 0 (0.0) 0 (0.0) 0 NS e20