Evaluation of Knowledge and Attitude toward LGBT Community, and the Effect of Education on Knowledge and Attitude in Medical Undergraduates
1MP Shah Govt Medical College, Jamnagar, Gujarat, India
2Department of PSM, MP Shah Govt Medical College, Jamnagar, Gujarat, India
3–6Department of Psychiatry, MP Shah Govt Medical College, Jamnagar, Gujarat, India
Corresponding Author: Lubna Mohammedrafik Nerli, MP Shah Govt Medical College, Jamnagar, Gujarat, India, Phone: +91 9624731989, e-mail: email@example.com
How to cite this article: Nerli LM, Shah VR, Tiwari DS, et al. Evaluation of Knowledge and Attitude toward LGBT Community, and the Effect of Education on Knowledge and Attitude in Medical Undergraduates. Ind J Priv Psychiatry 2020;14(2):51–56.
Source of support: Nil
Conflict of interest: None
Background: The people of the LGBT (lesbian, gay, bisexual, and transgender) community are underprivileged in healthcare settings. Knowledge and awareness about LGBT among the medical undergraduates would eventually fulfill the gap of healthcare services.
Aim: It is to evaluate the knowledge and attitude toward the LGBT community and the effect of education on knowledge and attitude.
Methods: This was a cross-sectional, interventional study of first-year medical students over a period of three days. The “Survey on California State University, Northridge (CSUN) attitude towards LGBT” was used as a survey tool.
Statistical test: Descriptive statistics and the Chi-square test were used for the analysis of data.
Results: Out of 51 students, 32 (62.74%) were raised in a religious household. The results also showed that as compared to males, females were more religious in terms of frequency of visiting religious places and practicing religious preaching. The majority percentage of students disagrees with the traditional gender roles without any significant gender differences. It was also found that as compared to females, more percentage of males are uncomfortable in interacting with LGBT people. The results show that the students have better knowledge about LGBT people; however, the change from “neutral” and “agreement” to “disagreement” is not much significant. The students have a positive attitude toward the LGBT people, but there is no significant change in the attitude postintervention.
Conclusion: This study concludes that though there is positive knowledge and attitude toward LGBT people among medical undergraduates, they are not comfortable in interacting with them.
Keywords: Attitude, Doctors, Knowledge, LGBT community, Religion, Undergraduates.
Lesbian, bisexual, gay, and transgender people are collectively referred to as LGBT group. This group is defined on the basis of gender, sexual orientation, race, and socioeconomic status of the individual. The percentage of this population is estimated to be less than five percent in the Western world as well as the rest of the world.1 Before 1960s, homosexuality was considered a mental disorder. There has been a shift in understanding of homosexuality from a pathological model to a normal variant model of sexuality. Homosexuality is no longer considered a mental disorder.2 On September 6, 2018, the Supreme Court of India ended the Section 377 from Indian Penal Code (IPC) and decriminalized homosexuality.3 In spite of this move, there remains a significant amount of homophobia among the Indian population.
Hudson and Ricketts defined “Homonegativism” as a multidimensional construct that includes judgment regarding the morality of homosexuality, the decision concerning personal and social relationship, and any response concerning belief, preferences, legality, social desirability, or similar cognitive responses.4 In this world where heterosexuality is the norm, this group faces few challenges due to its minority status, which include the experience of prejudiced events, expectations of rejection, hiding and concealment, and internalized homophobia.5 These stressors lead to mood disorders, anxiety disorders, increased suicidal risk, body dissatisfaction, and eating disorders in LGBT people.6–8
Healthcare setting is one of the places where the LGBTI community is faced with minority stressors. Studies have found that half of these people do not have access to basic primary healthcare and have faced discrimination due to their gender identity.9 Such attitude is seen due to little formal education given during medical studies about LGBT, rights of these people, and their special healthcare needs.10 In India, physicians discriminate against them by not treating them like other patients, addressing them in disrespectful manner, and frequently using male pronouns that they find very offensive.11
Studies have shown that Indian medical students have a negative attitude toward LGBT people as they have little knowledge about these people.12 The aim of this study is to evaluate the attitude and knowledge about the LGBT community in medical undergraduates and to see the impact of education on their knowledge and attitude.
This was a cross-sectional, interventional study of fifty-one first-year undergraduate medical students. Participants were selected through convenient sampling during September 2019. A batch of 51 students from 250 students of the first year allotted to the psychiatry department during the foundation course was selected for this study. Students were explained about the study objectives, and written informed consent was obtained. Ethical approval for this study was taken from the Institutional Ethics Committee.
Semistructured Pro Forma
It included details like age, racial background, gender assigned at birth, current gender, sexual orientation, the highest level of education, present education status, religion, and political ideology.
CSUN Attitudes toward LGBT Issues13
This questionnaire was used in a pilot study at California State University, Northridge (CSUN), to gather as much information as they can about the attitudes of their CSUN community members toward lesbian, gay, bisexual, transgender or transsexual, and intersexual matters. It is 13 domains questionnaire about beliefs, attitudes, and practices. The domains have further sub-questions. The domains include questions about the religiosity of the participant; religiosity of household; belief in traditional gender roles; level of comfortableness while interacting in person with people belonging to LGBTIQ community; knowledge about LGBT people; about the origin of sexuality and gender; attitudes toward issues pertaining on LGBT people; changes our institute should do for LGBT people; acceptability of public display of affection by LGBT people; their religion and its view on LGBT community; their families’ and friends’ view on LGBT; frequency of usage of derogatory words; and the number of LGBT people among their family, friends, and workplace. Their responses were accepted in the form of a Likert scale ranging from strongly agree, agree, disagree, strongly disagree to I don’t know. For convenience, the responses were then categorized into only agree, disagree, and I don’t know.
On the first day, students were explained about the study, and they were requested to fill the semistructured proforma containing sociodemographic details and CSUN attitudes toward LGBT issues’ questionnaire. Then, a brief lecture of about 45 minutes on sexual orientation, sexual identity, stigma faced by LGBT people (internal and external), discrimination toward them, and health issues faced by them was given. The next day, a roleplay by resident doctors was performed in front of the study participants. The students were again asked to fill the questionnaire to see the change in their attitude and knowledge for the LGBT community.
All the collected data were tabulated in Microsoft Excel and analyzed using statistical software “Statistical Package for Social Science Version 20.0.” Frequencies and percentages were computed for the sociodemographic details. Chi-square test was used for qualitative data. P < 0.05 was considered statistically significant.
Out of 51 students, 64.70% (n = 33) reported their gender at birth and current gender to be male and 35.30% (n = 18) reported their gender at birth and current gender to be female. In terms of sexual orientation, 98.03% (n = 50) students reported that they are straight and 1.60% (n = 1) student reported having a pansexual sexual orientation. Among a total of 51 students, 88.23% (n = 45) belonged to the Hindu religion and 3.92% (n = 2) belonged to Islam, Jainism, and Christianity each. While 54.90% (n = 28) students had a moderate political ideology, 37.25 (n = 19) had liberal ideology and 7.84 (n = 4) had a conservative political ideology.
Our study is one of the first in India, which evaluates the knowledge and attitude of the medical students and assesses the change in their knowledge and attitude after a brief education regarding LGBT. This study finds that there is higher knowledge in medical students toward the LGBT community as they have an understanding that the sexuality of LGBT community people is natural and is not nature’s mistake, which is similar to the results seen in a study done among the second-year medical students in Kolkata in 201812 (Table 4). The attitude of the students was also found to be positive as most of them disagreed on questions like marriages must be between man and woman, LGBT people should be avoided at places of occupation, and others asked in (Table 5). This is contradictory to what was predicted and was found in one of the studies in China14 on university students having negative attitude toward LGBT people. We assume that the positive attitude is due to Hijra community (transgender) acceptance in society since precolonial era, increasing level of education, awareness, and tolerance regarding LGBT right from the increasing use of social media. However, there is no significant change in the knowledge and attitude of few students after the brief education intervention owing to the firmly entrenched attitudes in few students, and also as we have immediately measured the outcomes. Similar results were found in the study among second-year medical students in the University of California by Kelly et al after brief critical intervention given to them regarding LGBT health.15
N = 33(64.70%)
N = 18(35.30%)
|Frequency of attending the place of worship/religious ceremony||Rarely||26 (78.87%)||9 (50.00%)||0.034*|
|Most of time||7 (21.21%)||9 (50.00%)|
|How often do you follow religious preachings and practices?||Rarely||21 (63.63%)||15 (83.33%)||0.026*|
|Most of time||12 (36.36%)||3 (16.66%)|
|Were you raised in a very religious household?||Disagree||7 (21.21%)||7 (38.88%)||0.356|
|Don’t know||4 (12.12%)||1 (5.55%)|
|Traditional gender role belief||Male
N = 33(64.70%)
N = 18(35.30%)
|I believe men and women have separate gender roles||Disagree||13 (39.39%)||6 (33.33%)||0.453|
|Don’t know||2 (6.06%)||0 (00.00%)|
|Agree||18 (54.54%)||12 (66.66%)|
|Task of childbearing, nurturing, and emotional support for women||Disagree||19 (57.57%)||10 (55.55%)||0.449|
|Don’t know||2 (6.06%)||3 (16.66%)|
|Agree||12 (36.36%)||5 (27.77%)|
|Task of breadwinning, strict discipline, and decision-making for men.||Disagree||19 (57.57%)||13 (72.22%)||0.109|
|Don’t know||2 (6.06%)||3 (16.66%)|
|Agree||12 (36.36%)||2 (11.11%)|
|Roles of men and women are to procreate for the continuation of species.||Disagree||8 (24.24%)||5 (27.27%)||0.133|
|Don’t know||4 (12.12%)||6 (33.33%)|
|Agree||21 (63.63%)||7 (38.88%)|
|To NOT conform to traditional gender roles is to go against nature and biology||Disagree||19 (57.57%)||8 (44.44%)||0.214|
|Don’t know||3 (9.09%)||5 (27.77%)|
|Agree||11 (33.33%)||5 (27.77%)|
N = 33(64.70%)
N = 18(35.30%)
|Gay men||Uncomfortable||18 (54.54%)||6 (33.33%)||0.337|
|Neutral||7 (21.21%)||5 (27.27%)|
|Comfortable||8 (24.24%)||7 (38.88%)|
|Lesbian||Uncomfortable||19 (57.57%)||5 (27.77%)||0.124|
|Neutral||10 (30.30%)||9 (50.00%)|
|Comfortable||4 (12.12%)||4 (22.22%)|
|Bisexual men||Uncomfortable||21 (63.63%)||6 (33.33%)||0.081|
|Neutral||7 (21.21%)||5 (27.77%)|
|Comfortable||5 (15.15%)||7 (38.88%)|
|Bisexual women||Uncomfortable||16 (48.48%)||9 (50.00%)||0.64|
|Neutral||12 (36.36%)||2 (11.11%)|
|Comfortable||5 (15.15%)||7 (38.88%)|
|Female-to-male transgender||Uncomfortable||21 (63.63%)||9 (50.00%)||0.091|
|Neutral||9 (27.27%)||3 (16.66%)|
|Comfortable||3 (9.09%)||6 (33.33%)|
|Male-to-female transgender||Uncomfortable||24 (72.72%)||7 (38.88%)||0.055|
|Neutral||5 (15.15%)||5 (27.77%)|
|Comfortable||4 (12.12%)||6 (33.33%)|
|Intersexual people||Uncomfortable||23 (69.69%)||6 (33.33%)||0.042*|
|Neutral||7 (21.21%)||9 (50.00%)|
|Comfortable||3 (09.09%)||3 (16.66%)|
|Androgynous people||Uncomfortable||18 (54.54%)||8 (44.44%)||0.788|
|Neutral||9 (27.27%)||6 (33.33%)|
|Comfortable||6 (18.18%)||4 (22.22%)|
|LGBT people’s sexual acts are against what god intended||Disagree||28 (54.90%)||28 (54.90%)||0.833|
|Neutral||10 (19.60%)||8 (15.68%)|
|Agree||13 (25.49%)||15 (29.41%)|
|LGBT people are unnatural||Disagree||38 (74.50%)||38 (74.50%)||0.924|
|Neutral||6 (11.76%)||5 (9.80%)|
|Agree||7 (13.72%)||8 (15.68%)|
|LGBT people are mentally sick or immature||Disagree||34 (66.66%)||32 (62.74%)||0.821|
|Neutral||12 (23.52%)||12 (23.52%)|
|Agree||5 (9.80%)||7 (13.72%)|
|LGBT people are sexual perverts||Disagree||17 (33.33%)||20 (39.21%)||0.801|
|Neutral||24 (47.05%)||21 (41.17%)|
|Agree||10 (19.60%)||10 (19.60%)|
|LGBT people are nature’s mistake||Disagree||28 (54.90%)||31 (60.78%)||0.330|
|Neutral||14 (27.45%)||8 (15.68%)|
|Agree||9 (17.64%)||12 (23.52%)|
|Homosexuality, bisexuality, and transgenderism are the result of too much freedom in the country||Disagree||31 (60.78%)||34 (66.66%)||0.750|
|Neutral||6 (11.76%)||4 (7.84%)|
|Agree||14 (27.45%)||13 (25.49%)|
|Marriage should only b/w a man and woman||Disagree||27 (52.94%)||26 (50.98%)||0.979|
|Neutral||4 (7.84%)||4 (7.84%)|
|Agree||20 (39.21%)||21 (41.17%)|
|There are public/occupations where homosexual and bisexual should be avoided (e.g., not allowed to teach)||Disagree||39 (76.47%)||44 (86.27%)||0.383|
|Neutral||5 (9.80%)||2 (3.92%)|
|Agree||7 (13.72%)||5 (9.80%)|
|There are public/occupations where transgender should be avoided (e.g., not be allowed to serve in the military)||Disagree||40 (78.43%)||43 (84.31%)||0.734|
|Neutral||6 (11.76%)||4 (7.84%)|
|Agree||5 (9.80%)||4 (7.84%)|
|LGBT couples should have the right to adopt children||Disagree||13 (25.49%)||11 (21.56%)||0.896|
|Neutral||1 (1.96%)||1 (1.96%)|
|Agree||37 (72.54%)||39 (76.47%)|
|Students should be exposed to age-appropriate lessons about LGBT||Disagree||7 (13.72%)||00 (0.00%)||0.004*|
|Neutral||4 (7.84%)||12 (23.52%)|
|Agree||40 (78.43%)||39 (76.47%)|
|Parents of students taking sex education should have the options to allow them to learn about LGBT||Disagree||10 (19.60%)||6 (11.76%)||0.482|
|Neutral||4 (7.84%)||3 (5.88%)|
|Agree||37 (72.54%)||42 (82.35%)|
|Students should be taught about tolerance/acceptance of LGBT||Disagree||4 (7.84%)||6 (11.76%)||0.799|
|Neutral||4 (7.84%)||4 (7.84%)|
|Agree||43 (84.31%)||41 (80.39%)|
Although there is positive knowledge among the medical students, they are still uncomfortable in interacting with LGBT people (Table 3). This would lead them to not properly communicate about the healthcare needs of the LGBT people. It is assumed that this discomfort may be due to lack of exposure to LGBT community as proposed by Kelly et al.15 or can also be due to local religious and social orthodoxy in the modern doctors in India.16 It is to be noted that we also found that gender differences exist in the degree of discomfort felt by respondents. As compared to females, males are more uncomfortable to interact with the LGBT people. This result may be due to the rigid attitude of men to maintain the male and female conformity and being threatened by the nonconformity as seen in the study by Winter in 2008 among Hong Kong undergraduate students.17
About 76.47% of our respondents agreed that the students should be exposed to age-appropriate lessons about the LGBT community. One of the studies in USA has found that the mean number of hours of the medical curriculum in medical undergraduate teaching was 2.5 hours only throughout 4 years of teaching.18 In India, there are no publications or formal reports regarding the amount of teaching hours of medical undergraduates about the LGBT community. General physicians (GPs) believed that the education regarding the health of nonheterosexual people is the need for better communication and treatment of LGBT people found out in a qualitative interview study with 22 GPs practicing in Sheffield, United Kingdom.19 The Association of American Medical Colleges recommends medical curricula to ensure students learn skills and attitudes necessary to provide comprehensive care for LGBT like training in communication skills with patients regarding sexual orientation and gender identity. In India, the inclusion of such training program is necessary for an increasing standard of healthcare of LGBT people.
This study concludes that though there is positive knowledge and attitude among medical undergraduates, discomfort among them is still a major issue that might lead to poor communication with and improper treatment of LGBT community people. The way of history taking and asking about their health problems has to be taught to the students so that they can inculcate these practices in their profession. The medical curriculum of India should include proper lectures and practical assignments regarding LGBT community health problems and discrimination faced by them.
Our study has few limitations. Firstly, it includes a very small number of participants, so the results cannot be extrapolated to the knowledge of all medical students. Secondly, the study was only conducted on the first-year medical students who have just taken admission. The understanding of senior students is more positive than them due to more knowledge regarding the LGBT community. Thirdly, the change in knowledge and attitude was assessed immediately after the intervention that would have not brought significant change.
Our recommendations are to develop a proper curriculum regarding LGBT community health needs and to develop proper communication skills in medical students to be effective all over India. Secondly, to carry out future research on this topic as a long-term follow-up study to know the efficacy of such intervention.
1. Bailey JM, Vasey PL, Diamond LM, et al. Sexual orientation, controversy, and science. Psychol Sci Public Interest 2016;17(2):45–101. DOI: 10.1177/1529100616637616.
2. Drescher J, Stein TS, Byne WM. Homosexuality, gay and lesbian identities and homosexual behavior. In: Sadock BJ, Sadock VA, editors. Kaplan & Sadock’s comprehensive textbook of psychiatry. 9th ed. Vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2009, p. 2060
3. Section 377: Here is everything you need to know [Internet]. The Economic Times. [cited 2020 May 18]. Available at: https://m.economictimes.com/news/politics-and-nation/sc-delivers-historic-verdict-heres-everything-you-need-to-know-about-section-377/articleshow/65698429.cms
4. Hudson WW, Ricketts WA. A strategy for the measurement of homophobia. J Homosex 2020;5(4):357–372. DOI: 10.1300/J082v05n04_02.
5. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003;129(5):674–697. DOI: 10.1037/0033-2909.129.5.674.
6. Sandfort TG, de Graaf R, Bijl RV, Schnabel P. Same-sex sexual behavior and psychiatric disorders: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Arch Gen Psychiatry 2001;58(1):85–91. DOI: 10.1001/archpsyc.58.1.85.
7. Arnarsson A, Sveinbjornsdottir S, Thorsteinsson EB, et al. Suicidal risk and sexual orientation in adolescence: a population-based study in Iceland. Scand J Public Health 2015;43(5):497–505. DOI: 10.1177/1403494815585402.
8. Siever MD. Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders. J Consult Clin Psychol 1994;62(2):252–260. DOI: 10.1037//0022-006x.62.2.252.
9. Kenagy GP. Transgender health: findings from two needs assessment studies in Philadelphia. Health Soc Work 2005;30(1):19–26. DOI: 10.1093/hsw/30.1.19.
10. Makadon HJ. Improving health care for the lesbian and gay communities. N Engl J Med 2006;354(9):895–897. DOI: 10.1056/NEJMp058259.
11. Chakrapani V, Babu P, Ebenezer T. Hijras in sex work face discrimination in the Indian health-care system. 3.
12. Kar A, Mukherjee S, Ventriglio A, et al. Attitude of Indian medical students towards homosexuality. East Asian Arch Psychiatry. 2018;28(2):59–63. DOI: 10.12809/eaap181728.
13. Survey on CSUN attitudes toward LGBT issues attitudes - Google Search [Internet]. [cited 2020 Jul 22]. Available at: https://www.google.com/search?q=SURVEY+ON+CSUN+ATTITUDES+TOWARD+LGBT+ISSUES+Attitudes&oq=SURVEY+ON+CSUN+ATTITUDES+TOWARD+LGBT+ISSUES+Attitudes&aqs=chrome..69i57.1791j0j15&sourceid=chrome&ie=UTF-8.
14. Chi X, Hawk ST. Attitudes toward same-sex attraction and behavior among Chinese university students: tendencies, correlates, and gender differences. Front Psychol 2016;7:1592. DOI: 10.3389/fpsyg.2016.01592.
15. Kelley L, Chou C, Dibble S, et al. A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students. Teach Learn Med 2008;20:248–253. DOI: 10.1080/10401330802199567.
16. Sathyanarayana Rao TS, Rao GP, et al. Gay rights, psychiatric fraternity, and India. Indian J Psychiatry 2016;58(3):241–243. DOI: 10.4103/0019-5545.192006.
17. Webster B, Cheung P. Measuring Hong Kong undergraduate students’ attitudes towards transpeople. Sex Roles 2008;59:670–683. DOI: 10.1007/s11199-008-9462-y.
18. Tesar CM, Rovi SL. Survey of curriculum on homosexuality/bisexuality in departments of family medicine. Fam Med 1998;30(4):283–287. PMID: 9568499.
19. Hinchliff S, Gott M, Galena E. “I daresay I might find it embarrassing”: general practitioners’ perspectives on discussing sexual health issues with lesbian and gay patients. Health Soc Care Commun 2005;13(4):345–353. DOI: 10.1111/j.1365-2524.2005.00566.x.
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.