Sackler School of Medicine, Tel Aviv University, Tel Aviv.
The physician-patient relationship is essential for providing quality and efficient care to the patient. Lesbian, gay, bisexual, and transgender people have specific medical needs, conceivably due to the high rates of discrimination that these communities face. This paper focuses on medical students at the Sackler School of Medicine in the American/ New York Program and their outlooks on treating LGBT patients. This study was designed using an anonymous online survey and was open to medical students in all four years of the program. Overall findings show that the students have positive personal feelings towards LGBT patients, but are apprehensive in treating these patients because of a lack of knowledge of how to approach LGBT topics. These views are not due to a personal bias towards LGBT people, but are due to a lack of education that would train physicians on how to approach LGBT patients and topics in medicine.
Throughout history, LGBT people have been marginalized in many sectors of life. In medicine, specifically, LGBT patients were not seen as mentally healthy until recent years. Homosexuality was classified as a mental disorder until 1973 when it was removed from the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (1). This recent stigmatization of non-heterosexual people still plays a role in today’s society and continually needs to be addressed. Discrimination of LGBT people is very prominent in the daily life of these individuals; homosexual and bisexual individuals were far more prone to reporting discrimination in their lifetime and in general day-to day experience (2). Specifically, gay men were much more likely to report discrimination in health care settings and in public areas, citing being threatened with harm and name calling (3). All of these forms of discrimination affect the individual receiving the negative criticism and can have disastrous outcomes.
Studies have shown a correlation between homosexuality, various mental disorders, and suicide attempts. In recent years, sexual orientation has emerged as an enormous risk factor for adolescent suicide (4). Results of meta-analyses reveal that, over the lifetime of gay and bisexual men, they are at least four times as likely as heterosexual men to attempt suicide. It was also found that it is 1.5 times more likely for non-heterosexual people to suffer from depression, anxiety, alcohol and substance abuse (5). In a study regarding high school students, the students who identified as gay, lesbian or bisexual were three times more likely to have attempted suicide than their peers (6). The stigma placed on these individuals may predispose them to discrimination, mental disorders, substance abuse, and an increase in suicide attempts. This makes the access to quality healthcare even more important for this community.
While lesbian, gay, and bisexual are sexual orientations, transgender is an umbrella term for people with various gender identities. Gender identity is a complex topic and represents an individual’s internal awareness of being masculine, feminine, or androgynous. It is not a binary concept and can include stages of masculinity to femininity and maleness to femaleness, including identifying as neither male nor female (7). Transgender people can also have different sexual orientations, not depending on an individual’s gender. Similarly to lesbian, gay, and bisexual people, findings suggest that transgender people experience widespread discrimination in health care, employment, and housing (8). Subsequently high rates of substance abuse, anxiety, and depression are witnessed in transgender individuals with the prevalence of attempted suicide at 32%, according to the results of a population-based study in San Francisco (9-10). Lesbian, gay, bisexual, and transgender are very subject to discrimination, mental disorders, and suicide attempts with varying degrees.
In medicine, LGBT patients have many obstacles to obtaining quality health care. Patients that identify as LGBT delay or even avoid medical treatment because of a fear of encountering prejudice while in a health care setting. Some seek treatment and are even turned away because of their gender identity or sexuality. Many receive subpar treatment from medical practitioners who may be discriminatory, uncomfortable, or lack sufficient knowledge towards LGBT patients (11). Patients may not even disclose their sexual orientation or gender identity to health care providers because of a fear of being stigmatized, homophobic reactions, or confidentiality concerns. Past negative experiences in health care settings can also play a role in the amount of personal information volunteered. They may end up withholding important information that is essential for quality treatment, and this compromises the health care being given (12). This makes the role of a health care provider extremely important for not only being able to give quality healthcare to LGBT patients, but for being non-judgmental, empathetic, and welcoming. In order to put LGBT patients at ease and allow them to divulge important information regarding their health, a warm and accepting environment is critical. With the increased incidence of mental disorders in LGBT patients, their access to healthcare is very important in general so that these issues can be positively dealt with.
This study was designed to evaluate the mindsets of medical students in the American Program at the Sackler School of Medicine, in Tel Aviv, Israel, towards treating LGBT patients. The future of medicine and patient care relies on current medical students and how they will treat their future patients. This study is aimed to 1) evaluate personal opinions of medical students on treating LGBT patients related to non-LGBT patients, 2) determine what subgroup of LGBT patients medical students felt most uncomfortable dealing with, and 3) their perceived challenges treating LGBT patients.
Materials and Methods
An anonymous survey was created using SurveyMonkey, which provides free, and customizable surveys, as well as data analysis. The survey was open to all students in the medical school and consisted of ten questions, ranging from multiple choice to ranking scenarios to open-ended responses. The survey was anonymous in order to allow students to share their true feelings without any judgment or coercion. One question involving ranking LGBT subgroups in the order of how comfortable students would feel treating these patients was purposely left without a no preference option and without the inability to give two groups the same ranking. This was done to most effectively determine which subgroup of LGBT patients medical students feel the least comfortable treating. In total 83 students participated in the study, with 22.89% being MS1(first year medical student), 48.19% MS2, 15.66% MS3, 10.82%MS4, and 2.41% recent graduates.
When asked about preference of their patient’s gender, an overwhelming amount of students, 86.75%, said that they have no preference of the gender of their patient. Whether male or female, students thought that the gender of their patient would not play a role in the quality of the care they could give to the patient.
When asked about preference of their patient’s sexual orientation, 87.95% had no preference about the sexual orientation of their patient.
Participants were then asked to rank in order what they would most likely do when feeling uncomfortable with a specific patient. Refer the patient to another doctor, avoid eye contact, and shorten interaction with the patient were the options. 51.25% of students would first refer the patient to another doctor first. Approximately 42% of students would shorten their interaction with the patient, and only 9.76% would mostly likely avoid eye contact.
Sackler students overwhelmingly think that there is significant discrimination in medicine today. About 54% of students think that there is discrimination when it comes to both certain genders and sexual orientations.
When asked if they think it is more difficult to discuss sexual behavior with homosexuals than with heterosexual patients, about 61% said there was no difference and 35% said it was more difficult.
Students were given eight options of heterosexual and LGBT subgroups, which included heterosexual male, heterosexual female, homosexual male, homosexual female, bisexual male, bisexual female, transgender male (born female), and transgender female (born male). They were asked to rank in order the patient-group that they would feel most comfortable treating to the group of patients that they would feel least comfortable treating. Heterosexual patients were the group of people the medical students felt most comfortable treating by far. 96.66% felt the most comfortable treating a heterosexual patient, with 53.42% preferring a heterosexual male patient and 43.24% preferring a heterosexual female patient. Comfortableness with both homosexual and bisexual patients of both genders was very similar to each other. These four groups of patients fell with a huge majority between the 3rd to 6th rankings, with all groups having over 75% of their rankings between 3rd and 6th. By a large majority, students felt least comfortable treating transgender patients. Transgender males and females were both over 88% likely to be placed in one of the last two ranking spots. Transgender females, individuals that were born male but identify as female, were mostly likely to be in the last ranking spot. 54.67% of students placed transgender females as the group of people that would be least comfortable treating.
Participants where lastly asked to explain what the most challenging aspect would be when treating a heterosexual patient, a homosexual patient, and a transgender patient.
For treating a heterosexual patient, the most frequently given answers were that there were no concerns, addressing the patient’s clinical presentation, and STDs. For homosexual patients the most common concern was making sure the student-physician was not disrespectful to the patient and that the patient was comfortable, followed by STD/HIV concerns. One student said that they would be concerned with a homosexual patient’s “comfort level with me as a heterosexual physician” and in “addressing sexual risk factors without coming across as passing judgment on their lifestyle choices.” The concerns with dealing with transgender patients largely have to do with using the correct pronoun, not understanding the patient’s situation, and being unaware of transgender issues in medicine. One student exclaimed that they were worried of “offending the patient by calling them by the wrong gender,” and another has concerns of not being “sensitive enough to their situation, and needing the time to understand their situation.” “Being unclear about the medicine” and a “lack of knowledge” when dealing with transgender patients were other challenges facing students.
By a large majority, the medical students surveyed had no preference in the gender or sexual orientation of their patient. They did, however, acknowledge that there is discrimination in medicine when it comes to both gender and sexual orientation. Most of the students have no apprehensions when discussing sexual behavior to homosexual patients compared to heterosexual patients. This signifies the fundamentally non-judgmental attitude towards LGBT patients in these students. Data from these questions point to the fact that these medical students do not have a personal bias towards LGBT patients whatsoever. The point that these students had no preference about these criteria in their patients may indicate that there will be less discrimination in the future when these open-minded students start practicing medicine.
In ranking how comfortable the students would be treating patients, transgender patients made the students most uncomfortable, specifically transgender females. However, when asked about the challenges in treating these patients, the students did not have personal bias towards these patients at all. However, based on the responses, the uncomfortable nature of the patient-physician interaction would not be due to the negative attitudes towards transgender people. The students, in fact, seem to accept the choices of transgender people. Instead, the factor that makes this interaction-possibility uncomfortable for the students is their lack of experience with transgender people in general. They are nervous to offend a transgender patient with their choice of words because they are not familiar with how to approach the situation. As a result of being niche topic in medicine and still somewhat taboo in society, transgender issues in medicine are often overlooked.
The LGBT issues in medicine, such as the mental disorders and high disposition to suicide, can be dealt with in and out of a healthcare setting. The degree of protection under the law for LGBT people has a correlation with the amount of discrimination, mental disorders, and suicide attempts in a given LGBT population. In the United States, the degree of protection under the law varies according to each state in regards to LGBT rights. Some of these social policies are marriage equality, prohibiting employer discrimination based on sexual orientation, and including sexual orientation as a protected category in federal hate crimes legislation. LGBT individuals living in states with policies that offer protections under the law have a significantly lower association between LGBT status and psychiatric disorders. Moreover, LGBT individuals living in states without legal protections have a stronger relation between sexual orientation and psychiatric comorbidity (13). All of these neglected policies are a type of institutional discrimination and must be improved upon to promote the well-being and status of LGBT persons. With an increased perceived acceptance of society, by LGBT persons, the rates of mental disorder and suicide attempts will decrease.
In the healthcare setting, there are many ways to improve the experience of LGBT patients and the effectiveness of their access to healthcare. Two of the main issues that LGBT patients face in medicine today are the reluctance by some LGBT patients to disclose sexual or gender identity when receiving medical care, and healthcare providers not being competent in dealing with LGBT issues as part of the medical care (12). To promote optimal care to sexual and gender minority patients, there must be clinical environments that advocate for open communication, and which allows for LGBT individuals to feel comfortable in discussing matters of their sexual identify and any other issues they may be having (14).
The most important aspect to creating a welcoming setting is having healthcare providers that are trained to professionally deal with these issues. These patients should be approached in a non-judgmental, gender-appropriate way. During the training of physicians and medical professionals, there should be an implemented program to address underlying issues surrounding LGBT issues in medicine. Physicians need to be prepared to treat LGBT patients and their specific needs. These specific aspects of medicine and the physical exam should be taught in the medical school curriculum, both in a clinic setting and in the classroom.
A survey of American medical students on ways to improve clinical knowledge showed that the students would like to have clinical exposure to LGBT patient groups at their schools (15). Students also suggested that their comfort with LBGT patients is strengthened when the students are exposed to LGBT culture outside of a teaching environment. In order to improve their comfort and readiness when dealing with LGBT patients, students want opportunities for clinical interactions with patients from this community and to learn how to bring classroom knowledge into clinical practice (15). This could mean that medical schools need to encourage students to have non-formal interactions with the LGBT population. Ways to bring medical students around the LBGT community to understand their daily life should be further researched.
At Case Western Reserve University School of Medicine, medical students benefited from courses that teach LGBT general knowledge and health issues (16). After a mandatory course consisting of a student-delivered presentation, a patient panel, and a small-group session, medical students were more confident in dealing with LGBT health issues and had an increase in their knowledge of LGBT topics. This course did not consist of a physical exam workshop, however, so this would be a great next step to incorporate into the LGBT healthcare curriculum. About one third of medical schools have zero hours of mandatory clinical teaching of LGBT health topics, and only about 14% of schools offer a clinical site dedicated towards teaching about the LGBT community (17). Improvements to the current curriculums of medical schools can offer ways for students to be exposed to more diverse patient groups.
Learning from LGBT patients themselves may be the most beneficial way for medical students to increase their healthcare knowledge of these patients. There should be outreach from medical schools into these communities in order to provide medical students opportunities to interact with these patients. Incorporating mandatory classes dealing with LGBT topics in healthcare should be implemented at medical schools. There should also be a comprehensive physical exam and history-taking workshop designed with LGBT patients in mind. Other possible integrations into the curriculum include clinical experience at specifically LGBT centers and opportunities to hear the experiences of LGBT people in a group or individual setting. Interactions with LGBT persons, who are willing to discuss their positive and negative interactions with physicians, is a essential way for medical students to understand what these patients want and expect from a healthcare professional. With the implementation of medical school programing that caters to LGBT issues in medicine, medical students will be more prepared to treat LGBT patients and will feel more comfortable doing so. The education of medical students is essential to improving the quality of care given to LGBT patients both in the present and future.
The author would like to thank all the medical students who participated in this study.
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