Improving LGBT Medical Training: Tips for Getting Started

In order to improve health care for lesbian, gay, bisexual, and transgender (LGBT) patients, we must include LGBT-related content in medical training. In 2014, the Association of American Medical Colleges’ Advisory Committee on Sexual Orientation, Gender Identity and Sex Development published a list of core competencies that medical schools could use to direct their coverage of sexual and gender minority topics in undergraduate medical education.¹Association of American Medical Colleges. 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. Washington (DC): Association of American Medical Colleges; 2014. However, in a national survey of medical students in 2015, only 31.1 percent reported that an identified sex and gender-based curriculum was included in their medical education.²Jenkins M, Herrmann A, Tashjian A, Ramineni T, Ramakrishnan R, Raef D, Rokas T, Shatzer J. Sex and gender in medical education: a national student survey. Biology of Sex Differences. 2016;7(S1). This article contains tips for medical educators and residency program directors on how to begin incorporating LGBT-inclusive content into medical curricula.

Define key terms related to LGBT identities and health

It is essential for clinicians to be informed about LGBT health because of the unique health disparities affecting LGBT populations; the prevalence of violence and victimization related to homophobia, biphobia, and transphobia; and the long history of anti-LGBT bias in health care.³Ard K. Understanding the Health Needs of LGBT People [Internet]. National LGBT Health Education Center; 2016. Available from: https://www.lgbthealtheducation.org/wp-content/uploads/LGBTHealthDisparitiesMar2016.pdf^,4Collazo A, Austin A, Craig S. Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice. Clinical Social Work Journal. 2013;41(3):228-237.^,5Lev A. Transgender Emergence: Understanding Diverse Gender Identities and Expressions [Internet]. NASW Focus; 2006 p. 11-18,21,24. Available from: http://www.choicesconsulting.com/assets/pro_writing/transgender[1].pdf^,6American Academy of Family Physicians. Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice [Internet]. American Academy of Family Physicians; 2020. Available from: https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint289D_LGBT.pdf It is therefore critical to understand sexual orientation, sexual behavior, gender identity, and gender expression.⁷Streed C. Terminology Related to Sexual Orientation, Gender Identity, and More [Internet]. Harvard Medical School Center for Primary Care, Office for Diversity Inclusion & Community Partnership; 2017. Available from: https://mfdp.med.harvard.edu/sites/default/files/files/HMS%20SOGI%20terminology%203.22.17.pdf^,8Center of Excellence for Transgender Health [Internet]. Prevention.ucsf.edu. 2018 [cited 2020 Jul 8]. Available from: https://prevention.ucsf.edu/transhealth

Download our Guide to LGBT Terminology to brush up on LGBT vocabulary.

Further, recognize that patients are the first experts on their bodies, and that clinicians should mirror the language that patients use to describe themselves and their behaviors.⁹Collazo A, Austin A, Craig S. Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice. Clinical Social Work Journal. 2013;41(3):228-237. Clinicians should ask patients to describe what they mean if the patient uses language with which they are not familiar.¹⁰Lev A. Transgender Emergence: Understanding Diverse Gender Identities and Expressions [Internet]. NASW Focus; 2006 p. 11-18,21,24. Available from: http://www.choicesconsulting.com/assets/pro_writing/transgender[1].pdf

Convey the prevalence of LGBT individuals and normalize LGBT identities

Researchers estimate that approximately 3.5 percent of United States adults identify as LGB and at least 0.3 percent of adults identify as transgender.¹¹Ard K. Understanding the Health Needs of LGBT People [Internet]. National LGBT Health Education Center; 2016. Available from: https://www.lgbthealtheducation.org/wp-content/uploads/LGBTHealthDisparitiesMar2016.pdf Even greater numbers of people engage in same-sex behavior or report attraction to members of the same sex.

Further, LGBT individuals have multiple intersecting identities and should not have their experiences reduced to solely being labeled LGBT. LGBT health should be taught longitudinally and not be relegated solely to modules on psychiatry, sexuality, or HIV.¹²Collazo A, Austin A, Craig S. Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice. Clinical Social Work Journal. 2013;41(3):228-237.^,13Hollenbach A, Eckstrand K, 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 [Internet]. Association of American Medical Colleges; 2014. Available from: https://www.aamc.org/system/files/c/2/157460-implementing_curricular_climate_change_lgbt.pdf^,14American Academy of Family Physicians. Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice [Internet]. American Academy of Family Physicians; 2020. Available from: https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint289D_LGBT.pdf One way to incorporate LGBT health throughout courses is to modify the language of question stems to include LGBT patients and families. This can be done with a ‘one-example’ or ‘one-case’ approach, which involves including one LGBT patient per lecture.

When incorporating LGBT patients into the curriculum, LGBT identity need not be critical to the disease entity or to the teaching point of the case. This will help to normalize LGBT individuals as typical patients. These are some examples of patients with intersecting identities:

• Lesbian woman with breast cancer
• Gender non-conforming patient seeking family planning counseling
• End of life scenario with black woman and her female partner
• Transgender man with pneumonia

Consistently use modifiers for all populations, not just minority populations

Patient modifiers in case presentations help students to identify risk factors based on health disparities. However, often these modifiers are only used to identify minority populations. For example, race modifiers are often only used to identify non-white patients.¹⁵Finucane T, Carrese J. Racial bias in presentation of cases. Journal of General Internal Medicine. 1990;5(2):120-121. A question stem might begin, “the patient is a 40-year-old man” or “the patient is a 40-year-old black man.” Selectively using these modifiers implies that the norm is to be white, and that other races are abnormal, unusual, or should evoke a stereotyped image or health concern. Similarly, sexual orientation and gender identity are often only mentioned in the context of LGBT patients. For example, a question stem may read, “the patient is a 20-year-old woman,” or, “the patient is a 20-year-old transgender woman.” Educators should update case presentations and question stems to consistently use modifiers, including for frequently assumed identities (e.g. “this is a 40-year-old white cisgender heterosexual man”).

Teach trainees to avoid making assumptions.

Do not make assumptions based solely on sexual orientation, gender identity, or gender expression

Gender identity and sexual orientation are distinct from how one expresses oneself and presents to the world.¹⁶Lev A. Transgender Emergence: Understanding Diverse Gender Identities and Expressions [Internet]. NASW Focus; 2006 p. 11-18,21,24. Available from: http://www.choicesconsulting.com/assets/pro_writing/transgender[1].pdf Regardless of sexual orientation or gender identity, being perceived as having an LGBT identity often puts individuals at risk of harm.¹⁷O’Malley Olsen E, Kann L, Vivolo-Kantor A, Kinchen S, McManus T. School Violence and Bullying Among Sexual Minority High School Students, 2009–2011. Journal of Adolescent Health. 2014;55(3):432-438.^,18Richmond K, Burnes T, Carroll K. Lost in trans-lation: Interpreting systems of trauma for transgender clients. Traumatology. 2012;18(1):45-57. As a result, LGBT individuals may not be ‘out’ in certain spaces, or may present in a way that does not align with their identities in order to preserve their safety.

Teach trainees to avoid making assumptions, to ask their patients how they identify, and to ask inclusive questions, such as:

• “Tell me about your sexual partners.”
• “How would your sexual partners identify their gender?”
• “Tell me about your sexual activity. What body parts are involved and how?”

These questions address the behaviors that influence risk and are more inclusive of all patients, including LGBT individuals.

Trust LGBT patients and clinicians

Case questions featuring LGBT patients or providers should be intentionally worded to prevent discussions where students question the lived experience of the LGBT individual. Poorly constructed cases present the opportunity for questioning the decisions the LGBT individual has made about their gender identity or presentation, sexual orientation, or disclosure (“coming out”).

The most important thing a clinician can do is to honestly evaluate their own feelings and implicit biases about LGBT communities.

Instead, discussions should emphasize the right of LGBT people to make decisions about their identities and should examine the impact of systemic barriers and victimization on access to care. For example, instead of asking whether an LGBT provider is obligated to disclose their identity to patients, discuss the power dynamic of the physician and patient and the benefit of safety planning before disclosure.

Acknowledge the lack of clinical research and epidemiologic data where it does not exist

Wide gaps in research on the health of LGBT populations exist.¹⁹Evans L, Lawler K, Sass S. Gathering Sexual Orientation Data on Statewide Behavioral Risk Factor Surveillance Surveys: A Call to Action for States [Internet]. Boston: The Fenway Institute; 2014. Available from: https://fenwayhealth.org/documents/the-fenway-institute/policy-briefs/COM484_BRFSS_Brief.pdf^,20Lesbian, Gay, Bisexual, and Transgender Health [Internet]. Healthypeople.gov. 2020 [cited 2020 Jul 8]. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health Many population-wide surveys do not include questions about LGBT identity or behavior, and formal epidemiologic studies on the incidence and prevalence of transgender and nonconforming identities have not been conducted.²¹The World Professional Association for Transgender Health. Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People [Internet]. The World Professional Association for Transgender Health; 2012. Available from: https://wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care_V7%20Full%20Book_English.pdf Further, research often focuses on LGBT individuals presenting at the hospital or at specialist gender clinics, neglecting marginalized LGBT individuals who face significant barriers in access to care.²²Mizock L, Fleming M. Transgender and gender variant populations with mental illness: Implications for clinical care. Professional Psychology: Research and Practice. 2011;42(2):208-213. Finally, sexual identity and sexual attraction can be disparate and do not always dictate sexual behavior. Rather than not mentioning health data on LGBT populations, clinician-educators should take the opportunity to acknowledge the lack of data and the barriers to researching LGBT populations.

Assess personal biases and assumptions

The most important thing a clinician can do is to honestly evaluate their own feelings and implicit biases about LGBT communities. Implicit anti-minority biases in physicians have been shown to lead to less positive perceptions of interactions with minority patients, lower referral rates for specialty care, undertreatment of pain, and lower rates of patient satisfaction.²³Chapman E, Kaatz A, Carnes M. Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities. Journal of General Internal Medicine. 2013;28(11):1504-1510. Clinicians and educators, regardless of their sexual orientation or gender identity, should be aware of their explicit beliefs and implicit biases about LGBT individuals.²⁴Fallin-Bennett K. Implicit Bias Against Sexual Minorities in Medicine. Academic Medicine. 2015;90(5):549-552.^,25Project Implicit [Internet]. Implicit.harvard.edu. 2020 [cited 2018 Jun 20]. Available from: https://implicit.harvard.edu/implicit/ The Safer Spaces Project from the Sexual Assault Centre of Brant has also developed a Personal Assessment of Anti-LGBTQ Bias, which provides statements and questions for self-reflection.²⁶Moses A, Hawkins, Jr. R. Personal Assessment of Anti-LGBTQ Bias [Internet]. Safe Spaces; 2020. Available from: http://thebridgebrant.com/wp-content/uploads/2014/03/3Personal-Assessment-of-Anti.pdf Understanding personal biases can help clinicians to adjust their behavior and language so that they can provide optimal health education.²⁷The World Professional Association for Transgender Health. Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People [Internet]. The World Professional Association for Transgender Health; 2012. Available from: https://wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care_V7%20Full%20Book_English.pdf

Acknowledgements: This article was reviewed and edited by Gregg Miller; Lila Flavin, M.D.; Zachary Barbati, M.M.Sc.; Robert Ryan Bradshaw; Daniel Heller; Shreya Bhatia; E. Caroline Bodager; Alexandra Rhodes, M.S.W.; Joshua St. Louis, M.D., M.P.H.; Carl G. Streed Jr., M.D., M.P.H.; and Ruben Hopwood, M.Div., Ph.D.