# Attitudes of Physical Therapy Students in Israel toward People Identifying as Lesbian, Gay, or Bisexual: A Cross-Sectional Survey

Authors: Michal Elboim-Gabyzon; Hadas Ofek; Roei Klein
Journal: Health & Social Care in the Community
 (2023)

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## Abstract

This study aimed to explore the attitudes of physical therapy (PT) students in Israel toward people who identify as lesbian, gay, or bisexual (LGB) and to identify the characteristics associated with the said attitudes. This multiinstitutional study is used as an observational design. Participants were 245 PT students (average age, 25.59 ± 3.10 years), who completed anonymous online questionnaires that included demographic characteristics; the Hebrew version of the Attitudes Toward Homosexuality Scale (ATHS); questions on learning about LGB, trans, queer, intersex, asexual, and other sexual and gender minorities (LGBTQIA+); healthcare issues in the entry-level PT; and previous clinical encounters with patients who identified as LGBTQIA+. The median ATHS score was 107 out of 110 (range, 48–110; higher score indicating more positive attitudes), and multivariate logistic regression analyses indicated that identifying as a woman and secular were predictors of positive attitudes toward LGB individuals. All students reported that they had no course on the LGBTQIA+ community in their undergraduate PT studies’ curriculum. Most (80.88%) of those who had a clinical practice reported that they had not had a clinical encounter with a patient identifying as LGBTQIA+. PT students in Israel demonstrated positive attitudes toward LGB individuals, as reflected by their ATHS scores. PT students who identify as men and religious are more likely to hold negative attitudes toward LGB individuals. There is a need to expand the curricula on LGBTQIA+ healthcare and increase students' experiences with LGBTQIA+ patients to increase cultural competence.


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## Body

## 1. Introduction

People who identify as LGBTQIA+ are at a higher risk for poorer physical (such as hypertension and diabetes) and mental (such as depression, anxiety, and risky sexual behaviors) health compared with the heterosexual and cisgender people [1–3]. Yet, sexual and gender minorities often delay or avoid seeking medical care as they are uncomfortable disclosing their sexual orientation and gender identity to healthcare professionals [2, 4, 5].The frequently inadequate quality of healthcare provided to sexual minorities is often the result of lack of knowledge among healthcare professionals, insensitivity to the unique needs of this community, and a high prevalence of negative attitudes and stigmatic behavior [6]. A recent systematic review of the qualitative studies demonstrated the following five themes in the interactions between health professionals and LGB patients in healthcare settings [7]: (1) lack of knowledge regarding LGB-specific health issues, (2) inadequate disclosure of sexual orientation, (3) mutual discomfort (patients and healthcare providers) during interactions, (4) patients’ experience of negative/heteronormative attitudes, and (5) patients’ experience of negative behavior. Similar results were reported in a systematic review of the experience of sexual minority women concerning healthcare services in the UK, who experienced heteronormative attitudes, ignorance, and prejudice from healthcare professionals [5]. In 2019, the United Nations published a call to educate healthcare providers to reduce the health inequities faced by LGBTI people [7].Focusing on the interactions between sexual minorities and physical therapists is justified because of the special nature of the profession. PT involves close physical contact with patients as part of the assessment or treatment and often requires exposure of the patient’s body parts [8]. As PT is usually not a single encounter but a continuous process, it is crucial to engage patients in the course of therapy, creating a relationship based on trust between patients and therapists. Accordingly, clinical encounters between physical therapists (PTs) and patients require cultural competence, which refers to “the ability to deliver services with appropriate consideration of the cultural beliefs, behaviors, and needs of the patient” [9].Several studies have focused on the different aspects of the interaction between PTs and sexual minorities [10–15]. Copti et al. [11] discussed the strategies to improve the quality of care for LGBT individuals and cultural competence in clinical settings by adapting the curriculum content of PT education programs to increase the knowledge applicable to sexual minority patients. This should include the use of appropriate terminology when addressing an individual in a sexual minority, a full understanding of the special health needs of this population, and self-reflection on attitudes toward sexual minorities that may lead to discrimination and bias.Positive attitudes and appropriate knowledge are precursors to cultural competence [9]; therefore, it is important to explore PT students’ attitudes and knowledge of LGBTQIA+ people and implement appropriate training and education that will render them culturally competent [12]. Furthermore, it is crucial to elucidate PT students’ attitudes to create a safe, respectful, and nondiscriminatory learning environment for LGBTQIA+ students [11].To our knowledge, only three studies [16–18] have explored the PT students’ attitudes toward LGBTQIA+ individuals. A cross-sectional online survey of 107 PT students in the UK demonstrated that they held positive attitudes toward providing care for LGBTQIA+ individuals [16]. Similar results were demonstrated in an additional online survey conducted among 1,015 students in a Doctor of Physical Therapy (DPT) program in the USA [17]. Nowaskie et al. [18] included PT students in a study comparing LGBT cultural competence across 1,701 healthcare students from different disciplines and found a significant difference between healthcare professionals in terms of formal education, attitudes, and clinical preparedness. The level of LGBT patient exposure and LGBT formal education varied considerably between students of different healthcare disciplines, with the highest score among social work students and the lowest among dental students, with PTs located in the middle range [18].The paucity of studies regarding PT students’ attitudes and the fact that these studies were performed only in two large Western countries (USA and UK) in which there is greater acceptance of LGBTQIA+ communities, support the need for research in other countries. The need for additional studies is particularly significant in countries such as Israel, steeped in the history of the three major religions (Judaism, Christianity, and Islam) [19, 20]. In fact, according to Israel’s Central Bureau of Statistics, a significant percentage of Jewish and Arab residents in Israel define themselves as traditional (25% and 57%, respectively) and religious (30% and 31%, respectively) [21]. As both Jewish and Muslim religious laws prohibit any manifestation of LGBTQIA+ practice, particularly gay practices.This may influence the students’ attitudes toward LGBTQIA+ members [22, 23]. For example, in a previous study conducted among 662 higher-education LGBTQIA+ students, 66.67% reported that they were exposed to offensive comments, jokes, and sexual harassment regarding their sexual orientation or gender identity [24]. More recently, the Association for LGBTQ Equality in Israel published in their 2019 report that 829 (39%) of “LGBTQphobia” offenses were in government institutions and 616 (29%) were in family settings [25]. In the 2021 publication, there was a 10% increase in “LGBTQphobia” reports (2,971 total), a 5-fold increase in “LGBTQphobia” incidences in the healthcare system (from 46 to 237 reports), and 444 young LGBTQs adults reported leaving/being forced out of their homes [26].Contrastingly, Israel is a modern and developed country with a growing acceptance of the LGBTQIA+ community, particularly among the secular population, and has increased legislation addressing the rights of sexual minorities [27, 28]. Some examples of the growing acceptance and understanding of the specific healthcare needs of this community include the expansion of LGBTQIA+ medical services in major health maintenance organizations (HMOs), the establishment of the field of LGBT medicine in Tel Aviv Sourasky Medical Center, the largest acute care facility in Israel [29], the passing of a reform enabling sexually active gay and bisexual men to donate blood [30], and the correction of the “surrogacy law” that enables single men, gay couples, and transgender people to legally become parents [31].To date, there have been no studies on PT students’ attitudes in countries such as Israel, characterized by large populations in which the topic may still be a taboo. There is also lack of validated and reliable assessment tools in Hebrew to measure the attitudes toward LGBTQIA+ people. The only currently validated and reliable tool in Hebrew is the Attitudes Toward Homosexuality Scale (ATHS), which only covers the LGB population.To address these gaps in the literature, we examined the following research questions:(1)
What attitudes do PT students in Israel hold toward people identifying as LGB?(2)
What background characteristics of PT students affect their attitudes toward LGB individuals?


## 2. Materials and Methods

An anonymous survey was conducted using the Qualtrics XM survey platform between November 2020 and March 2021. The study was approved by the Ethics Committee of the Faculty of Social Welfare and Health Sciences, University of Haifa (approval no. 19/388). The research recruitment notice included a link to the online survey. Instructions indicated that completing and submitting the survey was indicative of informed consent. In addition, it was stated that the anonymity of the participants was guaranteed.


### 2.1. Participants

In Israel, five academic institutions offer a bachelor’s degree in PT. All institutions offer full-time four-year programs which include clinical affiliations of at least 960 hours during 4-5 rotations. Since 2008, after completing the bachelor’s degree requirements, candidates must complete a government examination to be licensed to practice [27].The survey was written in Hebrew, which is the country’s official language, although the Israeli population is linguistically and culturally diverse. The survey was distributed to all PT undergraduate programs in Israel through representatives in each institution and by advertisements in student media groups. There were no restrictions as to the number of clinical affiliations undertaken or the school year.


### 2.2. Outcome Measures

The survey included the following four parts:(1)
Background questionnaire about age, sex, gender, sexual orientation, religion, religiousness, family status, and place of residence. Information on the academic background was also collected, including study year, clinical practice (yes/no question), and the number of rotations in clinical practices.(2)
Previous personal or professional acquaintance with a sexual minority was assessed by three yes/no questions: Do you have an LGBTQIA+ person in your family? Do you have a close friend identifying as LGBTQIA+? Did you treat an LGBTQIA+ person during your clinical rotation?(3)
Education regarding LGBTQIA+ during the undergraduate PT program was assessed by two yes/no questions: During your undergraduate studies, did you take a course on the LGBTQIA+ community? During your undergraduate studies, did you learn about the LGBTQIA+ community?(4)
PT students’ willingness to learn about the LGBTQIA+ community was assessed using four yes/no questions (followed by an open question for elaboration): Do you think it is necessary to learn about the LGBTQIA+ community during your PT undergraduate studies? Do you think there is sufficient consideration of the topic of the LGBTQIA+ community during PT undergraduate studies? Would you like to learn about the LGBTQIA+ community in your undergraduate program? Do you believe it is necessary to address patients’ sexual orientation during PT treatment?Attitudes were assessed using the Hebrew version of the ATHS, which was originally developed in English [32]. The ATHS is the only validated and reliable tool in Hebrew focusing on the attitudes toward homosexuality with good psychometric properties (internal consistency, Cronbach’s alpha = 0.93; test-retest reliability, r = 0.71) [33, 34]. The ATHS uses a five-pointLikert-type scale ranging from one (“strongly agree”) to five (“strongly disagree”). The ATHS has 21 statements and the Hebrew version added 1 additonal item, so the validated Hebrew version contains 22 statements including one additional item (the items are presented in Table 1). The overall score in the Hebrew version ranges from 22 to 110, with higher scores indicating more positive attitudes toward the LGB community. There are no reports on the cutoff value of the ATHS defining the level of negative/positive attitudes toward homosexuality.Table 1
The results of the Attitudes Toward Homosexuality Scale (median, interquartile range;N = 245).
VariablesMedian, range (IQR)Attitudes Toward Homosexuality ScaleTotal Attitudes Toward Homosexuality Scale score107.00, 48–110 (100.00–109.00)(1) I would not mind having homosexual friends5, (1–5) 5.00-5.00(2) Finding out that an artist was gay would have no effect on my appreciation of his/her work5, (1–5) 5.00-5.00(3) I would not associate with known homosexuals if I can help it5, (1–5) 5.00-5.00(4) I would look for a new place to live if I found out my roommate was gay5, (1–5) 5.00-5.00(5) Homosexuality is a mental illness5, (1–5) 5.00-5.00(6) I would not be afraid for my child to have a homosexual teacher5, (1–5) 5.00-5.00(7) Gays dislike members of the opposite sex5, (1–5) 5.00-5.00(8) I do not really find the thought of homosexual acts disgusting5, (1–5) 3.00–5.00(9) Homosexuals are more likely to commit deviant sexual acts, such as child molestation, rape, and voyeurism (peeping toms), than are heterosexuals5 (1–5), 5.00-5.00(10) Homosexuals should be kept separate from the rest of society (i.e., separate housing, restricted employment)5 (1–5), 5.00-5.00(11) Two individuals of the same sex holding hands or displaying affection in public is revolting5 (1–5), 5.00-5.00(12) The love between two males or two females is quite different from the love between two persons of the opposite sex5 (1–5), 4.00-5.00(13) I see the gay movement as a positive thing5 (1–5), 5.00-5.00(14) Homosexuality, as far as I am concerned, is not sinful5 (1–5), 5.00-5.00(15) I would not mind being employed by a homosexual5 (1–5), 5.00–5.00(16) Homosexuals should be forced to have psychological treatment5 (1–5), 5.00-5.00(17) The increasing acceptance of homosexuality in our society is aiding in the deterioration of morals5 (1–5), 5.00-5.00(18) I would not decline membership in an organization just because it has homosexual members5 (1–5), 5.00-5.00(19) I would vote for a homosexual in an election for public office5 (1–5), 5.00-5.00(20) If I knew someone was gay, I would still go ahead and form a friendship with that individual5 (1–5), 5.00-5.00(21) If I were a parent, I could accept my son or daughter being gay5 (1–5), 4.00-5.00(22) Homosexuals are guilty of spreading AIDS5 (1–5), 4.00-5.00Note. Although we used the validated Hebrew version, we include the original English items here. Items 1, 2, 6, 8, 13–15, and 18–21 were reverse-scored. IQR, interquartile range; AIDS, acquired immunodeficiency syndrome.


### 2.3. Data Analysis

Descriptive statistics were calculated for PT students’ background characteristics, previous acquaintance with LGBTQIA+ individuals, education on LGBTQIA+, attitudes toward education on LGBTQIA+, and ATHS results. Since the distribution of the results of the ATHS response score was not uniform among the possible scores, we categorized it for further statistical analyses (group comparisons and logistic regression analysis). Accordingly, the median score (107) of the ATHS variable was defined as the cutoff point and was converted into a categorical score. Scores above or equal to the median response of the sample (≥107) were in one category, and scores below the median (<107) were in the second category.Between-group comparisons were performed for gender, sexual orientation, religiousness, place of residence, and clinical experience (referring to clinical practice) using chi-square tests for categorical variables and Wilcoxon two-sample tests for age variables. Multivariate logistic regression analyses were used to predict the positive attitudes toward homosexuality (total ATHS score  ≥ 107) by gender, age, sexual orientation, religiousness, clinical experience, and place of residence. An odds ratio above one indicated more positive attitudes. Significance was set atp≤0.05.


## 2.1. Participants

In Israel, five academic institutions offer a bachelor’s degree in PT. All institutions offer full-time four-year programs which include clinical affiliations of at least 960 hours during 4-5 rotations. Since 2008, after completing the bachelor’s degree requirements, candidates must complete a government examination to be licensed to practice [27].The survey was written in Hebrew, which is the country’s official language, although the Israeli population is linguistically and culturally diverse. The survey was distributed to all PT undergraduate programs in Israel through representatives in each institution and by advertisements in student media groups. There were no restrictions as to the number of clinical affiliations undertaken or the school year.


## 2.2. Outcome Measures

The survey included the following four parts:(1)
Background questionnaire about age, sex, gender, sexual orientation, religion, religiousness, family status, and place of residence. Information on the academic background was also collected, including study year, clinical practice (yes/no question), and the number of rotations in clinical practices.(2)
Previous personal or professional acquaintance with a sexual minority was assessed by three yes/no questions: Do you have an LGBTQIA+ person in your family? Do you have a close friend identifying as LGBTQIA+? Did you treat an LGBTQIA+ person during your clinical rotation?(3)
Education regarding LGBTQIA+ during the undergraduate PT program was assessed by two yes/no questions: During your undergraduate studies, did you take a course on the LGBTQIA+ community? During your undergraduate studies, did you learn about the LGBTQIA+ community?(4)
PT students’ willingness to learn about the LGBTQIA+ community was assessed using four yes/no questions (followed by an open question for elaboration): Do you think it is necessary to learn about the LGBTQIA+ community during your PT undergraduate studies? Do you think there is sufficient consideration of the topic of the LGBTQIA+ community during PT undergraduate studies? Would you like to learn about the LGBTQIA+ community in your undergraduate program? Do you believe it is necessary to address patients’ sexual orientation during PT treatment?Attitudes were assessed using the Hebrew version of the ATHS, which was originally developed in English [32]. The ATHS is the only validated and reliable tool in Hebrew focusing on the attitudes toward homosexuality with good psychometric properties (internal consistency, Cronbach’s alpha = 0.93; test-retest reliability, r = 0.71) [33, 34]. The ATHS uses a five-pointLikert-type scale ranging from one (“strongly agree”) to five (“strongly disagree”). The ATHS has 21 statements and the Hebrew version added 1 additonal item, so the validated Hebrew version contains 22 statements including one additional item (the items are presented in Table 1). The overall score in the Hebrew version ranges from 22 to 110, with higher scores indicating more positive attitudes toward the LGB community. There are no reports on the cutoff value of the ATHS defining the level of negative/positive attitudes toward homosexuality.Table 1
The results of the Attitudes Toward Homosexuality Scale (median, interquartile range;N = 245).
VariablesMedian, range (IQR)Attitudes Toward Homosexuality ScaleTotal Attitudes Toward Homosexuality Scale score107.00, 48–110 (100.00–109.00)(1) I would not mind having homosexual friends5, (1–5) 5.00-5.00(2) Finding out that an artist was gay would have no effect on my appreciation of his/her work5, (1–5) 5.00-5.00(3) I would not associate with known homosexuals if I can help it5, (1–5) 5.00-5.00(4) I would look for a new place to live if I found out my roommate was gay5, (1–5) 5.00-5.00(5) Homosexuality is a mental illness5, (1–5) 5.00-5.00(6) I would not be afraid for my child to have a homosexual teacher5, (1–5) 5.00-5.00(7) Gays dislike members of the opposite sex5, (1–5) 5.00-5.00(8) I do not really find the thought of homosexual acts disgusting5, (1–5) 3.00–5.00(9) Homosexuals are more likely to commit deviant sexual acts, such as child molestation, rape, and voyeurism (peeping toms), than are heterosexuals5 (1–5), 5.00-5.00(10) Homosexuals should be kept separate from the rest of society (i.e., separate housing, restricted employment)5 (1–5), 5.00-5.00(11) Two individuals of the same sex holding hands or displaying affection in public is revolting5 (1–5), 5.00-5.00(12) The love between two males or two females is quite different from the love between two persons of the opposite sex5 (1–5), 4.00-5.00(13) I see the gay movement as a positive thing5 (1–5), 5.00-5.00(14) Homosexuality, as far as I am concerned, is not sinful5 (1–5), 5.00-5.00(15) I would not mind being employed by a homosexual5 (1–5), 5.00–5.00(16) Homosexuals should be forced to have psychological treatment5 (1–5), 5.00-5.00(17) The increasing acceptance of homosexuality in our society is aiding in the deterioration of morals5 (1–5), 5.00-5.00(18) I would not decline membership in an organization just because it has homosexual members5 (1–5), 5.00-5.00(19) I would vote for a homosexual in an election for public office5 (1–5), 5.00-5.00(20) If I knew someone was gay, I would still go ahead and form a friendship with that individual5 (1–5), 5.00-5.00(21) If I were a parent, I could accept my son or daughter being gay5 (1–5), 4.00-5.00(22) Homosexuals are guilty of spreading AIDS5 (1–5), 4.00-5.00Note. Although we used the validated Hebrew version, we include the original English items here. Items 1, 2, 6, 8, 13–15, and 18–21 were reverse-scored. IQR, interquartile range; AIDS, acquired immunodeficiency syndrome.


## 2.3. Data Analysis

Descriptive statistics were calculated for PT students’ background characteristics, previous acquaintance with LGBTQIA+ individuals, education on LGBTQIA+, attitudes toward education on LGBTQIA+, and ATHS results. Since the distribution of the results of the ATHS response score was not uniform among the possible scores, we categorized it for further statistical analyses (group comparisons and logistic regression analysis). Accordingly, the median score (107) of the ATHS variable was defined as the cutoff point and was converted into a categorical score. Scores above or equal to the median response of the sample (≥107) were in one category, and scores below the median (<107) were in the second category.Between-group comparisons were performed for gender, sexual orientation, religiousness, place of residence, and clinical experience (referring to clinical practice) using chi-square tests for categorical variables and Wilcoxon two-sample tests for age variables. Multivariate logistic regression analyses were used to predict the positive attitudes toward homosexuality (total ATHS score  ≥ 107) by gender, age, sexual orientation, religiousness, clinical experience, and place of residence. An odds ratio above one indicated more positive attitudes. Significance was set atp≤0.05.


## 3. Results

### 3.1. Participants

The number of participants that fulfilled the survey was 245 (mean age 25.59 years ± 3.10 years, with 35.1% men and 64.9% women). Details concerning students’ background characteristics are shown in Table2.Table 2
Participants’ demographic characteristics.
CharacteristicsParticipants (N = 245)Age, years mean ± SD, range25.59 ± 3.10, 19–39Sex, male,N (%):86 (35.10)Gendera, men; women, N (%):86 (35.10); 159 (64.90)Sexual orientationb, N (%)Heterosexual/straight210 (85.71)Gay8 (3.27)Lesbian17 (6.94)Bisexual5 (2.04)Other5 (2.04)Cisgender, yes, no (%)254 (100), 0 (0)ReligionN (%)Judaism212 (86.53)Islam2 (0.82)Christianity3 (1.22)Druze3 (1.22)Atheist25 (10.20)ReligiousnessN (%)Secular181 (73.88)Traditional29 (11.84)Religious27 (11.02)Very religious8 (3.27)Family statusN (%)Single121 (49.39)Married28 (11.43)In a relationship95 (38.78)Divorced1 (0.41)Place of residenceN (%)Urban190 (77.55)Other forms of residence (village, kibbutz, etc.)55 (22.45)Previous acquaintance with an LGBTQIA+, yes,N (%)Patient13 (19.12)Family member72 (29.39)Close friend167 (68.16)aOptions were men, women, nonbinary, and others. bOptions were straight, gay, lesbian, bisexual, queer, and others.Most who had a clinical practice reported that they did not have a clinical encounter with a patient who identified as LGBTQIA+. All students reported that they had no course on the LGBTQIA+ community in their undergraduate PT studies’ curriculum. Further details are presented in Table3.Table 3
Participants’ academic characteristics and education concerning LGBTQIA + health issues.
CharacteristicsParticipants (N = 245)Year of study,N (%):First103 (42.04)Second44 (17.96)Third60 (24.49)Fourth38 (15.51)History of clinical practiceN (%):Yes68 (27.76)No177 (72.24)The number of clinical practicesN (%):128 (41.18)217 (25.00)315 (22.06)48 (11.76)During your undergraduate studies, did you take a course on the LGBTQIA + community? yes, no,N (%)0 (0), 245 (100)During your undergraduate studies, did you learn about the LGBTQIA + community? yes, no,N (%)15 (6.12), 230 (93.88)


### 3.2. Attitude

The results for the ATHS total score and each item are presented in Table1. The median ATHS score was 107 out of 110, indicating favorable attitudes toward LGB individuals. The distribution of the Attitudes Toward Homosexuality (ATHS) total score among the responders is shown in Figure 1.Figure 1
Distribution of the Attitudes Toward Homosexuality Scale (ATHS) total score.The results of the three questions on the PT students’ attitudes toward education about LGBTQIA+ during the PT program are presented in Table4. Fifty-six participants held the attitude that they should learn about the LGBTQIA+ community as part of their bachelor’s degree in PT. Most believed that there was insufficient consideration of the LGBTQIA+ community during the PT undergraduate program, and only 16.73% believed it is necessary to address patients’ sexual orientation during PT treatment.Table 4
Participants’ attitudes toward the education on LGBTQIA during the PT program (N = 245).
Item, yes, noN (%)(1) Do you think it is necessary to learn about the LGBTQIA+ community during PT undergraduate studies?138 (56.33), 107 (43.67)(2) Do you think that there is sufficient consideration for the topic of the LGBTQIA+ community during PT undergraduate studies?64 (26.12), 181 (73.88)(3) Would you like to learn about the LGBTQIA+ community in your undergraduate program?137 (57.32), 102 (42.68)(4) Do you believe it is necessary to address the patients’ sexual orientation during PT treatment?41 (16.73), 204 (83.27)


### 3.3. Comparative Analysis of Background Characteristics and Attitudes toward Homosexuality

A significant difference in the number/percentage of men scoring below the median on the ATHS, as compared to women, was demonstrated (54 (44.3%); 68 (55.7%), respectively). The percentage of students who identified themselves as secular (referring to a nonreligious worldview where religious practices are not advocated) demonstrated more positive attitudes than traditional and religious individuals (91.9% and 8.1%, respectively). Conversely, clinical experience, sexual orientation, and place of residence made no difference to the participants’ attitudes toward LGB individuals (Table5).Table 5
Comparative analysis of participants’ background characteristics and Attitudes Toward Homosexuality (ATHS total score).
VariablesATHS total score<107 (N = 122)≥107 (N = 123)p valueAge (years) mean ± SDa25.2 ± 3.226.0 ± 2.90.024GenderbMen54 (44.3)31 (26.0)0.003Women68 (55.7)91 (74.0)Sexual orientation,N (%)bHeterosexual107 (87.7)103 (83.7)0.375Not heterosexual15 (12.3)20 (16.3)Religiousness,N (%)bReligious/traditional54 (44.3)10 (8.1)<0.0001Secular68 (55.7)113 (91.9)Place of residencebNot urban78 (63.9)66 (53.7)0.102Urban44 (36.1)57 (56.3)Clinic experiencebNo92 (75.4)85 (69.1)0.271Yes30 (24.6)38 (30.9)aWilcoxon two-sample test; bchi-square test; SD, standard deviation.Logistic regression analysis results indicated that only gender and religiousness significantly predicted PT students’ attitudes toward LGB individuals, as reflected in the ATHS scores. Women and secularity were predictors of positive attitudes toward LGB (ATHS value ≥ 107). The probability of women achieving an ATHS value ≥ 107 was 2.65 times greater than the probability of men. For individuals identifying as secular, the chance of achieving an ATHS value ≥ 107 was 8.75 times greater than a religious or traditional person (Table6).Table 6
Multivariance logistic regression analysis results for the prediction of Attitudes Toward Homosexuality Scale scores ≥107 indicating a positive attitude (odds ratio and confidence interval).
ATHS total score ≥107Age1.05 (0.94–1.17)Gender (woman)2.65 (1.43–4.91)∗∗Sexual orientation (not heterosexual)1.23 (0.53–2.84)Religiousness (secular)8.75 (4.07–18.82)∗∗∗Clinical experience1.07 (0.55–2.10)Place of residence (not urban)1.34 (0.74–2.44)Wald (df) = 42.09 (6)∗∗∗; C statistic = 0.75; ∗∗p<0.01; ∗∗∗p<0.0001.


## 3.1. Participants

The number of participants that fulfilled the survey was 245 (mean age 25.59 years ± 3.10 years, with 35.1% men and 64.9% women). Details concerning students’ background characteristics are shown in Table2.Table 2
Participants’ demographic characteristics.
CharacteristicsParticipants (N = 245)Age, years mean ± SD, range25.59 ± 3.10, 19–39Sex, male,N (%):86 (35.10)Gendera, men; women, N (%):86 (35.10); 159 (64.90)Sexual orientationb, N (%)Heterosexual/straight210 (85.71)Gay8 (3.27)Lesbian17 (6.94)Bisexual5 (2.04)Other5 (2.04)Cisgender, yes, no (%)254 (100), 0 (0)ReligionN (%)Judaism212 (86.53)Islam2 (0.82)Christianity3 (1.22)Druze3 (1.22)Atheist25 (10.20)ReligiousnessN (%)Secular181 (73.88)Traditional29 (11.84)Religious27 (11.02)Very religious8 (3.27)Family statusN (%)Single121 (49.39)Married28 (11.43)In a relationship95 (38.78)Divorced1 (0.41)Place of residenceN (%)Urban190 (77.55)Other forms of residence (village, kibbutz, etc.)55 (22.45)Previous acquaintance with an LGBTQIA+, yes,N (%)Patient13 (19.12)Family member72 (29.39)Close friend167 (68.16)aOptions were men, women, nonbinary, and others. bOptions were straight, gay, lesbian, bisexual, queer, and others.Most who had a clinical practice reported that they did not have a clinical encounter with a patient who identified as LGBTQIA+. All students reported that they had no course on the LGBTQIA+ community in their undergraduate PT studies’ curriculum. Further details are presented in Table3.Table 3
Participants’ academic characteristics and education concerning LGBTQIA + health issues.
CharacteristicsParticipants (N = 245)Year of study,N (%):First103 (42.04)Second44 (17.96)Third60 (24.49)Fourth38 (15.51)History of clinical practiceN (%):Yes68 (27.76)No177 (72.24)The number of clinical practicesN (%):128 (41.18)217 (25.00)315 (22.06)48 (11.76)During your undergraduate studies, did you take a course on the LGBTQIA + community? yes, no,N (%)0 (0), 245 (100)During your undergraduate studies, did you learn about the LGBTQIA + community? yes, no,N (%)15 (6.12), 230 (93.88)


## 3.2. Attitude

The results for the ATHS total score and each item are presented in Table1. The median ATHS score was 107 out of 110, indicating favorable attitudes toward LGB individuals. The distribution of the Attitudes Toward Homosexuality (ATHS) total score among the responders is shown in Figure 1.Figure 1
Distribution of the Attitudes Toward Homosexuality Scale (ATHS) total score.The results of the three questions on the PT students’ attitudes toward education about LGBTQIA+ during the PT program are presented in Table4. Fifty-six participants held the attitude that they should learn about the LGBTQIA+ community as part of their bachelor’s degree in PT. Most believed that there was insufficient consideration of the LGBTQIA+ community during the PT undergraduate program, and only 16.73% believed it is necessary to address patients’ sexual orientation during PT treatment.Table 4
Participants’ attitudes toward the education on LGBTQIA during the PT program (N = 245).
Item, yes, noN (%)(1) Do you think it is necessary to learn about the LGBTQIA+ community during PT undergraduate studies?138 (56.33), 107 (43.67)(2) Do you think that there is sufficient consideration for the topic of the LGBTQIA+ community during PT undergraduate studies?64 (26.12), 181 (73.88)(3) Would you like to learn about the LGBTQIA+ community in your undergraduate program?137 (57.32), 102 (42.68)(4) Do you believe it is necessary to address the patients’ sexual orientation during PT treatment?41 (16.73), 204 (83.27)


## 3.3. Comparative Analysis of Background Characteristics and Attitudes toward Homosexuality

A significant difference in the number/percentage of men scoring below the median on the ATHS, as compared to women, was demonstrated (54 (44.3%); 68 (55.7%), respectively). The percentage of students who identified themselves as secular (referring to a nonreligious worldview where religious practices are not advocated) demonstrated more positive attitudes than traditional and religious individuals (91.9% and 8.1%, respectively). Conversely, clinical experience, sexual orientation, and place of residence made no difference to the participants’ attitudes toward LGB individuals (Table5).Table 5
Comparative analysis of participants’ background characteristics and Attitudes Toward Homosexuality (ATHS total score).
VariablesATHS total score<107 (N = 122)≥107 (N = 123)p valueAge (years) mean ± SDa25.2 ± 3.226.0 ± 2.90.024GenderbMen54 (44.3)31 (26.0)0.003Women68 (55.7)91 (74.0)Sexual orientation,N (%)bHeterosexual107 (87.7)103 (83.7)0.375Not heterosexual15 (12.3)20 (16.3)Religiousness,N (%)bReligious/traditional54 (44.3)10 (8.1)<0.0001Secular68 (55.7)113 (91.9)Place of residencebNot urban78 (63.9)66 (53.7)0.102Urban44 (36.1)57 (56.3)Clinic experiencebNo92 (75.4)85 (69.1)0.271Yes30 (24.6)38 (30.9)aWilcoxon two-sample test; bchi-square test; SD, standard deviation.Logistic regression analysis results indicated that only gender and religiousness significantly predicted PT students’ attitudes toward LGB individuals, as reflected in the ATHS scores. Women and secularity were predictors of positive attitudes toward LGB (ATHS value ≥ 107). The probability of women achieving an ATHS value ≥ 107 was 2.65 times greater than the probability of men. For individuals identifying as secular, the chance of achieving an ATHS value ≥ 107 was 8.75 times greater than a religious or traditional person (Table6).Table 6
Multivariance logistic regression analysis results for the prediction of Attitudes Toward Homosexuality Scale scores ≥107 indicating a positive attitude (odds ratio and confidence interval).
ATHS total score ≥107Age1.05 (0.94–1.17)Gender (woman)2.65 (1.43–4.91)∗∗Sexual orientation (not heterosexual)1.23 (0.53–2.84)Religiousness (secular)8.75 (4.07–18.82)∗∗∗Clinical experience1.07 (0.55–2.10)Place of residence (not urban)1.34 (0.74–2.44)Wald (df) = 42.09 (6)∗∗∗; C statistic = 0.75; ∗∗p<0.01; ∗∗∗p<0.0001.


## 4. Discussion

To our knowledge, this is the first study to explore the attitudes of PT students in Israel toward people identifying as LGB. The results indicated that students hold positive attitudes toward LGB individuals, as assessed by the ATHS. As previous studies [16, 17] did not use the ATHS, it is not possible to directly compare our results to them. However, these results are supported by previous studies that used different assessment tools. Morton et al. [17] examined physical therapists’ attitudes toward, comfort with, and ability to provide care for LGBTQ patients, indicating that PT students’ attitudes were positive toward LGBTQ. Brenner et al. [16] demonstrated positive attitudes toward providing care for LGBTQIA+ patients among 107 PT students in the UK using the Heteronormative Attitudes and Beliefs Scale.In the present study, religiousness significantly predicted students’ attitudes toward LGB individuals, as reflected in their ATHS scores. Individuals identifying as secular were 8.75 times more likely to hold positive attitudes toward LGB than did religious or traditional individuals. This is consistent with previous studies showing a significant association between religiousness and negative attitudes toward LGB individuals among healthcare professionals [35–38]. All the PT programs in Israel are offered by secular institutions and most students identified as secular, which probably influenced their positive attitudes.Gender was also a predictor of attitudes toward LGB individuals, with a higher probability for a negative view among men as compared to women. This is similar to a previous study of undergraduate social work students in which men exhibited more homophobic attitudes than women [35]. A previous study [36] which also used the ATHS to measure attitudes toward LGB individuals among registered PTs in Israel, similarly, demonstrated that religious identity and gender were predictors of negative attitudes. Accordingly, the current results suggest that personal factors should be considered when designing components of LGBTQIA+-related content in the PT program curriculum.All participants, in the current study, reported that they did not have a course regarding the LGBTQIA+ community in their PT curriculum. These findings were consistent with previous studies on physical therapists and other health professions [6, 7, 11, 12, 16–18] that demonstrated the substantial absence of LGBTQ healthcare issues in the professional curriculum. Glick et al. [12], for example, assessed education and training on LGBTQ health issues by examining the curricula of DPT in the USA in 2015–2017. The results showed that 50% of the programs reported the inclusion of LGBTQ-related topics in their curricula. However, only 31% of the DPT education programs responded to the survey. Ross and Setchell [15] noted that 83% of the Australian physical therapists reported providing care for LGBTQIA+ patients, although only 5% had previous specialized training as part of their PT education. Studies indicate that lack of formal knowledge and negative attitudes toward LGBTQIA+ populations affect the therapists’ preparedness to provide unbiased and nondiscriminatory treatment [39–41]. Our study reinforced previous claims that the PT curriculum should be updated to include evidence-based LGBTQIA+ content [11, 16, 17].Nowaskie et al. [18], focusing on healthcare professional students (N = 1,701), demonstrated that the level of preparedness to treat LGBT in the USA was predicted not only by the curricular content but also by the students’ experiences with LGBT patients. Furthermore, integrating students into clinical care for transgender patients improved their level of preparedness [16, 42]. The current results indicated that only a small portion of the students (19.1%) had a clinical encounter with a patient identifying as LGBTQIA+. We thus posit that it is also necessary to expose students to patients identifying as LGBTQIA+ during clinical rotations.This study had a few limitations. We examined only explicit attitudes; it may be possible that examining PT students’ implicit attitudes would provide different results. We examined attitudes using the ATHS, which is the sole validated tool translated into Hebrew. However, it focuses only on LGB individuals without including other sexual and gender minorities. In addition, some statements (e.g., “gays dislike members of the opposite sex”) may have lesser relevance nowadays due to a growing understanding of the LGBTQIA+ community and greater personal exposure to LGBTQIA+ people. Further studies should address this lack of assessment tools by translating and validating other existing tools into Hebrew. Owing to the online distribution of the survey, it was impossible to calculate the compliance percentages. Thus, it is possible that some students, especially those with sexual prejudices or biases toward sexual and gender minorities, chose not to complete the survey to avoid doing something that was considered taboo. In contrast, some participants may have held biased interests in promoting the issues.


## 5. Conclusion

This is the first study to explore the attitudes of PT students in Israel toward people identifying as LGB. Overall, students held positive attitudes toward LGB individuals, as reflected by their high ATHS scores. PT students who identified as men or religious are more likely to hold negative attitudes toward LGB individuals as compared to their secular and women counterparts. The limited curricular content and exposure to the LGBTQIA+ community most likely affect the cultural competence of PT students in Israel. Future strategies should be considered to address these issues.



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