An estimated 3.5% of adults in the United States (US) are identify as lesbian, gay, or bisexual, and an estimated 0.3% identify as transgender.1 This equates to roughly 9 million lesbian, gay, bisexual, or transgender (LGBT) Americans. The LGBT acronym is insufficient to encompass the full spectrum of sexuality and gender expression. Despite the risk of inconsistent terminology, this study uses the more inclusive LGBTQ+ term whenever possible. The “Q” stands for “queer” or “questioning” and “+” is a placeholder for other sexuality and gender identities that do not fit into a succinct acronym.2 When referring to the results from a specific study, including our own, the term used in this report matches the source.
The LGBTQ+ umbrella includes widely diverse communities. Although common health concerns exist across these populations, unique needs also exist among subgroups. Disparities along the lines of sexual orientation and gender identity in the US are well documented.3–9 Disparities disproportionately affect LGBTQ+ people of color and people with lower incomes.10 LGBTQ+ individuals experience disproportionately high rates of chronic disease and increased disability where the subsequent body function and structure impairments, activity limitations, and participation restrictions can be addressed with skilled physical therapy interventions.11,12 Evidence suggests that health outcomes improve when healthcare providers are educated on the population-specific needs of their LGBTQ patients.4 Future physical therapists (PTs) must be educated and trained to provide culturally competent care to this large subset of the population.
This study responds to a 2016 call by Copti et al8 for research on inclusion of LGBTQ topics in physical therapy education published in the Journal of Physical Therapy Education. The purpose of our study was to determine to what degree LGBTQ health education and training is integrated into Doctor of Physical Therapy (DPT) program curricula. It identifies Program Directors' (PDs) report of current versus optimal curricular inclusion and classifies perceived barriers to inclusion of LGBTQ topics.
REVIEW OF LITERATURE
A 2011 Institute of Medicine report categorized 4 systemic factors perpetuating health disparities affecting LGBT communities: social stigma, barriers to access, lack of provider education, and unequal access to health insurance.5 Data show that LGBT individuals experience substandard health care for a variety of reasons, one of which is implicit and explicit discrimination by healthcare providers.3–5,9,13 Discrimination against LGBT individuals has been associated with increased risk of psychiatric disorders, minority stress syndrome, substance abuse, violence victimization, and suicide.5 Studies also suggest that LGBT adults experience higher rates of diabetes, hypertension, and reduced mobility.5,6,9,11,12 LGBT adults have also been shown to face personal and social barriers to optimal levels of physical activity.12
Data from the 2009 Lambda Legal Health Care Fairness survey (n = 4,916) showed that nearly 56% of LGB and 70% of transgender/gender–nonconforming people reported experiencing at least one type of discrimination in care, alienating these populations from the health care system and perpetuating documented disparities.10 A 2008 survey of 387 health care professionals (PTs = 176, nurses = 50) working with patients with spinal cord injury found that 44% of the nurses, compared with only 1% of the PTs, expressed attitudes of full respect for LGBT patients.14
A 2011 survey examining inclusion of LGBT-related content in medical school curricula (n = 132) found the median number of content hours to be 5, with substantial variation in quantity, content, and perceived quality of instruction.15 Research examining medical schools and nursing programs suggests that education and training on LGBT-specific health topics changes the beliefs and behavior of healthcare providers.16–20
A 2018 study by McNiel et al documented a baccalaureate nursing program that successfully addressed a need for increased education on LGBTQ-specific health topics. The program supported a 4.5-hour session for faculty and students facilitated by the campus Center for Equity and Diversity. The session addressed LGBTQ-focused health needs such as lifelong hormonal therapy, routine health screenings based on sex assigned at birth rather than gender identity, surgical intervention options, and current coverage for health services. Participants role played coming out to a health care provider, engaged with a panel of LGBTQ patients to discuss interactions with providers, and actively reflected on personal beliefs and biases through journaling and dialogue. After the session, students and faculty reported increased knowledge and awareness regarding LGBTQ health issues, ideas about how to change their practice patterns, and updated communication skills and style.21
According to the American Physical Therapy Association's (APTA's) 2014 Blueprint for Teaching Cultural Competence in Physical Therapy Education, primary dimensions of diversity include age, race, gender, sexual orientation, ethnicity/nationality, mental/physical ability, socioeconomic status, and religion.22 Existing literature on cultural competence in physical therapist education programs addresses many of these aspects.23–29 Although there has been a documented increase in medical schools' inclusion of LGBT-related health education and training, there is yet to be a similar increase in physical therapist education programs.8,30 Our study is the first to assess the inclusion of LGBTQ content in physical therapist education programs.
Using a mixed methods research design, inclusion of LGBTQ-related health education and training in DPT programs was evaluated through quantitative and qualitative content analysis of responses to an online survey.
The survey, accessed through an anonymous link created with Google Forms, was addressed to the directors of physical therapist education programs accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). The link was emailed to the contact email address listed on the CAPTE web site. This study was approved by the institutional review board at the University of Washington, Seattle, Washington.
The survey was adapted with permission from a published 2014 survey on LGBT health education and training in emergency medicine residency programs in the United States.19 Responses to the 7 survey questions that pertain to LGBTQ training and curricular content in DPT programs are reported in this study.
The survey included multiple-choice questions. For example, respondents were asked, “Approximately how many hours of didactic lectures on equitable care for LGBTQ patients did your program present to students in the 2016/17 academic year?” and “In your opinion, how many didactic hours per year should be devoted to equitable care for LGBTQ patients?”
To access additional valuable information from the survey questions that had “yes, no, I don't know” response options, participants were given the opportunity to further describe their curriculum with the addition of an open-ended question, “If yes, please describe.” For the survey question that identified barriers to curricular inclusion of LGBTQ health education and training topics, one could respond to the response option “other please describe.” The survey questions pertaining to LGBTQ health education and training are available in Supplemental Digital Content 1 (Appendix A, http://links.lww.com/JOPTE/A80).
The survey was sent twice (spring of 2017 and fall of 2017) to maximize the response rate. The survey sent in the Fall of 2017 began by asking whether the respondent had completed the survey previously and requested those answering yes to abstain from responding a second time. The first and second sending asked for responses pertaining to the 2015/16 or 2016/17 academic year, respectively. To maintain anonymity, no demographic data were collected.
Quantitative descriptive data analysis was performed on the responses to the survey's multiple-choice questions with single and multiple answers. Average didactic hours reported for both current and optimal hours questions were calculated using the midpoint of each range (eg, 1.5 hours was used to represent a respondent who selected “1–2 hours” in response to the question “In your opinion, how many didactic hours per year should be devoted to equitable care for LGBTQ patients?”).
A qualitative content analysis30,31 was conducted on the “If yes, please describe” responses given to the following curriculum related questions: “Did your program present didactic lecture(s) focused on LGBTQ health issues?” and “Apart from specific, dedicated lectures, has your program incorporated LGBTQ health concerns into general lecture topics where LGBTQ patients are disproportionately affected?” For reliability purposes, 4 researchers (first individually) read, coded, and categorized the data. Data were then summarized into key themes. Coding and themes were cross checked between the 4 researchers, and final themes and categorization of the content were determined. If any disagreements occurred, they were discussed and resolved if needed, by majority vote.
Curricular Inclusion: Current Versus Optimal Hours
Of 229 programs, 72 (31%) returned their survey. Fifty percent of the PDs who responded, reported “yes” their program presented didactic lectures focused on equitable care for LGBTQ patients, compared with 38% “no” and 12% “I don't know”. Reporting the number of didactic hours, 36% selected zero hours, 29% selected 1–2 hours, 21% selected 2–5 hours, and 1.4% (1 respondent) selected more than 5 hours. Thirteen percent selected “I don't know”. Of those who responded with any number of hours (ie, “zero hours” included but “I don't know” responses excluded), the average was 1.43 hours.
Responding to the question, “In your opinion, how many didactic hours per year should be devoted to equitable health care for LGBTQ patients?” (n = 70), 11% selected zero hours, 39% selected 1–2 hours, 39% selected 2–5 hours, and 11% selected more than 5 hours. The average number of didactic hours PDs believed should be spent on such education was 2.82 hours per year. These results are presented in Tables 1 and 2, respectively. Figure 1 highlights the difference in perception of current versus optimal hours delivered.
Table 1. -
Response Frequencies for the Current Number of Hoursa
||No. of Respondents
|I don't know
aApproximately how many hours of didactic lectures on equitable care for LGBTQ patients did your program present to students in the 2015/16 or 2016–2017 academic year? (Year respective to either spring or fall survey distribution).
Table 2. -
Response Frequencies for Optimal Number of Hoursa
||No. of Respondents
aIn your opinion, how many didactic hours per year should be devoted to equitable care for LGBTQ patients?
Barriers to Inclusion
When reporting barriers to the inclusion of education and training on equitable care for LGBTQ patients, PDs could select more than one response and had a write-in option. The lack of trained faculty and lack of time were the most common, with 34 selections each. The lack of perceived need (20) and lack of institutional requirements/support (10) were also selected. The lack of funding was the least common selection (3). Nine PDs reported no barriers (Figure 2).
Short answer responses to the perceived barriers to inclusion question reflected a wide range of perspectives among the PDs. For example, PDs responded by saying:
“Faculty struggled with the case discussion activity because they didn't feel that they were ‘experts’ on the topic.”
“It is one important part of social humility but cannot put it over other issues. There just isn't enough time in the curriculum to devote much more time.”
“The disparities in this group are no different from others. All disparities (in general) are discussed in curriculum.”
“This year, I found a guest lecture for sexuality and aging issues, particularly within the LGBTQ community. But, I am the only faculty person in my department doing anything like this, which sends the message this isn't important.”
Curricular Inclusion Themes
In total, the researchers coded 50 individual responses to the “If yes, please describe” responses to the 2 curricular inclusion-related questions, “Did your program present didactic lecture(s) focused on LGBTQ health issues?” and “Apart from specific, dedicated lectures, has your program incorporated LGBTQ health concerns into general lecture topics where LGBTQ patients are disproportionately affected?”
Three themes emerged from the qualitative analysis of the PDs’ responses to the open-ended questions: LGBTQ health topics included in the curriculum, teaching strategies used to present LGBTQ topics (pedagogy), and titles of courses that included LGBTQ topics. Table 3 presents the responses under each theme. What is notable is the number and variety of responses that were provided by the PDs that formed the themes.
Table 3. -
Open-Ended Questions' Responses Exemplifying the Current Approaches to Inclusion of Education and Training on LGBTQ
Health in DPT Programs
|LGBTQ Health Topics Included In DPT Programs' Curriculum
||Teaching Strategies Used to Present LGBTQ Topics (Pedagogy)
||Titles of Courses that Included LGBTQ Topics
|Access to unbiased care
|Cultural and societal competence
||Imbedded in all curriculum
||IPE case studies
|Diverse populations inclusive
||Read an article/watch a video
|Internal bias and discrimination
|Issues across the lifespan
|Patient centered care
|Patient treatment/management skills
|Variations in human sexuality
Abbreviations: DPT = Doctor of Physical Therapy; LGBTQ = lesbian, gay, bisexual, transgender, and queer.
A strong case exists for the relevance of LGBTQ topics to the physical therapy profession.8 Our data comparing current versus optimal number of hours spent on LGBTQ health education, (1.43 current vs 2.82 optimal), suggest that there is interest among PDs in increasing LGBTQ curricular inclusion. Our findings suggest that a majority (89%) of the DPT program directors who responded to our survey recognize a need for greater than zero annual curricular hours focused on LGBTQ topics. A small but significant number (11%) of PDs cited zero as the perceived optimal number of hours. The survey question regarding the optimal number of hours did not include an open-ended question; therefore, we cannot assess whether the opinion of these PDs is because of personal bias, lack of perceived need, lack of institutional support/funding, and/or other factors.
A review of the literature, as well as analysis of the open-ended question responses collected in our survey, suggest that education addressing the delivery of care to LGBTQ+ patients is conceptualized within general cultural competence curricula in allied health professional programs.21,32 As stated in the review of literature, the APTA's 2014 Blueprint for Teaching Cultural Competence in Physical Therapy Education identifies primary dimensions of diversity as age, race, gender, sexual orientation, ethnicity/nationality, mental/physical ability, socioeconomic status, and religion.22 This statement clearly places LGBTQ+ health issues, including disparities, barriers to access, and implicit and explicit discrimination from health care providers, within the cultural competence curriculum. Literature addressing cultural competency related to race, ethnicity, socioeconomic status, religion, and learning abilities in physical therapist education programs exists.26–29 However, our findings are consistent with the assertion by Copti et al8 that current cultural competency training and literature have not specifically included LGBTQ+ topics.
Our data indicate that increasing the curricular inclusion of LGBTQ+ topics is a priority among most PDs who responded, and the most common barriers—lack of time and/or trained faculty—are both modifiable factors. Our qualitative analysis suggests that programs are not sure where to place this content in the curriculum, resulting in significant variation in pedagogy, topics, and approaches to curricular inclusion. The diversity of responses detailing the current approaches to these topics indicates that physical therapist education programs lack a standardized approach to developing and delivering this content. Approaches range from dedicated workshops and learning activities independent of existing coursework, to attempting to include these topics within courses devoted to health disparities and cultural competency, to stating a general intention to weave LGBTQ+ representation throughout the entire curriculum using case studies and modeling inclusive language and attitudes.
In an effort to conceptualize a standardized curricular approach, DPT programs should consider the pros and cons to dedicated courses or learning activities versus integrating LGBTQ+ topics throughout existing course content. Romanello28 reviewed the published literature in the physical therapy field that touched on faculty threading cultural content into their existing course content rather than teaching a separate course on culture. When cultural competence is infused across the coursework, faculty and students understand that it an essential, not an elective, knowledge and skill. Cultural competence across all dimensions of diversity is an integral component of clinical competence and should be viewed as such by faculty. At the National APTA Conference in 2000, Purtilo33 addressed cultural competence to be a non-negotiable skill, subject to rigorous testing similar to kinesiology or any other core component of the physical therapy profession.
Some disadvantages of curricular integration or “weaving” of LGBTQ+ topics and cultural competence exist. Its success depends on the investment, skills, and competencies of all faculty members. It also depends on faculty members, across all courses, adhering to the concept that it is an important topic and having the ability to teach the identified content. If a single faculty member is designated or offers to teach all the LGBTQ+ population–specific content across courses and levels, it becomes quite time consuming. If the faculty member designated to teach the content leaves, the integration of content is often lost.34
Our data suggest that the most common barriers to increasing LGBTQ education are the lack of time and faculty training. These are both modifiable factors which may be addressed through the development of core competencies and standardized delivery but require enhancing resources. This makes a strong case for consideration of increasing and standardizing faculty training that supports the effective curricular delivery of LGBTQ+ population–specific content. Research is warranted to determine whether increasing faculty training influences the number of hours of LGBTQ+ health education in curricula.
Research to develop guidelines for incorporating LGBTQ+ health information into existing physical therapy curricula could help address the time constraint barrier identified in the survey. Further research is also needed to determine the most effective pedagogy and evaluation for LGBTQ+ topics and to identify physical therapy students' self-evaluation of their ability to provide care to LGBTQ+ patients.
One limitation of this study stems from collecting data during 2 academic years to increase the sample size. Beyond asking that respondents abstain from filling out a second survey, there was no control mechanism for duplicates. In some cases, it is possible that an administrative representative, who was not a program director, completed the survey. In addition, attitudes and curricula could have changed over the 8-month period between surveys, and if this were the case, it would not be reflected in the data amalgamation. Data were self-reported and therefore subject to response bias.
A second limitation of the study is the response rate of 31%. Although this is within the range of current criteria for acceptable response rates for email surveys, there is a risk that the respondent group is not a representative sample of views and practices across all CAPTE accredited DPT programs.35 Demographic data were not collected from the survey respondents in an effort to remove barriers to survey response. This makes it impossible to assess whether the sample group is truly representative of a diverse cross section of DPT programs nationwide and potentially limits the generalizability of our findings.
This study adds to the evidence in support of inclusion of specific information on delivery of ethical and effective care to LGBTQ+ patients in physical therapy education. Such inclusion would be in accordance with the APTA's Blueprint for Teaching Cultural Competence in Physical Therapy Education and encourage socially just care.22
The first principle of the APTA's Code of Ethics for the Physical Therapist states, “PTs shall act in a respectful manner toward each person, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.”36 PTs have a professional duty to meet each patient with respect. This is vital to therapeutic alliance, effective treatment, and optimal health outcomes for patients. It cannot be assumed that DPT students innately possess this foundational principle of physical therapy practice. Respect for LGBTQ+ patients can be learned, but to some, it must be taught. This is the responsibility of DPT program faculty and may require specific training for faculty to ensure effective delivery of the curricula addressing the population-specific needs of LGBTQ+ patients. Providing specific education and training for both faculty and students that includes the many dimensions of diversity represented in the patients we care for, including those who identify as LGBTQ+, will ensure that entry-level PTs are truly prepared to provide equitable care for all.
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