LGBTQ+ healthcare preparedness among undergraduate medical students in India: a cross-sectional study of awareness, attitudes, and clinical confidence

Abstract

Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) individuals in India experience significant healthcare disparities, including higher burdens of mental health conditions, HIV, and stigma, and frequently encounter discrimination in healthcare settings. Yet the Indian National Medical Commission’s Competency-Based Medical Education (CBME) curriculum contains no explicit LGBTQ+ health competencies. Prior studies have typically measured awareness, attitudes, and confidence independently, but whether attitudes link awareness to clinical confidence remains unexplored, particularly in CBME-trained cohorts in low- and middle-income countries. This study aimed to assess awareness, attitudes, and self-reported confidence in LGBTQ+ healthcare among undergraduate medical students, examine relationships between these domains across academic years, and test whether attitudes mediate the awareness–confidence pathway. An analytical cross-sectional study was conducted among 229 undergraduate MBBS (Bachelor of Medicine, Bachelor of Surgery; the primary undergraduate medical degree in India) students with at least six months of clinical exposure at a private medical college in South Karnataka, India (November 2024–January 2025). Data were collected using a structured questionnaire assessing awareness (31 items), attitudes (10 items), and confidence (6 items), adapted from a previously published instrument (Cronbach’s α: awareness = 0.95, attitude = 0.80, confidence = 0.81). Domain scores were summarised as median and interquartile range (IQR). Differences across academic years were examined using the Kruskal–Wallis test followed by Dunn’s post hoc test with Holm adjustment. Associations between domains were assessed using Spearman’s rank correlation. Multivariable linear regression was performed to identify independent predictors of confidence. Exploratory mediation analysis examined whether attitudes mediated the relationship between awareness and confidence. Students demonstrated moderate awareness (3.59 [3.03–4.06]) and generally favourable attitudes (3.40 [3.00–3.80]), but comparatively lower confidence (3.17 [2.83–3.67]). Awareness increased significantly with advancing academic year (χ²(2) = 38.32, p  < 0.001), whereas attitudes ( p  = 0.522) and confidence ( p  = 0.919) did not. In multivariable analysis, awareness (B = 0.446, 95% CI: 0.320–0.572), attitudes (B = 0.414, 95% CI: 0.289–0.539), and prior training (B = 0.245, 95% CI: 0.169–0.320) were independently associated with higher confidence (all p  < 0.001). Notably, after adjustment, third-year (B = − 0.256, p  = 0.005) and final-year students (B = − 0.275, p  = 0.009) demonstrated significantly lower confidence than second-year students. Exploratory mediation analysis demonstrated that attitudes partially mediated the awareness–confidence relationship (indirect effect = 0.145, 95% CI: 0.079–0.222; proportion mediated: 27.1%, p  < 0.001). To our knowledge, this is among the first studies to examine LGBTQ+ healthcare preparedness in a CBME-trained medical student cohort in India. Although awareness improved with academic progression, this did not translate into greater clinical confidence. The lower confidence among senior students after adjustment for awareness may reflect a curricular gap within CBME, whereby increasing clinical exposure occurs without the structured mechanisms needed to build applied competence. Attitudes accounted for only about a quarter of the awareness–confidence association, indicating that attitudinal change alone is unlikely to be sufficient without direct skills-based training. These findings support the integration of structured, assessed LGBTQ+ health content, including within the AETCOM framework, into the CBME curriculum.