Medical education could help solve disparities in LGBTQ+ healthcare
by: Mallory Hackett, MobiHealthNews
With the rising visibility of the LGBTQ+ community this pride month and beyond, it might seem as though this historically underserved and discriminated-against group has overcome most of its obstacles.
From the 2015 Supreme Court ruling that legalized same-sex marriage in the U.S. to last year’s SCOTUS decision that protected employees against discrimination on the basis of sexual orientation or gender identity, the community has made substantial strides in recent years.
But despite this progress, many LGBTQ+ people continue to face discrimination in their personal lives, in the workplace and the public sphere, and in healthcare. In fact, more than one-third of LGBTQ+ Americans experienced discrimination of some kind in 2020, according to a survey by the Center for American Progress.
Discrimination within healthcare is particularly troubling because one-quarter of LGBTQ+ people who were discriminated against in the last year either postponed or altogether avoided needed medical care over fears of further mistreatment.
Moreover, this discrimination has negative implications for LGTBQ+ people’s physical and mental health, according to the survey.
All of these problems and more are true for transgender people, who also report being misgendered by their doctor, having care refused to them for their gender identity, receiving care from a doctor who was visibly uncomfortable or having to teach the doctor about transgender people in order to get appropriate care.
This discrimination culminates in overall worse health outcomes in the LGBTQ+ community. Specifically, LGBTQ+ people are at a higher risk for cancer, mental illnesses and other diseases, and are more likely to smoke, drink alcohol, use drugs and engage in other risky behaviors, according to the Center for American Progress.
“There are huge health disparities in lesbian populations, gay populations and transgender populations. Like every version of health that you can think of, whether it’s physical or mental, those populations do worse than the hetero or cis populations,” Dr. Ann Zumwalt, associate professor in the Department of Anatomy and Neurobiology at Boston University School of Medicine, told MobiHealthNews.
“Also access to healthcare is worse, also trust in the healthcare system is worse. Everything is clearly worse, and that’s on us as medical educators. We need to do better. We need to do better for this whole part of our population who are not being served right.”
Research suggests better education and training of healthcare professionals that include LGBTQ+-related health topics is one way to improve the health of the community and reduce discrimination.
Today, a number of groups are trying to do just that – with the help of technology – from the very beginnings of healthcare education all the way through continued learning opportunities.
IMPROVING THE MEDICAL SCHOOL LGBTQ+ HEALTH CURRICULUM
Starting at the foundational level, medical educators at Boston University School of Medicine (BUSM) have created a curriculum assessment tool to determine whether it and other medical schools are adequately teaching about recommended LGBTQ+ core competencies.
“We all collectively decided we want to know how we can do better in teaching about LGBTQ+ healthcare, and the first step was essentially, ‘What are we doing?’” Zumwalt said. “We know we do some things well. We just don’t know all of what we do.”
Zumwalt and her colleagues created the Gender and Sexual Diversity Vertical Integration Group in 2018 to examine the state of BUSM’s LGBTQ+ health curriculum. To start, they reviewed the different course syllabi and sent out an informal student survey to gauge how well they thought these topics were being covered.
This initial stage revealed two key areas where the BUSM curriculum was lacking, according to Zumwalt.
“One was that there was no systemic plan, so like I said, topics would kind of pop up. Some topics were taught really well because that teacher happened to know about it and teach it really well, and care about the topic. But then it would disappear from the curriculum because the students would finish with that rotation, or whatever it was, and that was it.
“The parallel problem was that essentially faculty didn’t know what they should be teaching, because unless you happen to be an expert in the field, you don’t think like, ‘Oh, I teach topic X and LGBT [topics] can fit into this through this lens,’ right?
"If you’ve never thought about it, you just never thought about it. Our faculty are very open and really want to teach about this stuff in the right way, but they just didn’t know. So there was a lack of faculty development, basically.”
They knew there needed to be more structured planning and execution, which is why they built the Sexual and Gender Minority Curriculum Assessment Tool (SGM-CAT). The tool itself is a digital survey delivered by Qualtrics that provides quantitative, longitudinal data on where the strengths and gaps in LGBTQ+ health topics exist in the curriculum.
The group condensed the Association of American Medical Colleges’ list of 30 competencies that medical training curricula should address into 12 easy-to-understand topic areas. From there, they developed the SGM-CAT to assess whether these topic areas are addressed within the curriculum and, if they are, how and where.
After distributing the tool across all courses and clerkship programs required by the BUSM curriculum, the group discovered that, while LGBTQ+ topics are well-covered in the first two years, the education tapers off as students move through medical school.
“We have some pretty good attention to these topics in the first two years, and then very little in the second two years,” Zumwalt said. “And it’s driven a lot by [the fact that] the clerkships have so much to deal with in a relatively short amount of time that it’s not that surprising. But that’s where we’re putting a lot of our attention going forward.”
The group compiled a set of recommended course improvements based on these findings and shared them with the BUSM curriculum oversight body in January of last year, just a few months before the COVID-19 pandemic flipped the world on its head.
In spite of that, Zumwalt says the pandemic and last summer’s resurgence of the Black Lives Matter movement have brought a lot more attention to equity and how to teach about it.
“So that in some sense was good for our recommendations, because there’s much more energy around it. There was already energy around it, and now there’s really good energy around it,” she said.
Although some of the team’s high-priority recommendations were put on the back burner, a number of their proposals were implemented this past school year. Most of these focused on teaching faculty the differences between sex and gender, and about appropriate pronoun use.
Going into the second year since making these suggestions, Zumwalt and her team are creating more concrete plans on how to teach students about interviewing and examining LGBTQ+ patients and integrating more learning opportunities into the clerkship programs.
While the SGM-CAT was created at BUSM, Zumwalt says what makes it so exciting is its adaptability.
“It’s an easy-to-understand tool that is really easy to modify to any curriculum, so we think it’s really good for other schools, because, regardless of what the curriculum is, you can get a really quick sense of where topics are being taught and where they’re not.”
CONTINUING EDUCATION BEYOND MED SCHOOL
While improving LGBTQ+ healthcare training in medical schools is an important step forward, it can’t stop there, according to Dr. Dustin Nowaskie, the founder and president of OutCare Health, a national LGBTQ+ healthcare nonprofit.
“We know that disparities, terminology, all of this rapidly changes for the LGBTQ+ community. If you look at terminology in itself, there are well over 400 different sexual orientation and gender identities. Now, this is way higher than it was even one year ago and two years ago and five years ago,” he told MobiHealthNews. “So yes, you have to start foundational, but then you have to give that ongoing training, because cultural competency is not a static entity.”
Nowaskie, who grew up and attended med school in Indiana, created OutCare from his own experiences with healthcare as a member of the LGBTQ+ community. Even just seven years ago when he was in med school, Nowaskie remembers how challenging it was to find LGBTQ+ health resources or a healthcare provider who could give appropriate care.
“That’s kind of where OutCare was born. It was really born from me identifying as an LGBTQ+ member, so it was very personal to me. But it also was born out of anger at the time and passion to do something different, and to really spread the word about what the community is going through and continues to go through today, and what we can do better,” he said.
OutCare offers a range of resources and services related to LGBTQ+ healthcare, including online provider and healthcare resource directories, mentorship opportunities, medical education reform, webinars and virtual cultural competency training.
With a mission to improve access to quality healthcare for LGBTQ+ people, a key part of that is improving the cultural competency of healthcare providers.
The company has more than 50 unique virtual training programs that cover everything from foundational information, such as disparities and terminology, to specialized topics like providing trauma-informed care. The training programs are for anyone in healthcare, whether it's doctors and nurses or ancillary staff members.
“There are a lot of tenets of LGBTQ+ cultural competency,” Nowaskie said. “For us, it really means creating a welcoming environment for LGBTQ+ people, being able to provide that appropriate care to LGBTQ+ people, but then also being able to provide information and guidance about specific health issues that face LGBTQ+ people.”
Through its training program and with the growing prominence of LGBTQ+ healthcare, OutCare has an online directory, called the OutList, of more than 2,500 culturally competent providers that spans across the entire nation and over 50 different specialties. It also boasts a 35% increase in competency, a 150% increase in preparedness, a 30% increase in attitudes and an 80% increase in knowledge after the cultural competency training is complete.
Along with improving access to healthcare and bettering health outcomes of the LGBTQ+ community, enhancing medical education and training around this topic can improve healthcare more broadly, according to Zumwalt.
“Every person has a sexual identity. Every person has a gender identity. And if the physicians are taught to be sensitive to the nuances of how people move through the world, that’s good for everybody.”