Implicit bias against sexual minorities in medicine: cycles of professional influence and the role of the hidden curriculum

Transgender Health Care Curriculum Development: A Dual-Site Medical School Campus Pilot

Purpose: Lack of physician training contributes to health care disparities for transgender people. The limited generalizability and feasibility of published training approaches lessen their utility in lowering barriers for other institutions to adopt similar training. Methods: All first-year medical students at the Mayo Clinic Alix School of Medicine (MCASOM) in Minnesota and Arizona received a 1-h lecture introducing key concepts related to transgender people and their health disparities. Students completed a 21-question survey before and after the lecture, and 1 year later. Chi-square likelihood coefficients were used to compare responses between the three time points. Results: Eighty-six of 100 students answered the prelecture survey (86% response rate); 70 the postlecture survey; and 44 the 1-year follow-up survey. Twenty-five (29%) students had prior education in any lesbian, gay, bisexual, and transgender (LGBT+) health disparities, but this did not correlate with more favorable attitudes or knowledge. LGBT+ students and those with close LGBT+ friends had the most favorable attitudes and knowledge. The proportion of students comfortable with caring for transgender people changed significantly (76% self-reported very comfortable prelecture vs. 91% postlecture, p=0.0073) and remained at 89% 1 year later. The proportion of students comfortable with a transgender patient scenario significantly increased (67% self-reported very comfortable prelecture vs. 87% postlecture, p=0.032) even when surveyed 1 year later (95% very comfortable, p<0.0001). Conclusion: This study demonstrates that a 1-h lecture can increase the proportion of medical students who demonstrate positive attitudes and correct knowledge on transgender patient care for at least a year, and how a survey can gather essential information on student learning needs to guide training development.

Student Journal Club to Improve Cultural Humility with LGBTQ Patients

Health degree programs provide opportunities to reduce disparities in care for LGBTQ patients by exposing students to LGBTQ communities and current health issues. However, LGBTQ content is mostly absent from medical school curricula. This mixed method assessment study, conducted during the 2018 to 2019 academic year, examined the feasibility of implementing a medical student journal club focused specifically on LGBTQ health issues as a complementary training tool to support efforts to create an inclusive educational environment. Compared to the pre-test, mean response scores increased for most of the parameters including familiarity with LGBTQ healthcare issues, confidence in the ability to identify harmful medical provider practices, and reading and assessing scientific literature. Qualitative data showed increased confidence, comfort and knowledge about LGBTQ health barriers. This study offers a framework for using a journal club to provide an effective platform for enhancing students' LGBTQ cultural humility and research literacy.

Organizational strategies to reduce physician burnout and improve professional fulfillment

Burnout is highly prevalent among physicians and has been associated with negative outcomes for physicians, patients, staff, and health-care organizations. Reducing physician burnout and increasing physician well-being is a priority. Systematic reviews suggest that organization-based interventions are more effective in reducing physician burnout than interventions targeted at individual physicians. This consensus review by leaders in the field across multiple institutions presents emerging trends and exemplary evidence-based strategies to improve professional fulfillment and reduce physician burnout using Stanford's tripartite model of physician professional fulfillment as an organizing framework: practice efficiency, culture, and personal resilience to support physician well-being. These strategies include leadership traits, latitude of control and autonomy, collegiality, diversity, teamwork, top-of-license workflows, electronic health record (EHR) usability, peer support, confidential mental health services, work-life integration and reducing barriers to practicing a healthy lifestyle. The review concludes with evidence-based recommendations on establishing an effective physician wellness program.

Gêneros e sexualidades na educação médica: entre o currículo oculto e a integralidade do cuidado

Resumo As diretrizes curriculares nacionais dos cursos de graduação em Medicina reiteram a importância das questões de gênero e sexualidade para o desenvolvimento de competências relacionadas ao cuidado integral em saúde e promoção dos direitos humanos. Diante disso, foi implementado este debate no currículo de uma escola de Medicina no Brasil e discutida a influência na educação e prática em saúde da matriz heteronormativa e seu consequente preconceito social e institucional. Os dados e reflexões desta experiência foram analisados e apresentados a partir do referencial da autoetnografia performática, em diálogo com os estudos queer e culturais. Identificou-se que o cuidado integral em saúde se torna um grande desafio entre efeitos essencializadores e naturalizadores do currículo oculto sobre os corpos que deslizam as normas e expectativas de gênero e sexualidade. Concluiu-se que realizar ações de sensibilização e afetação aos(as) outros(as) com a efetivação de uma rede de apoiadores(as) foi fundamental para promover o sentimento de solidariedade, amorosidade e diálogo no enfrentamento de uma luta sem garantias, promovendo assim, o cuidado integral em saúde e os direitos humanos.

Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review

BACKGROUND

Lesbian, gay, bisexual, transgender and questioning (LGBTQ) individuals experience higher rates of health disparities. These disparities may be driven, in part, by biases of medical providers encountered in health care settings. Little is known about how medical, nursing, or dental students are trained to identify and reduce the effects of their own biases toward LGBTQ individuals. Therefore, a systematic review was conducted to determine the effectiveness of programs to reduce health care student or provider bias towards these LGBTQ patients.

METHODS

The authors performed searches of online databases (MEDLINE/PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar) for original articles, published in English, between March 2005 and February 2017, describing intervention studies focused on reducing health care student or provider bias towards LGBTQ individuals. Data extracted included sample characteristics (i.e., medical, nursing, or dental students or providers), study design (i.e., pre-post intervention tests, qualitative), program format, program target (i.e., knowledge, comfort level, attitudes, implicit bias), and relevant outcomes. Study quality was assessed using a five-point scale.

RESULTS

The search identified 639 abstracts addressing bias among medical, nursing, and dental students or providers; from these abstracts, 60 articles were identified as medical education programs to reduce bias; of these articles, 13 described programs to reduce bias towards LGBTQ patients. Bias-focused educational interventions were effective at increasing knowledge of LGBTQ health care issues. Experiential learning interventions were effective at increasing comfort levels working with LGBTQ patients. Intergroup contact was effective at promoting more tolerant attitudes toward LGBTQ patients. Despite promising support for bias education in increasing knowledge and comfort levels among medical, nursing, and dental students or providers towards LGBTQ persons, this systematic review did not identify any interventions that assessed changes in implicit bias among students or providers.

CONCLUSIONS

Strategies for assessing and mitigating implicit bias towards LGBTQ patients are discussed and recommendations for medical, nursing, and dental school curricula are presented.

The Impact of Unconscious Bias in Healthcare: How to Recognize and Mitigate It

The increasing diversity in the US population is reflected in the patients who healthcare professionals treat. Unfortunately, this diversity is not always represented by the demographic characteristics of healthcare professionals themselves. Patients from underrepresented groups in the United States can experience the effects of unintentional cognitive (unconscious) biases that derive from cultural stereotypes in ways that perpetuate health inequities. Unconscious bias can also affect healthcare professionals in many ways, including patient-clinician interactions, hiring and promotion, and their own interprofessional interactions. The strategies described in this article can help us recognize and mitigate unconscious bias and can help create an equitable environment in healthcare, including the field of infectious diseases.

Saúde da população LGBT+ no contexto da atenção primária em saúde: relato de oficina realizada no internato integrado de Medicina de Família e Comunidade/Saúde Mental em uma universidade pública

 Introdução: A saúde da população LGBT+ apresenta particularidades e vulnerabilidades que requerem atenção diferenciada. Sensibilizar e qualificar profissionais de saúde para as necessidades dessa população é fundamental para garanti-la o direito à saúde. Os currículos das graduações em saúde, que em geral não incorporam tais questões, têm sido interrogados pelo alunado com denúncias de LGBTfobia no curso médico e reivindicação de capacitação prática. Nesse contexto, o Internato Integrado de Medicina de Família e Comunidade e Saúde Mental da Faculdade de Medicina da Universidade Federal do Rio de Janeiro organizou oficina sobre Saúde da População LGBT, apresentada neste artigo. Métodos: Realizada em maio de 2018, teve como público alvo internos em estágio curricular na Atenção Primária em Saúde (APS), no município do Rio de Janeiro. Sensibilizar para o tema e apresentar ferramentas úteis para o cuidado na APS, e em outros cenários, foram os objetivos. Graduandos de medicina autodeclarados LGBT+ foram convidados a assumir a condução da atividade, preparada sob orientação de professoras do internato. O protagonismo dado a esses alunos permitiu articular à expertise científica, promovida nos estudos regulares sobre o tema, a expertise experiencial. A oficina ocorreu em 4 tempos: i) sensibilização; ii) discussão de casos; iii) informação e exposição de orientações para boas práticas em saúde; iv) dúvidas e avaliação. A duração total foi de 4 horas, com metodologias ativas e participativas. Resultados: Os objetivos foram alcançados e a atividade bem avaliada em sua organização e execução. Avaliação narrativa foi realizada com alunos e professores organizadores. Os internos participantes responderam questionário online com perguntas abertas e fechadas e também avaliaram positivamente a atividade nos quesitos metodologia e conteúdo. Conclusão/Desdobramentos: A oficina foi incluída nas atividades regulares do internato. Estão em construção, com vistas a difundir esses conhecimentos a outros estudantes do curso médico e a profissionais da rede de saúde municipal, disciplina eletiva e projeto de extensão. A inclusão longitudinal do tema no currículo permanece como desafio.

American Academy of Neurology members' preparedness to treat sexual and gender minorities

Objective

To measure the attitudes and knowledge of American Academy of Neurology (AAN) member neurologists in caring for sexual and gender minority (SGM) patients (e.g., those who identify in the lesbian, gay, bisexual, transgender, queer, or questioning [LGBTQ+] spectrum) to inform future educational offerings.

Methods

A questionnaire was created in an iterative process by the LGBTQ+ Survey Task Force, consisting of 21 questions examining self-reported knowledge, attitudes, and clinical preparedness in caring for SGM patients. Participants responded to each statement with a 5-point Likert scale (“strongly disagree” to “strongly agree”). The survey was distributed via electronic and conventional mail to a random, representative sample of 1,000 AAN members.

Results

The response rate was 13.5% (n = 135). Most respondents (60%–66%) were aware of local and national barriers that inhibit SGM individuals from using health care services; the majority (73%–91%) felt comfortable assessing SGM patients. Over half believed sexual orientation (SO) and gender identity (GI) to be social determinants of health (61% and 57%, respectively). Yet a third would not tailor neurologic care based on a patient's SGM identity, and 43% believed that SO/GI has no bearing on the management of neurologic illness.

Conclusions

Most neurologists surveyed were aware of overarching barriers to care experienced by SGM individuals; however, a minority of respondents recognized the intersection of SGM identity with neurologic health. Our results highlight awareness gaps that could be addressed via targeted educational opportunities, ensuring that neurologists provide high-quality neurologic care to patients of all sexual orientations and gender identities.

Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty

As the demographics in the United States continue to change, nurses must deliver care to patients from diverse cultural backgrounds. Cultural humility is a lifelong process of self-reflection which is also defined by that individual. It allows an individual to be open to other people's identities, which is core to the nursing standard of providing holistic care. Embracing and incorporating cultural humility is essential for creating a comprehensive and individualized plan of care. One of the ways to achieve cultural humility in nursing is to train future faculty to become agents of cultural humility. This also helps to create a pipeline of nurses who have respect and empathy for the patients they serve. The aims of this paper include: 1) define cultural humility and its importance to healthcare professionals; 2) explore the intrapersonal, interpersonal, and system levels of cultural humility; 3) provide insight on how to promote cultural humility; 4) reflect on best practices across a variety of healthcare disciplines; and 5) provide suggestions for practice.

Increasing cultural competence with LGBTQ patients

Many nurses practicing today lack basic education about LGBTQ (lesbian, gay, bisexual, transgender, queer) patient care. How can they better prepare to care for this population? This article provides insight on LGBTQ people, their health risks and disparities, and how nurses can work with LGBTQ patients to improve outcomes.

The Role of the Ethicist in an Interdisciplinary Transgender Health Care Team

Unique ethical issues arise in the provision of gender-affirming care to transgender and gender diverse people. One of the distinctive trends in transgender health care has been the development of interdisciplinary specialty teams with expertise in gender-affirming care. Clinical ethicists can play an important role on these teams in helping gender variant patients and gender-affirming providers navigate complex ethical issues, creating opportunities for enhancing patient experience, and easing provider moral uncertainty. Many opportunities exist for clinical ethicists to lend their skills to this area of clinical care. It is important for interdisciplinary transgender health care teams and other health care professionals providing transgender-specific care to understand the ethical issues involved in such care, the ways in which ethics expertise can be a resource, and the benefits and drawbacks of integrating a clinical ethicist into their team.

Transphobia rather than education predicts provider knowledge of transgender health care

PURPOSE

Transgender and gender diverse (TGD) patients face significant hurdles in accessing affirming, knowledgeable care. Lack of provider knowledge presents a substantial barrier to both primary and transition-related care and may deter patients from seeking health care. Little is known about factors that affect provider knowledge or whether exposure to TGD health content during training is associated with improved knowledge among providers. Using the TGD Healthcare Knowledge Scale, this study aimed to determine whether prior education on TGD health predicts clinicians' current knowledge regarding health care for TGD patients.

METHODS

An online survey examining exposure to TGD content and knowledge of TGD health care was distributed to all primary care providers in an integrated health care system in the Midwestern United States. Multivariable linear regression was used to predict provider knowledge, controlling for demographics, transphobia and other potential confounders.

RESULTS

The response rate was 57.3% (n = 223). The mean knowledge score was 7.41 (SD = 1.31) on a 10-point scale. Almost half (48.4%, n = 108) had no formal education on TGD health care, yet half (49.7%, n = 111) of providers reported previously caring for at least one transgender patient. In regression analysis, provider knowledge of TGD health care was associated with transphobia (β = -0.377, 95% CI = -0.559 to -0.194, p < 0.001), but not with hours of formal education (β = -0.027, 95% CI = -0.077 to 0.023, p = 0.292) or informal education (β = -0.012, 95% CI = -0.033 to 0.009, p = 0.259).

CONCLUSIONS

Increasing hours of education related to TGD health care may not be sufficient to improve providers' competence in care for TGD individuals. Transphobia may be a barrier to learning that needs to be addressed. Broader efforts to address transphobia in society in general, and in medical education in particular, may be required to improve the quality of medical care for TGD patients.

Queer Theory and Biomedical Practice: The Biomedicalization of Sexuality/The Cultural Politics of Biomedicine

This article works across multiple disciplinary boundaries, especially queer theory, to examine critically the controversial, and often socially controlling, role of biomedical knowledge and interventions in the realm of human sexuality. It will attempt to situate scientific/medical discourses on sexuality historically, socially, and culturally in order to expose the ways in which "proper" sexual health in medical research and clinical practice has been conflated with prevailing social norms at particular historical junctures in the 20th and 21st centuries. How might the relationship between clinical and cultural spheres be better engaged in biomedical knowledge and clinical practice in understanding sexual health, given the impact of homophobic and transphobic assumptions in the diagnostic histories of homosexuality and Gender Identity Disorder in Childhood, a new diagnostic category introduced into the DSM following the removal of homosexuality from the DSM-III? The article will argue further that biomedical knowledge is always already mediated through culture by analyzing normative racial, gender, class, and sexual ideologies that regulated early understandings of the epidemiology of the HIV/AIDS pandemic in the West and in the postcolonial world while informing global health policy on HIV/AIDS. The article concludes by examining the implications of medical education for both LGBTQI patients and medical professionals, for understanding gender and sexual rights as human rights, and for thinking about new kinds of interventions, contestations, and struggles to resist continued homophobic and transphobic assumptions in biomedical practice today and their ongoing effects in the everyday world.

Assessment of Women Physicians Among Authors of Perspective-Type Articles Published in High-Impact Pediatric Journals

IMPORTANCE

Most pediatricians are women; however, women pediatricians are underrepresented in academic leadership positions such as department chairs and journal editors and among first authors of original research articles published in pediatric journals. Publication of all types of articles, particularly in high-impact specialty journals, is crucial to career building and academic success.

OBJECTIVE

To examine the gender-related profile associated with authors of perspective-type articles in the 4 highest-impact general pediatric journals to determine whether women physicians were similarly underrepresented.

DESIGN AND SETTING

Cross-sectional study of perspective-type articles published between 2013 and 2017 in the 4 highest-impact general pediatric journals: Academic Pediatrics, JAMA Pediatrics, The Journal of Pediatrics, and Pediatrics.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the number and percentage of first-author women physicians as compared with men physicians. Secondary outcome measures included number and percentage of all men and all women among last authors and coauthors associated with physician first authors.

RESULTS

A total of 425 perspective-type articles were identified, with physicians listed as the first author on 338 (79.5%). Women were underrepresented among physician first authors of known gender (140 of 336 [41.7%]), particularly among physician first authors of article categories described as scholarly (range, 15.4%-44.1%) vs categories described as narrative (range, 52.9%-65.6%) in nature. Women were also underrepresented among last authors and coauthors of articles attributed to both men and women physician first authors, although the underrepresentation of women among last authors and coauthors was more pronounced if a man physician was the first author.

CONCLUSIONS AND RELEVANCE

Because perspective-type articles provide an opportunity for authors to express their opinions, provide insights that may influence their field, and enhance their academic resumes, there is a need for pediatric journal editors and leaders of medical societies who are associated with these journals to ensure the equitable inclusion of women in medicine. A hallmark of best practices for diversity and inclusion in academic medicine is transparency with regard to reporting of gender disparities in all areas of scholarship attribution and credit.

Self-Reported Discrimination in Health-Care Settings Based on Recognizability as Transgender: A Cross-Sectional Study Among Transgender U.S. Citizens

Discrimination has long been tied to health inequality. Rejected by families and communities because of their gender identity and gender-role behavior, transgender individuals are often socially marginalized. This study aimed to assess discrimination in health-care settings among persons self-identifying as transgender in the U.S. in relation to their recognizability as transgender, operationalized as how often they experienced that others recognized them as transgender. Data were obtained from the National Transgender Discrimination Survey (n = 6106 participants, assigned sex at birth = 3608 males, 2480 females, respectively). Binary logistic regressions were performed to examine associations between transgender recognizability and discrimination in health-care settings. Being recognized as transgender to any extent had a significant effect on perceived discrimination in health care. Always recognized as transgender showed significant associations with discrimination in a health-care setting (OR 1.48) and the following individualized health-care settings: social service settings (rape crisis and domestic violence centers, OR 5.22) and mental health settings (mental health clinic and drug treatment program, OR 1.87). Sex work and other street economy, which are known experiential factors affected by discrimination, were also significantly associated with discrimination in health-care settings. Discrimination in health-care settings is pervasive for transgender who are recognized as transgender. Public health efforts to improve access to equitable health care for transgender individuals may benefit from consideration of demographic, experiential, and medical risk factors to more fully understand the source of the seemingly excess risk of discrimination among persons recognized by others as being transgender.

The Hidden Curricula of Medical Education: A Scoping Review

PURPOSE

To analyze the plural definitions and applications of the term "hidden curriculum" within the medical education literature and to propose a conceptual framework for conducting future research on the topic.

METHOD

The authors conducted a literature search of nine online databases, seeking articles published on the hidden, informal, or implicit curriculum in medical education prior to March 2017. Two reviewers independently screened articles with set inclusion criteria and performed kappa coefficient tests to evaluate interreviewer reliability. They extracted, coded, and analyzed key data, using grounded theory methodology.

RESULTS

The authors uncovered 3,747 articles relating to the hidden curriculum in medical education. Of these, they selected 197 articles for full review. Use of the term "hidden curriculum" has expanded substantially since 2012. U.S. and Canadian medical schools are the focus of two-thirds of the empirical hidden curriculum studies; data from African and South American schools are nearly absent. Few quantitative techniques to measure the hidden curriculum exist. The "hidden curriculum" is understood as a mostly negative concept. Its definition varies widely, but can be understood via four conceptual boundaries: (1) institutional-organizational, (2) interpersonal-social, (3) contextual-cultural, and/or (4) motivational-psychological.

CONCLUSIONS

Future medical education researchers should make clear the conceptual boundary or boundaries they are applying to the term "hidden curriculum," move away from general musings on its effects, and focus on specific methods for improving the powerful hidden curriculum.

Changes in medical student implicit attitudes following a health equity curricular intervention

PURPOSE

This study assessed the: (1) effect of an LGBTQI + health equity curriculum (eQuality) on implicit attitudes among first (M1) and second year (M2) medical students and (2) utility of dedicated time to explore implicit bias.

METHOD

Implicit biases were assessed at baseline using implicit association tests (IAT) for all M2s and a random sample of first years (M1A). These students were then debriefed on strategies to mitigate bias. Following eQuality, all M1 and M2s completed post-intervention IATs. The remaining first years (M1B) were then debriefed. Paired sample t-tests assessed differences between pre/post. Independent sample t-tests assessed differences in post-IATs between M1 groups.

RESULTS

IATs indicated preferences for "Straight," "White," and "Thin" at both pre and post. M2s demonstrated statistically significant improvements pre to post for sexuality (p = 0.01) and race (p = 0.03). There were significant differences in post-intervention IAT scores between M1As who received the IAT and debriefing prior to eQuality and M1Bs for sexuality (p = 0.002) and race (p = 0.046). There were no significant changes for weight.

CONCLUSION

eQuality reduced implicit preference for "Straight" and "White." Differences in M1 post-intervention IAT scores between groups suggest dedicating time to debrief implicit attitudes enhances bias mitigation.

LGBT Cultural Competence and Interventions to Help Oncology Nurses and Other Health Care Providers

OBJECTIVES

To define and give an overview of the importance of lesbian, gay, bisexual, and transgender (LGBT) cultural competency and offer some initial steps on how to improve the quality of care provided by oncology nurses and other health care professionals.

DATA SOURCES

A review of the existing literature on cultural competency.

CONCLUSION

LGBT patients experience cancer and several other diseases at higher rates than the rest of the population. The reasons for these health care disparities are complex and include minority stress, fear of discrimination, lower rates of insurance, and lack of access to quality, culturally competent care. Addressing the health care disparities experienced by LGBT individuals and families requires attention to the actual needs, language, and support networks used by patients in these communities. Training on how to provide quality care in a welcoming and non-judgmental way is available and can improve health equity.

IMPLICATIONS FOR NURSING PRACTICE

Health care professionals and institutions that acquire cultural competency training can improve the overall health of LGBT patients who currently experience significant health care disparities.

Nonsuicidal Self-Injury and Suicidality Among Sexual Minority Youth: Risk Factors and Protective Connectedness Factors

OBJECTIVE

We investigated differences in prevalence of repetitive nonsuicidal self-injury (NSSI), suicidal ideation, and a suicide attempt among youth who identified as bisexual, gay/lesbian, and questioning. In addition, we examined which types of social connections were associated with reduced risk of repetitive NSSI and suicidality among youth who identified with a specific sexual minority group.

METHODS

Data came from the 2013 Minnesota Student Survey. The analytic sample included 77,758 students in grades 9 and 11. Connectedness factors included parent connectedness, teacher caring, connectedness to other nonparental adults, school safety, and friend caring. Logistic regression analyses, stratified according to sexual minority group, determined social connectedness factors associated with repetitive NSSI, suicidal ideation, and a suicide attempt, as well as moderating effects of significant connectedness factors on different risk factors (depression, anxiety, bullying, and violence victimization).

RESULTS

Approximately 3% identified as bisexual or questioning their sexual orientation, and <1% identified as gay/lesbian. Sexual minority youth, particularly bisexual youth, were significantly more likely than heterosexual youth to report repetitive NSSI and suicidality. Effects of connectedness varied across sexual minority groups and outcomes on the basis of types of connections. Parent connectedness emerged as a robust protective factor for all self-harm behaviors among bisexual and questioning youth. Feeling connected to nonparental adults and safe at school represented additional factors that reduced risk of repetitive NSSI and suicidality among certain groups.

CONCLUSIONS

In addition to facilitating connections between youth and parents, clinicians might consider encouraging sexual minority youth to remain connected to trusted nonparental adults who could offer support and care. Schools might consider implementing sociocultural norms of acceptance, tolerance, and positive identity development to reduce risk of self-harm.

OBSERVED DEFICIENCIES IN MEDICAL STUDENT KNOWLEDGE OF TRANSGENDER AND INTERSEX HEALTH

OBJECTIVE

Lesbian, gay, bisexual, transgender, and intersex (LGBTI) patients face many well-documented disparities in care which among transgender and intersex people can often be traced to providers' lack of knowledge.

METHODS

We administered surveys to examine the self-assessed knowledge and attitudes of all medical students at Boston University regarding different LGBTI subpopulations. Survey questions were based on a Likert scale from 1 to 5; analysis was conducted with Wilcoxon rank sum tests.

RESULTS

Overall there was a response rate of 24%, with the number of responses varying by class. Three of the 4 surveyed classes reported lower knowledge about transgender health than LGB health. Every class reported significantly lower knowledge of intersex health in comparison to LGB. Comfort with transgender or with intersex patients was lower than with LGB patients for all surveyed classes. Students across all self-identified groups (LGBTI, ally, not an ally) reported significantly lower average responses for knowledge and comfort regarding transgender or intersex health in comparison to that of LGB. Students in their preclinical years reported lower levels of knowledge in comparison with students in their clinical years. Students who identified as LGBTI reported significantly higher knowledge and comfort with only LGB and transgender health when compared with students who didn't identify as LGBTI. Respondents more frequently requested additional learning opportunities in transgender and intersex health than in LGB health.

CONCLUSION

Self-reported knowledge of transgender and intersex health lags behind knowledge of LGB health, though these deficits appear partially responsive to targeted educational intervention.

ABBREVIATIONS

BUSM = Boston University School of Medicine LGB = lesbian, gay, and bisexual LGBT = lesbian, gay, bisexual, and transgender LGBTI = lesbian, gay, bisexual, transgender, and intersex M1 = first-year medical student class M2 = second-year medical student class M3 = third-year medical student class M4 = fourth-year medical student class.

Queer Frontiers in Medicine: A Structural Competency Approach

In 2014, the Association of American Medical Colleges (AAMC) published a report proposing qualifiers of competence to guide medical educators towards training physicians to appropriately care for individuals who are or may be lesbian, gay, bisexual, transgender (LGBT); gender nonconforming (GNC); and/or born with differences in sex development (DSD). These qualifiers provide content and context to an existing framework heavily used in competency-based medical education, emphasizing individual and interpersonal abilities to enhance care delivered to individuals identifying as LGBT, GNC, and/or born with DSD. However, systemic and societal forces including health insurance, implicit bias, and legal protections significantly impact the health of these communities. The concept of structural competency proposes that it is necessary to consider these larger forces contributing to and sustaining disease and health in order to fully address identity-based health needs. Competing competency frameworks for addressing diversity may be counterproductive to the ultimate goal of improving health outcomes among diverse communities. In this article, frameworks are reconciled by proposing structural competency as one approach for teaching identity-based health-related competencies that can be feasibly implemented for medical educators seeking to comply with the AAMC's recommendations. This article aims to "queer"-or to open up-possibilities in medical education in an effort to ultimately support the provision of equitable and responsible health care to people who are LGBT, GNC, and/or born with DSD through the use of innovative frameworks and teaching materials.

Health Provider Views on Improving Antiretroviral Therapy Adherence Among Men Who Have Sex with Men in Coastal Kenya

HIV-positive Kenyan men who have sex with men (MSM) are a highly stigmatized group facing barriers to care engagement and antiretroviral therapy (ART) adherence. Because care providers' views are important in improving outcomes, we sought the perspective of those serving MSM patients on how to optimize ART adherence in a setting where same-sex behavior is criminalized. We conducted 4 focus group discussions with a total of 29 healthcare workers (HCWs) experienced in providing HIV care to MSM. The semistructured, open-ended topic guide used was based on an access-information-motivation-proximal cues model of adherence, with added focus on trust in providers, stigma, and discrimination. Detailed facilitator notes and transcripts were translated into English and reviewed for common themes. The HCW identified adherence challenges of MSM patients that are similar to those of the general population, including HIV-related stigma and lack of disclosure. In addition, HCWs noted challenges specific to MSM, such as lack of access to MSM-friendly health services, economic and social challenges due to stigma, difficult relationships with care providers, and discrimination at the clinic and in the community. HCWs recommended clinic staff sensitivity training, use of trained MSM peer navigators, and stigma reduction in the community as interventions that might improve adherence and health outcomes for MSM. Despite noting MSM-specific barriers, HCWs recommended strategies for improving HIV care for MSM in rights-constrained settings that merit future research attention. Most likely, multilevel interventions incorporating both individual and structural factors will be necessary.

Medical students' perception of lesbian, gay, bisexual, and transgender (LGBT) discrimination in their learning environment and their self-reported comfort level for caring for LGBT patients: a survey study

BACKGROUND

Historically, medical students who are lesbian, gay, bisexual or transgendered (LGBT) report higher rates of social stress, depression, and anxiety, while LGBT patients have reported discrimination and poorer access to healthcare.

OBJECTIVE

The objectives of this study were: (1) to assess if medical students have perceived discrimination in their learning environment and; (2) to determine self-reported comfort level for caring for LGBT patients.

DESIGN

Medical students at the University of Ottawa (N = 671) were contacted via email and invited to complete a confidential web-based survey.

RESULTS

Response rate was 15.4% (103/671). This included 66 cis-gender heterosexuals (64.1%) and 37 LGBT students (35.9%). Anti-LGBT discrimination had been witnessed by 14.6% and heterosexism by 31.1% of respondents. Anti-LGBT discrimination most often originated from fellow medical students. Respondents who self-identified as LGBT were more likely to have perceived heterosexism (favoring opposite-sex relationships) (OR = 8.2, p < 0.001) or anti-LGBT discrimination (OR = 6.6, p = 0.002). While half of LGBT students shared their status with all classmates (51.4%), they were more likely to conceal this from staff physicians (OR = 27.2, p = 0.002). Almost half of medical students (41.7%) reported anti-LGBT jokes, rumors, and/or bullying by fellow medical students and/or other members of the healthcare team. Still, most respondents indicated that they felt comfortable with and capable of providing medical care to LGBT patients (≥83.5%), and were interested in further education around LGBT health issues (84.5%).

CONCLUSION

Anti-LGBT discrimination and heterosexism are noted by medical students, indicating a suboptimal learning environment for LGBT students. Nonetheless, students report a high level of comfort and confidence providing health care to LGBT patients.