Base in(clusivity): A new type of prism in optometry school

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The demographic landscape of higher education in the US is rapidly evolving, particularly with respect to the growing number of students who identify as LGBTQ. This trend is especially noticeable in younger generations, with research indicating that more than 1 in 5 Generation Z adults self-identify as part of the LGBTQ community.¹ This demographic shift will inevitably affect optometry schools across the country, which presents a unique opportunity—and responsibility—for optometric education to evolve and ensure future optometrists are equipped to provide culturally competent and compassionate care.

Reading the rainbow tea leaves

The millennial and Gen Z cohorts are more likely to identify as LGBTQIA compared with their Generation X and baby boomer counterparts.¹ This trend is expected to continue, with Generation Alpha poised to show even greater diversity in gender and sexual identity. For optometry to be truly inclusive, educators must first acknowledge the existence and growth of the LGBTQIA population within both the student body and faculty and then take steps to ensure their needs are met.

The reality is that we simply don’t know how many students currently identify as LGBTQIA in optometry schools across the country, because this information is not being fully acquired when students apply or after they matriculate. However, although precise statistics on LGBTQIA representation in optometry schools are lacking, we can look to medical schools for context.

According to a report from the Association of American Medical Colleges (AAMC), medical schools have started tracking LGBTQIA identity more closely.² Since 2018, applicants to US medical schools have been allowed to specify their gender identity and pronouns, but the results suggest that LGBTQIA individuals are underrepresented by 17% to 21% compared with national expectations.³ This lack of visibility mirrors the broader challenges that the LGBTQIA community faces in many professional fields. Is optometry part of this trend, or is it an exception? The first and perhaps most straightforward way to answer this question is to acquire information on sexual and gender identity from current applicants and students.

Who cares about LGBTQIA care?

LGBTQIA patients often face unique health challenges, ranging from ocular manifestations of medical treatment, disparities in access to care, and discrimination from medical providers and insurance companies. According to a Centers for Disease Control and Prevention study in October 2024, more than 25% of transgender and gender-fluid high school students attempted suicide in the past year compared with 5% of cisgender male and 11% of cisgender female students.⁴ Culturally competent care means understanding the distinct experiences of LGBTQIA individuals and addressing their health needs in a way that is respectful and intentional.

Are students being prepared to care for this population? Let’s again look to medical education. Results from a 2011 study in JAMA found that medical students receive a median of 5 hours of training on LGBTQIA health issues, and more than one-third of survey respondents reported 0 hours of relevant training during their clinical education.⁵ In 2014, the AAMC released a call for the 158 US and Canadian medical schools to provide comprehensive training in caring for LGBTQIA patients,⁶ and as recently as 2022, some medical experts recommended that LGBTQ training should be increased to a minimum of 35 hours.⁷ That amount of time may not be appropriate for optometry students because our field is more specialized and focused on the eye, but the national LGBTQIA optometric organization PRIDE ODs argues that we should start somewhere and sometime, and that time is now.

The absence of LGBTQIA content in board/licensing examinations, inadequate educator knowledge, and political pressures surrounding LGBTQIA issues all serve to limit the inclusion of these topics in the curricula. However, as the need for cultural competence in health care grows, so too does the imperative for educational reform in optometry schools.

Incremental progress is still progress

Integrating comprehensive LGBTQIA education within the existing structure of optometry curricula is admittedly a lofty goal. Rather than aiming for sweeping changes all at once, optometry programs can begin by making smaller, more manageable adjustments.

One potential starting point is the introduction of standalone lectures on cultural competency, humility, and inclusion. A dedicated session on these topics would provide students with the foundation needed to understand LGBTQIA identities and terminologies and the origins of known health disparities. Defining even basic terms gives students the vocabulary necessary to engage in meaningful discussions about these issues.

Furthermore, educators can weave LGBTQIA topics more implicitly into case studies, ensuring that LGBTQIA patients are represented in everyday clinical scenarios. For example, case reports involving nonbinary patients or those undergoing gender-affirming hormone therapy would help normalize these experiences and prepare optometry students for real-world interactions they will inevitably have with patients during their internships and externships and after they graduate.

Beyond the curriculum itself, advocacy within academic institutions is essential. Faculty and administrators should be held accountable for creating inclusive environments, which could include simple actions such as ensuring pronouns and preferred names are respected on rosters and in class. Advocacy could also involve the establishment of LGBTQIA student groups; I work at the New England College of Optometry in Boston, Massachusetts, where we have a student group called PRISM, which provides a sense of representation, community, and support for students and faculty alike.

Looking ahead: A call to action

Although some progress has been made, much remains to be done to ensure that optometric education reflects the diversity of the population it serves. The creation of LGBTQIA programs within optometry schools, whether through curriculum updates or advocacy initiatives, is crucial to foster a safe and inclusive learning environment for students. Moreover, collaboration across institutions will be necessary to create long-term structural support for LGBTQIA professionals and foster a culture of belonging. Ultimately, these changes will lay the scaffolding for higher-quality care for our patients and the communities we serve.

References:

1. Jones JM. LGBTQ+ identification in U.S. now at 7.6%. Gallup. March 13, 2024. Accessed October 17, 2024. https://news.gallup.com/poll/611864/lgbtq-identification.aspx

2. Perceptions of Diversity, Equity, and Inclusion Among LGB+ Faculty at U.S. Medical Schools. Association of American Medical Colleges. July 2022. Accessed October 17, 2024. https://www.aamc.org/data-reports/report/perceptions-diversity-equity-and-inclusion-lgb-faculty-us-medical-schools

3. Cech EA, Pham MV. Queer in STEM organizations: workplace disadvantages for LGBT employees in STEM related federal agencies. Soc Sci. 2017;6(1):12. doi:10.3390/socsci6010012

4. Suarez NA, Trujillo L, McKinnon II, et al. Disparities in school connectedness, unstable housing, experiences of violence, mental health, and suicidal thoughts and behaviors among transgender and cisgender high school students - Youth Risk Behavior Survey, United States, 2023. MMWR Suppl. 2024;73(4):50-58. doi:10.15585/mmwr.su7304a6

5. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971-977. doi:10.1001/jama.2011.1255

6. Hollenbach AD, Eckstrand KL, Dreger A. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD: A Resource for Medical Educators. Association of American Medical Colleges. 2014. Accessed October 17, 2024. https://inside.nku.edu/content/dam/inclusive/docs/Implementing%20Curricular%20and%20Institutional%20Climate%20Changes%20to%20Improve%20Health%20Care%20for%20Individuals%20who%20are%20LGBT.pdf

7. Nowaskie DZ, Patel AU. How much is needed? patient exposure and curricular education on medical students’ LGBT cultural competency. BMC Med Educ. 2020;20(1):490. doi:10.1186/s12909-020-02381-1