An Assessment of LGBTQ+ Cultural Competency and Attitudes of US Otolaryngologists.

Otolaryngologists can play a significant role in the care of lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) patients through gender-affirming care and routine care in everyday practice. To avoid stigmatizing LGBTQ+ patients, otolaryngologists should maintain high levels of LGBTQ+ cultural competency; however, US otolaryngology programs offer limited amounts of LGBTQ+ topics in didactic curricula, and the LGBTQ+ cultural competency of otolaryngologists remains unknown. A cross-sectional survey of demographics, attitude questions, and the 7-point Likert LGBT-Development of Clinical Skills Scale was distributed to otolaryngologists across the United States. Otolaryngologists (n = 176) had moderately high Overall LGBTQ+ cultural competency (mean, 5.82; range, 3.83-7.00), moderately high Basic Knowledge (mean, 5.43; range, 1.53-7.00), moderately high Clinical Preparedness (mean, 5.34; range, 2.00-7.00), and high Attitudinal Awareness (mean, 6.51; range, 2.42-7.00). Attending otolaryngologists had significantly lower LGBTQ+ Basic Knowledge than residents and fellows (P = .002). Further education at all levels of practice, including attendings, is necessary to improve LGBTQ+ cultural competency among otolaryngologists.

Otolaryngologists have an important role in the care of lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) patients. Gender-affirming care is frequently offered by subspecialist facial plastic and reconstructive surgeons who perform facial feminizing and masculinizing surgery as well as by laryngologists who offer gender-affirming voice therapy and surgery. Aside from gender-affirming care, all otolaryngologists will care for LGBTQ+-identified individuals, regardless of the care being offered. As such, it is important that otolaryngologists maintain high LGBTQ+ cultural competency to avoid stigmatizing this population and exacerbating existing health disparities.

Curricular education is often used to combat bias and improve comfort in caring for LGBTQ+ patients.[1,2] However, US otolaryngology residency programs offer a limited amount of didactic curricula on LGBTQ+-related topics, and nearly 20% of US programs offer no education on LGBTQ+ topics at all. Despite a majority of otolaryngology trainees finding importance in receiving training in gender-affirming care, prior work has demonstrated that less than one-third of US otolaryngology residents had exposure to transgender patient care.

LGBTQ+ cultural competency evaluations have been conducted in medical students, plastic surgeons, and primary care physicians. These studies offer insight into where targeted educational initiatives may be needed. In this study, we evaluate the LGBTQ+ cultural competency and attitudes of US otolaryngologists. We believe these findings can lend value in designing strategic educational initiatives to improve LGBTQ+ care by otolaryngologists.

Methods

Instrument

An anonymous, self-reporting survey of 28 questions was used. The survey consisted of demographic questions, items querying the importance of LGBTQ+ health topics in otolaryngology, and the validated, 18-item LGBT–Development of Clinical Skills Scale (LGBT-DOCSS), which assessed LGBTQ+ cultural competency in 3 domains: Attitudinal Awareness, Basic Knowledge, and Clinical Preparedness (see Supplementary Table S1 in the online version of the article).

Procedure

Otolaryngology program directors of 127 residencies were contacted by email and asked to distribute the survey to their institution’s attendings, fellows, and residents. Participation was voluntary. This procedure was granted exemption by the University of Michigan Institutional Review Board (HUM00212078).

Analysis

All data were coded. Incomplete responses were excluded. Statistical tests (t tests) were conducted in SAS (SAS Institute). Significance was set at P < .05.

Results

There were 176 complete responses, which were nationally representative from all regions: 21% Northeast, 34% Midwest, 27% South, and 18% West. Most respondents were men (48%), heterosexual (74%), white/Caucasian (64%), and non-Hispanic (82%). The age of respondents ranged from 26 to 71 years (mean, 38.9 years). Respondents were 57% attendings, 39% residents, and 4% fellows.

On average, respondents agreed that knowledge of LGBTQ+ health is important for the practice of otolaryngology (mean [SD], 5.86 [1.47]; range, 1.00-7.00) and that training needs additional emphasis on aspects important to the care of LGBTQ+ patients (mean [SD], 5.24 [1.68]; range, 1.00-7.00). Facial plastic and reconstructive surgery and laryngology were the subspecialties most selected as where knowledge of LGBTQ+ health is necessary; however, all subspecialties had over 50 selections.

Respondents, on average, had moderately high Overall LGBT-DOCSS scores (mean, 5.82; range, 3.83-7.00), moderately high Clinical Preparedness (mean, 5.34; range, 2.00-7.00), high Attitudinal Awareness (mean, 6.51; range, 2.42-7.00), and moderately high Basic Knowledge (mean, 5.43; range, 1.53-7.00). When comparing attendings and nonattendings, there were no significant differences in Overall LGBT-DOCSS (P = .13), Attitudinal Awareness (P = .48), or Clinical Preparedness (P = .95) scores. However, attendings had statistically significant lower Basic Knowledge scores than nonattendings (P = .002) ( ).

Table 1.

LGBT-DOCSS Scores out of 7 by Attending and Nonattending Level.

Survey domain	Mean (SD) score out of 7
Overall LGBT-DOCSS
Aggregate	5.82 (0.73)
Attending	5.74 (0.64)
Nonattending	5.91 (0.67)
Basic Knowledge
Aggregate	5.43 (0.50)
Attending	5.18 a (1.2)
Nonattending	5.75 a (1.1)
Attitudinal Awareness
Aggregate	6.51 (0.66)
Attending	6.46 (0.71)
Nonattending	6.56 (0.97)
Clinical Preparedness
Aggregate	5.34 (0.66)
Attending	5.35 (0.96)
Nonattending	5.34 (0.97)

Abbreviations: DOCSS, Development of Clinical Skills Scale; LGBT, lesbian, gay, bisexual, and transgender.

Statistically significant difference between attending and nonattending at α = 0.95.

Discussion

To our knowledge, this is the first LGBTQ+ cultural competency evaluation of otolaryngologists and shows that while otolaryngologists, on average, possess moderately high levels of competency, attendings possess lower Basic Knowledge than residents and fellows, suggesting a generational gap. In addition, on average, otolaryngologists agree that otolaryngology training needs additional emphasis on LGBTQ+ care. These findings demonstrate a need for increased exposure to basic LGBTQ+ care topics for otolaryngologists.

LGBTQ+ health education in residency programs is becoming increasingly prevalent in core curricula. However, many otolaryngology programs offer no formal training on LGBTQ+ care. Novel educational initiatives are typically implemented at the residency education level given existing teaching curriculums. However, these results demonstrate that educational efforts for all otolaryngologists, including attendings, may be necessary to improve LGBTQ+ Basic Knowledge and overall cultural competency for this group.

Notably, otolaryngologists had very high levels of Attitudinal Awareness and moderately high levels of all other competency subscores. This speaks to the strengths of otolaryngologists’ culturally informed attitudes but also demonstrates lags in Basic Knowledge and Clinical Preparedness. Nevertheless, the positive attitudes of otolaryngologists toward LGBTQ+ care showcase an opportunity for departments to improve gaps in knowledge and preparedness through educational efforts.

Limitations of this study include the use of convenience sampling, which was done in order to cover a wide geographic sample. In addition, reliance on program directors to distribute the survey to their institution’s otolaryngologists makes calculation of an accurate response rate difficult. As this study used self-reporting, sampling bias and inability to assess implicit bias are limitations. While this study drew from a sizable, nationally representative sample of otolaryngologists at all levels of training, larger national samples at varying time points are needed to fully characterize the LGBTQ+ cultural competency of otolaryngologists. Future study examining changes in competency as a result of training efforts as well as correlating competency to patient outcomes is needed.

Conclusion

This nationally representative sample of otolaryngologists at all levels of training has moderately high overall LGBTQ+ cultural competency, moderately high Basic Knowledge, moderately high Clinical Preparedness, and high Attitudinal Awareness. Attending otolaryngologists have significantly lower LGBTQ+ Basic Knowledge than residents and fellows. Further education at all levels of training is necessary to improve LGBTQ+ cultural competency among otolaryngologists.

Author Contributions

Anuj Umesh Patel, conception design, acquisition of data, interpretation of data, draft manuscript, revisions and final approval; Jeffrey S. Moyer, conception design, acquisition of data, interpretation of data, draft manuscript, revisions and final approval.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: Anuj Umesh Patel was funded through MICHR TL1 grant number 5TL1TR002242-05.

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Supplemental material, sj-docx-1-opn-10.1177_2473974X221126167 for An Assessment of LGBTQ+ Cultural Competency and Attitudes of US Otolaryngologists by Anuj Umesh Patel and Jeffrey S. Moyer in OTO Open: The Official Open Access Journal of the American Academy of Otolaryngology-Head and Neck Surgery Foundation