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.