Long interested in improving care for transgender people, Richard Greene, MD, worried that a big barrier would be a knowledge gap among providers.
He often heard from his trainees at New York University (NYU) School of Medicine that they had little confidence in their ability to provide care to transgender patients. He’d also met with transgender patients who reported discrimination and insensitivity when seeking medical help. To help close the knowledge gap, Greene, an associate professor in the Department of Medicine and director of Gender and Health Education at NYU, turned to a common medical school teaching tool: the standardized-patient scenario.
“A key is understanding that improving health care for sexual and gender minority patients is really about improving care for everyone.”
John Davis, MD, PhD
University of California, San Francisco, School of Medicine
In 2017, in one of the first published studies using a transgender person as a standardized patient, Greene and his colleagues tested 23 residents on their communication skills and patient satisfaction. Their results underscored a need for stronger transgender health education in the classroom and clinic and showed that transgender standardized patients are effective in teaching new doctors.
“The residents felt it was a really amazing way to feel more comfortable caring for transgender patients, whereas before they were sort of flying blind,” Greene says. “This allowed residents to learn in a low-stakes environment.”
NYU isn’t alone among medical schools and teaching hospitals in working to improve health care for the estimated 1.4 million U.S. adults who identify as transgender. According to the most recent AAMC Curriculum Inventory data collected from 131 U.S. medical schools, more than 65% offer some level of transgender-related education, and more than 80% of those who provide such content do so in required courses. That education runs the gamut from how to approach gender identity with sensitivity to how to manage hormone therapy for transitioning patients. Last year, for example, New York City’s Mount Sinai Health System launched two first-of-their-kind fellowships—one in transgender surgery and another in transgender psychiatry.
The AAMC released the first medical school curriculum guidelines on caring for people who are LGBT, gender-nonconforming, or born with differences in sex development, which was authored in collaboration with medical school faculty from across the country in 2014. Since then, interest has only grown, says Tiffani St. Cloud, AAMC director of educational initiatives.
“There’s definitely been a steady increase in teaching sexual and gender minority health,” says St. Cloud. Much of that education, she notes, focuses on how to remove the barriers that prevent many transgender people from seeking care in the first place.
Understanding transgender patients’ needs
Transgender populations experience significant health disparities and inequities. For example, a 2017 study in JAMA Internal Medicine found that transgender adults are more likely to report depression, be uninsured, and forego needed care due to cost. And according to the 2015 U.S. Transgender Survey—which polled almost 28,000 transgender adults—nearly one-third of respondents who saw a health provider in the previous year reported a negative experience related to being transgender, such as verbal harassment or refusal of care.
Educating future physicians on how to dismantle such barriers is the first step in improving transgender care, says John Davis, MD, PhD, associate dean for curriculum at the University of California, San Francisco (UCSF), School of Medicine.
“A key is understanding that improving health care for sexual and gender minority patients is really about improving care for everyone,” he says. “We don’t present it as a stand-alone topic. It’s about understanding the spectrum of patients you’ll care for and understanding that all patients have unique aspects of care.”
At UCSF School of Medicine, pedagogical approaches include integrating transgender-specific information into existing classes and offering rotations at clinics that serve transgender communities. In addition, all first-year students participate in the Clinical Microsystem Clerkship, a longitudinal learning experience focused on how health delivery systems “serve—or perhaps fail to serve—certain populations,” Davis explains.
“The corollary is that it’s providing medical students with the skills they need to be advocates for their patients,” he says.
A “sea change” in demand for education
Interest in learning to provide appropriate transgender health care is growing significantly, note leaders in the field.
“There’s an explosion of interest and demand for technical assistance in providing [transgender care],” says Alex Keuroghlian, MD, MPH, director of the National LGBT Health Education Center at The Fenway Institute and an assistant professor of psychiatry at Harvard Medical School.
Keuroghlian points to the center’s Transgender Health ECHO project, which trains interprofessional health care teams to better support transgender and gender-nonconforming patients. During the last round of applications for the project, he notes, more than 200 federally qualified health centers applied for just 25 spots.
“There’s been a complete sea change,” Keuroghlian says. “The demand for this education is moving at warp speed among young students and providers.”
To meet that demand, many medical schools are including transgender health education in both the classroom and clinic. In fact, research published in January 2018 suggests that didactic education alone is less likely to improve transgender care than is a combination of didactic and clinical exposure.
“We have far to go to regain the trust of transgender people,” says Katherine Imborek, MD, clinical associate professor of family medicine at the University of Iowa Roy J. and Lucille A. Carver College of Medicine and codirector of the University of Iowa (UI) LGBTQ Clinic. “Fortunately, today’s generation [of medical students] is more in tune with the difference they can make in the lives of transgender patients.”
Culturally competent care
The UI LGBTQ Clinic, which is open every Tuesday evening, cares for more than 500 transgender patients, with the clinic often booked solid for months at a time. The clinic offers basic services, such as preventive screenings and chronic disease care, as well as more transgender-specific care, such as hormone therapy management. Imborek reports that about 80% of the clinic’s patients are transgender, and many travel hours just to get primary care at the clinic.
“Today’s generation [of medical students] is more in tune with the difference they can make in the lives of transgender patients.”
Katherine Imborek, MD
University of Iowa Roy J. and Lucille A. Carver College of Medicine
Before opening the clinic in 2012, Imborek and her codirector and fellow UI Carver College of Medicine professor Nicole Nisly, MD, spent months building institutional buy-in, meeting with members of the transgender community, and creating an affirming, inclusive environment.
In the clinic, for example, staff are trained to respectfully ask about which pronouns patients prefer and to use those pronouns in records accessible via the online patient portal. That switch—which might seem like a small matter—can be “life changing” for many transgender patients, Imborek says.
In addition to didactic coursework and clinical rotations, UI Carver College of Medicine students can spend Tuesday nights at the clinic during their internal medicine clerkships, notes Imborek, and she nearly always has a family medicine or pediatric resident working with her there. She adds that beyond formal education, improving the health of transgender patients also requires personal reflection on unconsciously perpetuating barriers to care.
“That’s where we have to start,” Imborek says. “It goes to the heart of why we go into medicine in the first place.”
Michelle Forcier, MD, MPH, an associate professor of pediatrics at The Warren Alpert Medical School of Brown University, notes the pressing need for better transgender health care.
“Doing nothing when it comes to transgender care is not a neutral position—it has harmful consequences,” says Forcier, who’s been serving transgender patients for nearly two decades.
At Alpert Medical School, Forcier reports, transgender health education reaches students and residents through a variety of avenues. For example, medical students can participate in a four-year scholarly concentration in LGTBQ health, and Forcier and colleagues are now working to integrate gender and sexual minority health care longitudinally across the four-year curriculum.
“This is primary care,” Forcier says of the skills needed to adequately serve and care for transgender people. “Diversity isn’t pathology, it isn’t deviation," she says. “It’s part of the human condition.”