Sexual and Gender Minority Health-Related Content in Geriatric Fellowships

Abstract

Introduction:

Despite a growing number of older lesbian, gay, bisexual transgender and queer (LGBTQ) adults in the United States, education on care for this vulnerable population has historically been inadequate across all levels of training. This research assessed the extent of LGBTQ education in geriatric medicine fellowship curricula across the United States.

Methods:

We designed a survey to anonymously collect information from geriatric medicine fellowship programs on LGBTQ curricular content. Eligible participants included all 160 fellowship directors on record with the American Geriatrics Society. The survey addressed: demographics of the fellowship program, current state of inclusion of LGBTQ content in didactic curricula and in clinical settings, and other available training opportunities.

Results:

Out of those contacted, 80 (50%) completed the survey. Of the programs surveyed, 60 (75%) were housed in internal medicine, 19 (24%) were in family medicine, and one was in their own department. Forty-seven fellowships (59%) reported some formal didactic session (e.g. lecture or case based) with the majority of these programs (72%) featuring 1–2 hours of formal instruction. Forty-five programs (56%) reported offering no formal clinical experiences. There was less than 50% coverage for all surveyed topics in the required curriculum (range 46% for discrimination to 9% for gender affirming care). Time and lack of expertise were cited as the main barriers to content inclusion.

Conclusions:

Curricular content regarding care for LGBTQ older adults is inadequate in geriatric medicine fellowships. Faculty development of current educators and providing standardized guidelines and curricula are steps towards addressing this deficit.

INTRODUCTION

In the US, there are estimated to be over 3.5 million older adults over the age of 60 identifying as lesbian, gay, bisexual, transgender or queer (LGBTQ) (or sexual or gender minorities) ¹ With the growth of our aging population, the older LGBTQ population is expected to grow to 5 million by 2030.² Despite these growing numbers and increasing visibility, LGBTQ adults in the US have reported refusal of care, disrespectful health care, and discriminatory treatment.³ They have also experienced internalized stigma and concealment of identity. This life time of minority stress has likely contributed to older LGBTQ adults experiencing health disparities and mental health issues. However, older LGBTQ adults have also developed resiliency in the form of agency and self-efficacy as they coped with these challenges earlier in life. ^4–5

Of note, terminology has been developed by the LGBTQ community (see figure 1), with the previously used acronym LGBT expanded to include queer persons with the addition of “Q,” intersex persons with “I” and all sexual and gender minority community members with the “+.”^6,7 Since queer was used in the past as a pejorative, it is not used by all sexual and gender minorities, particularly by our oldest adults.⁸ How groups of people are described should reflect their own language and changes over time. For the purpose of this paper, LGBTQ will be used to reflect our sexual and gender minority community members as part of the LGBTQI+ community.

Figure 1:

Definition of Lesbian, Gay, Bisexual, Transgender, Queer and Plus (LGBTQ+).

To help address these disparities in marginalized older adult populations, the American Geriatric Society (AGS) and researchers, and community organizations including Services & Advocacy for GLBT Elders (SAGE) have called on efforts to improve the education and training of health care providers in LGBTQ health.^9–12 Inadequate training in care for LGBTQ communities exists at various levels of health professions education, particularly for physicians. Starting with medical student training, despite positive student attitudes and willingness to learn, education on care for LGBTQ people of all ages is lacking.^13,14

Many graduate medical training programs also inadequately prepare their trainees due to lack of didactics and clinical exposure to LGBTQ related content.¹⁵ Surveys of program directors in select graduate medical residencies show a range in how much coverage of LGBTQ related content is included in their curricula.^16–17 A survey of graduating internal medicine residents revealed knowledge of LGBTQ topics was poor.¹⁸ Similarly, many practicing physicians recognize they lack training in LGBTQ cultural competence.¹⁹ There exists a gap, then, in clinician educators’ literacy in care for LGBTQ patients and the medical trainees they will be educating.²⁰ This training gap extends to health care providers caring for older adults, with many reporting limited LGBTQ knowledge.²¹

For any medical fellowship, training to respect and respond to diverse populations across different genders and sexual orientations is required²², but the focus on the intersection of aging with LGBTQ specific care is especially pertinent in geriatrics fellowships.²³ However, we currently lack evidence that this content is consistently included in Geriatric Medicine fellowship training programs. In this study, we surveyed directors of geriatric medicine programs to assess the extent of LGBTQ education in fellowship curricula across the United States, including coverage of specific content topics, and barriers and resources needed to expand curricula in this essential area of training.

METHODS

We designed a survey to collect information from geriatric medicine fellowship program directors on LGBTQ curricular coverage. The survey was adapted from a 2011 study on LGBTQ curriculum in undergraduate medical education.²⁴

The survey addressed various domains including the following: demographics of the fellowship program (department in which program was housed and number of fellows currently enrolled); current state inclusion of content in formal didactic curriculum (number of hours, format of sessions, teaching faculty expertise); clinical settings featuring education on care for LGBTQ older adults (required vs elective, additional LGBTQ focused offerings such as research, advocacy and/or community research).

To further delineate curricular coverage, we assessed 21 content areas to determine if these areas were a required component of the curriculum, were present but not required (potentially available in other settings such as an elective) or were not present. LGBTQ content areas covered were adapted from the 2011 survey and supplemented with more geriatric-focused areas such as advance care planning, long term care, cancer care and polypharmacy. Participants were also surveyed about overall adequacy of coverage of topics, barriers to including LGBTQ content, and resources needed to increase this content.

To distribute this survey, the Association of Directors of Geriatrics Academic Programs (ADGAP) provided contact information for current fellowship program directors. We emailed the survey in January 2022 to 160 program directors through Qualtrics, the electronic platform used to design the survey. The survey responses were anonymous. The survey remained open for approximately six weeks with weekly reminders. This survey was determined to be exempt by the UCLA Institutional Review Board.

To assist with analysis, we compared data across fellowship departments (internal medicine vs. family medicine) and fellowship size (small=1–2 fellows, medium=3–5 fellows, and large=6 or more fellows). For these comparisons, we used chi-square tests for independence, or Fisher’s Exact tests (when appropriate), and reported the corresponding p-values. For education topics, we considered both responses of “Yes, but not in required curriculum (available in other settings, such as elective)” and “Yes, in required curriculum” to represent “Yes, topic covered.” We coded open ended questions for themes. Finally, for internal medicine-based fellowships versus family medicine-based fellowships size, Mann-Whitney U test was used to assess for differences.

RESULTS

Basic program characteristics are presented with descriptive statistics such as frequencies and percentages (see Table 1). Of the 160 geriatric fellowship program directors invited to participate in this survey, 80 (50%) completed surveys of which three (2%) were partially completed, and three of the study authors, as program directors, completed the survey (see table 1). Of these programs, 60 (75%) were housed in internal medicine, 19 (24%) were in family medicine, and one was their own department. Over half of the fellowship programs surveyed (53%) had two fellows or fewer, with programs in family medicine being smaller in size compared to internal medicine-based programs (median 1 vs 3 fellows, p<0.01).

Table 1.

Program Characteristics

	Internal Medicine N=60 (%)	Family Medicine N=19 (%)	Total N=80 (%)
Program Size
Small: 1–2 fellows	26 (43)	16 (84)	42 (53)
Medium: 3–5 fellows	25 (42)	2 (11)	27 (34)
Large: 6 or more fellows	9 (15)	1 (5)	11 (14)
Median	3	1	2
Hours of formal LGBTQ content in didactic curriculum
0	26 (43)	7 (37)	33 (41)
1–2	24 (30)	8 (10)	33 (41)
3–4	8 (10)	1 (1)	9 (11)
5 or more	1 (1)	3 (4)	4 (5)
Did not respond	1 (1)	-	1 (1)
Median for programs with formal content	2	2	2
In what clinical settings do fellows receive education on LGBTQ populations?
No formal clinical experiences	37 (62)	7 (37)	45 (56)
Outpatient primary care clinic	15 (25)	8 (42)	23 (29)
Nursing home*	15 (25)	8 (42)	23 (29)
Inpatient hospital	5 (8)	5 (26)	10 (26)
Assisted living facility or group home	3 (5)	2 (11)	5 (11)
Assisted living facility or group home	3 (5)	2 (11)	5 (11)
Hospice	1 (2)	2 (11)	3 (4)
Site dedicated to the care of older LGBTQ adults	-	1 (5)	1 (1)
What additional LGBTQ focused opportunities are offered to fellows?
Community outreach*	4 (7)	8 (42)	12 (15)
Research	7 (12)	2 (11)	9 (11)
Curriculum development	7 (12)	2 (11)	9 (11)
Advocacy	5 (8)	2 (11)	7 (9)

^*significant difference between IM and FM programs - p value <0.05 in Fisher’s Exact tests

Regarding coverage of LGBTQ content, 47 (59%) fellowships reported formal didactic coverage. Of the 46 programs that reported specific hours, 33 (72%) had between 1–2 hours of formal instruction. Larger programs (those with six or more fellows) had more LGBTQ content covered in formal didactic sessions (100%) compared with small and medium sized programs (59% and 55% respectively) (p<0.01). The primary modalities to complete this teaching were lectures (91%), case-based teaching (32%) and didactics from outside of their institution (i.e. GERI-A-FLOAT) (27.7%) (a national virtual curriculum for geriatrics fellows; link to access). Of these programs, 85% utilized core faculty to teach this content, and 26% of programs engaged an LGBTQ specialist to teach. 

Regarding clinical settings in which fellows receive education on LGBTQ populations, 45 (56%) programs reported offering no formal clinical experiences. For programs offering clinical experiences, the setting in which these were most likely to occur was in the outpatient primary care clinic (n=23, 29%). Only one program (1%) offered training in a site dedicated to the care of older LGBTQ adults. Family medicine-based fellowships reported more LGBTQ based nursing home experiences compared to internal medicine-based programs (32% vs 8%, p<0.05). Smaller programs, independent of where the program was housed, were more likely to offer primary care opportunities (p<0.01). 

In terms of additional LGBTQ focused opportunities available to fellows outside of the formal curriculum, 28 programs offered additional opportunities (35%). The most common opportunity was for community outreach (n=12, 15%). Family medicine-based fellowships were more likely to offer this opportunity in community outreach than internal medicine-based programs (42% versus 7%; p<0.001).

With regards to specific coverage of topics germane to LGBTQ communities, Table 2 displays the percentage of programs that cover topics either in the required curriculum or in an optional format. The most common topics included in the required curriculum were discrimination (n=36, 46%) and sexual orientation (n=35, 44.3%). The least commonly covered topics in the required curriculum were gender-affirmation (including gender affirming care) (n=7, 9%) and hormone therapy and medication interactions in older transgender adults (n=8, 10%). On average, large programs covered more topics in the required curriculum (46% of surveyed topics) than medium (23%) and small (25%) programs. In large fellowship programs, the topics of mental health, gender identity and coming out were covered at significantly higher rates than in medium and small sized programs (p<0.05).

Table 2:

Frequency of Coverage of LGBTQ Content Areas in the Geriatric Medicine Fellowship Curricula

Question Prompt: “Does your institution provide education for geriatric medicine fellows in the following content areas regarding older LGBTQ adults at any point in the geriatric fellowship curriculum?” (N=79)	Yes, required %	Yes, but not required %
Discrimination faced by older LGBTQ adults	46	20
Sexual orientation	44	25
Barriers to accessing medical care for older LGBTQ adults	38	17
Older LGBTQ adults in long term care, assisted living and senior housing	38	20
Gender identity	35	22
Mental health in older LGBTQ adults	35	20
Chronic disease risk for older LGBTQ populations	34	14
Advance care planning in older LGBTQ adults	32	22
Family structure in older LGBTQ adults (i.e. families of choice)	32	23
HIV in older LGBTQ adults	29	18
Affirming clinical practice for older LGBTQ adults	28	23
Alcohol, tobacco, or other drug use among older LGBTQ adults	27	15
Coming out	24	10
Unhealthy relationships (intimate partner violence) in older LGBTQ adults	24	14
Safer sex for older LGBTQ adults	20	10
Sexually transmitted infections (not HIV) in older LGBTQ adults	20	14
Cancer care considerations in older LGBTQ populations	20	14
Trauma informed care for older LGBTQ adults	19	13
High risk indications for pre-exposure prophylaxis (PrEP) in older LGBTQ adults	11	19
Hormone therapy and medication interactions in older transgender adults	10	18
Gender affirmation (including gender affirmation surgery)	9	11

Only 33% of programs reported any evaluation of their teaching of LGBTQ-specific content. Evaluations most commonly included knowledge assessments (n=11, 14%) and direct observation of patient interactions (n=9, 12%).

Of the 77 program directors who responded to the question regarding the adequacy of curricular coverage of LGBTQ health in older adults, none reported in-depth coverage, 11 programs reported moderate coverage (14%) and 66 programs not enough coverage (86%). Programs were also surveyed about plans to develop additional coverage and barriers to increasing educational content. Some program directors expressed interest in inclusion of more LGBTQ content, but few programs reported concrete plans to do so. The most common barriers cited to including more content were time, expertise and access to resources. Although 33 programs reported their institution provides faculty development opportunities to learn about LGBTQ health, when asked to describe the type of opportunities the faculty participate in, responses suggested most to be voluntary and ill-defined (i.e. grand rounds, SAGE, department equity, diversity and inclusion programming).

DISCUSSION

Our survey of geriatric medicine fellowship directors revealed limited coverage of LGBTQ content including both clinical and didactic opportunities, with some programs reporting no LGBTQ training at all. To our knowledge, this is the first survey of LGBTQ curricular coverage in geriatric fellowship programs, however the absence of coverage is consistent with prior research in graduate medical education.^26–28 The older LGBTQ population is already vulnerable and described as “invisible,” which further predisposes them to suboptimal care in clinical settings when providers lack adequate training. ²⁵ Furthermore, given historical lived experiences of older LGBTQ adults, these patients have been described as “invisible” to health care and are often not presenting to the health care system “out and proud,” but more often rely on providers to have LGBTQ literacy and to provide affirming care.^25,26

Limited and inconsistent coverage of LGBTQ curriculum was seen across all programs, regardless of whether they were housed in internal or family medicine and regardless of size. Although large programs offer slightly more topic coverage, such as mental health, gender identity and coming out, overall coverage of topics surveyed was still less than 50%. It is concerning that curricular topics related to transgender and gender diverse older adults such as gender affirmation (i.e. gender affirming medical and surgical therapies) and hormone therapy and medication interactions, were virtually absent from fellowship curricula. Transgender older adults are an especially vulnerable group, with higher rates of poverty and mental illness when compared with their cisgender sexual minority peers.^27,28

Even though 44% of programs reported offering clinical experiences, primarily in the outpatient setting, there are still many fellowships that offer no formal clinical experiences. It is not clear there is consistent recognition of the presence of this population, as one of the respondents noted “we don’t have any LGBTQ patients in our geriatric clinic to date.” Another respondent commented on being in a “very conservative region,” which likely also impacts awareness of the presence of LGBTQ patients in general, let alone older adults.

In terms of differences between family and internal medicine-based programs, the main finding was that more family medicine programs reported offering community outreach opportunities for LGBTQ older adults. This strength of these programs may provide opportunities to investigate best practices and could help guide other programs in developing more community outreach.

Program directors generally recognized that curricular coverage for LGBTQ older adults was inadequate and also expressed interest in further curricular development and resources. However, they expressed several key barriers to curricular expansion, including time and expertise, consistent with prior barriers identified in the literature.²⁹ This is of concern as geriatricians are often called on to provide training to other care providers and trainees. If they lack expertise, they are unable to adequately educate others on the care of older LGBTQ adults. Although content experts were cited as an educational resource for some programs, others noted the lack of access to experts and resources as barriers. This discrepancy identifies an area where programs could benefit from access to content experts, which other programs have access to as educators. Finally, a few programs used external resources such as GERI-A-FLOAT, the Geriatric Review Syllabus, or those provided by national organizations such as SAGE. While these are appropriate initial resources in improving training, these resources are limited and insufficient in providing comprehensive education and training.

Given the limited and inconsistent existing curricular coverage and the barriers faced by geriatric medicine fellowships nationally, we make a call to action to reform fellowship education to better prepare geriatricians to care for LGBTQ communities. This aligns with Accreditation Council for Graduate Medical Education (ACGME)’s directive to better train physicians to care for diverse populations and existing geriatric fellowship milestones addressing the comprehensive geriatric assessment in marginalized communities.^22,30 Ultimately, this reform should also align with inclusion of training for LGBTQ communities at all levels of medical training, including in medical school and residency.

Concerning this fellowship reform, we propose the creation of a standardized curriculum that can be adapted by individual institutions nationwide to meet the needs of their local environment. Curricular development could include collaboration with national organizations such as AGS and SAGE to develop high quality resources. This will help address the lack of resources and knowledge cited by fellowship directors as a barrier to including more LGBTQ content. To empower fellowship directors and other program faculty to teach this content, we further propose offering “train the trainer” programs, such as in the form of national conference workshops.

Although our study had a 50% response rate of program directors, there are some limitations. The survey was anonymous, which limits our ability to characterize non-responding programs and identify any potential selection bias. For example, we have no ability to distinguish the representation of size of programs in our study sample. This study is also limited by the knowledge that fellowship program directors have about less standardized components of their program. For example, directors may not have full knowledge of content covered in clinical settings or of nuances of contents covered in didactics. On the other hand, there may have also been some recall bias with an overestimation with the extent of coverage in the curriculum. The self-admitted lack of knowledge of the LGBTQ community may have also impacted responses. Ultimately, it will be important to assess fellows’ actual knowledge and competence in caring for this population, but that was beyond the scope of this particular project.

Inclusive care is an important value of geriatric care. Providing affirming care for the LGBTQ community that models inclusive care principles can provide a template for care for all diverse communities of older adults. Additional curricular coverage and resources for educating trainees and faculty on care for LGBTQ older adults will help narrow the gaps that currently exist in geriatric medicine fellowship programs. Improving education of providers will ensure better care for our patients.

Key Points.

• There is a growing population of lesbian, gay, bisexual, transgender or queer (LGBTQ) older adults in the United States.

• Care for this population is inadequate and at times discriminatory.

• Our findings reveal education of future geriatricians regarding care of LGBTQ adults is insufficient, with opportunities for development of faculty and standardized curricula to address educational barriers.

Why does this matter?

LGBTQ older adults are a particularly vulnerable population subject to disparities in health care. Geriatric medicine fellowship programs should exemplify providing education directed towards improving care for this population. Our survey of program directors revealed that there is currently little to no education regarding LGBTQ older adults during fellowship. We found barriers to education included lack of faculty expertise, limited curricular time, and inadequate educational resources. By identifying these barriers, we hope to suggest improvements to education regarding LGBTQ older adults and to better provide affirming and equitable care.