LGBTQ+ Health Education: Student Experiences at a Midwest Medical School

About 7.6% of the population in the United States identify as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+).¹ LGBTQ+ communities experience health disparities,^2-5 report negative experiences with healthcare providers,^6-8 and may not seek care due to fear of discrimination.^7,9 Access is further threatened by state legislation that restricts access to care for members of LGBTQ+ communities, especially those who are transgender and gender diverse (TGD).^10-12

Beyond healthcare, the current sociopolitical landscape in the US threatens LGBTQ+ individuals in many aspects of life. Discrimination against LGBTQ+ people exists at both the interpersonal and institutional levels and includes experiences of harassment and microaggressions across many contexts, including in housing, employment, educational, and legal settings.^7,8,13,14 Discrimination has been found to exacerbate mental health challenges for LGBTQ+ communities.^8,15 Taken altogether, LGBTQ+ people face inequities and injustices, including related to health, emphasizing the importance of adequate physician preparation.

Despite the demonstrated need, medical education on LGBTQ+ health is variable and often incomplete.^16,17 Medical students have gaps in knowledge and preparedness to care for these populations, especially TGD patients.¹⁶ Two studies to date have demonstrated that state legislation limiting access to care for TGD individuals impacts medical student applications and plans for residency.^18,19 Further research is needed to elucidate how this legislation and the broader sociopolitical landscape impact medical training.

Recent evaluations at our institution identified gaps in preclinical LGBTQ+ health education through a systematic content evaluation²⁰ and medical student surveys.²¹ Our study explores medical student experiences learning about LGBTQ+ health, including educational materials used, factors that impacted their learning, aspects of LGBTQ+ health education they would change, and the ways, if at all, the sociopolitical environment surrounding LGBTQ+ communities impacts their education or anticipated career trajectory.

We conducted focus groups of medical students at a single Midwest institution. Figure 1 displays an overview of our methods. The University of Wisconsin-Madison Health Sciences Institutional Review Board determined this study to be exempt from review.

The facilitator guide included nine questions that were posed to all groups (Appendix 1). The facilitator was a medical student on the research team (T.I.J.). We felt it was necessary to have a facilitator with a comprehensive understanding of the curriculum and used a student facilitator as we anticipated that medical student participants would feel more comfortable expressing their opinions with a peer as opposed to a faculty or staff member. Participants could say as much or little as they wanted and could refrain from responding. To protect anonymity, we did not collect demographics aside from year in school.

For qualitative thematic analysis we used an inductive systematic hierarchical approach²⁴ (Figure 1).

Eighteen medical students participated in three focus groups. This included six first-year medical students, two second-year, four third-year, five fourth-year, and one completing an additional year in a dual degree or research position. Twelve (67%) had participated in clinical rotations.

The research team identified 13 key themes. These were grouped into three common domains: (1) elements that impacted student learning; (2) aspects participants would change regarding how LGBTQ+ health is taught; and (3) ways the sociopolitical landscape has impacted their education or anticipated career trajectory.

Six key themes represent elements that impacted medical student education on LGBTQ+ health in their preclinical and clinical education (Table 1). These include educational sources (both preclinical and clinical), information organization and coverage, personal experiences, and other people (eg, faculty and peers, in preclinical and clinical settings). The sources were discussed positively, negatively, and neutrally. Lived personal experience was a source of education in the preclinical and clinical settings and also informed negative learning experiences (eg, feeling upset by how their identity was portrayed or excluded). Almost half of the participants who had started clinical rotations reported feeling prepared to engage in aspects of care for LGBTQ+ patients when they began the clinical rotations, most of whom attributed this to their personal lived experience.

Four key themes were identified related to aspects participants would change with how LGBTQ+ health is taught in this medical school (Table 2). These themes include what, where, how, and by whom LGBTQ+ health information is taught.

Most participants described at least one way that the current sociopolitical landscape surrounding LGBTQ+ health has impacted their education or anticipated career trajectory. The analysis demonstrated three key themes (Table 3). Specifically, participants described impact due to (1) their personal identity or significant other, (2) desire for residency training in LGBTQ+ health topics, and (3) medical school education.

This study found that medical students describe a range of positive, negative, and neutral experiences learning about LGBTQ+ health. These are informed by various sources in the preclinical and clinical settings, both through intentional programming and the hidden curriculum.²⁵

Similar to findings across medical schools^16,17 and reflected in other evaluations at our institution,^20,21 focus group participants described the inadequacy of LGBTQ+ health education for medical students. Many evaluations of medical student education on LGBTQ+ health have used surveys,¹⁶ and a few studies have used focus groups.^26-29 Our study builds upon existing literature by using the depth of focus groups to further explore medical student experiences learning about LGBTQ+ health. This exploration yielded 13 key themes spanning the areas of elements that impacted student education, aspects students would change in this education and ways the sociopolitical environment surrounding LGBTQ+ communities impacts student education or career trajectory.

The themes uncovered in our study found that LGBTQ+ medical students may have negative experiences in both preclinical and clinical learning settings. This aligns with prior studies that found that LGBTQ+ medical students experience discrimination and mistreatment and face a lack of visibility of their identity in medical school curricula.³⁰ Medical schools must understand this multifaceted learning experience, as factors beyond the sheer presence of content may impact medical students’ learning experiences. This likely extends to students’ mental health, as a large study of medical students found that those who identified as lesbian, gay, or bisexual had eight times greater predicted probability of burnout compared to heterosexual students.³¹

When beginning clinical rotations, participants who felt prepared to engage in aspects of care for LGBTQ+ individuals often felt so because of their personal lived experiences, not as a result of their preclinical medical education, suggesting that limited positive instances in student education are not sufficient to prepare students to care for LGBTQ+ individuals on clinical rotations. Participants described multiple changes they would make in medical education on LGBTQ+ health, suggesting that in addition to an increase in content, medical schools should increase contact with LGBTQ+ communities and promote cultural competency. Several studies explore LGBTQ+ cultural competency interventions,³² and these may enhance patient interactions and LGBTQ+ medical student experiences as organizational climates become more inclusive.

Most participants described how the sociopolitical landscape surrounding LGBTQ+ health has impacted their education or career, related to personal identity, training goals, and medical education experience. This study contributes to the growing data demonstrating how this may impact the distribution of the physician workforce,^14,18,19,33 and suggests that medical schools and residency programs should ensure they offer learning opportunities on LGBTQ+ health and that they provide an inclusive space for LGBTQ+ trainees.

This study was likely influenced by selection bias, as only 18 medical students among the total 704 across all classes elected to participate in focus groups. While some participants chose to disclose their own LGBTQ+ identity, we did not explicitly collect this demographic data from each participant, and LGBTQ+ identity, among other demographics, may impact the educational experiences evaluated in this study.

Despite the need for medical education on LGBTQ+ health, gaps persist throughout the preclinical and clinical curricula, including at our study institution. Preclinical medical education may not adequately prepare medical students to participate in aspects of care for LGBTQ+ patients, and learning is influenced by multiple factors outside of the required curriculum content. The current sociopolitical landscape surrounding LGBTQ+ communities may influence where medical students pursue future training and careers due to learning goals, their identity or their significant other. Future studies should explore interventions to improve medical education on LGBTQ+ health by integrating it longitudinally throughout the curriculum, education for teaching faculty on inclusive language, and the impact of the sociopolitical landscape on medical education and the physician workforce.