LGBT clinical competency among physiotherapy students
This study is the first to assess the competency of physiotherapy students in Israel regarding LGBT patients. These preliminary results illustrate that PTSs exhibited a low level of clinical competency, as indicated by a total LGBT-DOCSS score of 4.55 (± 0.61) out of 7. Two previous studies [18, 33] have delved into clinical competency regarding working with LGBT individuals among PTSs utilizing the same LGBT-DOCSS tool employed in this study. Nowaskie et al. [18] assessed clinical competence related to LGBT issues among students in various healthcare disciplines in the USA. Their study included a sample of 1701 healthcare professional students, 42 (2.5%) of whom were physical therapists. The findings closely parallel the results of our study, demonstrating that students exhibited a low level of preparedness, with LGBT-DOCSS scores averaging 4.96 (± 0.8). Primeau et al. [33] showed a moderate level of competency among 15 PTSs in Canada, as evidenced by a total LGBT-DOCSS score of 5.10 (± 0.66) out of 7. It is possible that the slight increase in competency level (a score difference of 0.55) compared to the current study might be attributed to differences in characteristics, notably gender and self-identified sexual orientation. These are recognized as factors that can influence competency level [33, 34].
Low clinical competency has been linked to the emergence of health disparities in healthcare settings, including issues such as discrimination and barriers to accessing by the LGBTI community [35, 36] Ross and Setchell [37] demonstrated that LGBTQ patients may experience discomfort, discrimination, due to a lack of relevant knowledge when treated by physiotherapists. They also highlighted that physiotherapist may create negative encounters and biases within the healthcare setting.
LGBT clinical competency across different levels of religiosity
The current study demonstrated significant differences in clinical competency among various levels of religiousness. The highest level of clinical competency was observed among secular individuals, while the lowest was found among those who identified as religious. An analysis of the subscales within the total LGBT-DOCSS score revealed that the lower level of cultural competence among elderly people was primarily attributed to more negative attitudes toward LGBT individuals compared to their secular counterparts. Additionally, there was a lower level of clinical readiness. However, it is worth noting that a direct comparison of these findings was impossible due to the absence of similar studies that have examined differences in LGBT-DOCSS scores in relation to the subjects’ religious affiliations. Yet, the presence of more negative attitudes toward LGBT individuals among religious PTSs and registered PTs compared to secular individuals has been previously documented in Israel [15, 21]. Janssen and Scheepers [38] found that globally, individuals who consider their religion to be the only accepted religion are deeply integrated within their religious community and adhere to traditional gender roles and tend to hold more negative views toward homosexuality than others. Furthermore, there is a large body of evidence demonstrating a connection between religious affiliation and negative attitudes toward LGBT individuals among healthcare professionals, which also extends to increased discomfort when examining and treating patients who identify as part of the LGBT community [9, 20, 33, 34, 39,40,41].
A possible explanation for the significantly lower level of self-reported clinical preparedness observed in the current study among religious students, in comparison to their secular counterparts as revealed in this study, may be rooted in the students’ choices for reduced exposure to this population during their studies. This is because exposure has been identified as one of the factors that influences the level of clinical preparedness [23]. This hypothesis could not be evaluated within the confines of the available data, as there were no data regarding the students’ exposure to LGBT patients from the community regarding the level of religiosity. Further research is warranted to explore the potential association between religiosity and the knowledge, self-reported clinical preparedness, and actual clinical preparedness of pre-clinical medical students. This might entail adjusting curricular components and potentially creating a specialized subspecialty for students interested in serving specific communities, with considerations regarding their religious affiliation.
LGBT clinical competency across genders
The current study’s results indicate a significant influence of gender on all three subscales of clinical competency among PTSs. Specifically, men demonstrated greater self-reported levels of knowledge and clinical preparedness, although they displayed more negative attitudes compared to their female counterparts. However, there was no discernible significant difference between the genders in terms of the total LGBT-DOCSS score. This finding warrants further exploration. The current finding that men have more negative attitudes than women was also found in a previous study that examined the attitudes of PTSs in Israel [21], as well as among students of other health professions who also used the tool and tested the effect of gender on clinical competency [42, 43]. The results of the current study revealed that men demonstrated higher levels of self-reported clinical preparedness than women. This finding aligns with the results reported by a prior study by Nowaskie and Najam [42] involving health profession students, medical students specializing in psychiatry and dementia caregivers. Nowaskie and Najam [42] explained that, as the LGBT-DOCSS questionnaire relies on self-reports from the subjects regarding their level of readiness, women’s self-assessment might be influenced by unconscious biases regarding their abilities. In contrast, Badat et al. [43] found that the gender of medical students had no influence on the scores of the clinical preparedness subscale in the LGBT-DOCSS questionnaire. Regarding the subscale of knowledge in the LGBT-DOCSS, this study found that men possessed more knowledge than women. However, the two previous studies cited above [42, 43], which focused on health professionals other than physical therapists, reported contrasting results, where women exhibited higher knowledge levels than men. Consequently, it appears that there is a need for further research into the role of gender in healthcare provision to LGBT patients by PTSs.
LGBT clinical competency based on sexual orientation
The current results indicate that PTSs who identify as non-heterosexual exhibit a statistically significant higher level of clinical competence compared to their heterosexual counterparts. This finding aligns with the previous study of Nowaskie et al. [42]. , which explored LGBT cultural competency among 2254 healthcare professionals using the same tool (LGBT-DOCSS) employed in our study. They demonstrated that sexual minority professionals scored higher on the LGBT-DOCSS, reflecting greater LGBT competence compared to heterosexual professionals. These results were attributed to the personal identification, values, and experiences of sexual minority professionals with stigma and discrimination. Consequently, these professionals may develop enhanced competence through increased recognition and awareness of LGBT healthcare, personal experiences with multiple minority identities, and the pursuit of advanced education and training. To date, only one study [18] has examined the LGBT clinical competence of PTSs, along with students from other healthcare disciplines such as occupational therapy, pharmacy, and physician assistant programs. This study included a total sample of 1701 students from three universities across the United States and utilized the LGBT-DOCSS tool to assess clinical competency. It is noteworthy that physical therapy students comprised a small percentage of the total sample (2.5%, 42 participants). Among these physical therapy students, 88.1% identified as heterosexual, a percentage comparable to the 84.1% found in our current study. However, this study did not analyze the impact of sexual orientation on clinical competence. Accordingly, it is not possible to compare the research findings to previous studies, and this indicates the need for follow-up studies to strengthen the findings of the current study.
Self-reported knowledge of physiotherapy students about the LGBT community
The present study found that all students (100%) reported not having received any LGBTQ + community-related courses during their undergraduate studies in physical therapy. This concerning situation aligns with findings from previous studies among PTs and PTSs in Israel [15, 21] and underscores the position paper by Copti et al. [14] in 2016 and Primeau et al. [23] in 2022 emphasizing the urgent need to enhance the knowledge of PTs regarding the LGBTQ + community to enhance clinical competence. This enhancement is based on the tripartite model of clinical competence, which encompasses the Attitudes subscale, skills, and knowledge [22].
Hebrew version of the LGBT-DOCSS questionnaire
A secondary objective of this study was the translation and validation of the LGBT-DOCSS questionnaire into Hebrew. The research demonstrated that the internal consistency coefficient of the overall score was good, with a Cronbach’s alpha of 0.73, which was slightly lower than that of the original English version (Cronbach’s alpha = 0.86) [31]. The values for the subscales were as follows: the knowledge subscale value (Cronbach’s α = 0.83) was consistent with that of the original version (Cronbach’s α = 0.83) [31]. The remaining two subscales had slightly lower values compared to the original version (clinical preparedness: 0.65 versus a value of 0.88 in the original version, and attitudes subscale: 0.73 versus a value of 0.8 in the original version). Nevertheless, the current Cronbach’s alpha coefficients confirm that the Hebrew version maintains good internal reliability. Therefore, it can be considered a reliable tool for evaluating clinical competency among health professionals in Israel.
Study limitations and further research
Several study limitations should be considered. We utilized a tool that assesses explicit attitudes and self-reported clinical preparedness, and it is possible that examining the implicit attitudes and actual clinical preparedness of PTSs could yield different results. Regarding our recruitment method, which involved using social media and a snowballing approach, there were several drawbacks: compliance percentages could not be calculated as the questionnaires were distributed online, and we could not determine the total number of PTSs who received the link but chose not to complete the questionnaires. In addition, this approach might have implications for the representativeness of the population of interest. Specifically, individuals with strong sexual prejudices or biases, whether positive or negative, toward sexual and gender diverse populations may have been more likely to complete the survey, while those with more moderate views might have opted not to participate, as no rewards were offered to incentivize their involvement. Future research should account for participants’ sexual orientation and gender identities, which may have influenced the outcomes. Additionally, subsequent studies should assess LGBT clinical competency of PTSs through practical evaluations, including objective tests of knowledge and clinical skills.
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