Concerning lack of cultural safety standards for international medical graduates regarding treating LGBTQI+ patients

Culturally safe practice has had increasing emphasis in the delivery of health care over the last couple of decades and is a requirement for medical practice in Australia and New Zealand (Aotearoa). There continues to be a focus on understanding and respecting the cultural diversity within our communities and the individual and institutional biases that can compromise access to care and health outcomes. In New Zealand, the related concept of cultural competency is enshrined in law under the Health Practitioners Competency Assurance Act 2003. Medical registration authorities in both countries include sexual and gender minorities within their definition of culture and stipulate that doctors must acknowledge their own biases and be able to function respectfully and effectively with members of all cultures. In both countries, legislation protects the rights of the lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) community.

Despite these protections in law and policy, higher rates of discrimination towards LGBTQI+ communities contribute to double the risk of mental health disorders and increased inequities in health outcomes, such as cardiovascular disease and cancer survivorship, compared with their non-LGBTQI+ counterparts. It is unacceptable that LGBTQI+ patients continue to report discriminatory and inadequate medical care. Discrimination within the health care system leads to avoidance of care, amplifying negative health consequences. For example, trans patients who experience discrimination are more likely to avoid preventive and urgent health care services than trans patients who do not experience discrimination. To address these inequities, it is essential that medical training includes specific education on LGBTQI+ health care needs.

Although volume and content vary, this training need has been recognised in undergraduate education and all medical schools in New Zealand — and most in Australia — include LGBTQI+ specific training within their curriculum. Teaching includes the role that stigma, discrimination and violence play in health outcomes as well as skills training on respectful language. Clinical placements also include exposure to and experience with LGBTQI+ patients.

Despite the well documented health inequities and clear requirements for cultural safety, health authorities in both countries have failed to apply this knowledge and standard to the many doctors that enter Australasia from overseas. Workforce surveys demonstrate our heavy reliance on international medical graduates (IMGs). In New Zealand, over 40% of registered doctors are international graduates; with the highest proportions in primary practice (50%), obstetrics and gynaecology (50%), and psychiatry (60%). In Australia, IMGs comprise 28.8% of the workforce, with a higher representation in rural and regional areas and in general practice. No attention has been given to the fact that many of the IMGs entering Australasia to practise come from countries that reject and criminalise LGBTQI+ communities. Sixty-one countries continue to criminalise same sex conduct (eg, Algeria, Guyana, Bangladesh, Turkmenistan, Afghanistan, Brunei). Of these, at least seven countries retain the death penalty, including Brunei, Iran, Mauritania, Saudi Arabia, Nigeria, Uganda and Yemen. Several countries also criminalise forms of gender expression including Brunei, Malawi, Malaysia, Oman, Saudi Arabia, South Sudan, Tonga and the United Arab Emirates. Some countries that do not have a federal law still criminalise sexual and gender minorities under Sharia law (eg, Malaysia and Nigeria). Saudi Arabia has no codified law, but police will arrest people based on their gender expression.

For IMGs from these countries, education, understanding and clinical exposure to the LGBTQI+ communities cannot be assumed to be similar to Australasian graduates when these IMGs come from a context that marginalises, denigrates or criminalises sexual and gender minorities. Lack of experience, knowledge and understanding compromises patient care and risks worsening health inequities. Education and clinical exposure for IMGs who have not received undergraduate training or exposure to LGBTQI+ communities must become a priority for health authorities. Compromised care also exposes IMGs to the risk of complaint and sanction, which can have a profound impact on both their careers and wellbeing. Given the reliance of Australia and New Zealand on IMGs, there is an urgent need for additional training and assessment for these doctors.

Dr Cindy Towns is a general physician, geriatrician and clinical ethicist based in Wellington, New Zealand.  She has been lecturing on cultural safety for the LGBTQi community for the University of Otago for a decade and also presents to a wide variety of community and allied health groups. She is the past chair of the RACP ethics committee and a previous member of the National Ethics Advisory Committee.

Read the full perspective in the Medical Journal of Australia.