LGBTQIASB+ content in medical education: what lies ahead?

LGBTQIASB+ people deserve access to health care providers who are knowledgeable and skilled in providing inclusive, patient-centred care, writes Flynn Halliwell…

THROUGH my role as the 2022 Chair of the Australian Medical Students’ Association (AMSA) Queer group, I have had the privilege of hearing from medical students across the country regarding their experiences of LGBTQIASB+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, sistergirl, brotherboy)* teaching. What I have been told has been nothing short of disappointing and concerning.

Medical education is failing LGBTQIASB+ people.

LGBTQIASB+ people are a diverse community with a rich and proud history, many of whom live healthy and happy lives. However, despite representing a significant proportion of Australia’s population, representation of LGBTQIASB+ teaching is scarce within medical curricula across the country, with most medical schools reporting 0–5 hours dedicated to teaching LGBTQIASB+ content “during the required pre-clinical phase”. This curricular erasure subsequently leads to a hidden medical curriculum that positions cisgender, heterosexual, endosex, and allosexual people as the healthy “norm”, and LGBTQIASB+ people as a pathological “other” (here and here).

At a public health level, the downstream consequences of insufficient LGBTQIASB+ teaching within medical education are clear.

It is well established that LGBTQIASB+ people experience health inequities as a consequence of the interpersonal, institutional and sociocultural discrimination that comes with navigating the world as an LGBTQIASB+ person (here and here). Importantly, inability to access health care professionals who are knowledgeable and skilled in providing safe and inclusive health care for LGBTQIASB+ people  is a significant contributor to these health inequities.

These barriers to safe and responsive health care are especially important to consider for patients with intersecting identities or experiences who face additional barriers, such as racism, ableism and/or other forms of discrimination, when accessing health care.

To date, the Australian Medical Council standards for assessment and accreditation do not outline the need for specific LGBTQIASB+ teaching within Australian medical curricula, despite calls from AMSA and the Australian Medical Association (AMA) to do so. As a result, teaching regarding LGBTQIASB+ content is neither mandatory nor standardised, with significant variation in the amount, contents and quality of LGBTQIASB+ health topics taught across medical schools.

This year, AMSA Queer liaised with students across 14 medical schools in Australia, whereby students reported that not only are LGBTQIASB+ health topics often excluded from the curriculum, but that some content which is included can be reductionistic, inappropriate or otherwise inadequate.

Feedback from students indicated that teaching regarding LGBTQIASB+ health is often limited to cases of human immunodeficiency virus (HIV) infection in men who have sex with men. Students particularly highlighted room for improvement across teaching on trans and gender diverse health, the health and human rights of people with innate variations in sex characteristics, Aboriginal and Torres Strait Islander LGBTQIASB+ health, as well as intersectional representations of LGBTQIASB+ people broadly.

Students are not alone with this concern. Emerging literature continues to highlight that inadequate LGBTQIASB+ education leads to medical students who feel underprepared to navigate clinical encounters with LGBTQIASB+ patients. While students usually report wanting to receive greater LGBTQIASB+ training, many are required to turn to self-directed extra-curricular learning to achieve this (here). Concerningly, opt-in approaches to teaching may mean that LGBTQIASB+ education does not reach the students who need it most.

The consequences for patients are significant. Medical students and doctors who are not equipped with knowledge and skills relevant to working with LGBTQIASB+ people can lead to unsafe care and harm to patients. Experiences of stigma or discrimination from health service providers are known reasons for under-utilisation of health services and delayed seeking of care by LGBTQIASB+ people in Australia. Insufficient training in LGBTQIASB+ health also places added burden on LGBTQIASB+ patients to self-advocate or educate their providers in order to obtain appropriate care (here).

For years, medical students across Australia have called for a unified, top-down commitment to inclusion of LGBTQIASB+ teaching in the medical curriculum. However, the responsibility of LGBTQIASB+ teaching still often falls on the shoulders of LGBTQIASB+ students. This means that on top of being exposed to potentially distressing situations in the classrooms and on the wards, the onus is on students to educate their peers and staff, provide lectures and learning resources, as well as meet with faculty to advocate for changes to the curriculum. Not only does this work come at a cost to students’ own time and learning, but also to their mental health and wellbeing.

Generally speaking, medical faculties are willing to receive feedback on the curriculum and are often able to recognise the deficit of LGBTQIASB+ content within the curriculum once alerted to this issue. However, a major barrier often lies in subsequently enacting the changes to the curriculum.

Understandably, the breadth of the topic may be daunting for faculties, especially if staff themselves feel inadequately trained in LGBTQIASB+ health. Responses to student feedback often quote the lack of space within the curriculum, the time and effort involved in updating the curriculum, or simply a lack of clear solutions regarding what best practice LGBTQIASB+ curricula look like.

However, the challenges faced by faculties should not come at the cost of attempting to implement an LGBTQIASB+ curriculum, but rather warrant a reconception of what inclusivity in medical education looks like. Importantly, this includes grappling with the historical and ongoing role of medicine in perpetuating structural violence against LGBTQIASB+ people, and a broader interrogation of the normative biases that medical pedagogy currently operates within.

Where do we go from here?

AMSA Queer is working in this space through two key mechanisms: Wavelength and AMSA’s LGBTQIASB+ health and gender equity in medical curricula guide.

Wavelength is a free, open access educational resource on LGBTQIASB+ health for medical students and health professionals, designed to help fill the current gaps in the medical curriculum.

Wavelength was founded by a group of medical students, with expert input from community representatives and leaders in LGBTQIASB+ health, and is currently managed by AMSA Queer. The Wavelength modules serve as an accessible and interactive learning tool, providing lectures, clinical scenarios and quizzes on LGBTQIASB+ health.

Alongside developing learning resources, AMSA Queer is also advocating for a nationwide medical curricular reform to ensure that all medical students are provided with structured teaching regarding LGBTQIASB+ health. AMSA is developing its LGBTQIASB+ health and gender equity in medical curricula guide, a collaboration between AMSA’s Queer and Gender Equity groups, and seeks to answer the question of what a best practice curriculum looks like. This document will serve as an up-to-date, evidence-based, community-consulted tool for medical school faculties, medical student societies, and individual student advocates to use as a starting point for integrating LGBTQIASB+ education into their respective curricula.

The recommendations in the guide will be centred around scaffolding LGBTQIASB+ health into the medical curriculum through an integrated and skills-based framework that is explicitly intersectional, community-led, and transdisciplinary in nature.

Key recommendations explored within the guide will include:

• development of graduate outcomes specific to LGBTQIASB+ health;
• integration of a long term, iterative LGBTQIASB+ syllabus into the existing medical curricula, including learning objectives specific to language, knowledge, and clinical and professional skills relevant to working with LGBTQIASB+ people;
• adoption of an intersectional approach to all LGBTQIASB+ teaching;
• use of transdisciplinary and multimodal teaching methods, including formal and informal assessment;
• community-led teaching that prioritises lived experience and curriculum codesign;
• training and upskilling of all teaching staff in LGBTQIASB+ health;
• considerations for safeguarding LGBTQIASB+ student safety and wellbeing; and
• implementation of accessible and anonymous student feedback mechanisms.

In highlighting these recommendations, it is imperative to acknowledge the crucial contributions of the many advocates who have worked, and continue to work, in LGBTQIASB+ medical education and research. Without their continuing commitment to this space, AMSA Queer’s development of this resource would not be possible.

The time has come for medical schools across the country to look to the future of the LGBTQIASB+ medical curriculum. LGBTQIASB+ people deserve access to health care providers who are knowledgeable and skilled in providing inclusive, patient-centred care. Medical education is uniquely positioned to provide this knowledge and skill to an entire generation of incoming health care professionals and thereby transform the health care experiences of LGBTQIASB+ people across the country.

What are we waiting for?

* LGBTQIASB+ stands for lesbian, gay, bisexual, transgender, queer, intersex, asexual, sistergirl and brotherboy, with the “+” denoting the expansive and non-exhaustive nature of the acronym in representing all individuals of diverse gender identities, sexualities, romantic orientations and sex characteristics. 

Flynn Halliwell is the 2022 Chair of AMSA Queer and a Doctor of Medicine (MD) student at the University of Melbourne.

 AMSA is the peak representative body for Australia’s 17 000 medical students. AMSA Queer is the representative body for queer medical students and works to improve health outcomes for all LGBTQIASB+ individuals through education and advocacy.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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