Abstract
Background
Patients who identify as 2SLGBTQIA + report negative experiences with physiotherapy. The objectives were to evaluate student attitudes, beliefs and perceptions related to 2SLGBTQIA + health education and working with individuals who identify as 2SLGBTQIA + in entry-level physiotherapy programs in Canada and to evaluate physiotherapy program inclusiveness towards 2SLGBTQIA + persons.
Methods
We completed a nationwide, cross-sectional survey of physiotherapy students from Canadian institutions. We recruited students via email and social media from August-December 2021. Frequency results are presented with percentages. Logistic regression models (odds ratios [OR], 95%CI) were used to evaluate associations between demographics and training hours with feelings of preparedness and perceived program 2SLGBTQIA + inclusiveness.
Results
We obtained 150 survey responses (mean age = 25 years [range = 20 to 37]) from students where 35 (23%) self-identified as 2SLGBTQIA + . While most students (≥ 95%) showed positive attitudes towards working with 2SLGBTQIA + patients, only 20 students (13%) believed their physiotherapy program provided sufficient knowledge about 2SLGBTQIA + health and inclusiveness. Students believed more 2SLGBTQIA + training is needed (n = 137; 92%), believed training should be mandatory (n = 141; 94%) and were willing to engage in more training (n = 138; 92%). Around half believed their physiotherapy program (n = 80, 54%) and clinical placements (n = 75, 50%) were 2SLGBTQIA + -inclusive and their program instructors (n = 69, 46%) and clinical instructors (n = 47, 31%) used sex/gender-inclusive language. Discrimination towards 2SLGBTQIA + persons was witnessed 56 times by students and most (n = 136; 91%) reported at least one barrier to confronting these behaviours. Older students (OR = 0.89 [0.79 to 0.99]), individuals assigned female at birth (OR = 0.34 [0.15 to 0.77]), and students self-identifying as 2SLGBTQIA + (OR = 0.38 [0.15 to 0.94]) were less likely to believe their program was 2SLGBTQIA + inclusive. Older students (OR = 0.85 [0.76 to 0.94]) and 2SLGBTQIA + students (OR = 0.42 [0.23 to 0.76]) felt the same about their placements. Students who reported > 10 h of 2SLGBTQIA + training were more likely to believe their program was inclusive (OR = 3.18 [1.66 to 6.09]).
Conclusions
Entry-level physiotherapy students in Canada show positive attitudes towards working with 2SLGBTQIA + persons but believe exposure to 2SLGBTQIA + health and inclusiveness is insufficient in their physiotherapy programs. This suggests greater attention dedicated to 2SLGBTQIA + health would be valued.
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Background
The acronym 2SLGBTQIA + can be used to describe individuals who identify as Two-Spirit, lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual and additional identities not considered heterosexual (i.e., attracted to the opposite sex) or cisgender (i.e., identifying with a gender typically associated with their sex assigned at birth by societal standards). Individuals who identify as 2SLGBTQIA + experience worse health outcomes than heterosexual, cisgender peers [1,2,3,4,5,6] and face high rates of stigmatization and discrimination, social pressures/exclusion, trauma, abuse, poverty, and substance abuse [7,8,9]. Disparities also continue to widen as a sequela of the COVID-19 pandemic [10, 11].
Individuals of the 2SLGBTQIA + community lack safe, accessible healthcare environments, possibly due to hetero- and cis-normativity present in healthcare [12, 13]. Negative experiences with healthcare are documented by 2SLGBTQIA + individuals, including reports of discrimination and/or harassment or denial of care from health providers [14,15,16,17], leading many patients to delay medical care or forego it entirely [18,19,20]. In physiotherapy, patients who identify as 2SLGBTQIA + have reported incorrect assumptions about their sexuality or gender identity from their therapists, physical discomfort, fear of discrimination, and frustrations with educating their own healthcare professionals about 2SLGBTQIA + health needs [21]. Physiotherapists identifying as 2SLGBTQIA + have also highlighted the hetero- and cis-normative discourse present in physiotherapy practice, impacting 2SLGBTQIA + patients and peers alike [22].
Negative outcomes and experiences for 2SLGBTQIA + persons in healthcare may reflect the education and social environments provided in physiotherapy programs. Recent calls to action have emphasized the importance of 2SLGBTQIA + health and inclusiveness education for physiotherapy practice and advocate for its inclusion in entry-level programs [23, 44].
2SLGBTQIA + Identity
Our study results also highlight differences in survey responses between students who identify as 2SLGBTQIA + and heterosexual, cisgender students, which is similar to findings reported in the UK [25] and US [26]. We found students who identify as 2SLGBTQIA + showed greater clinical preparedness and attitudinal awareness in working with patients who identify as 2SLGBTQIA + based on their LGBT-DOCSS scores. Students were also more likely to feel confident in their ability to communicate with 2SLGBTQIA + clients and were less likely to believe their physiotherapy program and clinical placements are inclusive to 2SLGBTQIA + persons. These results are not surprising as 2SLGBTQIA + students may have more experience communicating on a regular basis with individuals who share similar identities, and thus may help with building connection with patients who identify as 2SLGBTQIA + . Additionally, 2SLGBTQIA + students are also likely to have a greater understanding and heightened awareness of 2SLGBTQIA + inclusivity based on personal and lived experiences and, subsequently, have a better knowledge of potential 2SLGBTQIA + microaggressions that could threaten 2SLGBTQIA + person safety and/or feelings of inclusion [38]. However, it is important to highlight again these sentiments were also expressed by heterosexual, cisgender students, and explanations and potential strategies for improving physiotherapy program inclusivity will need to be explored in future studies.
Limitations and generalizability
The 150 students who completed the survey only represent approximately 13% of current physiotherapy students in Canada and fewer responses were received from central (e.g., Manitoba, Saskatchewan, and Alberta) and eastern (e.g., Dalhousie) Canadian provinces. Therefore, our results may not be generalizable to all physiotherapy students in Canada. Furthermore, while French programs make up around 30% of physiotherapy students in Canada, our survey responses from French programs comprised only 10% of the total. This discrepancy is expected considering only one out of the five French institutions we contacted agreed to share recruitment materials for our survey with their students. We also acknowledge that we assume respondents answered questions honestly and completed the survey only once. While we asked potential participants to only complete the survey once in the letter of information and consent, due to the anonymity of the survey, we are unable to confirm whether respondents completed the survey more than once. The French translation of the LGBT-DOCSS questionnaire has also not been validated. However, it was translated by the first author (C.P.), a francophone, and verified by two francophones during survey pre-testing. Students who had more vested interest in the research topic (positively or negatively) may have been more willing to complete the survey. That is, 23% of students identified as 2SLGBTQIA + which is higher than the national proportion of reported individuals who self-identify as 2SLGBTQIA + in Canada (4%) [8], suggesting possible self-selection bias [45]. Most respondents also identified as women and assigned female at birth, which may impact generalizability of results. Alternatively, some questions from the survey could be triggering for some students and may have deterred them from completing the survey. However, we attempted to account for this by anonymizing the survey to protect confidentiality [46], and this was outlined for participants in the letter of information and consent prior to participation. Finally, Hawthorne effects may have led students to feel the need to answer questions a specific way from pressures of expected answers from society and may therefore not reflect their true perceptions [47]. Anonymization of the survey results should also address this.
Conclusion
While physiotherapy students in Canada show positive attitudes towards working with individuals who identify as 2SLGBTQIA + , they consider their exposure to 2SLGBTQIA + health as insufficient in their entry-level physiotherapy programs. Students believe greater attention towards 2SLGBTQIA + education is needed and show a strong willingness to learn. There also appears to be a lack of 2SLGBTQIA + inclusiveness in Canadian physiotherapy programs, including reports of witnessing 2SLGBTQIA + discrimination in their program or on placement. These findings suggest greater attention to 2SLGBTQIA + health and inclusion training in Canadian physiotherapy programs would be greatly valued and is needed.
Availability of data and materials
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.
Abbreviations
- 2SLGBTQIA + :
-
Individuals identifying as Two-Spirit, lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual and additional sexual orientations, and gender identities not considered heterosexual and/or cisgender
- CCPUP:
-
Canadian Council of Physiotherapy University Programs
- CI:
-
Confidence Interval
- COVID-19:
-
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
- IQR:
-
Interquartile Range
- LGBT-DOCSS:
-
The Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale Questionnaire
- MD:
-
Mean difference
- OR:
-
Odds Ratio
- REB:
-
Research Ethics Board
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Acknowledgements
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Funding
This research was undertaken, in part, thanks to a Transdisciplinary Training Award from the Bone and Joint Institute at Western University, Canada, and an Ontario Graduate Scholarship (CAP). HTP is also supported by a Frederick Banting and Charles Best Doctoral Award from the Canadian Institutes of Health Research and CYL is supported by The Arthritis Society Training Graduate PhD Salary Award and Canadian MSK Rehab Research Network 2017 Trainee Award. Funders were not involved with study design, data collection, analysis or interpretation of the data or writing of the manuscript.
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CAP contributed to study design, data acquisition, analysis, and interpretation, and drafted the manuscript. HTP, KV, TBB and JCM contributed to study design, data acquisition, and interpretation, and drafted the manuscript. JU and CYL contributed to data acquisition, and interpretation and revised the manuscript. All authors read and approved the final manuscript.
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The study was approved by Western University’s Research Ethics Board for Health Sciences Research Involving Human Subjects (REB # 119132). All participants provided informed and written consent prior to participation in any study-related activities.
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The authors declare they have no competing interests.
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Supplementary Information
Additional file 1: Appendix A.
Supplemental material. Supplemental Figure 1. Canadian physiotherapy students (n=150) group means for students who identify as cisgender and heterosexual (n=115) and for students who identify as 2SLGBTQIA+ (n=35) for the Overall, Clinical Preparedness, Attitudinal Awareness, and Basic Knowledge subscales of the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS) Questionnaire. Each subscale is scored from 0 to 7 points.
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Primeau, C.A., Philpott, H.T., Vader, K. et al. Students’ attitudes, beliefs and perceptions surrounding 2SLGBTQIA + health education and inclusiveness in Canadian physiotherapy programs. BMC Public Health 23, 1661 (2023). https://doi.org/10.1186/s12889-023-16554-2
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DOI: https://doi.org/10.1186/s12889-023-16554-2