Medically Speaking – Call to action: Improving transgender health education

Medically Speaking — A call to action: Improving transgender health education in US medical schools

The American College of Physicians and other medical institutions have widely voiced support of incorporating transgender health topics into medical school curriculums. However, studies have found that the implementation of such training has remained deficient.1 By one estimate, only 16% of medical schools accredited by the Liaison Committee on Medical Education (LCME) have established a comprehensive LGBTQ training program. Fifty-two percent of institutions have no such training established.2 It is not surprising that topics specific to transgender health, such as gender-affirming hormones, surgeries, and routine health screenings, are the least understood of all LGBTQ health topics among medical students. 3 This educational shortcoming among future physicians may further perpetuate poor health outcomes in this vulnerable population, including heightened rates of mental illness, suicide, and HIV infection. In the setting of a current political climate that actively seeks to bar transgender individuals from receiving necessary healthcare, these concerning data should be a call to action among medical school Deans that curriculum reform is needed.

Medical school curricula are an attractive target for interventions that can help address health disparities in the transgender population. Medical school Deans are uniquely empowered to shape the way the next generation of physicians heal and lead their communities. Although national surveys have found most medical educators are in favor of improved LGBTQ health training, several implementation barriers have been identified. Such limitations include little time availability in medical school curricula, shortage of clinical professors well-versed in providing care for gender-expansive patients, and insufficient support from institution administrators. Recently, however, medical educators have been tasked with adapting lesson plans in response to current events and social movements, including trainings in pandemic medicine and anti-racism. These success stories prove that curriculum reform is possible if there is enough momentum behind a cause. Over the past year, we have seen a staggering increase in violence against the transgender community and a rise in state-level legislation stripping trans individuals of their rights to healthcare. There is no better time than now to counter this tumultuous climate with activism and health education. 

Although not every medical student will be managing hormones or performing gender-affirming surgeries, all future physicians have the urgent responsibility to provide compassionate, quality care for patients of all identities. The 2015 US Transgender Survey found that of the 27,715 respondents, 33% reported having at least one negative experience related to their gender in the past year. This included refusal of treatment, verbal harassment, and having to teach their doctor about transgender people to receive appropriate care. Further, 1 in 4 respondents did not seek necessary medical care due to fear of mistreatment by providers.4 These staggering statistics are inexcusable and illustrate the need for intervention. Providing compassionate healthcare necessitates that physicians have an appreciation for cultural humility, refined communication skills, and a comprehensive understanding of the challenges that transgender individuals may face. These are attributes that can be effectively taught and learned. In current medical curricula, LGBTQ health topics, if broached at all, are often presented within the context of social determinants of health: how you understand your gender and who you love can influence health outcomes same as your skin color, home address, or tax bracket. While medical schools are increasingly emphasizing how an individual’s identity and social conditions impact their predisposition to disease, this topic often feels like an afterthought following anatomy, pathology, and pharmacology lectures. What many medical schools are missing is practical, skills-based training on critical topics in LGBTQ health.

Surveys of medical students across the United States help highlight knowledge gaps and suggest opportunities for curriculum improvement. Of medical students surveyed at the University of Michigan in a recent pilot study, nearly three quarters of respondents strongly agreed that they would benefit from additional training on using gender-inclusive language in the clinical space. A 2018 study of students at nine medical schools in New England found that 77% of 661 respondents reported feeling “not competent” or “somewhat not competent” in describing treatment options for transgender patients, including pre-pubertal hormone blockers, hormone therapy, and gender-affirming surgeries.5Additional education topics may include strategies for fostering inclusive care environments and special considerations for contraception options and sexually transmitted infection screening in gender-expansive populations. 

Opportunities to implement this training exist within the current framework of most medical schools. For pre-clinical students, standardized patient encounters provide a low-risk setting in which students can practice using inclusive language and navigating care encounters with transgender individuals. These skills can translate seamlessly to real patient interactions during transgender medicine rotations as a required component of internal medicine, family medicine, or obstetrics and gynecology clinical clerkships. Ideally, students will gain both confidence and competence in providing care for gender minority patients as well as appreciate the need for multidisciplinary care teams to provide holistic healthcare. Importantly, such trainings should be incorporated into the formal medical school curricula as to ensure completion by all students. Required trainings also send the message that these topics are important for all physician trainees to learn, regardless of future career plans. Many transgender health courses are offered to medical students on an elective or voluntary basis, which may self-select for students who are already somewhat knowledgeable about such topics or allies independently committed to improving the health of LGBTQ communities.

The onus is on physicians, students, and educators to reimagine our medical training to better meet the needs of our gender-expansive patients. By adapting our medical curricula accordingly, we can graduate a new generation of physicians who are prepared to provide the highest quality care for all patients, and to do so with the respect, empathy, and compassion that each of us deserve.

About the Author

Sloane Brazina (she/her/hers) is a 4th year medical student at the University of Michigan Medical School applying into Obstetrics and Gynecology. She has a special interest in improving health outcomes for transgender and gender non-conforming individuals through health education and direct patient care. 

References

1. Dubin, S. N., Nolan, I. T., Streed, C. G., Jr, Greene, R. E., Radix, A. E., & Morrison, S. D. (2018). Transgender health care: improving medical students’ and residents’ training and awareness. Advances in medical education and practice, 9, 377–391. https://doi.org/10.2147/AMEP.S147183.
2. Khalili J, Leung LB, Diamant AL. Finding the perfect doctor: identifying lesbian, gay, bisexual, and transgender-competent physicians. Am J Public Health. 2015;105(6):1114–1119.
3. White W, Brenman S, Paradis E, et al. Lesbian, gay, bisexual, and transgender patient care: medical students’ preparedness and comfort. Teach Learn Med. 2015;27(3):254–263. 
4. 2015 US Transgender Survey, National Center for Transgender Equality, https://www.ustranssurvey.org/ Chapter 7: Health, pages 92-129.
5. Zelin, N. S., Hastings, C., Beaulieu-Jones, B. R., Scott, C., Rodriguez-Villa, A., Duarte, C., Calahan, C., & Adami, A. J. (2018). Sexual and gender minority health in medical curricula in new England: a pilot study of medical student comfort, competence and perception of curricula. Medical education online, 23(1), 1461513.