Curricular initiatives that enhance student knowledge and perceptions of sexual and gender minority groups: a critical interpretive synthesis.

BACKGROUND
There is no accepted best practice for optimizing tertiary student knowledge, perceptions, and skills to care for sexual and gender diverse groups. The objective of this research was to synthesize the relevant literature regarding effective curricular initiatives designed to enhance tertiary level student knowledge, perceptions, and skills to care for sexual and gender diverse populations.


METHODS
A modified Critical Interpretive Synthesis using a systematic search strategy was conducted in 2015. This method was chosen to synthesize the relevant qualitative and quantitative literature as it allows for the depth and breadth of information to be captured and new constructs to be illuminated. Databases searched include AMED, CINAHL EBM Reviews, ERIC, Ovid MEDLINE, Ovid Nursing Database, PsychInfo, and Google Scholar.


RESULTS
Thirty-one articles were included in this review. Curricular initiatives ranging from discrete to multimodal approaches have been implemented. Successful initiatives included discrete sessions with time for processing, and multi-modal strategies. Multi-modal approaches that encouraged awareness of one's lens and privilege in conjunction with facilitated communication seemed the most effective.


CONCLUSIONS
The literature is limited to the evaluation of explicit curricula. The wider cultural competence literature offers further insight by highlighting the importance of broad and embedded forces including social influences, the institutional climate, and the implicit, or hidden, curriculum. A combined interpretation of the complementary cultural competence and sexual and gender diversity literature provides a novel understanding of the optimal content and context for the delivery of a successful curricular initiative.


Introduction
Sexual and gender minority (SGM) populations experience significant health and social inequity compared to the rest of society. 1 Sexual minority is a term used to describe the diverse and unique populations who identify as gay, lesbian, or bisexual (LGB), are unsure of their sexual orientation, or have had sexual contact with persons of the same sex or both sexes. 2 Gender minority groups are described as those whose gender identity or expression differs from the sex they were assigned at birth. 3 SGM populations are more vulnerable to negative health and social exposures and their associated outcomes. For example, SGM populations experience disproportionately high rates of depression, anxiety, substance abuse, and psychological problems. [4][5][6] In addition, SGM populations are more likely to attempt suicide, run away from home, and experience harassment and violence. [7][8][9][10][11] Gender minority groups are also more likely to experience discrimination within employment, housing, and healthcare situations. 12,13 For example, Lombardi 14 found that 37% of those who identified as transgender experienced economic discrimination, and 60% experienced harassment or violence.
The vulnerability and inequity faced by SGM populations may precipitate increased contact and greater need from health and social services. Thus, it is critical that health and social service providers act in an equitable manner and respond accordingly to their crucial role in the health and wellbeing of SGM populations. Despite the health and social disparity faced by SGM populations, the literature suggests that many of those working in health and social services are ill-prepared to effectively care for members of SGM groups. For example, prior literature reports that medical students are not adequately prepared with the knowledge or skills to effectively engage with SGM patients in a clinical setting. 15,16 Likewise, Logie, Bridge & Bridge 4 found that social work students had low self-reported competence when providing care to SGM populations.
Also, students may be exposed to a narrow view of the health and social needs of SGM groups. Van Voorhis and Wagner 17 reviewed 12 social work journals, and found that only 1% of the articles related to SGM groups were not focused on HIV/AIDS. This narrow research focus fails to acknowledge the broad social and health needs of SGM populations, and can perpetuate further stigma. In addition, this paucity of literature around SGM populations makes it difficult for those working in social services to find further information about this topic.
The literature also suggests that a significant proportion of health, psychology and social work students may have harmful perceptions about SGM groups [18][19][20] . These beliefs hinder their ability to provide equitable care. Nuyen et al. 20 reported that twenty-seven percent of medical students had observed judgemental behaviours toward SGM patients from physicians, and slightly more than half had observed judgemental behaviours toward SGM patients from their peers, the hidden curriculum at work. Raiz and Saltzburg 21 found that less than forty percent of social work students expressed outright acceptance of members of the gay and lesbian community and support for their rights while Logie, Bridge & Bridge 4 found that a high proportion of social workers are biased against SGM groups.
Lack of preparation to equitably care for SGM groups, in conjunction with harmful perceptions, result in significant implications to health and wellbeing of SGM populations. 6 For example, SGM populations are more likely to experience inadequate assessment, treatment, and preventive care. 22 Morrison and L'Heureux 9 also reported ramifications including discriminatory treatment and assessment, misunderstandings resulting in misdiagnosis, and pathologizing.
A variety of tertiary institutions have added sexual and gender minority related curricular content in an attempt to equip future professionals with the appropriate knowledge, perceptions, and skills to equitably address the needs of SGM groups. A range of curricular initiatives have been implemented to prepare students to engage effectively with SGM groups, however, it is not clear which initiatives are most effective. Few curricular strategies have been e123 evaluated, and many of those that have been, have reported conflicting findings about efficacy.
The complementary Cultural Competence literature, which focuses on preparing students with the requisite knowledge, attitudes, and skills to effectively engage in cross-cultural interactions, may offer valuable insight to guide the development and refinement of SGM curricula. [23][24][25] According to Betancourt 25 , cultural competence curricula should include an integrated triad of knowledge, attitude and skill components. Each of these components is essential to the success of cultural competence training, but is insufficient on its own.
Although the Cultural Competence literature focuses on different populations than the SGM literature, the same fundamental concepts underpin many of the inequities faced by both populations. For example, SGM and cultural minority groups experience organizational, structural, and clinical barriers including inequitable access to resources, power, health care, and legal standing. 26 In addition, the inequity experienced by SGM and cultural minority groups is produced and maintained by the same structural forces such as privilege, hegemony, and bias which go largely unexamined by society.

27-30
Thus, shared interpretation of the cultural competence and SGM literature may illuminate the shared foundations between these complementary topics, and further highlight the intersectionality of cultural, sexual, and gender identities.
The cultural competence literature also highlights the necessity of a supportive explicit and implicit curriculum. The explicit curriculum is the curriculum that is intentionally taught and often reflected through stated learning objectives. Conversely, the implicit curriculum, sometimes referred to as the "hidden curriculum", is the set of premises that are unintentionally or subconsciously taught through interactions, role modelling and the climate of the institution. 31 Curriculum development in relation to SGM groups is still an emerging field, and has been slower to materialise than for cultural competence. Although social attitudes toward SGM populations have evolved over time, much of the foundational literature in the SGM field consists of the earlier work. 32 By contrast, the cultural competence literature has undergone significant refinement, evaluation, and critique since its inception, which can offer valuable insight to the development and evaluation of SGM curricula. For example, the integration of knowledge, attitude, and skills components in the explicit curriculum and the awareness of the sub-text of the implicit curriculum is absent in a significant portion of the SGM literature, but included in much of the cultural competence literature.
This paper presents a synthesis of the relevant literature that has described and evaluated curricular initiatives designed to optimize student knowledge, attitudes or skills to care for SGM populations. The paper discusses the characteristics of effective educational initiatives, and places and contrasts these within a broader framework of cultural competence. The role of the implicit curriculum and the assumptions that are embedded in the research regarding student knowledge and perceptions of SGM populations are then discussed. The paper concludes with limitations and recommendations for further research.

Methods
A modified Critical Interpretive Synthesis (CIS) methodology 33 was used to amalgamate the qualitative and quantitative data regarding curricular interventions to improve student knowledge and perceptions of SGM populations. This method was chosen because it allows for the synthesis of data from both qualitative and quantitative studies in a way that allows the sum to become greater than its parts and new constructs to become illuminated. The CIS process can be iterative, interactive, and dynamic. It also allows searching, sampling, critique, and analysis to happen concurrently. 33 Although the framework of a CIS can involve selective and purposive sampling, this review has modified the approach to take a more systematic and comprehensive approach for identification and inclusion of relevant literature. Quality appraisal of qualitative research is contentious, and therefore only qualitative and quantitative studies deemed to be fatally flawed have been excluded. 33 See Appendix 1 for the completed data extraction form.

Inclusion and Exclusion Criteria
Articles were eligible for inclusion if they described and qualitatively or quantitatively evaluated a curricular intervention designed to address tertiary student knowledge, perceptions, or skills to care for SGM groups. For pragmatic reasons, only studies written in English were eligible for inclusion. Articles from any time period and both qualitative and quantitative papers were eligible for inclusion in an effort to capture the depth and breadth of information.
Studies were excluded if they did not meet the inclusion criteria, if the initiative was not described in sufficient detail, and if the initiative was not formally evaluated. Qualitative papers were deemed fatally flawed and excluded if they did not have a clear research question; the research question, data collection, or analysis was not appropriate for qualitative research; or claims were not supported by sufficient evidence.

Literature Search Strategy
A literature search was conducted in May 2015 to locate the relevant literature regarding curricular initiatives designed to address student knowledge, perceptions, or skills to care for SMG. No limits were used to restrict the year of publication. Citations and article references were reviewed in order to identify additional articles for potential inclusion. See Figure  1 for a Flow diagram of included and excluded studies.
Search terms for sexual orientation and gender included: LGBT, lesbian, gay, bisexual, sexual orientation, transgender, transsexual, queer, sexual minority, homosexual, and sexual orientation. Search terms in search engines for education included: medical education, evaluation, and curricul*.  Of the 31 included studies, 13 used one or more of the different scales to assess student attitudes. See Table 1 for the scales used in each study. Fourteen studies used pre-and post-comparisons, one study compared post-test scores from the intervention group to the control group, 34 and two studies used student reflections. 35,36 Also, two studies used scales as pre-and post-tests, as well as comparisons between intervention and control groups. 37,38 There is a paucity of research regarding the comparability of the scales, therefore the comparability of the findings will be limited.
A variety of curricular approaches have been implemented in an attempt to provide students with the knowledge, perceptions, and skills required to care for SGM groups. Delivery methods for teaching sessions include discrete sessions, such as lectures, panel sessions, discussions, intergroup dialogues, case vignettes, and movies. Multi-modal strategies include combinations of the aforementioned strategies, as well as coursework paired with clinical exposure, combined research and sexual minority content, and the infusion method which integrates content into substantial portions of coursework.  Although standalone discrete sessions appear to be ineffective, initiatives that paired a discrete session with an opportunity for processing 44 or informal conversation 45 showed positive effect on student attitudes toward SGM populations.

Multimodal sessions
A variety of multi-modal sessions have reported positive shifts in student knowledge about SGM populations including a "Safe Space" program, a cultural humility session, a HEALE curriculum focused on treatment of SGM elders, a three-part intervention, and a SGM Health Issues Immersion Day. 20,46-49 The "Safe Space" program content included SGM terminology, bias, stereotypes, coming out, and information about suicide risk, prevention, and resources. 46 The two-hour cultural humility session consisted of pre-readings, a lecture, a patient as professor panel, and an interactive question and answer opportunity. 47 The HEALE curriculum included six separate modules: SGM terminology; health disparities; barriers to care; sex and sexuality; the transgender community; and HIV. 48 The three-part curriculum consisted of a processing, and multi-modal teaching, such as integration into the larger curriculum, intergroup dialogue, and the opportunity to apply learning to practice. However, no individual curricular initiatives have included the triad of knowledge, attitude, and skill components. In addition, only one initiative explicitly evaluated a portion of skills. Thus, it is unknown whether these initiatives will have any effect on care provision to SGM groups, and therefore, the health and wellbeing of SGM groups.

Discussion
Many similarities exist between the cultural competence literature and the SGM literature. However, some aspects of the cultural competence literature have moved beyond the traditional paradigm to establish a more critical consciousness of self and others, as well as a commitment to social justice. 67 Reflection of self and privilege, awareness of social forces, and a commitment to advocacy were also present in some of the effective SGM initiatives, and may constitute a positive contribution to future initiatives.
The cultural competence literature also provides some additional insight into the necessity of providing well-designed opportunities for practical application of skills. 68  e128 Focusing on the Other also neglects the structural and social forces that contribute to inequity. Therefore, the disparity experienced by SGM populations may be attributed to internal risk factors, biological imperative, pathologized or regarded as an unavoidable consequence of the natural hierarchy instead of as a product of social stigma. 26,27,[69][70][71][72] The cultural competence literature complements these findings, and asserts that in many cases, learners are not assessed on their understanding of white privilege, they are only assessed on their understanding of the effects of ethnocentrism and racism on the minority Other. 23 Heteronormative assumptions were also embedded in many of the initiatives and the scales that measured their efficacy. The initiatives were geared toward teaching heterosexual, cisgender students about the sexual and gender minority Others. However, prior research has suggested that sexual and gender diversity exist within tertiary student cohorts. 73 Also, questions on the scales, such as the Index of Attitudes toward Homosexuals 74 including "I would feel comfortable if a member of my sex made an advance toward me", and "I would feel comfortable knowing that I was attractive to members of my sex", shows an embedded assumption that respondents are heterosexual. The scoring system for these scales suggest that comfort with these statements is a reflection of positive attitude, however, this comfort may actually be a reflection of same sex attraction.
The SGM literature included in this review focused on disparity as a result of a marginalized sexual or gender identity in isolation. This siloed approach ignores or oversimplifies the intersectionality of the characteristics of individuals, and does not allow for the illumination of the interplay between identities. The tenets of cultural competence training are very similar to those within SGM education, and therefore, may provide an opportunity for collaboration and co-facilitation to promote greater understanding of intersectionality.
One of the limitations of this article is that it is only a synthesis of explicit curricular initiatives. The influence of the implicit curriculum is highlighted in the cultural competence literature. For example, students are more likely to internalize the unintended messages transmitted by faculty or stakeholders through the quality of interactions, language used, facilitation, preparation, and debriefing than the intended messages from the explicit curriculum.

23,75
Therefore, it is counterintuitive to research the effects of explicit curricular interventions without firstly assessing the perceptions of the people who are delivering the implicit curriculum. Some potential avenues for creating an ideal implicit curriculum have been provided by Kripalani, 68 and include buy-in from stakeholders and faculty, promoting cultural diversity among medical students and at all levels of the medical school, and development of a cadre of dedicated faculty.
The comparability of findings from each of the included studies is limited by the variation of scales used. In addition, it appeared that many of the staff members that conducted the curricular initiatives also collected student knowledge and perceptions data. Therefore, social response bias may have influenced student responses, presumably in a positive direction. Also, the majority of articles reported on the average change in perception. Very few articles reported on the magnitude of change for specific groups within the overall cohort; those that did found that some groups experienced greater changes than others. Thus, it is possible that these differences also occurred within other initiatives, but were not identified.
Only one of the included articles focused on skill development. Thus, it is unknown whether the majority of initiatives would have any effect on clinical or social outcomes. Although knowledge and perceptions are key components of a curriculum, these components alone are insufficient. Therefore, further development is recommended to find out whether any future initiatives have any effect on care and equity for SGM populations.

Conclusions
The success of an initiative will depend upon personal characteristics of students, the explicit curriculum, and the implicit curriculum. The literature suggests that an ideal explicit curriculum will include multi-modal teaching strategies that integrate knowledge, attitude, and skill components.

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The explicit curriculum will also encourage selfreflection and appreciation of structural forces. An optimal implicit curriculum will have support and buy-in from students, staff, and stakeholders. In addition, an ongoing critical reflection of the assumptions, methods, tools, and criteria used to facilitate and evaluate student learning is necessary for the continued growth and refinement of this area.
Further research into faculty and stakeholder perceptions is essential. In addition, the development of institutional support to assist students with the reconciliation of their personal beliefs with the ethical and professional requirements of their future occupation is necessary.
Research that evaluates the efficacy of a curricular initiative on provision of care and health and social outcomes is of utmost importance to establish the relevance and utility of this curriculum.
Cultural competence training and SGM educational initiatives have significant fundamental synergies inherent in their concepts and content. Further collaboration and development between these areas could be mutually beneficial, and may enhance student understanding of intersectionality. An exploration of co-facilitated delivery of these topics may further enhance understanding and maximize scarce curricular time. The group mean score remained in the lowgrade homophobic category throughout the 3 year study Deeply held beliefs that influence patient care should be examined