Introduction to Safe Space Training: Interactive Module for Promoting a Safe Space Learning Environment for LGBT Medical Students

Abstract

Introduction

Lesbian, gay, bisexual, and transgender (LGBT) students face challenges in achieving their educational goals. By understanding concepts surrounding sexual orientation and gender identity, faculty, staff, and students can support LGBT community members and provide a safe educational space. In order to address this we created a condensed training resource that focused on skill building and is easily implemented institution-wide for students, residents, fellows, faculty, and staff.

Methods

This module serves as an introduction to concepts integral to the LGBT community. It is structured into two sections and takes approximately 30 minutes to complete, including pre-/postevaluations. The first section of the module focuses on presenting basic information about the LGBT world experience and basic terminology. The second section contains two real-world scenarios aimed at demonstrating skills used to create a safe educational learning space. Each scenario contains interactive questions that allow participants to practice applying their new skills.

Results

To date, 89 institutional community members at the Northwestern University Feinberg School of Medicine have completed the module. Survey results demonstrate that the module was well-received and effective at improving attitudes towards creating a safe space.

Discussion

While this module provides a foundation in terminology and phenomena relevant to the LGBT experience, it is just one part of creating a positive institutional climate for LGBT community members. Additional in-person skills-based training should also be considered to complement and enhance this module's contents.

Educational Objectives

By the end of this module, learners will be able to:

• 1.Demonstrate a basic understanding of terms used to describe sexual orientation and gender identity.
• 2.Describe how lesbian, gay, bisexual, and transgender (LGBT) world experiences require community members to actively create a safe space.
• 3.Apply skills to create a safe and healthy learning environment for members of the LGBT community.

Introduction

Despite the growing exposure and public acceptance of the lesbian, gay, bisexual, and transgender (LGBT) community, members of the LGBT community still face real and perceived discrimination in their everyday lives and may encounter specific challenges in achieving their educational goals.¹ LGBT safe space training can begin to improve the institutional climate so that LGBT students, faculty, and staff can thrive in a safe and comfortable environment. Safe space training refers to an educational program that aims to provide straight, cisgender allies with the basic knowledge and skills needed to support LGBT peers. Most LGBT safe space education efforts utilize large in-person trainings. While these training sessions can be effective, they have limitations. In-person trainings often lack the exposure to reach a large audience. In addition, many of these trainings focus on learning general knowledge of the LGBT community and do not focus on particular skills in specific settings such as medical schools. We sought to fill this gap in LGBT safe space education by creating an easily accessible online module that focuses on skill building in the medical school setting. Additionally, by delivering LGBT safe space training as an online module, we can reach a broad audience and allow learners to move through the content at their own pace. To our knowledge, our module is the first LGBT safe space online module focused on the particular challenges members of the LGBT community may face in the medical school setting.

In recent years, many interventions at the medical school level have been geared towards reducing the rate of physician burnout, which is currently estimated at about 46%.² LGBT medical students are particularly susceptible to burnout. Numerous studies have linked an LGBT identity with increased rates of depression and anxiety, especially among those who are “in the closet.”^3,4 Therefore, there is an opportunity to improve the wellness of LGBT community members by creating an environment where LGBT people feel safe to express themselves.

A 2015 national study of medical students revealed that 29.5% students identifying as a sexual minority concealed their identity and 60% of students identifying as a gender minority concealed their identity. The most common reasons for concealing one's sexual or gender identity were fear of discrimination in medical school, social or cultural norms, and lack of support.⁵ These numbers are staggering and reveal that medical schools need to implement targeted policies and programs to support these students. LGBT safe space training can serve as an initial step to demonstrate an institutional commitment to LGBT community members, as well as develop safe and healthy learning environments.

An important aspect of mitigating the challenges that LGBT individuals face is a strong understanding of the concepts surrounding sexual orientation and gender identity, including how they apply to the LGBT community. Traditional education, medical or otherwise, has been largely unsuccessful in meeting this need. The purpose of this module is to serve as an introduction to concepts integral to the LGBT community. Learners can leverage this knowledge to begin to address the challenges facing LGBT individuals in education. The target audience for completion of the LGBT safe space training includes students, faculty, residents, and staff affiliated with an academic medical center and there are no prerequisite knowledge or skills needed. It is unlikely an online module alone would be sufficient to create a safe learning environment for LGBT community members, and as described in the Discussion section below, we suggest that in-person workshops and larger institutional changes accompany this online module.

Methods

This module was developed by a committee comprised of the authors and other faculty involved in gender and sexual identity education at Northwestern University Feinberg School of Medicine. Through monthly meetings over the course of 6 months, the committee determined content and format for the module and created the postcompletion questionnaire using an interative process and various sources.⁶ All content is original and was developed specifically for this purpose. The primary goals were to create a training resource that was easily accessible, condensed, and focused on skill building. The committee decided an online module was the ideal format as it could be readily shared and accessed. In addition, an online module allows for interactivity and thus, more effective skill building. Once the module was complete, it was reviewed by a pilot group of 10 faculty and students who provided additional feedback for content and clarity.

The Introduction to Safe Space Training module (Appendix A) takes approximately 30 minutes to complete and can be accessed from any internet-enabled device including phones and tablets, making it easily implemented institution-wide. In addition to a pretest to assess baseline knowledge, the module consists of two content sections. The first section of the module presents basic information about the LGBT world experience and basic terminology. The narration is accompanied by on-screen animations and illustrations. The second section contains two real-world scenarios aimed at demonstrating skills used to create a safe space. The first scenario focuses on skills and terminology surrounding sexuality, coming out, and creating a safe space in the mentor-mentee relationship. The second scenario focuses on skills and terminology surrounding gender identity, pronouns, and creating a safe space in a clinical learning environment. Each scenario contains interactive questions that allow participants to practice applying their new skills.

Upon completing the module, participants complete a posttest which contains attitude questions, knowledge questions, and questions regarding educational effectiveness. We have included the pre-/posttest questions in the Results section below, which were administered using an external survey tool (i.e., Qualtrics). Additionally, participants are offered the opportunity to register for an additional 90 minute in-person safe space workshop session.

Results

Overall, feedback for the module has been overwhelmingly positive as demonstrated by both quantitative and qualitative feedback. At the time of submission, 89 institutional community members completed the module. To assess attitudes pre- and postmodule completion, we asked participants to respond to two questions using a Likert scale (1 = strongly disagree; 5 = strongly agree). Performing a Fisher's exact test on participant responses (Table) showed a significant increase in attitudes for both questions.

Table. Participant Responses to Pre- and Posttest Attitude Questions.

Questiona and Test	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Pb
I am confident in my ability to respond appropriately when an LGBT community member “comes out” to me.
Pretest	0	4	22	44	27
Posttest	0	1	7	48	33	.014
I am confident in my ability to ask community members which pronouns they use.
Pretest	1	21	28	33	14
Posttest	0	1	8	48	32	<.000001

^aFive-point Likert-type scale (1 = strongly disagree, 5 = strongly agree).

^bFisher's exact test.

Participant satisfaction with the module was extremely high. When asked “Would you recommend this module to a friend, colleague, or other community member?,” 88 (99%) participants responded “yes,” with the lone dissenter stating, “I'd recommend the module to people that weren't at all familiar with these issues, but it would likely be review to most friends and colleagues.” After completing the module, 78 (88%) participants elected to register for an additional 90-minute in-person workshop session.

Participants' enjoyment in completing the module is also demonstrated in the following comments, which are representative of overall themes:

• •
  Satisfaction with Module

  • ○
    “Loved this module. Thanks for putting it together.“
  • ○
    “It was a great training, and I really liked how the role plays were used to teach key concepts. I wish that the training was longer actually and included more information.”
• •
  Increased Understanding

  • ○
    “[I will] be aware of the LGBT situation. Always ask open-ended questions about the pronouns and use the pronouns that a LGBT member wants, at appropriate situations.”
  • ○
    “I want to stop asking about “preferred pronouns” and start asking about what pronouns a person uses. I also want to remember to connect others with LGBT resources in addition to creating a safe space.”
  • ○
    “[It was a] guide on how to clearly ask open-ended questions (i.e. not using “preferred” pronouns which from my perspective was more understanding but I now understand that has negative connotations associated with it)”
  • ○
    “[I learned] how to differentiate between gender identity, sexual orientation, biological sex, and gender expression. I also found the “two worlds” and “continuous coming out” ideas very insightful.”
  • ○
    “The most important thing that I learned was the difference between gender expression and gender identity. The module did a great job at explaining these two in a very simplistic, yet effective manner.”
  • ○
    “I learned the definition of gender expression and how it intersects with gender identity, sexual orientation, and natal sex. I honed some skills for how to respond when another person comes out to me.”
• •
  Creating a Safe Space

  • ○
    “[I learned how] to take advantage of an opportunity to be more actively inclusive instead of just acting nonchalant when someone identifies themselves as other than straight and cisgender.”
  • ○
    “I have always struggled with situational awareness and asking open-ended questions, so this seems to have helped with that on a more basic level.”
• •
  Areas for Improvement

  • ○
    “Keep the audio, add more questions throughout to keep the interaction high.”
  • ○
    “[The workshop] filled up quickly, before some of the other residents in my department had the chance to sign up. It'd be great if this course could be offered more throughout the year, and/or made available online for anyone.”
  • ○
    “I'd like to see a similar training for other minority groups (black, Latino, biracial). There are many similarities.”
  • ○
    “[I suggest you] discuss more of how you approach patients in this situation, i.e. how to ask questions and how to identify issues that are more related to the LGBT population.”

Discussion

We successfully developed and implemented a module that can effectively increase student, staff, faculty, and other academic medical center community member attitudes towards creating a safe space for LGBT students. Institutional dissemination of this module is efficient, low cost, and effective. By providing access to the module, we hope that additional academic medical centers will use it as part of their efforts to create a safe and healthy learning environment for LGBT students.

While this module provides a foundation in terminology and phenomena relevant to the LGBT experience, it is just one part of creating a positive institutional climate for LGBT community members. Additional measures such as in-person skills-based trainings should also be considered to solidify the application of the module's contents. Institutions can also implement other programs focusing on inclusive nondiscrimination and benefit policies, well-defined mechanisms to report mistreatment, and the inclusion of LGBT health topics within curricula to create positive LGBT organizational change⁷. An important focus of these skills-based trainings should be how community members could intervene if they witness aggressions or microaggressions. The decision to intervene is highly context specific and skills-based trainings should discuss the pros and cons of intervening, including ensuring safety. We suggest incorporating resources that focus on de-escalation techniques and bystander intervention.⁸

An important limitation of this module is that it does not present all the skills needed to provide medical care for LGBT individuals in a culturally competent way. During our planning and dissemination of this module, we encountered many faculty members and staff asking about those skills. While we plan on creating another module that will present these clinical skills, the aim of our current module was to focus on creating a safe space for LGBT students and not necessarily patients. While many of the skills presented in our module are applicable to the clinical care of LGBT patients, providing medical care for LGBT individuals requires additional skills such as sexual history taking, organ inventories for transgender patients, etc. Additionally, understanding the intersection between sexual orientation, gender expression, and identity, with other identities (i.e., racial, ethnic, socioeconomic, etc.) is vital to provide culturally competent care that meets the needs of a diverse LGBT patient population.⁹

We view the development of this module as an iterative process and plan to implement updates (e.g., hiring voice actors, including more complex topics, and including testimonials from students and faculty) over time. Additionally, we plan to identify other community stakeholders and elicit their input and resources.

Appendices

A. Introduction to Safe Space Training folder

All appendices are peer reviewed as integral parts of the Original Publication.