LGBTQ Inclusivity in Physical Therapy

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Background

On my very first clinical rotation in an outpatient physical therapy clinic, my CI and I were referred a patient following a rotator cuff tear. In the first appointment, the patient told us that she previously had been seen by another therapist who made discriminatory remarks to her after she mentioned her wife in casual conversation, which obviously made the patient feel very uncomfortable and unsafe. She asked her doctor to refer her to a different clinic, waited weeks to get on our schedule and was very nervous about working with us, all factors that delayed her healing. This incident made me realize that physical therapy students receive very little education or training on addressing disparities in the LGBTQ population. The more I thought about it, I began to realize we did not even have case scenarios or test questions where the ‘patients’ were LGBTQ, and every single scenario involved cisgender and heterosexual individuals. This is simply not an accurate representation of the patients we will encounter as we begin our own physical therapy professional practice, as no setting only has straight, cisgender patient encounters. To help take steps to address this gap in physical therapist education, I decided to create an online teaching module to accompany the SafeZone training that we receive our first year of PT school. This module goes in depth about the health disparities and additional challenges the LGBTQ population face seeking and receiving quality health care, thereby addressing ways that physical therapists can help reduce these burdens and provide resources for future clinicians to further their knowledge on LGBTQ health.

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Statement of Need/Purpose

In recent years, the LGBTQ population has had growing visibility across the United States, yet they face a vast number of barriers to living in an inclusive society, free of discrimination.¹ This population is still considered to be the most marginalized and underserved population in medicine, which is represented in four main issues; a patient’s reluctance to disclose, lack of healthcare provider experience, knowledge and resources, structural barriers within the medical system and financial barriers to accessing health care.² While many of these issues are not going to be changed by one student’s capstone project and require a greater demand for change and reform, the education of future healthcare providers is an easily modifiable factor, and one that is imperative to address. In a survey done in 2015 of more than 6000 transgender and gender non-binary people, 50% of participants responded that they ended up having to teach providers about their own healthcare.³ Equipping future healthcare providers with the knowledge to better address the needs of transgender and gender non-binary patients is one small step in reducing the health disparities that this population faces. Educating future physical therapists to provide inclusive care, with the necessary knowledge to appropriately, sensitively and compassionately treat and refer people who identify as LGBTQ that they encounter in any setting is a necessary step in that direction. Allied health students, including physical therapy have limited exposure to these topics and the curriculum of many health care programs do not address them, or provide very little content.^4–7

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Products

Evidence Table: To complete my evidence table I reviewed 24 resources published from 2010 to 2020, with one exception to include a study from 2008 which was only one of two that focused specifically on physical therapist attitudes toward LGBTQ patients. The literature was categorized into 3 sections: barriers to health care for the LGBTQ population, cultural humility, bias education and awareness of the LGBTQ community among health care providers and considerations for LGBTQ care across the lifespan (focused on pediatrics and geriatrics). This literature was analyzed for its purpose, design, subjects, measurements, results and strengths/limitations when these categories were applicable. These resources were used to construct the majority of the Voicethread presentation.

Interviews: I conducted interviews with LGBTQ individuals regarding their experiences with healthcare. I included these in my Voicethread but also wanted them as separate resources as I think they are an incredibly valuable component of my project on their own. Increasing exposure to LGBTQ patients and their experiences could be beneficial in improving cultural humility in students in health care.⁵ A systematic review by Morris et al., determined that videos and discussion panels of LGBTQ patients describing their experiences in healthcare settings were effective in raising awareness of LGBTQ health issues and reducing bias toward this population.⁸ Additionally, in a study by McCave et al., 93% of the allied health and medical students included in the study found the inclusion of transgender speakers sharing their health care stories into their educational experience useful.⁹

W’s Interview

C’s Interview

CRS’s Interview

H’s Interview
Coming soon

Voicethread: I created a Voicethread presentation with the intention that it will be used in PHYT 750 as a follow up to the SafeZone training that we receive as first year physical therapy students, and be available as a resource for PT students throughout their careers. Prior to beginning the Voicethread, students will fill out the LGBT-Development of Clinical Skills Scale (LGBT-DOCSS). This is a self-assessment developed by Bidell that has been determined to be a reliable and valid method to measure health care providers’ LGBTQ clinical preparedness and awareness as well as self-explore where weaknesses are in knowledge regarding the LGBTQ population.¹⁰

LGBT-DOCSS
LGBTQ Inclusivity in Physical Therapy Presentation – .pdf

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Objectives for the Learner

I intend for my products to address the following learning objectives:

• • Identify health disparities and inequities faced by members of the LGBTQ population
  • Recognize the importance of including LGBTQ educational components in PT curriculum
  • Identify specific and unique health care needs and issues for LGBTQ patients across the lifespan
  • Recognize ways to increase personal learning on health and care of LGBTQ patients
  • Interact with and care for LGBTQ patients in a competent manner
  • Implement effective strategies to provide high quality gender-affirming care to future patients

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Health Literacy

The intended audience for the materials I created for my Capstone project is physical therapy students, with the intention that it will be used as an asynchronous learning tool. I strove to keep the slides simple, yet interesting with bright colors and visuals with appropriate font size and slide content in order to maximize student engagement. As this presentation is to be used for asynchronous learning, I ensured that the sound quality of the presentation was of the highest possible, as to not impede learning with the distraction of poor audio. The language and depth of topics covered is appropriate for physical therapy students pursuing a doctoral degree and I used a portion of my presentation to define terms students may not be familiar with. As many of these students may not know what area of physical therapy they are specifically interested in, I kept the information presented as broad as possible in regard to physical therapy settings in order to ensure its relevance. Additionally, I included a slide of case scenarios so students could see the applicability of the information provided, and linked to resources for additional case scenarios in order to provide the opportunity for them to practice this information on their own time. Along this line of thinking, I thought it was important to include interviews of LGBTQ’s personal experiences within the healthcare system in order to further raise awareness of the impact these health disparities have on people.⁸

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Evaluation

I created an evaluation for individuals who viewed my Voicethread to fill out upon completion of the presentation. My intention with this evaluation is to see how effectively the presentation meets my learning objectives and how useful it is for future clinical practice while remaining engaging to the viewer. I also value any feedback given regarding improvements that could be made to this project for its future uses.

This evaluation can be found here: LGBTQ Inclusivity in Physical Therapy Evaluation

In addition to this evaluation, I acquired feedback from my faculty advisor, Lisa Johnston, PT, MS, DPT and two committee members, Jennifer Harrington, PT, DPT, WCS, CLT and Alicia Hess, DPT, Cert. DN  as well as Shae Bardgett, RN, throughout the creation of this project. Their guidance helped me to determine a focus for this project, as well as how to best present the research and information I gathered in order to make a cohesive and engaging presentation.

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Self-reflection

This capstone project proved to be a challenging learning experience, but greatly opened my eyes in regards to just how vast and prevalence health disparities faced by the LGBTQ population really are and how major changes in educational curriculums and continuing education need to occur in order to address this. Additionally, I learned many strategies to incorporate into clinical practice in order to make it more inclusive. It has always been important to me to become an inclusive clinician who has the skills and knowledge necessary to provide appropriate, sensitive and compassionate care to patients of all identities in any setting I may end up working in. I feel that through the completion of this project, I have taken strides towards becoming this type of provider. I hope that with the education it provides to future UNC students, it can be a small step in improving the health care received by the LGBTQ population.

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Acknowledgements

I would like to thank the following for their contributions to this project:

Dr. Debbie Thorpe, PT, PhD: Thank you for providing feedback on my initial Capstone proposal and helping to guide the beginnings of this project.
Dr. Lisa Johnston, PT, MS, DPT: Thank you for serving as my faculty advisor, patiently advising me through so many unexpected twists the past few months and providing feedback and guidance throughout the entire Capstone process
Dr. Jennifer Harrington, PT, DPT, WCS, CLT: Thank you for agreeing to serve on my Capstone committee despite your already insane schedule, taking the time to talk to me on your drives home and contributing your clinical knowledge and experience to this project
Dr. Alicia Hess, DPT, Cert. DN: Thank you for agreeing to serve on my Capstone committee solely based on the referral of a friend. I appreciate you taking the time out of your own life and practice in order to contribute to this project, as well as you taking the time to check in on me from time to time.
Shae Bardgett, RN: Thank you for guiding me to the idea for this project, spending your time educating me and sharing your wonderful resources.
My amazing and wonderful partner and friends who contributed to this project both physically and emotional-support wise. I am so appreciative of all of you. I owe an extra special thank you to those who contributed their personal experiences and trusted me with sharing their stories.

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References

1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
2. Roberts TK, Fantz CR. Barriers to quality health care for the transgender population. Clin Biochem. 2014;47(10-11):983-987. doi:10.1016/j.clinbiochem.2014.02.009
3. Deutsch MB. Center of Excellence for Transgender Health. Center of Excellence for Transgender Health. June 2016.
4. Copti N, Shahriari R, Wanek L, Fitzsimmons A. Lesbian, gay, bisexual, and transgender inclusion in physical therapy: advocating for cultural competency in physical therapist education across the united states. Journal of Physical Therapy Education. 2016;30(4):11-16. doi:10.1097/00001416-201630040-00003
5. Nowaskie DZ, Patel AU, Fang RC. A multicenter, multidisciplinary evaluation of 1701 healthcare professional students’ LGBT cultural competency: Comparisons between dental, medical, occupational therapy, pharmacy, physical therapy, physician assistant, and social work students. PLoS One. 2020;15(8):e0237670. doi:10.1371/journal.pone.0237670
6. Burch A. Health care providers’ knowledge, attitudes, and self-efficacy for working with patients with spinal cord injury who have diverse sexual orientations. Phys Ther. 2008;88(2):191-198. doi:10.2522/ptj.20060188
7. McCann E, Brown M. The inclusion of LGBT+ health issues within undergraduate healthcare education and professional training programmes: A systematic review. Nurse Educ Today. 2018;64:204-214. doi:10.1016/j.nedt.2018.02.028
8. Morris M, Cooper RL, Ramesh A, et al. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 2019;19(1):325. doi:10.1186/s12909-019-1727-3
9. McCave EL, Aptaker D, Hartmann KD, Zucconi R. Promoting affirmative transgender health care practice within hospitals: an IPE standardized patient simulation for graduate health care learners. MedEdPORTAL. 2019;15:10861. doi:10.15766/mep_2374-8265.10861
10. Bidell MP. The Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS): Establishing a New Interdisciplinary Self-Assessment for Health Providers. J Homosex. 2017;64(10):1432-1460. doi:10.1080/00918369.2017.1321389