Abstract
Results of this study offer evidence that a basic level of continuing education can improve occupational therapy practitioners’ knowledge of and skills for working with LGBT populations.
Well-documented disparities in health outcomes exist among sexual and gender minorities (SGM; e.g., lesbian, gay, bisexual, and transgender persons) compared with sexual and gender majority populations. These disparities include a higher risk for SGM persons to experience mental health disorders, suicide, substance abuse, trauma, chronic health conditions, and homelessness (Joint Commission, 2011). Stigma and experiences of discrimination may lead SGM persons to avoid or delay treatment, contributing to adverse health outcomes (Kuzma et al., 2019). Inequalities are magnified by intersections with other experiences of stress, marginalization, or discrimination based on racial and ethnic minority status, education level, income, language, culture, or disability (Moore & Dukes, 2019).
A lack of knowledge and bias on the part of health care providers contribute to occupational injustice for people who identify as SGM (Suarez-Balcazar et al., 2020). To mitigate inequity in health care, the Joint Commission (2011) published cultural competencies and recommended that hospitals provide educational programs that support the needs of SGM persons. Decisions about how to implement training were left to the discretion of individual institutions, and practices vary widely. Topics related to SGM are often embedded in education related to cultural competence and humility, which often focus on racial and ethnic minority populations (Hammell, 2013) and frequently assume that the majority group is White, heterosexual, and cisgender (Butler et al., 2016). Such programs may increase awareness of social justice and advocacy for marginalized groups in general (Shih et al., 2009), but they are often ineffectual in facilitating positive social justice–related attitudes and behaviors toward SGM (Gonzalez et al., 2019).
A paucity of information is available about SGM-related continuing education across occupational therapy practice settings and the number of practitioners who seek training independently. Research indicates that many practitioners lack competence in addressing sexuality in their general practice because of educational (Areskoug-Josefsson et al., 2016), institutional, and practice setting barriers (Young et al., 2019). In addition, some practitioners hold attitudes and beliefs that create barriers to integrating sexuality and gender into health care discussions (Kirsh et al., 2006; Mc Grath & Sakellariou, 2016).
As a profession that promotes health, well-being, and participation in occupations (inclusive of sexual health and participation in intimate and social relationships), it is crucial that occupational therapy examine occupational therapy practitioners’ preparation for meeting the needs of SGM communities (Areskoug-Josefsson et al., 2016). This information is essential to informing the design of educational interventions that may lead to improved quality of care, lessen barriers to care, and address health disparities (McCann & Brown, 2018). The purpose of this study was to examine occupational therapy practitioners’ self-reported knowledge about, perceptions of clinical preparedness for, and awareness of attitudes toward working with lesbian, gay, bisexual, and transgender (LGBT) clients. Additional questions explored the relationship of demographics (e.g., gender, work setting) to these measures.
Method
Design
Cross-sectional data were collected from occupational therapy practitioners using a web-based survey. The study design was reviewed by the San José State University Human Subjects Institutional Review Board, which deemed the study exempt from further review.
Respondents
Respondents included currently practicing occupational therapy assistants and occupational therapists residing in the United States. They were recruited through announcements on occupational therapy social media groups, state association websites, and emails to occupational therapy educators and practitioners (using a snowball technique).
Instrument
We chose the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT–DOCSS; Bidell, 2017) to measure respondents’ self-assessed basic knowledge (awareness of LGBT health disparities), clinical preparedness (clinical experiences, training, assessment skills, feelings of competence), and attitudinal awareness (explicit bias and prejudice). Prior research on the LGBT–DOCSS found it to have good internal consistency, test–retest reliability, and construct validity compared with other established scales (Bidell, 2017). The LGBT–DOCSS has 18 questions, with separate questions related to gender (transgender populations) and sexual orientation (lesbian, gay, and bisexual populations). Respondents answered 12 additional demographic questions.
Procedure
Respondents opened the electronic link and completed an agreement to participate before starting the survey. All responses were anonymous. The survey was available online from February 7, 2020, to April 17, 2020.
Data Analysis
All response data were analyzed using IBM SPSS Statistics (Version 26). Responses with incomplete LGBT–DOCSS data were excluded from analysis. Composite scores were created for each of the three subscales (Knowledge, Clinical Preparedness, and Attitudinal Awareness) following the guidelines provided by Bidell (2017). Scores on each subscale were used as dependent measures in analyses. We used a one-way analysis of variance or a t test (depending on the number of groups) to examine whether a difference existed within and between mean scores for demographic variables. We conducted multivariate linear regression analyses to examine which demographic variables were significantly associated with higher scores on LGBT–DOCSS subscales, when controlling for other independent variables.
Results
Respondent Characteristics
We received complete responses from 589 respondents. The survey was opened by 752 people, and 163 were excluded from analysis because they declined to participate (n = 2), were not occupational therapy practitioners (n = 7), or did not complete the LGBT–DOCSS (n = 154). Descriptive characteristics of the respondents are presented in Table 1.
Demographic Characteristics of Occupational Therapy Practitioners
Note. N = 589, except where noted. OT = occupational therapy; SGM = sexual and gender minority.
10 participants declined to state.
Knowledge of, Clinical Preparedness for, and Attitudes Toward LGBT Persons
LGBT–DOCSS scores can range from 1 to 7, with 7 representing more positive performance. Overall subscale mean scores for respondents were as follows: Knowledge, 4.7 (SD = 1.5); Clinical Preparedness, 4.4 (SD = 1.4); Attitudinal Awareness, 5.6 (SD = 0.9). Mean scores and standard deviations for each LGBT–DOCSS subscale are summarized in Table 2. The results of multivariate analyses are also reported in Table 2, with notations about characteristics and demographics that significantly predicted subscale scores (while controlling for other variables). The categories for nonheterosexual (lesbian, gay, bisexual, queer+) and categories for noncisgender respondents (transgender, gender nonconforming, or another label) were combined for analyses because of the small number in each group.
LGBT–DOCSS Subscale Scores by Respondent Demographic Characteristics
Note. N = 589, except where noted. LGBT–DOCSS = Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale; OT = occupational therapy; SGM = sexual and gender minority.
Reference group in multivariate linear regressions.
p < .05.
p < .01.
p ≤ .001.
Scores on all three subscales were significantly higher for respondents with graduate degrees in occupational therapy, practitioners working in mental health settings, and those who identified someone close to them as being an SGM person. A higher number of years in practice and older age were associated with lower knowledge scores. Cisgender men and women scored significantly lower on Clinical Preparedness than those who identified as other than cisgender. Respondents who identified religion as very important and who participated in religious practices more than once per week had significantly lower Attitudinal Awareness and Knowledge scores than respondents for whom religion was less important or who attended religious services less frequently.
Discussion
In this study, we examined occupational therapy practitioners’ self-reported knowledge about, clinical preparedness for working with, and attitudinal awareness of LGBT clients using the LGBT–DOCSS. We identified higher scores across domains of the LGBT–DOCSS that were based on higher levels of academic preparation, participation in LGBT-specific continuing education hours (compared with none), and practice setting (with highest scores observed among respondents who worked in mental health and acute care settings). Sexual minority status and having someone close who identifies as an SGM were also associated with higher scores on all subscales. Higher religiosity and frequency of religious practice were associated with lower scores on the Knowledge and Attitudinal Awareness subscales.
Self-reported knowledge and clinical preparedness were significantly higher for respondents who reported even a small number (1–2 hr) of continuing education compared with those who reported no training. Continuing education was measured specific to SGM, which is an important distinction because general cultural awareness courses have not been effective in improving clinical preparedness and attitudes among people who work with SGM populations (Gonzalez et al., 2019). SGM-specific training should include reflections on personal and societal biases, prejudices, and stigma; knowledge of health care and psychosocial issues; and professional skills grounded in standards of care (Bidell, 2013). Although continuing education contributed to higher scores on the Knowledge and Clinical Preparedness subscales, Attitudinal Awareness scores were not significantly affected. Internalized SGM bias and stigma may be difficult to change at a personal level and may require concomitant institutional change (Herek, 2016).
Knowledge and Attitudinal Awareness scores were significantly lower among respondents with higher levels of religiosity than among those to whom religion was less important. This finding is consistent with those of other studies (Bidell, 2014; Sharma et al., 2019). Attitudes are difficult to change, given that they represent more deeply held ways of thinking, and practitioners need to be willing to explore differences in values between their personal and professional lives, which can be uncomfortable and create cognitive dissonance (Paprocki, 2014). For example, practitioners whose religious beliefs deem homosexuality a sin and who have core professional values of altruism, equality, freedom, justice, dignity, truth, and prudence (American Occupational Therapy Association [AOTA], 2020), require a safe way to integrate their personal beliefs with their professional beliefs (Paprocki, 2014). Positive cultural humility can have a moderating effect on discriminatory attitudes toward lesbians and gay men among people with strong religiosity (Choe et al., 2019); future research might explore how training or activities that foster cultural humility might be extended to explicitly include religion and religiosity. Experiential learning experiences for health professionals have been shown to improve comfort levels with and attitudes toward working with SGM persons (Morris et al., 2019).
The highest mean LGBT–DOCSS scores across settings were recorded by respondents who worked in mental health settings. Occupational therapy practitioners in such settings may have more training to work with SGM clients, but it is incumbent on professionals in all practice areas to be able to meet the unique needs of their clients. For example, SGM parents and families need to feel welcome in child-based practices, and therapists may need to support children who are SGM. The median age at which children begin to suspect they are SGM is 12 yr (Pew Research Center, 2013). SGM children need a welcoming, inclusive environment and curriculum as well as clear anti-bullying policies in occupational therapy clinics and school settings (Fleshman, 2019). Older adults may have experienced many years of stigma, discrimination, and trauma resulting from sexual orientation or gender identity, and it is crucial that practitioners understand the occupational needs of this population (Twinley, 2014).
An institutional commitment to creating positive and affirming environments for SGM clients is essential to effective practice. Individual health care practitioners’ gains in regard to reducing their implicit bias must be reinforced in the organizational context. For example, research suggests that education decreases reported bias but that, if this is not followed up with ongoing support, professionals may revert to the pretraining bias levels found in their structural organizations (Vuletich & Payne, 2019). Institutions must develop strong nondiscrimination policies and programs, inclusive training for all staff, and an environmental review that includes all internally and externally displayed information, and they must assess both quantitative and qualitative outcomes (Beagan et al., 2013).
Educational institutions must also reexamine their culture and curricula. The curricula—formal, informal, and hidden—may unconsciously project a narrow cultural worldview (Beagan, 2018). Grenier (2020) observed that whereas Canadian occupational therapy schools have been successful in increasing the diversity of their student populations, few changes have been made to health care education frameworks, paradigms, and pedagogical approaches. Although Grenier was addressing racial inequality, her call to examine and rebuild key professional frameworks and models to eliminate inequity and ensure inclusion are relevant to advancing training related to SGM populations.
Study Limitations
This study has several limitations. Respondents contacted through occupational therapy social media may overrepresent people who are more engaged in professional issues; as a consequence, our findings cannot be generalized to all occupational therapy professionals. There was a potential for response bias (Jongen et al., 2018), in particular given studies suggesting that health care professionals might overestimate their skills (Johnson & Federman, 2014). There may also have been self-selection bias, with greater participation among those with an interest in SGM topics. In addition, the LGBT–DOCSS is a composite measure that does not capture differences in practitioner preparation for working with SGM subgroups. Finally, our results are based on cross-sectional data and thus are not sufficient to test causal relationships.
Implications for Occupational Therapy Practice
The AOTA (2020) Code of Ethics states that occupational therapy practitioners must be committed to promoting inclusion, participation, safety, and well-being for all service recipients. Optimizing care for SGM populations involves treating clients, groups, and populations with respect, fairness, discretion, and integrity and advocating for change to eliminate health inequities and disparities. This study demonstrates that a relatively small number of SGM-related continuing education hours may positively influence occupational therapy practitioners’ self-perceived knowledge of and clinical preparedness to work with LGBT clients. This should be of interest to occupational therapy educators, managers, and practitioners who seek to improve the equity and inclusiveness of health care for SGM clients. Attitudinal awareness is a more stable trait, and further investigation is needed in this area. Suggested actions include individual reflection about one’s cultural humility and proficiency for working with LGBT clients and then identifying areas that need improvement. Individual actions need to be supported by the elimination of structural biases in workplace and academic settings, along with qualitative and quantitative measures for analyzing change.
Conclusion
This study underscores the importance of academic and continuing education in addressing gaps in occupational therapy practitioners’ knowledge about, preparedness for, and attitudes toward working with LGBT clients, in conjunction with institutional changes. Further research is needed regarding best practices in teaching and education as well as how occupational therapy practice with diverse sexual and gender minorities may affect health outcome (equity) measures.
Footnotes
Acknowledgments
We thank Laurie Drabble for editorial advice and Sulekha Anand for statistical consultation.