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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2024 Dec 14;37(2):185–197. doi: 10.1080/19317611.2024.2435281

Characterization of Knowledge, Attitudes, Comfort, and Perception of Discrimination Regarding Sexual and/or Gender Minoritized People: Comparison Between Two Cohorts of Medical Students - 2018–2023

Ana Macedo a,✉, João Ferreira a,b, Ana Rita Gutierrez b, Jorge Gato c,d
PMCID: PMC12091925  PMID: 40400566

Abstract

Objectives

Despite progress made in the medical field to address the health concerns of sexual and gender minoritized identities, LGBTQIA+ individuals continue to experience discrimination in healthcare. This study aims to evaluate the effects of incorporating a seminar on gender identity and sexual orientation into the medical curriculum of a Portuguese Medical School, after 5 years. The study’s main objective was to compare the changes in students’ knowledge, attitudes, comfort, and perception of discrimination against LGBTQIA+, pre and post-intervention.

Methods

A total of 313 students in their third, fourth, fifth, and sixth year at a Portuguese Medical School were assessed in 2018 (pre-intervention) and 2023 (post-intervention). The data collected were analyzed regarding age, gender identity, sexual orientation, number of friends or family members who identify themselves as LGBTQIA+, and level of religiosity.

Results

The overall knowledge regarding LGBTQIA+ people specific health aspects improved from the 2018 cohort to the 2023 cohort, with significant differences in questions regarding gender identity (OR = 2.0, p = .007), sexual orientation (OR = 2.9, p <.001), and mental health (OR = 3.2, p <.001). The perceived discrimination against homosexual patients was similar in both cohorts, with approximately 60% of respondents from both groups agreeing that homosexual patients were discriminated against in healthcare.

Conclusion

Although the perception of discrimination against LGBTQIA+ people in healthcare remained high across the two cohorts, positive changes were observed regarding students’ overall knowledge of LGBTQIA+ individuals’ health, clinical preparation and comfort in treating LGBTQIA+ people, and attitudes toward lesbian women and gay men. These results reinforce the need to develop training and information strategies targeting medical students, promoting greater knowledge and, above all, increasing contact and clinical practice with LGBTQIA+ people, since relationships and personal contact are the most differentiating aspects for nondiscrimination.

Keywords: Medical students, LGBTQIA+, sexual and gender minorities, equity, discrimination

Introduction

Achieving authentic equity in the health outcomes of minoritized groups, particularly LGBTQIA+ people (lesbian, gay, bisexual, trans, queer, intersex, asexual, and individuals with other minoritized sexual and gender identities), necessitates the convergence of numerous social, cultural, economic, individual, and institutional elements (Eckhert et al., 2023; Gonzales & Henning-Smith, 2017; Hatzenbuehler, 2016; Hoffman et al., 2018; Maragh-Bass et al., 2023; Salway et al., 2019; Williams et al., 2020). Educational institutions, particularly medical schools, play a pivotal role in both the dissemination of culturally competent knowledge and individual development of future physicians. They either endow students with the necessary technical and interpersonal abilities that foster inclusivity or fail to do so (Ayhan et al., 2020; Bunting et al., 2021; Hayes et al., 2015; Karpel et al., 2023). Our goal in the present study was to assess the extent to which the introduction of a seminar on gender identity and sexual orientation in clinical practice, in the curriculum of medical students from a University in Portugal resulted in changes in students’ knowledge, attitudes, comfort, and perception of discrimination regarding LGBTQIA+ individuals. Next, we will provide some information about the Portuguese legal and social context for LGBTQIA+ individuals as well as the discrimination they are often victim of in the health services. We will then review evidence about culturally competent and affirmative healthcare with this population.

In the last two decades, several laws regarding the civil rights of sexual and gender minoritized people have been approved in Portugal. In fact, this was the first country in Europe (and the fourth in the world) to constitutionally prohibit discrimination based on an individual’s sexual orientation. Another important legal landmark was the marriage equality law in 2010. In 2016, same-sex adoption was approved (Law no. 2/2016, 2016 Diário da República) and public funded access to Assisted Reproductive Technologies was guaranteed for all women, irrespective of their sexual orientation, civil state, and fertility status (Law no. 17/2016, 2016 Diário da República). Since 2018 trans individuals aged 18 or older have the right to have their (binary) gender identity recognized in the civil registry (Law no. 38/2018, 2018 Diário da República). Given these changes, in 2023 Portugal ranked 11 out of 49 European countries in terms of their legal and policy practices toward LGBTQIA+ people (ILGA-Europe, 2024).

According to the Global Acceptance Index (Williams Institute, 2021), which ranks countries according to their average LGBTQIA+ acceptance score, Portugal evolved from a 5.5 score in the 2000–2003 report to a 6.87 score in the 2017–2020 report, following the trend of countries with higher levels of acceptance. Similarly, data from the most recent Eurobarometer survey, which tracks discrimination in the European Union (EU), generally indicate an increase in positive attitudes toward LGBTQIA+ people (European Commission, 2023).

Some signs of this social acceptance comprise the proliferation of pride marches and the upsurge in the number of LGBTQIA+ organizations and community groups in various regions across the country; the growing number of rainbow flags hoisted in town halls to celebrate the International Day Against Homophobia and Transphobia (May 17); the increased visibility of LGBTQIA+ people in the media; or the growing attention devoted by the scientific community to this population (Gato, 2022).

Despite these legal and social developments, LGBTQIA+ individuals are less visible in Portugal in comparison to many Western European countries, including neighboring Spain [19]. Concomitantly, high levels of stigmatization have been reported. Of the 4,294 Portuguese LGBTI people who responded to the most recent survey of the European Union Agency for Fundamental Rights (Tuthill et al., 2020), thirty percent said they had been harassed due to their sexual orientation; one in five said they had not reported physical and/or sexual aggression to the police authorities for fear of possible homophobic attitudes from the police; and 65% never or rarely openly exposed their sexual orientation or gender identity. It should also be noted that, within the LGBTQIA+ group, people with transgender and intersex identities reported more negative experiences compared to people who self-identified as LGB.

Discrimination in the health services

Despite progress made in the medical field to address the health concerns of sexual and gender minoritized identities, LGBTQIA+ individuals continue to experience discrimination in healthcare (Cahill & Makadon, 2014; Conron et al., 2010; Trinhet al., 2017; Tuthill et al., 2020). Pieri and Brilhante (2022) described the inadequacy of some health professionals when interacting with LGBTQIA+ patients by using a cisheteronormative discourse. According to the European Union Agency for Fundamental Rights (2020), 12% of the LGBTQIA+ people surveyed felt discriminated against by health and social service professionals (in the subsample of trans people the percentage rose to 21%) and 52% had never revealed their LGBTQIA+ identity to any healthcare professional (37% in the case of trans individuals, probably due to gender affirmation processes carried out in a health context).

The situation of trans individuals is particularly worrying given their specific health needs. Rodrigues et al. (2020) investigated the experiences of 71 trans individuals in Portuguese health services. Half of the sample reported having been victims of at least one episode of discrimination, including use of prejudiced or insulting language (27.9%), denial of gender identity (20.6%), discouragement of exploration of gender identity (19.1%), refusal of assistance or termination of care (17.6%), and ridicularization or diminishing (16.2%). Nearly 35% of the surveyed participants stated they did not feel comfortable discussing issues related to trans health.

Research has shown that this discrimination affects both LGB and/or transgender patients and LGBTQIA+ health care professionals. Discrimination, whether overt or subtle, can result in a range of negative consequences. First, it causes LGBTQIA+ individuals to avoid seeking healthcare as they perceive the experience as aggressive and stressful. This gives rise to significant disparities that result in increased cancer mortality, particularly breast cancer (Banerjee et al., 2018; Matthews et al., 2018; Quinn et al., 2015), greater frequency of cardiovascular disease, the presence of cardiovascular and cerebrovascular risk factors (Beach et al., 2018; Hatzenbuehler et al., 2013), and a higher prevalence of mental illness (King et al., 2008; Salway et al., 2019). Second, healthcare professionals are often not adequately prepared to address the specific health issues faced by LGBTQIA+ individuals due to a lack of knowledge and comfort with the situation. This leads to communication difficulties and a subsequent lack of trust between patients and health care providers (Brandt et al., 2022; Fakhrjahani et al., 2023; Government Equalities Office, 2018; Karpel et al., 2023).

Furthermore, medical students often have some degree of negative bias toward their patients’ sexuality, which can be associated with prejudice and intersect with other socio-demographic issues such as origin, ethnicity, religion, profession, or economic status (Crandall et al., 2007; Wilson et al., 2014). These characteristics elicit an emotional response and contribute to the development of stereotypes and heteronormative perspectives.

Medical schools

In recent years, there has been a growing recognition of the need to include LGBTQIA+ issues in medical school curricula as a means of eliminating health care disparities and providing culturally competent care. In 2014, the Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity and Sexual Development published a detailed report outlining 30 competencies in eight domains that are necessary to meet the needs of LGBTQ+ patients in medical education (Association of American Medical Colleges, 2014; Zumwalt et al., 2022). Despite these recommendations, the extent to which LGBTQ+ health is addressed in medical education in the US remains variable and often limited across different programs emphasizing the need for standardized LGBTQIA+ medical education. The inclusion of LGBTQIA+ topics in medical school curricula not only improves students’ understanding of LGBTQIA+ health disparities, but also promotes a more inclusive and supportive healthcare environment (Jewell & Petty, 2024). It is also important to note that medical students’ opinions on the inclusion of specific topics in the curriculum may be influenced by biases and prejudices, even when these topics are highly relevant (Varas-Díaz et al., 2019).

Numerous medical schools and organizations representing medical students have voiced their concerns about the well-being of LGBTQIA+ individuals and made efforts to ensure that these aspects are integrated into the curriculum (Association of American Medical Colleges, 2014; Keuroghlian et al., 2022; White et al., 2015; Yoshida et al., 2022). Various studies have been conducted to evaluate the efficacy of various teaching-learning approaches, and the outcomes are consistent in highlighting the significance of close relationships and personal experiences with individuals with sexual and gender minoritized identities (Macedo et al., 2024). In fact, LGBTQIA+ students, or those who have several LGBTQIA+ friends or family members, tend to be more engaged and attentive, resulting in better outcomes in these initiatives. Furthermore, training programs that feature LGBTQIA+ individuals are typically rated more highly by students and more likely to be successful.

The assessment of changes in students’ knowledge, attitudes, and perceptions of discipline over time, particularly in relation to modifications in medical course curricula, is an essential yet often-overlooked aspect of educational research. In the case of the University of Algarve, a curriculum change was implemented in 2018, which introduced a seminar on gender identity and sexual orientation in clinical practice. This study seeks to evaluate the extent to which the introduction of this seminar has resulted in changes in knowledge about LGBTQIA+ people-specific health, clinical preparation and comfort in treating LGBTQIA ± people, perception of discrimination against LGBTQIA ± people in healthcare and attitudes toward homosexuality among cohorts 2018 (pre-intervention) and 2023 (post-intervention).

Material and methods

This study aimed to compare two cohorts of medical students. The assessment of the cohorts was conducted in a cross-sectional manner in 2018 and 2023. The first cohort, 2018, included all fourth, fifth, and sixth year students at the Faculty of Medicine of the Algarve University. The second cohort, 2023, included all third, fourth, fifth, and sixth year students at the Faculty of Medicine at Algarve University. Although the students present in 2018 should have completed their course by 2023, anyone who had completed the questionnaire in 2023 was asked not to fill it in again.

The Algarve Biomedical Center Ethical Committee reviewed and approved the study. The questionnaires used in both years were identical, were administered on paper, and were distributed at the end of the lectures. The completed questionnaires were collected in opaque boxes to ensure total anonymity.

It is important to note that no financial or other incentives were provided to students to participate in the study. Instead, they were informed that they could deposit blank questionnaires in the boxes.

Measurement instruments

The survey was based on previous research that evaluated healthcare providers’ attitudes, practices, and knowledge of LGBTQIA+ individuals’ health (Arseneau et al., 2013; Shetty et al., 2016; Walch et al., 2012). The survey encompassed various dimensions, such as specific LGBTQIA+ health knowledge, beliefs and comfort treating LGBTQIA+ people, communication patterns, prejudice, and encouragement of sexual orientation and gender identity disclosure. The evaluation of perceived discrimination against LGBTQIA+ patients, students, and physicians as well as the necessity and significance of training programs focused on specific health concerns affecting the LGBTQIA+ community were also examined. Additionally, general characterization questions were included, such as age, gender identity, sexual orientation, number of LGBTQIA+ friends or family members, and religiosity.

Knowledge about LGBTQIA ± people-specific health

The assessment of knowledge regarding LGBTQIA+ people specific health topics was conducted using an adapted version of the knowledge measurement instrument employed by Shetty et al. (2016), comprising 9 items that evaluated awareness of topics such as lesbian women and obesity (1 item), lesbian women and HIV (1 item), men who have sex with men and anal cancer (1 item), LGBTQIA+ individuals and mental health (1 item), LGBTQIA+ individuals and smoking habits (1 item), and gender identity and sexual orientation (5 items). The responses to these statements were scored as either true or false.

Clinical preparation and comfort in treating and follow LGBTQIA ± people

The clinical preparation and comfort in treating and follow LGBTQIA+ people questionnaire was derived from the Sexual Orientation Beliefs Scale (Arseneau et al., 2013), the Attitudes Toward Transgendered Individuals Scale (Walch et al., 2012), and attitudes regarding LGBT health (Shetty et al., 2016). It consisted of 10 statements addressing preparation and 5 questions about comfort level treating and follow LGBTQIA+ people. All items were scored on a 4-point Likert-type scale, with 1 (very low) being the lowest score and 4 (very high) being the highest score.

Perception of discrimination against LGBTQIA ± people in healthcare

Perceptions of discrimination were evaluated using a 4-point Likert scale, with responses ranging from 1 (strongly disagree) to 4 (strongly agree) in relation to the discrimination faced by LGBTQIA+ medical students, LGBTQIA+ healthcare professionals, and LGBTQIA+ patients in the Portuguese healthcare.

Attitudes toward homosexuality

Attitudes toward homosexuality were evaluated using the Multidimensional Scale of Attitudes Toward Lesbians and Gay Men - MSATLG (27 items) (Gato et al., 2014; Lopes et al., 2016). This scale, validated for Portuguese university students, comprises 27, each of which can be evaluated individually or grouped assessing three negative attitudinal dimensions: rejection of proximity, homosexuality pathologization, and modern heterosexism, and one positive attitudinal dimension, support. Items in the original instrument were assessed using a 6-point Likert scale. However, in in the present research, depending on how the question is worded, a true or false answer indicated negative attitudes toward lesbian women and gay men. Cronbach’s alpha ranged from 0.91 to 0.87 for the four domains of the scale (Gato et al., 2012).

Gender identity and sexual orientation seminar (intervention)

The seminar on gender identity and sexual orientation was held as part of a series of clinical seminars for fourth-year students implemented since 2018–2019. It was a 2-h event, organized in a brainstorming and case-based discussion format. The concepts of gender identity, gender expression, sex assigned at birth, and sexual orientation were presented. The notions of female and male and the concept of the gender spectrum were discussed. Concerning transgender people, examples of gender affirmation processes were presented, including psychological, social, and clinical aspects. Students were welcome to participate in a discussion about their thoughts and biases regarding gender identity and sexual orientation during the session. The main goals were to explain the meanings of gender, gender identity, gender expression, and gender spectrum, as well as to bring attention to the health disparities experienced by transgender individuals. Additionally, the session featured a video interview with a non-binary young person who share their experiences in healthcare. In terms of sexual orientation, the session aims to clarify the terms and raise awareness of the prevalence of heteronormative situations in everyday life and healthcare.

Study population and sample size

The subject population for the study comprised all medical students at the University of Algarve, totaling 150 individuals in 2018 and 240 individuals in 2023. The data collection tools were introduced to the students in a classroom setting, and participation was voluntary. Furthermore, the collected data was kept anonymous and confidential. One hundred and thirteen and 200 students participated, in 2018 and 2023, respectively. This study had 80.0% power to detect a Odds ratio = 2.

Statistical analyses

A descriptive analysis of the variables was performed by estimating the absolute and relative frequencies for the categorical variables and the mean, median, standard deviation, interquartile range (IQR), and maximum and minimum for the numerical continuous variables. The data collected on knowledge, beliefs, and comfort levels in treating LGBTQIA+ individuals, as well as perceptions of discrimination, were analyzed regarding the profession, age, gender identity, sexual orientation, number of friends or family members who identify themselves as LGBTQIA+, and level of religiosity. The chi-square test was performed for categorical variables and the Mann-Whitney independent samples test was used for numerical continuous variables. A significance level of 0.05 was considered for statistical significance.

Results

General characteristics

A total of 313 students were enrolled in the study, including 200 students from the 2023 cohort and 113 students from the 2018 cohort. An analysis of the demographic and social characteristics of the two cohorts revealed that the 2023 cohort was younger, with no further statistically significant differences (Table 1).

Table 1.

General characteristics.

  Cohort 2018 Cohort 2023 Sig.
Age     <.001
 Mean (SD) 33.0 (3.4) 29.4 (5.7)
 Median (IQR) 33 (30–36) 28 (25–32)
Year of medical school      
 3rd 0 61 (31.2)
 Fourth 28 (25.2) 59 (30.3)
 Fifth 45 (40.5) 39 (20.0)
 Sixth 38 (34.3) 36 (18.5)
Gender identity     .111
 Female 67 (60.4) 138 (70.8)
 Male 44 (39.6) 54 (27.7)
 Transgender/ non-binary 0 1 (0.5)
Sexual orientation     .348
 Non-heterosexual (asexual, bisexual, gay, lesbian, pansexual) 8 (7.1) 20 (10.4)
 Heterosexual 104 (92.9) 173 (56.6)
Number of LGBTQIA+ friends or family     .749
None 17 (15.3) 22 (11.3)
 1–2 16 (14.4) 34 (17.4)
 3–5 41 (37.0) 66 (33.9)
 6–10 21 (18.9) 39 (20.0)
 >10 16 (14.4) 34 (17.4)
Importance of religion in everyday life (1 not at all important to 6 extremely important)     .890
 1 42 (37.2) 79 (40.7)
 2 16 (14.2) 32 (16.5)
 3 21 (18.6) 34 (17.5)
 4 16 (14.2) 24 (12.4)
 5 14 (12.4) 17 (8.8)
 6 4 (3.4) 8 (4.1)
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Knowledge about LGBTQIA ± people specific health topics

The overall knowledge regarding specific health aspects of LGBTQIA+ individuals improved from the 2018 cohort to the 2023 cohort, with significant differences in questions regarding gender identity, sexual orientation, and mental health (Table 2). The level of knowledge regarding cardiovascular risk factors (such as obesity) and oncological conditions (such as anal cancer) remained very poor.

Table 2.

Knowledge about LGBTQIA+ people specific health topics.

  Cohort 2018 Cohort 2023 OR
OR [IC]		 Sig.
Sexual orientation is usually well established by adolescence. (False) 47% 72% 2.9
[1.8–4.8]		 <.001
A homosexual person’s gender identity does not coincide with their biological sex. (False) 57% 72% 2.0
[1.2–3.3]		 .007
Lesbian women have a higher risk of obesity than heterosexual women. (True) 4% 8% 1.9
[0.6–5.9]		 .189
Homosexual people have an increased incidence of anxiety and depression compared to heterosexual people. (True) 66% 86% 3.2
[1.7–6.0]		 <.001
Most homosexual women and men would like to be heterosexual. (False) 94% 94% 0.9
[0.3–2.8]		 .559
Gay men have a higher risk of anus cancer than heterosexual men. (True) 54% 57% 0.9
[0.5–1.5]		 .411
Homosexual people are usually identifiable by their appearance or mannerisms (False) 66% 66% 1.0
[0.6–1.6]		 .999
Lesbian women, who only have sex with women, have a lower risk of HIV infection than heterosexual women. (True) 26% 18% 0.6
[0.3–1.1]		 .116
Children brought up by openly homosexual parents are more likely to become homosexual than children brought up by heterosexual parents. (False) 90% 90% 1.0
[0.4–2.2]		 .565
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Bold: p < .05.

The results of the knowledge questionnaire indicated that two variables were associated with achieving at least 50% correct answers: sexual orientation and having friends or family members who identify themselves as LGBTQIA+. Non-heterosexual students were more likely to get at least half of the questions right (75%) than heterosexual students (52%), and this difference was statistically significant (p = .042). Additionally, students with three or more friends or family members who identified themselves as LGBTQIA+ also performed better on the questionnaire (p = 0.022).

Clinical preparation and comfort in treating LGBTQIA ± people

Students’ individual perceptions of their degree of comfort with people with different gender identities and sexual orientations were high and similar in the 2018 and 2023 cohorts (Table 3). Regarding self-perception of their clinical preparation to address different topics related to sexual orientation and sexuality, gender identity, or specific aspects of the health of LGBTQIA+ people, there were also no significant differences between the 2018 and 2023 cohorts, except for the question on “safe sex practices,” where there was a reduction in the percentage of students who felt well or very well prepared to address this topic. There was a low or very low percentage of students who feel prepared to address issues such as “gender identity,” “gender affirmation treatments (hormones and/or surgery),” “changes in sexual development/intersex people,” “coming out” and “mental health issues,” while the percentage of those who feel prepared for issues relating to “sexually transmitted infections” and “HIV infection” is relatively high (Table 3).

Table 3.

Level of comfort and readiness to engage specific topics with LGBTQIA+ patients.

  Cohort 2018 Cohort 2023 OR
OR [IC]		 Sig.
Level of comfort regarding: (high or very high)        
 Sexual orientation 96% 95% 1.0
[0.3–2.9]		 .688
 Sexual practices 88% 89% 1.0
[0.5–2.1]		 .790
 Gender identity 89% 90% 1.0
[0.5–2.1]		 .782
 Transition process in transgender people 78% 81% 1.2
[0.7–2.2]		 .527
 Lesbian and gay families (two mothers or two fathers) 95% 96% 1.3
[0.4–4.1]		 .679
Readiness to engage specific topics with LGBTQIA+ patients: (very good/good)
 Safe sex practices 90% 81% 0.8
[0.7–1.0]		 .067
 Sexual orientation 64% 65% 1.0
[0.8–1.1]		 .860
 Barriers to accessing health care 60% 57% 1.0
[0.8–1.1]		 .600
 Sexually transmitted infections 89% 87% 1.1
[0.6–2.4]		 .607
 HIV infection 83% 80% 0.9
[0.7–1.1]		 .518
 Gender identity 51% 46% 0.9
[0.8–1.1]		 .398
 Changes in sexual development/ intersex people 38% 31% 0.9
[0.7–1.1]		 .212
 Gender affirmation treatments (hormones and/or surgery) 21% 23% 1.0
[0.9–1.3]		 .685
 Mental health 44% 52% 1.1
[0.9–1.3]		 .177
 Coming Out 24% 22% 1.0
[0.8–1.2]		 .687
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Perception of discrimination against LGBTQIA ± people in healthcare

The results indicated that the perception of discrimination against homosexual patients was comparable between the two cohorts, with approximately 60% of respondents from both groups agreeing that homosexual patients were discriminated against in healthcare (p = .066). Furthermore, the 2023 cohort showed a slightly lower percentage of respondents who agreed that transgender users were discriminated against: 68% versus 79% in the 2018 cohort (p = 0.006).

Regarding the cohort of medical students in 2023, 30% of respondents indicated that they believed there was discrimination against homosexual individuals, while 4% expressed total agreement. In comparison, the figure for 2018 was 27%, with no respondents indicating total agreement (p <.001). Similarly, 69% of the respondents in 2018 and 49% in 2023 believed that transgender medical students experienced discrimination. Only 2023 were respondents who expressed total agreement, with 8% indicating such agreement (p <.001).

Approximately 42% of respondents indicated that homosexual physicians face discrimination in the healthcare system, a figure that remains consistent across both cohorts. In the 2023 cohort, 4% of respondents strongly agreed with this statement, whereas in the 2018 cohort, only 1% did so (p = .050).

In the 2018 cohort, 75% of the respondents reported that there is discrimination against transgender physicians versus 60% in the 2023 cohort. However, it is worth noting that in the 2023 cohort, 10% of the respondents strongly agreed that discrimination existed, compared to only 3% in the 2018 cohort (p = .009).

Attitudes toward homosexuality

Attitudes toward homosexuality, as assessed by the MSATLG in both cohorts, showed high levels of support and low levels of prejudice and discrimination. However, overall, the 2023 cohort showed even higher levels of support and lower levels of prejudice and discrimination than the 2018 cohort. In terms of individual questions, there were statistically significant differences in three, with an increase in the percentages of agreement in the 2023 cohort compared to 2018 in the statement “If I were a parent, I could accept my son or daughter being homosexual” and an increase in the percentages of disagreement in the statements “Celebrations like ‘gay pride day’ are ridiculous because they assume that sexual orientation should be a source of pride” and “I wouldn’t vote for a homosexual candidate in the elections.” Conversely, there was a reduction in the percentage of agreement in the 2023 cohort compared to 2018 for the statement, “A school sex education program should refer to all sexual orientations” (Table 4).

Table 4.

Attitudes toward homosexuality – MSATLG.

  Cohort 2018 Cohort 2023 OR
OR [IC]		 Sig.
1. It’s the same for me whether my friends are heterosexual or homosexual. – Yes 97% 99% 5.3
[0.5–51.2]		 .143
2. Homosexuality is a psychological disorder. – No 97% 99% 2.6
[0.4–15.7]		 .266
3. I believe that homosexual fathers and mothers are just as competent as heterosexual parents. – Yes 96% 97% 1.1
[0.3–4.2]		 .537
4. Gays and lesbians get on my nerves. – No 97% 99% 5.2
[0.5–50.7]		 .145
5. Legalizing same-sex marriage undermines the fundamental principles of society. – No 92% 93% 1.2
[0.5–2.7]		 .480
6. Homosexuality is an inferior form of sexuality. – No 99% 98% 0.4
[0.1–3.9]		 .400
7. If I were a parent, I could accept my son or daughter being homosexual. – Yes 94% 98% 4.2
[1.1–16.6]		 .033
8. Being raised in a homosexual home is quite different from being raised in a heterosexual home. – No 76% 78% 1.1
[0.6–2.0]		 .392
9. A school sex education program should refer to all sexual orientations. – Yes 100% 95% 0.1
[0.05–1.3]		 .078
10. The growing acceptance of homosexuality in our society is contributing to the deterioration of moral values. – No 95% 98% 3.6
[0.9–14.8]		 .062
11. Organizations that promote the rights of homosexuals are necessary. – Yes 92% 92% 1.0
[0.4–2.2]		 .560
12. I would hesitate to support homosexual people for fear of being mistaken for them. – No 96% 98% 2.2
[0.6–8.4]		 .199
13. Same-sex couples should, like heterosexual couples, be able to adopt children. – Yes 95% 96% 1.3
[0.4–4.1]		 .452
14. People who come out as homosexual should be admired for their courage. – Yes 54% 56% 1.1
[0.7–1.8]		 .406
15. I don’t mind if a company hires an openly homosexual public figure to advertise its products. – Yes 82% 84% 1.2
[0.6–2.0]		 .368
16. I wouldn’t mind working with a person who was homosexual. – Yes 82% 87% 1.5
[0.8–2.2]		 .140
17. Lesbians and gays still need to fight for equal rights. – Yes 92% 89% 0.7
[0.3–1.5]		 .238
18. I would feel uncomfortable if I knew that my son’s or daughter’s teacher was gay. – No 96% 97% 1.5
[0.4–4.9]		 .374
19. Celebrations like "gay pride day" are ridiculous because they assume that sexual orientation should be a source of pride. – No 64% 77% 1.9
[1.1–3.2]		 .011
20. If they really wanted to, lesbians and gay men could be heterosexual. – No 96% 99% 4.5
[0.9–23.5]		 .064
21. I would feel uncomfortable if I found out that my doctor wasn’t heterosexual. – No 96% 99% 7.2
[0.8–65.3]		 .061
22. Lesbians and gay men should undergo therapy to change their sexual orientation. – No 98% 100% 8.9
[0.4–186.2]		 .132
23. I feel you can’t trust someone who is homosexual. – No 99% 99% 0.9
[0.1–9.8]		 .702
24. I wouldn’t vote for a homosexual candidate in the elections. – No 90% 98% 5.2
[1.6–16.8]		 .003
25. When I hear about a romantic relationship, I assume that it’s between two people of the opposite sex. – No 52% 60% 1.4
[0.9–2.2]		 .186
26. Gays and lesbians should stop pushing their lifestyle on others. – No 74% 77% 1.2
[0.7–2.1]		 .293
27. I see the gay movement as something positive. – Yes 70% 82% 1.8
[1.1–3.3] 		.020
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Bold: p < .05.

Discussion

Our goal in the present study was to assess the extent to which the introduction of a seminar on gender identity and sexual orientation in clinical practice in the curriculum of medical students from a University in Portugal resulted in changes in students’ knowledge, attitudes, comfort, and perception of discrimination regarding LGBTQIA+ individuals. Two cohorts of medical students at the University of Algarve in Portugal were assessed in 2018 and 2023.

The overall knowledge regarding specific health aspects of LGBTQIA+ individuals improved from the 2018 cohort to the 2023 cohort, namely regarding gender identity, sexual orientation, and mental health aspects. The level of knowledge regarding physical health conditions (e.g., cardiovascular and oncological conditions) remained very poor. Having more friends or family members who identified themselves as LGBTQIA+ was associated with better knowledge of specific health aspects of LGBTQIA+ individuals, a result which is consistent with previous studies’ findings (Beach et al., 2018; Hatzenbuehler et al., 2013; King et al., 2008; Salway et al., 2019).

The seminar was attended by almost all the students of the 2023 cohort and took place (between 2018 and 2023) when the students were in their third year. Despite the committed participation and the very interesting discussions generated during the sessions, the result does not seem to have a direct impact on a change in the level of knowledge. This data makes us reflect on the need to change the format of the session, giving it more formal objectives that reflect what is required in terms of knowledge about the specificities of the health of LGBTQIA+ people. The new format will be implemented in 2024, and it is expected to be reevaluated in 3 years.

Regarding the clinical preparation and comfort in treating LGBTQIA+ people, students felt better prepared to address physical health issues, such as sexually transmitted infections, than sexual and gender identity-related aspects (e.g., gender affirmation procedures, intersex conditions, coming out, or mental health issues). However, there were no changes after the implementation of the seminar. Clinical preparation and comfort, especially in communication and language, require longer periods of contact with LGBTQIA+ people, in the classroom or in a real-life context. Our results underline the need for a deeper and more transversal inclusion of LGBTQIA+ health issues in the curriculum, addressing social and cultural competencies in medical education (Association of American Medical Colleges, 2014; Keuroghlian et al., 2022; White et al., 2015; Yoshida et al., 2022).

Overall, more positive attitudes toward homosexual persons were observed in 2023 relative to 2018. This result is consistent with the more positive attitudes toward sexual and gender diversity observed in Portugal in the last decade (European Commission, 2023; Williams Institute, 2021). Interestingly, the greatest attitudinal change occurred regarding the disagreement with the statement “Celebrations like ‘gay pride day’ are ridiculous because they assume that sexual orientation should be a source of pride.” The increase in LGBTQIA+ visibility (e.g., the proliferation of pride marches, the growing number of rainbow flags hoisted in town halls, or the upsurge in the visibility of LGBTQIA+ people in the media might account for this result (Gato, 2022).

The perception that lesbian and gay patients are discriminated against in healthcare remained stable across the two cohorts, and this is consistent with both international (ILGA-Europe, 2024; Law no. 2/2016, 2016 Diário da República; Law no. 17/2016, 2016 Diário da República; Law no. 38/2018, 2018 Diário da República) and national research (European Union Agency for Fundamental Rights, 2020; Pieri & Brilhante, 2022; Rodrigues et al., 2020). While these numbers indicate that students are aware that discrimination exists, they also mean that no changes have occurred regarding this aspect. Legal changes introduced in 2018, granting trans individuals aged 18 or older the right to have their (binary) gender identity recognized in the civil registry, might have contributed to a decrease in the perception of discrimination against transgender users, medical students, and physicians.

Limitations

The main limitations of this study relate, on the one hand, to the lack of validated instruments for collecting information, namely knowledge, comfort, and communication regarding specific aspects of LGBTQIA+ people’s health; and, on the other hand, even though the study included almost all the medical students at XX University, both in 2018 and 2023, the sample size is still limited. To what extent observed changes are due to the introduction of a seminar on gender identity and sexual orientation in clinical practice in the curriculum of medical students or are associated with social and legal changes occurring in the country regarding higher acceptance of LGBTQIA+ people is a question that remains unanswered. Future studies should consider the use of a control group to overcome this limitation.

Conclusion

Although the perception of discrimination of LGBTQIA+ in healthcare remained high across the two cohorts, positive changes were observed regarding students’ overall knowledge of LGBTQIA+ individuals’ health, clinical preparation and comfort in treating LGBTQIA+ people, and attitudes toward homosexual persons. These results reinforce the need to develop training and information strategies aimed at medical students, promoting greater knowledge and, above all, increasing contact and clinical practice with LGBTQIA+ people, since relationships and personal contact are the most differentiating aspects for nondiscrimination.

Acknowledgments

Not applicable.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Internal review board (IRB) statement

This study was reviewed and approved by Algarve Biomedical Centre's Ethical Committee.

Data availability statement

Data are available under a reasoned request to the authors.

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Data Availability Statement

Data are available under a reasoned request to the authors.

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