The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: Where are we now?

Despite identified inequities and disparities in lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) health, past studies have shown little or no education at the medical school or residency level for emergency physicians. With increased focus on health inequities and disparities, we sought to reexamine the status of sexual and gender minority health education in U.S. emergency medicine (EM) residencies.


INTRODUC TI ON
Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) patients are ubiquitous in emergency medicine (EM) and vulnerable to health inequities and disparities. 1 Despite this, emergency physicians traditionally have had limited training in LGBTQ+ health. A study of medical school curricula in 2011 found a median of 5 hours of instruction on LGBTQ+ health, with one-third having no instruction during clinical years. 2 The first study to examine LGBTQ+ education in EM training in 2013 found that the majority (74%) of EM residency program respondents did not offer education specific to LGBTQ+ health, with a median of 0 minutes of content. 3 EM residents have reported decreased comfort in caring for and obtaining a history from LGBTQ+ patients compared to sexual and gender majorities. 4,5 Since the 2013 survey on LGBTQ+ education in EM residencies, there has been growing literature and education by organizations on LGBTQ+-specific health. 4,6 In 2016, the National Institutes of Health designated sexual and gender minorities as a health disparity population. 7 Additional societal influences such as marriage equality, increasing visibility, awareness, and acceptance of LGBTQ+ individuals have also occurred. 8 Despite this, the majority of medical students in a 2017 study desired more education than they received on LGBTQ+ health, suggesting that the gap in LGBTQ+ education has not closed in undergraduate medical education. 9 More recent surveys from non-EM residencies show that a substantial gap in actual versus preferred hours of LGBTQ+ education exists at the graduate medical education level. [10][11][12][13][14][15][16] The 2019 Model of the Clinical Practice of Emergency Medicine has added gender identity, sexual orientation, and transgender care to the core content adopted by the American Board of Emergency Medicine. 17 It is unclear if these developments have led EM residency programs to implement or expand LGBTQ+specific education in their curricula or if a gap in EM training remains.
In this study, we sought to determine the current state of sexual and gender minority education in U.S. EM residency programs.
Moving beyond the original needs assessment, we also hypothesized that more programs may be providing LGBTQ+ education than in 2013.

ME THODS
We used a 2013 survey of residency program directors of Accreditation Council for Graduate Medical Education (ACGME)accredited EM residency programs. 18 That survey was pilot tested at four EM programs prior to use and publication. This study was determined to be exempt by the institutional review board at Virginia Commonwealth University.

Survey content and administration
A 14-question survey from the original 2013 survey was used (Data Supplement S1, available as supporting information in the online version of this paper, which is available at http://onlin elibr ary.wiley.

Data analysis
Categorical variables were described using frequencies and percentages. Actual and preferred time spent on LGBTQ+ health education (in hours) were described using medians and interquartile ranges (IQR). Hours spent on LGBTQ+ health education were compared across demographic characteristics using the Mann-Whitney U and Kruskal-Wallis tests. The actual number of hours and the preferred number of hours were compared using the Wilcoxon signed-rank test and Spearman correlation. Sets of categorical variables were compared using the chi-square test. For analyses involving geographic a notable increase from 26% of responding programs providing education in 2013.
Several barriers still exist, and the content, impact, and completeness of education remain areas for further study. region, U.S. Census Bureau standards for regions and divisions of the United States were used. 19 Analyses were conducted using SPSS (v. 26; SPSS, Inc., Armonk, NY).

RE SULTS
A total of 113 responses from 229 eligible programs were received (response rate 49.3%). Program demographics are shown in Table 1.
The majority of responding programs (75%) reported offering educational didactic on LGBTQ+ health (Table 2). Programs had a median (IQR) of 2 (1-3) hours and a range of 0 to 22 hours of content.
Fifty-five percent incorporated sexual and gender minority health Response by region Respondents preferred more hours of content than programs delivered (median = 4 hours, IQR = 2-5 hours; p < 0.001; Figure 1,  4,9,21,22 We hypothesized that organizational and societal changes since 2013 would lead to an increase in the percentage of programs that delivered LGBTQ+ health content in EM and the amount of content for those that did provide it. We found that 75% of respondents offered LGBTQ+ content in 2020, a marked increase from 26% in 2013. 3 The median amount of content increased from 0 minutes to We did find that respondents identified as employed by private groups have less education delivered but not preferred and were less likely to be aware of LGBTQ+ residents and faculty. There were no differences in provision or knowledge of same-sex domestic part- We found that the majority of responding programs know of openly LGBTQ+ faculty and residents. Programs with known LGBTQ+ faculty were more likely to deliver LGBTQ+ content as was previously found. 3 In this study 69% of responding programs knew of LGBTQ+ faculty, and 81% of residents knew. status is of fundamental concern to LGBTQ+ residents and faculty.
We suggest that program directors should be aware and inclusive by knowledge if protections and benefits for LGBTQ+ residents exist.
The need for LGBTQ+ health education has been clearly demonstrated, and advances in quantity are noted with this study.
Education on LGBTQ+ health is not universal, despite its recent in-

LI M ITATI O N S
Data were self-reported and thus subject to response bias. Although the survey was originally pilot tested, there may be individual interpretation of questions that has the potential to affect results. The survey was sent to program directors, who may defer curriculum development to other faculty, which may affect the accuracy of their report. Because it was an anonymous survey, we had no mechanism to eliminate duplicate responses but attempted to limit this possibility by sending a specific link to each program director using Qualtrics. Although we found some correlations based on employer type, these must be interpreted with caution. Both results were self-reported, and we cannot verify independently the validity of their self-reported classifications. Although our respondents include 49.3% of all EM training programs with residents in 2019, it is possible that nonrespondents may have significantly affected outcomes.
In seeking to assess progress since our initial study, we used a broad inclusive definition of LGBTQ+ in our survey. The authors acknowledge and agree that sexual orientation and gender identity are distinct and separate areas that, although commonly included in aggregate, each deserve separate and dedicated study, education, and approaches. It is not possible, therefore, to determine what degree of education actual or desired are on gender identity, sexual orientation, or both.
Finally, there are unique challenges to performing research on LGBTQ+ populations. This survey asked program directors for knowledge of LGBTQ+ faculty and residents, which may be unknown or not disclosed to them, especially when a significant number of states do not protect LGBTQ+ employees from employment discrimination. There may also be some bias due to an individual being more likely to either positively or negatively respond if they have strong feelings on this topic.

CON CLUS ION
There has been a notable increase in LGBTQ+ education in emergency medicine residency programs since 2013. In our previous