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Attitudes Toward LGBT Patients Among Students in the Health Professions:

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 70
LGBT Health ORIGINAL ARTICLE
Volume 00, Number 00, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/lgbt.2013.0016

Attitudes Toward LGBT Patients Among

Students in the Health Professions:
Influence of Demographics and Discipline

Christina K. Wilson, PhD,1 Lindsey West, PhD,2 Lara Stepleman, PhD,2 Margo Villarosa, MA,2
Brittany Ange, MS,2 Matthew Decker, PhD,3 and Jennifer L. Waller, PhD 2

Abstract

Health providers’ personal and professional experiences may predict attitudes toward lesbian, gay, bisexual, and
transgender (LGBT) individuals and can therefore serve as key targets for health professions training aimed at de-
creasing barriers to high-quality patient care. This study explored the relationship between professional, demo-
graphic, and training characteristics and health professions student attitudes toward LGBT patients. Students
from a health sciences university and applied mental health programs in Georgia (N = 475) completed a survey
that included a modified version of the Attitudes Toward LGBT Patients Scale (ATLPS). Profession, sexual orien-
tation, current financial status, religion, religiosity, spirituality, and self-reported familiarity with various religious
perspectives on sex were associated with ATLPS scores. However, religiosity and self-reported familiarity with var-
ious religious perspectives on sex were the only significant predictors of ATLPS scores when these variables were
included in one general linear model. Health professions students with higher levels of religiosity and lower levels of
self-reported familiarity with various religious perspectives on sex reported less positive attitudes toward LGBT in-
dividuals. Results suggest that personal factors may be important to address in interprofessional curriculum related
to LGBT patient care. Self-report biases and other factors may limit the accuracy and generalizability of the findings.

Key words: health professions, interprofessional training, LGBT.

Background across specialty areas serve as significant barriers to quality

care for LGBT individuals. Deficits in training related to

D espite the large numbers of lesbian, gay, bisexual,

and transgender (LGBT) individuals in the United
States,1 sexual minorities continue to experience systematic
discrimination and marginalization.2 The Gay and Lesbian
Medical Association highlighted health needs among LGBT
individuals specifically related to experiences of prejudice
and discrimination, including violence, hate crimes, and lim-
ited access to healthcare.3 Additional well-documented health
concerns requiring special attention in LGBT communities in-
clude, but are not limited to, obesity in women,4 eating disor-
ders and anal cancers in men,5,6 access to and long-term health
impact of hormones in transgender individuals,7,8 and sexually
transmitted infections9 and tobacco use10,11 across multiple
sexual and gender minority groups.
Insufficient training on LGBT-specific health needs and
negative bias toward LGBT patients by healthcare providers
LGBT populations have been documented across various lev-
els of training in medical education,12–16 as well as in clinical
psychology,17 dentistry,18 and nursing.19 A survey of medical
students across the United States and Canada found that stu-
dents who felt they had received inadequate training in patient
sexuality, students with sexual problems, and those with lim-
ited sexual experience were most likely to indicate being un-
comfortable addressing patient sexuality.16
Though training context is important, providers’ values and
attitudes toward patient sexuality are also important factors to
consider in the provision of care to LGBT individuals. In fact,
the World Health Organization identified the eradication of dis-
crimination and prejudice related to sexual minorities as a key
strategy needed for the promotion of sexual health world-
wide.20 Health professionals’ negative views toward sexual mi-
norities,21 clinician beliefs that patient sexuality is not pertinent

1
Atlanta VA Medical Center, Atlanta, Georgia.
2
Georgia Regents University, Augusta, Georgia.
3
Ohio Christian University, Circleville, Georgia.

1

2 WILSON ET AL.
to provision of quality healthcare,22 and practice settings that
fail to communicate the importance of cultural awareness
and competency in regard to LGBT health23 all negatively af-
fect patient care.
Negative bias toward LGBT individuals, including hetero-
sexism and homophobia, is a significant concern that nega-
tively impacts relationships between healthcare providers
and patients and ultimately reduces the quality of patient
care.21 One interprofessional study of healthcare professionals
found that respondents were more likely to endorse attitudes of
tolerance rather than respect for their patients who are LGBT,
with the majority of the sample (70%) rating themselves as
having low self-efficacy for treating LGBT patients.24 Dinkel
and colleagues found that patients avoided disclosure of sexual
orientation to healthcare providers because of fears that disclo-
sure would lead to discrimination and lower quality care.21
Researchers have identified several factors that contribute to
improved comfort and skill in provision of care to LGBT pa-
tients, including number of classroom hours dedicated to pa-
tient sexuality, student religious background, and experience
with LGBT patients and/or individuals.25,26 While these ef-
forts may increase comfort or skill, it is unclear if these efforts
serve to shift health professionals’ attitudes toward LGBT pa-
tients. If students’ biases toward LGBT individuals are not
addressed, their willingness or openness to internalizing the
education received on the healthcare needs of LGBT patients
may be limited, which in turn may affect the care they provide
as they enter the workforce. While a significant body of re-
search has documented the negative effects of provider bias
on patient care,21 several questions remain about what factors
may account for this bias among health professionals.
The current study builds upon previous research by assess-
ing attitudes toward LGBT patients in a diverse sample of
health professions students at a health sciences university
and applied mental health programs in Georgia. Deficits in
training and personal factors such as religious preferences
have both been identified as predictors of attitudes toward
LGBT patients among health professionals.25,26 More specif-
ically, inadequate training and more conservative religious
values are both correlated with less acceptance and comfort
with LGBT patients. The research question for this study is
whether profession, demographic characteristics, and training
experience serve as predictors of attitudes toward LGBT pa-
tients in a sample of health professions students. On the
basis of the existing literature, we hypothesized that (1) health
professions programs with more training emphasis on sexual
health, such as medicine and nursing, would have higher Atti-
tudes Toward LGBT Patients Scale (ATLPS) scores than
other health professions surveyed, and (2) personal values
related to religion, including religiosity and familiarity with
various religious perspectives on sex, would predict ATLPS
scores, higher levels of religiosity, and less familiarity with
various religious perspectives on sex corresponding with
lower ATLPS scores. Improved understanding of factors as-
sociated with attitudes toward LGBT patients can serve to
inform training curriculum for health professions students.
It also is important to acknowledge that, though the term
LGBT as used in this context is consistent with many as-
pects of the social and scholarly literature related to sexual
and gender minority populations, there are key limitations
with this phraseology. In particular, although the intention
of this study was to explore factors contributing to health pro-
71
fessions student attitudes toward LGBT patients overall, the
term LGBT can serve to unduly conflate gender identity and
sexual orientation, and therefore must be viewed with these
limitations in mind.
Methods
Participants
Students were recruited from a health sciences university
and applied mental health programs in Georgia to voluntarily
complete an online survey for an interprofessional education
sexual health study of which LGBT attitudes were one com-
ponent. Interestingly, 187 potential participants refused to
complete the survey; reasons for refusal ranged from survey
length to personal reservations regarding participating in a
survey related to the topic of sexual health, with the former
being cited significantly more frequently than the latter. In
total, 563 students began some portion of the survey. Of the
individuals who did participate in the survey, 475 responded
to the questions necessary for this study’s analyses. Partici-
pants were required to be over the age of 18 and currently en-
rolled in a graduate program meeting the degree requirements
for licensure in mental health, medicine, nursing, dentistry, or
an allied health sciences professional (e.g., dental hygiene, oc-
cupational therapy, physical therapy, and physician assistant).
Consistent with the approximate makeup of the students at
this health sciences university, medical students comprised
over half of the sample (n = 270 [57%]), followed by allied
health (n = 94 [20%]), dentistry (n = 48 [10%]), and nursing
(n = 31 [7%]). We also recruited a small sample of mental
health students (n = 32 [7%]) via professional psychology
listservs in Georgia, as this health sciences university had
no training programs for this specialty. Inclusion of mental
health students was critical given their growing role in provi-
sion of care in medical settings, particularly in health psy-
chology and medical psychology contexts.
Measures
Demographic questionnaire. The background question-
naire included questions on a range of demographic variables
such as age, gender, sexual orientation, race, religious affili-
ation, religiosity, spirituality, economic status, and class-
room and clinical training experiences in the area of sexual
health. Religion was defined as ‘‘an organized system of wor-
ship that gives a framework to the relationship we have with
the universe and with a higher power.’’ Religiosity was defined
as ‘‘the degree to which the individual identified as religious.’’
Spirituality was defined as ‘‘a sense of connection to the uni-
verse and to a higher power.’’ Religiosity and spirituality
addressed the degree to which participants identified as reli-
gious or spiritual and ranged on a five-point scale from ‘‘not
at all’’ to ‘‘extremely.’’ Participants rated a single item regard-
ing their self-reported familiarity with different religious views
on sex on a scale ranging from ‘‘not at all’’ to ‘‘extremely.’’
Attitudes Toward LGBT Patients Scale.26 The ATLPS is
a 13-item questionnaire measuring attitudes toward LGBT
patients that includes comfort with LGBT patient encoun-
ters, opinions about same-sex relationships, and views of
professional responsibilities. Each item on the ATLPS is an-
swered on a 5-point Likert scale ranging from 1, ‘‘strongly
disagree,’’ to 5, ‘‘strongly agree.’’ Items 2, 3, 5, 7, 8, and
 72
ATTITUDES TOWARD LGBT PATIENTS 3

9 were reverse scored to calculate overall attitude scores, alyses with ATLPS total scores; the missing items were im-
with a score of 5 being the most positive. The ATLPS was puted. For analyses involving the individual LGBT attitude
derived by Sanchez and colleagues26 from a validated survey items, subjects with nonmissing data were included. To iden-
of medical resident and physician attitudes toward patients tify potential covariates, each demographic and training var-
with AIDS.27 The reliability of the adapted version of this iable was examined to assess whether it was associated with
measure was not reported, but researchers did find positive
correlations between ATLPS total scores and age, female
gender, and number of clinical encounters with LGBT pa- Table 1. Demographic and Training
tients. Our study utilized a modified version of the ATLPS Characteristics of Sample
such that it could apply across training years and health profes- Variable Level Statistic
sion specialties. There were two questions from the original
ATLPS that were omitted for the current study because of Profession, n (%) Allied health 94 (19.79)
their specificity in regard to medical practice (e.g., ‘‘Is it Dentistry 48 (10.11)
more challenging to conduct a physical exam on a homosexual Medicine 270 (56.84)
patient than on a heterosexual patient?’’ and ‘‘Is it more chal- Nursing 31 (6.53)
lenging to conduct a genitourinary exam on a homosexual pa- Psychology 32 (6.74)
tient than on a heterosexual patient?’’). Survey language was Age, M (SD) 25.74 (4.69)
changed to use the term LGBT, a more inclusive term than Gender, n (%) Male 183 (38.69)
those contained in the original measure, in order to represent Female 290 (61.31)
the full range of sexual minorities. A faculty member in Sexual orientation, Heterosexual 446 (94.29)
each of the represented health professions reviewed this mea- n (%) Gay, lesbian, bisexual, 25 (5.28)
sure to ensure appropriate language and face validity to his or transgender, asexual,
her field. The original instrument was designed to be used as a other
single scale though its multidimensional properties have not Prefer not to answer 2 (0.42)
been assessed to our knowledge. In a principal components Race, n (%) Black 44 (9.40)
analysis with varimax rotation, the revised instrument is best White 342 (73.08)
captured by three components, explaining 64% of the variance. Asian 61 (13.03)
Items 1 through 6 loaded on component one (eigenvalue 4.0) Other 21 (4.49)
and describe general opinions about LGBT healthcare and pro- Religion, n (%) Christian 319 (67.87)
vider comfort related to others’ awareness of the provider treat- Muslim 12 (2.55)
ing LGBT patients. Items 10 and 11 loaded on component two Jewish 17 (3.62)
(eigenvalue 1.75) and describe an individual’s opinion regarding Hindu 26 (5.53)
Atheist 22 (4.68)
the nature of same-sex behavior and attraction. Finally, items 7
Other 29 (6.17)
through 9 loaded on component three (eigenvalue 1.28) and de- No affiliation 45 (9.57)
scribe provider–patient interactions related to sexual orientation.
Religiosity, n (%) Not at all 83 (17.55)
Coefficient alphas for each subscale are 0.81, 0.92, and 0.56, re-
Slightly 66 (13.95)
spectively. We decided to use the ATLPS, which serves as our Somewhat 144 (30.44)
dependent variable, as a single scale given that the original in- Quite 133 (28.12)
strument was designed to be and has been exclusively used in Extremely 47 (9.94)
this manner, that the construct of ‘‘attitudes toward LGBT pa- Spirituality, n (%) Not at all 30 (6.38)
tients’’ is complex and arguably influenced by all of these com- Slightly 50 (10.64)
ponents, and that the internal reliability of the items when the Somewhat 130 (27.66)
instrument is used as a whole is quite strong (Cronbach’s Quite 179 (38.09)
a = 0.84). Extremely 81 (17.23)
Self-reported Not at all 42 (8.88)
Procedure familiarity with Slightly 111 (23.47)
IRB approval was granted before data collection. Partici- religious views Somewhat 210 (44.40)
about sex, n (%) Quite 91 (19.24)
pants were voluntarily recruited using the health sciences Extremely 19 (4.02)
university online evaluation system and through profes-
sional organizations and mental health graduate program Sexual education Poor 48 (12.06)
training quality, Average 94 (23.62)
listservs and e-mail groups in Georgia (where the health sci- n (%) Satisfactory 158 (39.70)
ences university is located as well). After informed consent, Good 77 (19.35)
participants were directed to the full content of the survey. Excellent 21 (5.28)
Participants completing the survey were given the option Classroom hours 8.56 (29.87)
to enter a raffle to win one of fifteen $50 gift certificates. on sexual health
topics, M (SD)
Statistical analysis Estimated hours 8.26 (33.59)
All statistical analyses were performed using SAS 9.3. addressing
Statistical significance was assessed using an alpha level of sexual health
issues with
0.05 unless otherwise noted. Participants having at least patients, M (SD)
80% completed data on each measure were included for an-
 73
4 WILSON ET AL.

profession or ATLPS total score using chi-square, Fisher’s
exact tests when assumptions were violated, or one-way
analysis of variance (ANOVA). One-way ANOVA was
used to examine differences in the overall ATLPS score
across profession. Post hoc tests were performed using a
Tukey–Kramer multiple comparison procedure to control
the overall alpha level.
General linear models (GLM) were used in a stepwise
model-building process to arrive at a final model that identi-
fied relative contributions of profession as well as any demo-
graphic or training variables that were significant at the 0.05
level. Variables were entered the model if they were signif-
icant at the 0.10 alpha level and were removed if they were
not statistically significant at the 0.05 alpha level. Model
building was performed on participants with complete data
for all the variables used in the model building process.
After the determination of the final model from the complete
case analysis, the estimates for the final model that are pre-
sented include all participants with nonmissing data for the
independent variables in the final model. Estimates for the
final model did not differ significantly from the original
model used at the outset of the model building process.
Results
See Table 1 for participant demographic characteristics. Dem-
ographic and training variables associated with profession are
listed in Table 2. Variables associated with ATLPS total scores
included sexual orientation (F(1, 469) = 8.52, p = 0.004), current fi-
nancial status (F(1, 470) = 4.89, p = 0.027), religion (F(6, 46) = 5.32,
p < 0.001), religiosity (F(1, 471) = 63.12, p < 0.001), spirituality
(F(1, 468) = 22.83, p < 0.001), and self-reported familiarity
with various religious perspectives on sex (F(1, 471) = 6.42,
p = 0.012). Variables associated with profession or ATLPS
total scores were controlled for in subsequent analyses. Signif-
icant differences were found between ATLPS scores and reli-
gion, such that Christians had significantly lower mean
ATLPS scores than atheists, Hindus, and those with ‘‘other’’
or no religious affiliation. Hindu students had significantly
higher mean ATLPS scores than Muslims. See Table 3 for sig-
nificant associations between demographic and training vari-
ables and ATLPS total scores.
Examination of ATLPS total scores and individual items
revealed significant associations between profession and
ATLPS scores. Of note, psychology students had signifi-
cantly higher mean ATLPS total scores than nursing stu-
dents, with variation in mean differences across profession
for individual scale items. See Table 4 for differences across
professions.
Significant relationships for both profession and ATLPS
total scores were entered into a GLM to determine if the re-
lationship between profession and ATLPS total scores was
accounted for by background or training characteristics of
the sample. In this model (see Table 5), the contribution
of profession (F(4) = 0.75, p = 0.555), sexual orientation
(F(1) = 2.12, p = 0.146), current financial status (F(1) = 3.03,
p = 0.083), and religion (F(6) = 0.63, p = 0.703) to ATLPS
total scores became nonsignificant. Religiosity (F(1) = 36.12,
p < 0.001) and self-reported familiarity with various religious
perspectives on sex (F(1) = 4.74, p = 0.029) were the only sig-
nificant variables in this model. Of note, individuals reporting
higher levels of religiosity and lower self-reported familiarity
with various religious perspectives on sex had significantly
lower mean ATLPS total scores than those with lower levels

Table 2. Demographic and Training Characteristics Associated with Profession

Variable Medicine Nursing Allied health Dentistry Psychology Statistic p
Age, M (SD) 25.3 (3.1) 24.6 (5.4) 25.0 (3.9) 26.3 (4.3) 31.9 (10.2) F(4, 451) = 17.30 < 0.001
Female gender, n (%) 125 (46.1) 31 (100.0) 82 (88.2) 26 (54.2) 27 (84.4) v24 = 83.31 < 0.001
Current financial status, 3.3 (0.7) 2.9 (0.5) 3.0 (0.6) 3.1 (0.6) 2.9 (0.6) F(4, 467) = 8.82 < 0.001
M (SD)
Race, n (%)
Black 16 (6.0) 6 (20.0) 4 (4.3) 5 (10.4) 13 (40.6) v212 = 67.07 < 0.001
White 190 (71.7) 19 (63.3) 84 (90.3) 32 (66.7) 17 (53.1)
Asian 47 (17.7) 3 (10.0) 3 (3.2) 8 (16.7) 0 (0.0)
Other 12 (4.5) 2 (6.7) 2 (2.2) 3 (6.3) 2 (6.3)
Religion, n (%)
No Affiliation 37 (14) 0 (0) 2 (2.1) 2 (4.2) 4 (12.5) < 0.001a
Jewish 13 (4.9) 0 (0) 3 (3.2) 1 (2.1) 0 (0)
Christian 154 (58.1) 28 (90.3) 79 (84) 36 (75) 22 (68.8)
Muslim 8 (3) 2 (6.5) 0 (0) 2 (4.2) 0 (0)
Hindu 20 (7.6) 0 (0) 1 (1.1) 1 (2.1) 4 (12.5)
Atheist 16 (6) 0 (0) 2 (2.1) 3 (6.3) 1 (3.1)
Other 17 (6.4) 1 (3.2) 7 (7.5) 3 (6.3) 1 (3.1)
Religiosity, M (SD) 2.8 (1.3) 3.6 (0.8) 3.4 (1.1) 3.2 (1.1) 2.8 (1.2) F(4, 468) = 7.75 < 0.001
Self-reported familiarity 3 (1) 2.8 (1.1) 2.7 (0.9) 2.8 (1) 2.5 (0.9) F(4, 468) = 3.13 0.015
with religious views
about sex, M (SD)
Sexual education training 2.9 (1) 3 (1.1) 3 (1) 2.6 (1) 2.1 (1) F(4, 393) = 4.99 < 0.001
quality, M (SD)
a
Fisher’s exact test.
 74
ATTITUDES TOWARD LGBT PATIENTS 5

Table 3. Demographic and Training Characteristics Associated with Attitudes Toward

LGBT Patients Scale Total Scores
Variable Level M SD Slope SE p
Sexual orientation Heterosexual 42.4 6.0 0.004
Not heterosexual 46.0 7.6
Current financial status 0.90 0.40 0.027
Religion No affiliation 44.6 6.3 < 0.001
Jewish 44.0 6.6
Christian 41.7 5.9
Muslim 41.8 6.6
Hindu 47.1 6.9
Atheist 44.3 5.9
Other 44.2 5.9
Religiosity 1.70 0.20 < 0.001
Spirituality 1.20 0.30 < 0.001
Self-reported familiarity with religious views about sex 0.70 0.30 0.012

of religiosity or higher self-reported familiarity with various Discussion

religious perspectives on sex. See Table 6 for GLM displaying
the contributions of profession, religiosity, and self-reported The present study explored whether type of profession,
familiarity with various religious perspectives on sex to demographic characteristics, and training experience were
ATLPS total. predictors of health professions students’ attitudes toward

Table 4. Differences in Mean Attitudes Toward LGBT Patients Scale Scores Across Profession
Profession
Medicine Nursing Allied health Dentistry Psychology
M SD M SD M SD M SD M SD p
1. LGBT patients deserve the same level of 4.6 0.7 4.5 0.7 4.6 0.7 4.6 0.6 4.8 0.5 0.688
quality care from medical institutions as
heterosexual patients.
2. LGBT patients should only seek healthcare 1.7 0.9 1.8 0.9 1.6 0.9 1.6 0.9 1.3 0.5 0.251
from gay and lesbian health clinics.a
3. Healthcare professionals in private practice 4.2 0.9 4.2 0.9 4.4 0.7 4.3 0.9 4.3 0.9 0.526
have a responsibility to treat LGBT patients.a
4. I would be comfortable if I became known 4.2 0.9 4.1 0.9 4.1 1.0 4.0 1.1 4.1 1.2 0.457
among my professional peers as a health
professional who cares for LGBT patients.
5. I am concerned that if heterosexual patients 4.0 1.0 3.6 1.0 3.9 1.0 3.7 1.1 4.3 1.1 0.045b
learned that I was treating LGBT patients,
they will no longer seek my care.a
6. I would be comfortable telling my intimate 4.4 0.9 4.2 0.9 4.2 0.9 3.9 1.1 4.5 0.8 0.007c
partner that I cared for LGBT patients.
7. It would be more challenging to gather a 3.6 1.1 3.6 0.8 3.7 1.1 3.8 0.9 4.0 1.0 0.283
history from an LGBT patient than from a
heterosexual patient.a
8. It is more challenging to discuss sexual 3.3 1.2 2.8 0.9 3.3 1.1 3.4 1.0 3.8 1.1 0.028b
behavior with LGBT patients than with
heterosexual patients.a
9. LGBT patients should disclose their sexual 3.6 1.0 3.7 0.9 3.1 1.1 3.3 1.0 2.9 1.1 < 0.001d
orientation to their healthcare providers.a
10. Same-sex sexual attraction is a natural 3.4 1.2 3.0 1.2 3.1 1.1 3.1 1.1 3.5 1.2 0.060
expression of sexuality in humans.
11. Same-sex sexual behavior is a natural 3.3 1.2 2.7 1.2 3.1 1.2 2.9 1.1 3.3 1.3 0.039e
expression of sexuality in humans.
LGBT attitude total score 43.1 6.3 40.7 5.3 41.9 6.0 41.3 6.0 44.1 6.2 0.048b
a
Item was reverse scored; higher scores are indicative of more positive LGBT attitudes on each item.
b
Nursing students had lower mean scores than psychology students.
c
Dentistry students had lower mean scores than medicine and psychology students.
d
Allied health and psychology students had lower mean scores than medicine and nursing students.
e
Nursing students had lower mean scores than medicine students.

6 WILSON ET AL.
Table 5. General Linear Model Analyzing
Contribution of Profession, Sexual Orientation,
Current Financial Status, Religion, Religiosity, and
Self-Reported Familiarity with Various Religious
Perspectives on Sex to LGBT Attitudes Scores
Variable df Mean square F p
Profession 4 25.15 0.75 0.555
Sexual orientation 1 70.79 2.12 0.146
Current financial status 1 100.92 3.03 0.086
Religion 6 21.11 0.63 0.703
Religiosity 1 1203.34 36.12 < 0.001
Self-reported familiarity 1 158.01 4.74 0.030
with various religious
perspectives on sex
LGBT patients. Provider attitudes toward LGBT patients are a
crucial area of study—several healthcare institutions, includ-
ing the American College of Physicians28 and the Gay and
Lesbian Medical Association,29 have identified values as a
key domain to address to improve healthcare for LGBT pa-
tients. Contrary to hypothesis 1, training variables such as
classroom hours on sexual health and clinical contact with pa-
tients on sexual health issues did not predict student attitudes
toward LGBT patients. Hypothesis 2, which posited that
higher levels of religiosity and less familiarity with various re-
ligious perspectives on sex would be associated with lower
mean ATLPS scores, was confirmed. Though attitudes toward
LGBT patients did differ based on other factors such as profes-
sion, sexual orientation, current financial status, and religious
affiliation, the contribution of these variables to ATLPS total
scores became nonsignificant when accounting for religiosity
and self-reported familiarity with various religious perspec-
tives on sex. Individuals with higher levels of religiosity and
less self-reported familiarity with various religious perspec-
tives on sex reported lower mean ATLPS scores.
The lack of relationship found between participant training
experiences in sexual health and LGBT attitudes is quite nota-
ble when placed in the context of existing literature. Training
in patient sexuality16 and student experience with LGBT pa-
tients and/or individuals26 has been found to be predictive of
comfort and skill in provision of care to LGBT patients.
Though students in this survey were queried about their expe-
riences receiving education in sexual health topics, it is un-
clear whether these curricula specifically addressed patient
sexuality or diversity issues relevant to LGBT patients.
Table 6. Final General Linear Model Analyzing Contribution of Profession, Religiosity,
and Self-Reported Familiarity with Various Religious Perspectives on Sex to LGBT Attitudes Scores
Variable Level
Profession Medicine
Nursing
Allied health
Dentistry
Psychology
Religiositya
Self-reported familiarity with various
religious perspectives on sexa
a
Indicates the statistics for those factors are the slope.
75
The finding that religiosity and self-reported familiarity
with various religious perspectives on sex predicted LGBT
attitudes after controlling for profession, sexual orientation,
current financial status, and religious affiliation is quite strik-
ing. These results raise important questions about the ways in
which health professionals are able to honor their personal
beliefs while also being held to certain expectations related
to respect for, and appreciation of, patient diversity. While
an individual’s degree of religiosity may not be as mutable
as sexual health training or curriculum, this study’s findings
do reveal other noteworthy points of possible intervention. In
particular, training focused on increasing health professionals’
awareness of the myriad of views related to sex and sexuality
may be particularly useful. The concept of cultural humility,
which refers to a clinician’s practice of self-reflection and
awareness of how cultural factors influence the clinician–
patient interaction,30 lies squarely at this intersection between
personal values and patient care. While the World Health
Organization has acknowledged that the pursuit of scientific
knowledge can never truly be values-free,20 they have also
identified the elimination of prejudice and discrimination to-
ward sexual minorities as a core strategy for the promotion
of sexual health. Identifying ways to expand training in sexual
health, medical needs of LGBT patients, and various cultural
perspectives on sex and sexuality is one approach to improv-
ing care. Efforts to shift institutional culture to demonstrate a
commitment to cultural competency and diversity for LGBT
individuals may also promote improved attitudes.31
While important implications stem from the current re-
search, there are a number of limitations to address. It is impor-
tant to note the limitations in the ATLPS. First, LGBT patients
are not a homogenous group, and more specific assessment of
attitudes toward specific sexual and gender minority groups
may elucidate differences in attitudes that more appropriately
reflect variance in gender identity and sexuality identity. There
also are limitations in the language used in this measure. For
example, there is no specific reference to transgender individ-
uals outside of the inclusion of this population in the acronym
LGBT, though the experiences of transgender individuals war-
rant specific attention. Also, the current measure does use the
term ‘‘same-sex’’ for two items and this may not be the most
inclusive way of measuring attitudes toward patients identify-
ing across the LGBT spectrum of identities. Furthermore,
while this measure assesses health professions student attitudes
toward LGBT patients, ultimately this measure is more likely
to capture student attitudes toward the patients they perceive as
LGBT or to the patients who have self-identified as LGBT.
Least square mean or slopea SE F p
42.63 0.36 0.86 0.486
41.88 1.05
42.73 0.61
41.69 0.84
43.97 1.03
1.69 0.22 57.21 < 0.001
0.77 0.28 7.56 0.006

ATTITUDES TOWARD LGBT PATIENTS
This is particularly noteworthy given evidence that many pa-
tients do not disclose their sexual orientation to healthcare pro-
viders because of fears of homophobia or bias.23
It would also be beneficial to capture more specific informa-
tion from study participants about the sexual health training
they have received to determine if institutions are including
topics such as sexual orientation, specific health needs of
LGBT populations, and professional expectations concerning
provider interactions with LGBT patients in existing sexual
health curriculum. In addition, use of single-item measures
to assess religion, religiosity, and spirituality limits the ability
to measure the validity and reliability of these constructs. More
robust and multidimensional measures of these constructs will
be suggested in future research. The lack of established psy-
chometric properties of the ATLPS is another related measure-
ment limitation. To date, there is a limited pool of competency
measures specific to LGBT patients, and continued develop-
ment and validation of measures is warranted. Factor analyses
of the modified ATLPS used in this study may clarify mean-
ingful dimensions of this construct worthy of further investiga-
tion. The potential of social desirability bias that is inherent
in self-report measures is another measurement limitation.
Though students may want to portray themselves in a positive
light on the subject of patient diversity, additional measures
such as patient reports or surveys of clinical supervisors or fac-
ulty members may provide a more accurate view of current
student attitudes. In addition, 187 students opted out of the
study. The length of the survey was the most cited barrier to
participation; however, a number of students indicated that dis-
comfort with the survey topic was the primary reason for their
refusal. The omission of such a large number of students may
reflect a selection bias affecting the results. Furthermore, the
results of this study are limited to health professions students
in a single state in the southeastern United States, as this
study was part of a larger project primarily aimed at informing
interprofessional curriculum development efforts at this insti-
tution. Whereas most students were recruited through an eval-
uation system at one institution, obtaining mental health
student respondents separately from a state-wide professional
listserv is a current limitation to this study’s methodology. A
geographically disparate, multisite study using one primary re-
cruitment method would be more effective in distinguishing
variables that may be site- or region- or profession-specific
from those that are more generalizable to these categories.
The results of this study highlight several opportunities for
future research and programmatic interventions focused on
provision of care to LGBT patients. For example, although re-
sults identified significant differences in ATLPS scores based
on religious affiliation, with individuals identifying as Chris-
tian reporting significantly lower mean ATLPS scores than
atheists, Hindus, and those with reporting no or ‘‘other’’ reli-
gious affiliation, additional research is needed to elucidate
these findings. Institutional efforts may include assessments
of LGBT-specific curriculum and competency and efforts to
ensure that institutional culture reflects values of cultural di-
versity and respect. Professional efforts may focus on the de-
velopment of clear expectations among and across health
professions related to the level of knowledge, skills, and cul-
tural competency required. Furthermore, cultural competency
related to sexual and gender diversity may be an appropriate
target for interprofessional curricula development since train-
ees present with comparable attitudes and content needs
76
7
across each profession. Interprofessional training efforts
have been successful in other areas relevant to patient care,
such as HIV/AIDS,32 and may serve as helpful models for
the development of curricula related to patient sexuality.
Acknowledgments
Funding for this project was provided by the Georgia
Health Sciences University Educational Innovation Insti-
tute’s foundation funds.
Author Disclosure Statement
No competing financial interests exist for any of the authors.
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Address correspondence to:
Lara Stepleman, PhD
Georgia Regents University
997 St. Sebastian Way
Augusta, GA 30912
E-mail: lsteplem@gru.edu