Developing a module on the care of LGBTQIA+ individuals for health professionals: Research protocol.

Background

The Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual (LGBTQIA+) are a varied group of people with different gender identities, sexual orientations, and reproductive development. All members of the LGBTQIA+ community have different healthcare-related problems and requirements, even though they are sometimes grouped as a coalition. However, they share the stigma and discrimination that have hindered them from accessing quality healthcare in several ways (Agarwal & Thiyam, 2022; MacKenzie et al., 2020). Human health and social systems are interrelated. According to a Yang (2021) study, LGBTQIA+ individuals confront social challenges such as stigma, homophobia, discrimination, coming out, insufficient social support systems, and a lack of LGBTQIA+-friendly medical resources that not only put them in danger of physical and mental harm but also put their health at risk. LGBTQIA+ individuals face discrimination, violence, and bullying as they come to terms with their identity. LGBTQIA+ individuals are more vulnerable to mental health problems including anxiety and depression as a result of this type of minority stress (Yang, 2021). According to the original model of Meyers (2003), stressors are generated from having a minority status, which is overrun by the circumstances of their environment, leading to mental and physical ill-effects that have a negative impact on the lives of the socially stigmatized LGBTQIA community.

Individuals can self-identify in different ways, including gender identity and sexual orientation. For the remainder of the text, we will refer to this spectrum collectively as the LGBTQIA+ community. The terms “L” for lesbian and “G” for gay refer to people who are attracted to people of the same gender; “B” for bisexual means they are attracted to people of both genders; and “T” for transgender means they identify as a gender other than the one they were given at birth; Q for Queer a sexual orientation that isn't only straight or heterosexual. It's a general word that covers those with gender-fluid or non-binary identities. It may also imply ‘Questioning’- A person who seeks answers about their gender identity or sexual orientation is said to be "questioning”; "I" stands for intersex, a term used to characterize individuals who do not conform to traditional classifications of female or male due to differences in their reproductive anatomy or sex features. Differences may exist in terms of internal sex organs, hormones, chromosomes, genitalia, and/or secondary sex traits; "A" stands for "asexual," a term used to characterize someone who is not attracted to or desirous of other people sexually. It's not the same as celibacy when individuals choose not to engage in sexual behaviours. The ‘+’ recognizes and includes additional identities and orientations not covered by the initials and refers to the community’s dynamic nature (Agarwal & Thiyam, 2022). A person’s sexual and emotional attraction to another person, any resulting behaviour, and/or social connection are all considered to be part of their sexual orientation. The strongly held, innate notion that a person has of being a boy, a man, or another member of the male, female, or alternate gender is considered their gender identity. The way society views homosexuality varies widely between countries and historical eras. Heterosexuality is now accepted as the standard across the globe. LGBTQIA+ individuals face stigma and stereotypes in many countries. Despite the Delhi High Court's 2009 decriminalization of homosexuality, on December 11, 2013, the Indian Supreme Court upheld section 377 of the Indian Penal Code, which criminalizes adult consensual same-sex intercourse (Kar et al., 2018; Sathyanarayana Rao & Jacob, 2012; Somasundaram & Murthy, 2016). The Supreme Court of India recognized LGBTQIA+ people as the third gender in April 2014, and any discrimination against them was viewed as a violation of their constitutional rights (Kar et al., 2018; Khatri Babbar, 2016).

Despite recent developments in the acceptance of LGBTQIA+ individuals, education on LGBTQIA+ health requirements for health professionals still lags far behind despite evidence showing a tremendous rise in LGBTQIA+ acceptance and the achievement of equality in many sectors. Multiple studies and reviews of health issues have shown a persistent gap in healthcare education, with no standard texts that include information concerning care for LGBTQIA+ individuals (Keuroghlian et al., 2017). LGBTQIA+ community members encounter several difficulties regarding sexual orientation and gender identity in a heteronormative culture. Additionally, they frequently experience prejudice and sexual assault. Further, their medical requirements are more likely to be overlooked or socially rejected due to their sexual orientation and gender identity, which can affect their medical rights and the medical care they receive. LGBTQIA+ individuals frequently struggle with coming out when dealing with medical professionals. Two things worry them; First, medical professionals’ ignorance, bias, and discrimination may impair their right to get medical care. Second, incomplete information disclosure may influence a disease’s diagnosis or possibly lead to a misdiagnosis. LGBTQIA+ individuals must carefully balance the risks of coming out with the benefit of having the right medical attention and support. These factors frequently lead to psychological pressure, which is harmful to both physical and mental health (Yang, 2021).

The stigmatized and discriminated populations must be addressed by healthcare practitioners. Understanding how medical students feel about homosexuality is crucial for improving the healthcare system. Patients who identify as LGBTQIA+ have encountered stigmatization, discrimination, and even refusal of care within the healthcare system (Kar et al., 2018). In 2017, the Joint United Nations Programme on HIV/AIDS UNAIDS report stated that LGBTQIA+ individuals made up 4.3% of the population in India who were at high risk of contracting AIDS (Kar et al., 2018). Due to the underrepresentation of such information in medical school curricula, clinicians may not be aware of or sensitive to the needs and issues faced by LGBTQIA+ patients when they encounter them (Sequeira et al., 2012; Magnus & Lundin, 2016).

Healthcare professionals are frequently not trained in or sensitive to the requirements of LGBTQIA+ individuals’ health. Additionally, it might be challenging for professionals to talk about identity in general, especially when it comes to sexual orientation and gender identity. Medical education institutions can sometimes become the breeding ground for a heteronormative ideology that supports heterosexualism (Lundin, 2011; Magnus & Lundin, 2016). Heteronormativity refers to the belief that only two opposite and mutually complementary genders exist – or that gender and sexual variation simply do not exist in social institutions (Kannisto, 2019). Healthcare professionals frequently lack the necessary training and awareness regarding the health needs of LGBTQIA+ individuals. Moreover, they often find it challenging to have a conversation regarding sexuality, especially when it comes to gender identity and sexual orientation. LGBTQIA+ individuals have obstacles in receiving adequate healthcare because of inadequate training, heterosexist attitudes, or both. Inaccurate risk estimates for pregnancy, STIs, and the ineffective or improper use of screening tools can all be caused by heterosexist attitudes. These challenges could have a detrimental impact on the management of these patients' treatments and, eventually, their health (Wahlen et al., 2020).

The LGBTQIA+ community is substantially more likely to experience various risk factors for poor health than heterosexual people, such as being less likely to have health insurance, being more likely to be obese, smoking more regularly, and engaging in binge and heavy drinking, the population’s age warrants additional attention. In addition, compared to heterosexual women, lesbian and bisexual women may undergo fewer preventative screenings for colon, breast, and cervical cancer. This is partly due to fear of not receiving respectful healthcare. Healthcare professionals are at the forefront of this effort and have the chance to treat everyone with respect, regardless of their sexual orientation and gender identity. Lack of time, finances, education, and clinical experience are a few obstacles that can prohibit physicians from providing respectful medical care (Walker et al., 2016). Doctor-patient interaction is essential for enhancing people’s health (Parker & Bhugra, 2000). Patients may opt to keep their sexual orientation and gender identity private. In such situations, healthcare professionals must be vigilant and compassionate to deliver the best care (Grabovac et al., 2014).

There are no such policies or curricula for treating LGBTQIA+ patients in India’s healthcare sector. LGBTQIA+ people have common social tendencies and decisions that impact their behavior while seeking healthcare, preventative health measures, and illness risk (Kaufman et al., 2014). It is vital to make accessible, responsive, appropriate, and well-resourced healthcare services provided by knowledgeable and trained healthcare professionals to support a better patient experience. Higher education institutions and healthcare organizations have a significant role in developing curricula (Cui, 2023) that can be accessed by all groups, including those who identify as LGBTQIA+ (McCann & Brown, 2018). Healthcare institutions must create a welcoming environment and make allowances for people with diverse gender identities and sexual orientations (Hafford-Letchfield et al., 2017).

Medical school teachers play a vital role in helping medical students become better prepared to treat these underserved communities and reduce healthcare disparities (Alhanachi et al., 2021; Chinchilla & Arcaya, 2017). Training healthcare professionals during their studies can help them feel more at ease when caring for these patients and give better treatment, an essential technique for improving understanding and attitudes about LGBTQIA+ persons among healthcare professionals (Wahlen et al., 2020). Inculcating positive LGBTQIA+ attitudes among healthcare providers plays a great role in reducing homophobia and transphobia (Gegenfurtner, 2021). The scope of the proposed research is to develop a module on the care of LGBTQIA+ individuals for health professionals and pilot test on faculty and students of health sciences, including faculties and students from MSc nursing, MPhil psychology, Head nurses, Medicine, and Nurse educators in the form of workshops. For this purpose, a need assessment through a review of the literature and focus group discussion with LGBTQIA+ individuals will be done. The project contributes to enhancing the UN's sustainable goals, such as SDG 3- Good health and well-being, and SDG 10- Reduced inequality.

Research plan

Research questions

How is a module on the care of LGBTQIA+ individuals on health professionals effective in increasing their knowledge?

Primary research question

What are the healthcare needs of LGBTQIA+ people?

To answer the primary research question, lead questions will be used to assess LGBTQIA+ individuals’ care needs, barriers to accessing care, and expectations from healthcare professionals.

Secondary research question

How effective is a module on the care of LGBTQIA+ individuals in increasing the knowledge of health professionals?

To achieve this question, a structured knowledge-based questionnaire on LGBTQIA+ care will be administered to the health science students and faculty to assess their knowledge about LGBTQIA+ care.

Hypothesis/Assumptions

It is hypothesized that a module on the care of LGBTQIA+ individuals will significantly increase the knowledge of health professionals.

Based on the previously published literature related to the needs of LGBTQIA+, it is assumed that

• a. LGBTQIA+ individuals experience stigma and discrimination.

• b. The present health science curriculum does not have a specific unit that deals with the management of LGBTQIA+ health problems.

• c. There is a lack of structured guidelines for managing the health conditions of LGBTQIA+ people.

Design

The study includes two phases: Phase I - development of a module on the care of LGBTQIA+ individuals for health professionals based on the literature and the need assessment through the focus group discussion among LGBTQIA+ individuals; and Phase II - A pilot testing of the module for health science faculty and students with pre- and post-test assessment design. A conceptual framework of the research design is shown in Figure 1.

Figure 1. A conceptual framework of the research design.

Discussion

The previous study findings show that LGBTQIA+ individuals face more difficulties accessing care because of their sexual orientation and gender identities. The study found that young adult lesbians had a harder time getting access to care than young adult homosexual males. This finding is consistent with earlier research that identified differences in the healthcare experiences of sexual minority individuals. Additionally, due to negative experiences associated with their sexual orientation and identity, gay males were more prone than lesbians to delay care. Young men may be more forthcoming about their sexual orientation and identity in healthcare, which may increase the potential for negative experiences, whereas young women may be more reticent to disclose their sexual orientation and identity to providers and, as a result, feel limited in their ability to access affirming care (Macapagal et al., 2016).

Contrary to earlier findings, few individuals claimed to have encountered LGBTQIA+-related discrimination in medical settings. Furthermore, the majority stated that telling their provider about their gender identity and sexual orientation had a neutral to positive impact on their care (Mosack et al., 2013). The findings from previous studies suggested that changes in the healthcare system will promote inclusive care. Studies have shown that reluctance to talk about sexual orientation and gender identity was brought on by ignorance of the medical requirements for LGBTQIA+ patients (LaVaccare et al., 2018). According to a previous research study, students who had more contact with LGBTQIA+ patients were more likely to ask about a patient’s sexual orientation and gender identity and check for children in the patient’s family. The disclosure of this information during patient interactions may be improved by early intervention by educators who teach students appropriate questions to ask during the history-taking process (Sanchez et al., 2006).

The current study will explore the healthcare needs of LGBTQIA+ individuals and will result in education programs and initiatives that can improve knowledge about LGBTQIA+ individuals. It will also provide practical techniques that can easily be included in the health science curriculum, which will help reduce disparities. The module will improve the healthcare professionals’ knowledge about sexual orientation, gender identity, sexual behaviour, and sex anatomy comfort of LGBTQIA+ patients. It will also enhance the self-confidence and comfort of healthcare professionals who treat LGBTQIA+ people. Previous studies have found health professionals who are trained in inclusive LGBTQIA+ care were able to address sexual health without shame, hesitation, or ignorance and help the members of the LGBTQIA+ community (Agarwal & Thiyam, 2022). The module will summarize the healthcare needs, barriers, and expectations based on FGD and primary care recommendations for LGBTQIA+ patients. This study will support the necessity for a curricular framework to reduce unconscious bias among students of healthcare professions toward LGBTQIA+ patients.

Conclusion

The study will address the critical gap in the healthcare professional curriculum in terms of LGBTQIA+ care. The module will enhance the skills and knowledge of healthcare providers in caring for LGBTQIA+ individuals and help them understand their needs and expectations. It will promote healthcare professionals’ positive attitudes toward LGBTQIA+ patients and improve comfort working with LGBTQIA+ patients. The module will guide researchers and educators looking to reduce prejudice against LGBTQIA+ patients in healthcare professionals, as well as a framework for teaching students to recognize and overcome their own biases. Educational Strategies that reduce bias in healthcare providers are essential steps to improving LGBTQIA+ communities' access to treatment and reducing health inequalities.