Do HCPs need specific LGBTQ+ training?

Article by Aida Sánchez-Bretaño Sánchez, PhD; Associate Science Liaison at EPG Health

In 2019, The World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, also known as WONCA, approved the creation of a new WONCA Special Interest Group focused on Lesbian, Gay, Bisexual, Transgender and Queer/Questioning Health (SIG on LGBTQ)¹. Since then, its members have been actively working on programs and events focused on improving the situation of LGBTQ+ patients.

This year, as part of WONCA 2022, held in London from 28 June through 1 July, several speakers introduced the audience to the challenges faced by these patients when accessing primary healthcare and basic health related services, like screenings. As part of their talks, these speakers highlighted the ways healthcare professionals (HCPs) can help to improve the experience of these patients within the healthcare system.

Professor Mark Rickenbach, in his presentation, provided the audience with some advice on how to ensure inclusion in their clinics by using neutral expressions, such as partner instead of wife/husband, for example². Later in the congress, Doctor Julien Artigny chaired a session on how to be an ally for LGBTQ+ patients where he remarked upon similar approaches for these patients who are at risk in healthcare settings³.

LGBTQ+ healthcare inequalities: a multifactorial issue

The problem of healthcare inequalities for the LGBTQ+ community is a cross-sectional one that involves different aspects, including politics and socio-economics. Members of the LGBTQ+ community form a very diverse group, with people from different races, ethnicities and identities with unique needs and challenges. However, there are common defining barriers in their access to healthcare.

In 2016, the National LGBT Health Education Center in Boston published a guide on “Understanding the Health Needs of LGBT People” where they identified several health disparities among LGBT populations, including higher rates of sexually transmitted infections, lower rates of mammography and Pap smear screenings, higher rates of depression/anxiety and higher rates of violence victimisation⁴.

In general, available evidence worldwide demonstrates that LGBTQ+ patients have poorer health outcomes compared to general population^5-7. Their fear of being excluded, ridiculed, not taken seriously and not fully understood makes LGBTQ+ patients less likely to seek medical advice.

In 2020, the European Commission published their “Union of Equality: LGBTIQ Equality Strategy 2020-2025” where, among other relevant aspects, they planned strategies for a more LGBTQ+ inclusive healthcare system⁸. In this document, the European Commission indicated that “46% of LGBTI people are never open to medical staff or healthcare providers about being LGBTI”.

Societal stigmatisation also has a high impact on their mental health, making them more prone to develop anxiety, depression. The Trevor Project’s 2022 National Survey on LGBTQ Youth Mental Health found that 45% of LGBTQ+ youth seriously considered attempting suicide in 2021⁹.

The importance of a proper training

Last year, Naila Segule, a Payne Fellow at Harvard’s Chan School of Public Health, indicated in an online discussion panel organised by WomenNC that despite approximately 4.5% of the American population identifying themselves as part of the LGBTQ+ community, most medical schools in the United States dedicate only 5 hours of their curricula to discuss LGBTQ+ specific training¹⁰. 

McCann and Brown, in their 2018 study, highlighted the need of implementing consolidated educational curricula to address LGBTQ+ health at various stages of medical education, including undergraduate, postgraduate and continuing professional development (CPD) programmes¹¹.

In a UK study involving medical students, almost 85% of the participants reported a lack of LGBT+ education, nearly half of them said that they would not routinely ask about sexuality and gender identity needs when assessing patients and they openly admitted feeling a lack of confidence regarding LGBT+ specific health care terminology, affecting their communication with patients¹².

Similarly, there is a lack of understanding and training on LGBTQ+ health related issues among HCPs and this can lead to incorrect or suboptimal care of patients of this community. An example of this is the lower rates of LGBTQ+ patients that complete recommended screenings compared with the general population. Professor Rickenbach explained in his WONCA 2022 presentation how transgender people have their gender updated in clinical records, leaving no trace of their previous gender, which makes them invisible to the systemic reminders patients receive when a screening is due, thus leaving them vulnerable to sex-specific diseases like breast cancer². Such patients lack the protection provided by regular screening that the rest of the population may take for granted.

In 2016, the department of Public Health from the European Commission implemented a pilot project entitled Health4LGBTI with the aim to reduce health inequalities experienced by these patients¹³. To do so, they designed a training for HCPs across Europe to learn about inclusivity and the existing challenges for LGBTQ+ members of their respective communities.

In their final report from 2018, this department firstly indicated that more than half of the medical volunteers that joined the pilot considered themselves as part of the LGBTQ+ community and that they joined out of personal interest¹⁴. Regardless, this pilot programme involving sites from 6 different countries in Europe helped increase knowledge within even these participants, increasing their awareness and competence in care provision for LGBTI patients. The final conclusion of this report was an understanding of the need for a wider roll-out of the training, reaching to more sites and more countries.

A systematic review on the impact of appropriate medical student and HCP training published in 2017 investigated the outcomes of 25 studies where the participants were trained specifically to take care of LGBTQ+ patients¹⁵. This study’s main conclusion was the same as that observed in the European Commission report a year later: while these studies had clear limitations, their potential to improve LGBTQ+ patients’ healthcare experiences was clear, and that such programmes should be scaled up. 

This lack of proper training for the HCPs was also discussed during WONCA 2022 where not only clinicians, but also associations like Live Through This, described the need to better prepare HCPs in all fields of medicine, including primary care settings, to ensure that they are able to create a safe environment for their patients to discuss their healthcare needs and consider care options.

Next steps towards LGTBQ+ equity in healthcare settings: the relevance of allies, advocates and organisations

In the last years several organisations and governments have advocated for LGBTQ+ rights regarding healthcare, and they have published texts and strategies to ensure there is a plan in place to protect these patients.

However, there is a long path ahead of us.

As mentioned before, the LGBTQ+ community is diverse and not all members have the same healthcare requirements among themselves, nor in relation to the general population. This is the reason why caring for these patients requires they be viewed under the prism of equity, where each individual is treated fairly and according to their needs.

More and better training needs to be implemented at all stages of a medical career to ensure HCPs are better able to engage and empathise with these patients. The support of organisations such as PFlag in the United States or Live Through This is critical. These patient-focused groups provide knowledge regarding the needs and requirements of LGBTQ+ patients and advocate for better policies that will support both ends – clinician and patient.

During WONCA 2022, there was a common question in all the presentations focused on LGBTQ+ healthcare: “What can I do, as an HCP, to be an ally for the LGBTQ+ community in my clinic?” The answer was always the same: be open to learn and modify your practice accordingly.

Read more about communication in healthcare on Medthority

Doctor–patient communication

Communication between physicians

References

1. WONCA. WONCA Special Interest Group: LGBTQ Health. https://www.globalfamilydoctor.com/groups/SpecialInterestGroups/LGBTQ.aspx. Accessed 12 July 2022.
2. Rickenbach M. Transgender - how primary care can be supportive, inclusive to all and fair in approach. Presented at the 27th WONCA Europe Conference 2022, 29 June. London.
3. Artigny J. How to be an ally for LGBTQIA+ patients? Presented at the 27th WONCA Europe Conference 2022, 1 July. London.
4. National LGBT Health Education Center. Understanding the Health Needs of LGBT People. March 2016. Available at: https://www.lgbtqiahealtheducation.org/wp-content/uploads/LGBTHealthDisparitiesMar2016.pdf. Accessed 12 July 2022.
5. Williams H, Varney J, Taylor J, Fish J, Durr P, Elan-Cain C. Public Health England. The Lesbian, Gay, Bisexual and Trans public health outcomes framework companion document. 2013. Available at: https://www.london.gov.uk/sites/default/files/LGBT%20Public%20Health%20Outcomes%20Framework%20Companion%20Doc.pdf. Accessed 12 July 2022.
6. Centers for Disease Control and Prevention. About LGBT Health. https://www.cdc.gov/lgbthealth/about.htm. Accessed 12 July 2022.
7. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. The National Academies Collection: Reports funded by National Institutes of Health. Washington (DC): National Academies Press (US); 2011.
8. European Commission. Union of Equality: LGBTIQ Equality Strategy 2020-2025. 12 November 2020. Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:52020DC0698&from=EN. Accessed 12 July 2022.
9. The Trevor Project. Facts About LGBTQ Youth Suicide. https://www.thetrevorproject.org/resources/article/facts-about-lgbtq-youth-suicide/. Accessed 12 July 2022.
10. Critical Conversations: LGBTQ+ Healthcare Access. https://www.youtube.com/watch?v=nNizh4N3xVE. Accessed 12 July 2022.
11. McCann E, Brown M. The inclusion of LGBT+ health issues within undergraduate healthcare education and professional training programmes: A systematic review. Nurse Educ Today. 2018;64:204-214.
12. Parameshwaran V, Cockbain BC, Hillyard M, Price JR. Is the Lack of Specific Lesbian, Gay, Bisexual, Transgender and Queer/Questioning (LGBTQ) Health Care Education in Medical School a Cause for Concern? Evidence From a Survey of Knowledge and Practice Among UK Medical Students. J Homosex. 2017;64(3):367-381.
13. European Commission. Health4LGBTI: Reducing health inequalities experienced by LGBTI people. https://health.ec.europa.eu/social-determinants/projects/european-parliament-projects_en#fragment2. Accessed 12 July 2022.
14. European Commission. Piloting the health4LGBTI training course in 6 European countries: evaluation report. March 2018. Available at: https://health.ec.europa.eu/system/files/2018-07/2018_lgbti_evaluationreport_en_0.pdf. Accessed 12 July 2022.
15. Sekoni AO, Gale NK, Manga-Atangana B, Bhadhuri A, Jolly K. The effects of educational curricula and training on LGBT-specific health issues for healthcare students and professionals: a mixed-method systematic review. Journal of the International AIDS Society. 2017;20(1):21624.