Queer Frontiers in Medicine: A Structural Competency Approach

Experiences of gender-affirming practices in healthcare settings and HIV testing among transgender and nonbinary young adults in the United States

Transgender and nonbinary young adults in the United States (U.S.) experience disproportionately high rates of HIV and face unique barriers to accessing HIV testing, a key component of HIV prevention. Gender-affirming practices in healthcare settings may improve care access and reduce care avoidance among transgender and nonbinary people. To our knowledge, no study has examined the association between gender-affirming practices in healthcare settings and HIV testing among transgender and nonbinary U.S. young adults. This study analyzed national cross-sectional, online data from transgender and nonbinary U.S. young adults aged 18-30 years (N = 225) to assess the association between the gender affirmation sub-scale of the Transgender and Gender Diverse Healthcare Discrimination and Adverse Experiences Scale (range: 0-20) and past-year HIV testing using multivariable logistic regression. We found that a one-point increase in the gender affirmation sub-scale score was positively associated with past-year HIV testing (odds ratio = 1.15; 95% confidence interval: 1.06, 1.26), adjusting for age, geographic region, gender identity, educational attainment, employment status, having a usual source of care, and health insurance status. Our findings provide additional evidence that access to gender-affirming healthcare settings is important in facilitating utilization of preventive services among transgender and nonbinary U.S. young adults.

Identifying potential LGBTQIA+ competencies for genetic counseling student training

The LGBTQIA+ community faces considerable health disparities. Developing and integrating LGBTQIA+ competencies into healthcare provider training programs is one way to promote inclusive high-quality care to potentially improve this community's health. Currently, there are no established LGBTQIA+-specific competencies for genetic counseling graduate programs (GCPs), so training across GCPs likely varies. This qualitative focus group-based study aimed to explore current topics related to genetic counseling (GC) for LGBTQIA+ patients covered in North American GCPs, their learning objectives, and LGBTQIA+-specific competencies that GC students (GCSs) should achieve by graduation. Eligible participants were program leaders at ACGC-accredited GCPs and/or faculty who taught LGBTQIA+-related content in at least one GCP over the last 5 years. A semistructured interview guide was used to conduct virtual focus groups that were recorded and transcribed. Transcripts were analyzed using reflexive thematic analysis and an inductive iterative approach that generated themes regarding what content is taught and what knowledge, attitudes, and skills GCSs should demonstrate as a result. Thirteen people participated, including nine LGBTQIA+ people. They represented 12 GCPs (22% of current GCPs) across the United States and Canada. Focus groups ran 73-90 min. Transcript analysis identified six themes, framed as learning objectives (LOs), and 24 subobjectives. These included recognizing the breadth of the LGBTQIA+ community and their lived experience with the healthcare system, demonstrating respect for and responding to patient identities to provide inclusive GC, employing strategies to mitigate social aspects that influence health care, and assessing personal biases and the impact of socialization. Participants used several teaching methods including didactic lectures, simulation, written activities, reflections, and fieldwork experiences. The six identified LOs may be a starting point for GCPs looking to develop or refine their LGBTQIA+ curricula. Competency-based education may enhance GCSs' abilities to provide inclusive GC to the LGBTQIA+ community.

School-Based Health Centers Addressing Health Equity for LGBTQ + Patients (SBHCs HELP): protocol for a stepped-wedge trial to implement innovations promoting structural competency

BACKGROUND

School-based health centers (SBHCs) provide vital behavioral, sexual, and reproductive healthcare services to school-aged youth across the United States. Adolescents who are sexual and gender diverse (SGD) are far more likely to suffer from adverse health outcomes than their cisgender and heterosexual peers. Emerging structural competency frameworks call for cultivating capacities in SBHCs to modify organizational service delivery environments, including provider and staff knowledge and behaviors, to influence SGD adolescent well-being. Nationally recognized guidelines for nurturing structural competency include (1) adopting, disseminating, and adhering to SGD supportive policies and procedures; (2) creating welcoming physical environments; (3) systematically documenting and using sexual orientation and gender identity information in clinical care; (4) training all employees in best practices for interacting with SGD patients; and (5) developing the clinical workforce to deliver high-quality services to SGD patients. This community-engaged study will test the effectiveness of the Dynamic Adaptation Process (DAP) in implementing these guidelines in SBHCs in culturally and geographically diverse areas of New Mexico.

METHODS

We will conduct mixed-method readiness assessments to identify inner- and outer-context determinants affecting the implementation of structurally competent changes in SBHCs; employ a stepped-wedge trial to examine how the DAP-enabled implementation impacts adoption and changes in SBHC, student (patient), and implementation outcomes; and investigate inner- and outer-context determinants, bridging factors, and associated mediators and moderators influencing implementation processes and outcomes related to guideline adoption and SGD student care (e.g., reduced barriers, greater satisfaction and engagement).

DISCUSSION

This study addresses the long-term goal of high-quality care and decreased health disparities for SGD youth. As investments in SBHCs rise nationwide, opportunities to enhance services for SGD youth will also grow. This study will demonstrate the usefulness of a multifaceted implementation strategy, the DAP, in helping SBHCs build structural competency to serve a sizeable population of students affected by stigmatization, discrimination, and other social forces that create inequities in health. Accordingly, we will advance a model featuring a set of implementation strategies to reduce knowledge and practice gaps, create welcoming environments, and improve the quality of care for SGD youth.

TRIAL REGISTRATION

ISRCTN13844475; 20 September 2024.

"That's not at all what I needed" trans adults' perspectives on trans-affirming primary care and eating disorders

Transgender and gender diverse adults, referred to collectively as trans, experience eating disorders (EDs) at high rates and struggle to find primary care providers (PCPs) knowledgeable in both gender-affirming care and EDs. Most research regarding healthcare experiences of trans people with EDs focuses on specialized treatment. This qualitative study explored the experiences of trans patients with ED symptoms in trans-affirming primary care, which offers clinical support for gender affirmation in the context of interpersonally gender-affirming primary care services. Twenty-two participants were recruited via social media to participate in focus groups (n = 5). Researchers utilized thematic analysis. Participants reported gender-affirming and non-affirming experiences, experienced unwelcome comments from providers regarding bodies and gender, encountered barriers to disclosing their ED symptoms, felt transition-related medical care supported recovery but did not always resolve their ED symptoms, felt they had to self-advocate, and wanted their providers to recognize them as whole people (beyond their ED and transness) who experience joy. Importantly, despite being trans-affirming, participants critiqued trans-affirming primary care as perpetuating weight stigma and binary gender norms. Participants recommended providers receive ED training, implement universal ED screening, and explore how sociocultural norms regarding weight and gender negatively impact trans health outcomes.

Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: A Structural Competency Approach

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults experience significant health disparities. Examining these disparities has become an international research priority, but gaps remain. In this review article, we summarize major contributions of and ongoing gaps in health disparities research among LGBTQ+ older adults, while focusing on four major content areas: (a) social determinants of health disparities, (b) mental, cognitive, and physical health disparities, (c) reproductive and sexual health disparities, and (d) seeking LGBTQ+-affirming and age-friendly care. Using a structural competency approach, we develop a four-part agenda for this research area that enhances our understanding of how macro-level systems, institutions, and structures drive health disparities among aging LGBTQ+ communities. We also outline future research on structural competency in LGBTQ+ older adult health, while providing recommendations for researchers and clinicians. These recommendations illuminate potential best practices for bettering the health and quality of life of LGBTQ+ older populations.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Transgender and gender diverse people with endometriosis: A perspective on affirming gynaecological care

Transgender and gender diverse people presumed female at birth experience gynaecological conditions, such as chronic pelvic pain at elevated rates, estimated to impact between 51% and 72% of this population, compared to rates of up to 26.6% in cisgender women. The negative impact of these conditions is likely amplified due to limited access to safe and affirming healthcare. Despite this high prevalence rate, there is limited research investigating the prevalence, presentation or management options for trans and gender diverse people with endometriosis. Cisgender women with endometriosis report barriers to accessing care, with lengthy times to diagnosis and limited treatment options available. However, barriers for trans and gender diverse individuals are enhanced by physician bias and lack of education in gender-affirming care. This is reflected in stories of discrimination and denial of basic healthcare. A healthcare environment built on the presumption that gynaecological patients are women, others trans and gender diverse patients, which can result in avoidance of needed medical care. A lack of knowledge of gender-affirming care alongside healthcare provider bias highlights a need for gender-affirming care and bias reduction training in undergraduate healthcare provider curricula. Research to date assessing current curriculum in Australia and Aotearoa (New Zealand) shows limited inclusion of lesbian, gay, bisexual, trans, queer, intersex, asexual and other related identities content as a whole with gender-affirming care being among the least-frequently addressed topics. This review will detail barriers to accessing gender-affirming healthcare specific to gynaecology, interweaving the experiences of a non-binary individual seeking access to gender-affirming endometriosis care.

Queer(ing) medical spaces: queer theory as a framework for transformative social change in anesthesiology and critical care medicine

Queer theory is a disruptive lens that can be adopted by researchers, educators, clinicians, and administrators to effect transformative social change. It offers opportunities for anesthesiologists, critical care physicians, and medical practitioners to more broadly understand what it means to think queerly and how queering anesthesiology and critical care medicine spaces improves workplace culture and patient outcomes. This article grapples with the cis-heteronormative medical gaze and queer people's apprehensions of violence in medical settings to offer new ways of thinking about structural changes needed in medicine, medical language, and the dehumanizing application of medical modes of care. Using a series of clinical vignettes, this article outlines the historical context underlying queer peoples' distrust of medicine, a primer in queer theory, and an understanding of how to begin to "queer" medical spaces using this critical framework.

Working Through Stigma: A Constructivist Grounded Theory of Delivering Health Services to Diverse 2SLGBTQ Populations

Previous research inadequately explores processes and factors influencing the delivery of health services to sexual and gender minorities in ways that equitably attend to the infinite diversity held by these groups. This study employed Intersectionality and Critical Theories to inform Constructivist Grounded Theory methods and methodology; social categories of identity were strategically adopted to explore domains of power operating across multiple forms of oppression, think through subjective realities, and generate a nuanced rendering of power relations influencing health service delivery to diverse 2SLGBTQ populations in a Canadian province. Semi-structured interviews were conducted and the co-constructed theory of Working Through Stigma, with three interrelated concepts, depending on context, resolving histories, and surviving the situation, was generated. The theory depicts the concerns of participants and what they do about power relations influencing health service delivery and broader social contexts. While the negative impacts of stigma were widely and diversely experienced by patients and providers, ways of working within power relations emerged that would be impossible if stigma was not present, highlighting opportunities to positively impact those from stigmatized groups. As such, Working Through Stigma is a theory that flouts the tradition of stigma research; it offers theoretical knowledge that can be used to work within power relations upholding stigma in ways that increase access to quality health services for those whose historical underservicing can be attributed to stigma. In doing so, the stigma script is flipped and strategies for working against practices and behaviours that uphold cultural supremacies may be realized.

Using the Community Readiness Model and Stakeholder Engagement to Assess a Health System's Readiness to Provide LGBTQ+ Healthcare: A Pilot Study

Background

Despite broad social and policy changes over the past several decades, many LGBTQ+ people face barriers to healthcare and report mistreatment and disrespect in healthcare settings. Few health systems level interventions have been shown to improve sexuality- and gender-related health disparities. Using the Community Readiness Model, we developed and implemented a rigorous assessment and priority-setting intervention at one mid-sized health system in the midwestern US. We evaluated the system's readiness to provide LGBTQ+ healthcare and developed immediate action steps that are responsive to local context. We engaged diverse stakeholder groups throughout the process.

Methods

Led by the Community Readiness Model, we identified key groups within the health system and conductedstructured interviews with 4-6 key informants from each group. Two trained scorers external to the study team individually scored each interview on a numerical scale ranging from 1 (no awareness of the problem) to 9 (community ownership of the problem) and discussed and reconciled scores. Group scores were averaged for each dimension of readiness and overall readiness, and then triangulated with stakeholders to ensure they reflected lived experiences. Finally, specific recommendations were generated to match the needs of the system and move them towards higher levels of readiness.

Results

We convened an advisory committee of LGBTQ+ patients of the health system and a panel of local experts on LGBTQ+ wellness. Both groups contributed significantly to research processes. 28 interviews across 6 staff subcommunities indicated readiness levels ranging from "3: Vague Awareness" of the issue, and the "4: Preplanning" stage. Discrepancies across staff groups and dimensions of readiness suggested areas of focus for the health system. The evaluation process led to immediately actionable recommendations for the health system.

Conclusions

This pilot study demonstrates the potential impact of the Community Readiness Model on improving health systems' readiness to provide LGBTQ+ healthcare. This model combines strengths from community-based research and implementation science approaches to form an intervention that can be widely disseminated and maintain the flexibility and agility to meet local needs. Future research will evaluate changes in readiness at the same health system and test the process in additional health systems.

Embedding LGBTQI+ competency into nursing education: Formative evaluation of an interdisciplinary project

BACKGROUND

In order to avoid perpetuating inequities faced by lesbian, gay, bisexual, transgender, queer, intersex, and other minority (LGBTQI+) communities, future nurses need to recognize and resist discriminatory, oppressive, heteronormative and cisnormative health and social systems.

OBJECTIVES

To share the development, embedding, and formative evaluation of an interdisciplinary project to improve LGBTQI+ health content across an undergraduate nursing curriculum.

METHODS

This paper describes a collaborative interdisciplinary project to embed LGBTQI+ health content across a 3-year undergraduate nursing degree. An anonymous cross-sectional online survey was sent to 87 student nurses enrolled in the final semester of their undergraduate degree. The survey included six Likert scale-type questions and five open-ended questions. Qualitative data were analyzed by inductive, reflexive thematic analysis.

RESULTS

Most students rated the topic relevant 'extremely' relevant (77 %) to nursing. Students' self-reported comfort discussing LGBTQI+ health in class varied from 'extremely' (42 %) through to 'not at all' (6 %). Thematic analysis of student responses to open-ended questions identified five themes: (1) Becoming aware of LGBTQI+ diversity; (2) Personal values and beliefs; (3) Learning in order to improve clinical encounters; (4) Inconsistency and a lack of incorporation across the curriculum; and (5) (Dis)comfort in the learning environment.

CONCLUSIONS

Opportunities to better embed LGBTQI+ competency included clear acknowledgement of wider systems of power and oppression, integration and consistent modeling by nursing faculty, and linkage of content to other equity issues to address the intersectional nature of inequities.

Knowledge Retention and Clinical Skills Acquisition in Sexual and Gender Minority Health Curricula: A Systematic Review

PURPOSE

To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD).

METHOD

The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020.

RESULTS

Of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation.

CONCLUSIONS

Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.

Queer and present danger: understanding the disparate impacts of disasters on LGBTQ+ communities

LGBTQ+ communities comprise 16 million individuals in the United States, yet this population is often rendered invisible within disaster policies. Bias in federal disaster response programmes, a lack of recognition of LGBTQ+ families, and the prevalence of faith-based organisations in disaster relief services together heighten the risks that LGBTQ+ individuals face. This paper describes the ways in which this reality combines with the contextual vulnerability of LGBTQ+ communities, whereby existing inequalities and marginalisation are exacerbated during disasters and in their aftermath. As a result, the immediate trauma of a disaster, such as physical injury or the loss of loved ones or possessions, is compounded in multiple ways for LGBTQ+ individuals, making them less likely to benefit from disaster relief services. To address these inequalities, the paper concludes with a set of policy recommendations to inform prevention, mitigation, and recovery planning, as well as to reduce the impacts of disasters on LGBTQ+ individuals.

A Concept Analysis of Structural Competency

Structural competency is a concept that offers a way to understand and respond to health inequities and work toward antiracism in health care. This article undertakes a concept analysis of structural competency using Rodgers' evolutionary method. Based on this analysis, structural competency refers to the ability to recognize and act on structural inequities, skill development, multidisciplinary collaboration, and the reproduction of inequity over time. The meanings and use of this concept differ among disciplines. Multidisciplinary applications of structural competency offer insight into how this concept can foster health equity and antiracism in nursing care, education, research, and health services delivery.

Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators

Health disparities faced by transgender people are partly explained by barriers to trans-inclusive healthcare, which in turn are linked to a lack of transgender health education in medical school curricula. We carried out a theory-driven systematic review with the aim to (1) provide an overview of key characteristics of training initiatives and pedagogical features, and (2) analyze barriers and facilitators to implementing this training in medical education. We used queer theory to contextualize our findings. We searched the PubMed/Ovid MEDLINE database (October 2009 to December 2021) for original studies that reported on transgender content within medical schools and residency programs (N = 46). We performed a thematic analysis to identify training characteristics, pedagogical features, barriers and facilitators. Most training consisted of single-session interventions, with varying modes of delivery. Most interventions were facilitated by instructors with a range of professional experience and half covered general LGBT+-content. Thematic analysis highlighted barriers including lack of educational materials, lack of faculty expertise, time/costs constraints, and challenges in recruiting and compensating transgender guest speakers. Facilitators included scaffolding learning throughout the curriculum, drawing on expertise of transgender people and engaging learners in skills-based training. Sustainable implementation of transgender-health objectives in medical education faces persistent institutional barriers. These barriers are rooted in normative biases inherent to biomedical knowledge production, and an understanding of categories of sex and gender as uncomplicated. Medical schools should facilitate trans-inclusive educational strategies to combat transgender-health inequities, which should include a critical stance toward binary conceptualizations of sex and gender throughout the curriculum.

Embedding Behavioral and Social Sciences across the Medical Curriculum: (Auto) Ethnographic Insights from Medical Schools in the United Kingdom

Key concepts and theories that are taught in order to develop cultural competency skills are often introduced to medical students throughout behavioral and social science (BSS) learning content. BSS represents a core component of medical education in the United Kingdom. In this paper, we examine, through (auto)ethnographic data and reflections, the experiences of BSS in medical education. The empirical data and insights have been collected in two ways: (1) through long-term ethnographic fieldwork among medical students and (2) via autoethnographic reflexive practice undertaken by the co-authors who studied, worked, examined, and collaborated with colleagues at different UK medical schools. Our findings indicate that despite BSS constituting a mandatory, essential component of the medical curriculum, medical students did not always perceive BSS as useful for their future practice as doctors, nor did they find it to be clinically relevant, in comparison to the biomedical learning content. We suggest that it is paramount for all stakeholders to commit to cultivating and developing cultural competency skills in medical education, through robustly embedding BSS learning content across the undergraduate medical curriculum. We conclude with recommendations for a wide range of educational practices that would ensure a full integration of BSS in the medical curriculum.

Building a Diverse Psychiatric Workforce for the Future and Helping Them Thrive: Recommendations for Psychiatry Training Directors

The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.

Structural competency in emergency medical education: A scoping review and operational framework

Objectives

Existing curricula and recommendations on the incorporation of structural competency and vulnerability into medical education have not provided clear guidance on how best to do so within emergency medicine (EM). The goal of this scoping review and consensus building process was to provide a comprehensive overview of structural competency, link structural competency to educational and patient care outcomes, and identify existing gaps in the literature to inform curricular implementation and future research in EM.

Methods

A scoping review focused on structural competency and vulnerability following Arksey and O'Malley's six-step framework was performed in concurrence with a multistep consensus process culminating in the 2021 SAEM Consensus Conference. Feedback was incorporated in developing a framework for a national structural competency curriculum in EM.

Results

A literature search identified 291 articles that underwent initial screening. Of these, 51 were determined to be relevant to EM education. The papers consistently conceptualized structural competency as an interdisciplinary framework that requires learners and educators to consider historical power and privilege to develop a professional commitment to justice. However, the papers varied in their operationalization, and no consensus existed on how to observe or measure the effects of structural competency on learners or patients. None of the studies examined the structural constraints of the learners studied.

Conclusions

Findings emphasize the need for training structurally competent physicians via national structural competency curricula focusing on standardized core competency proficiencies. Moreover, the findings highlight the need to assess the impact of such curricula on patient outcomes and learners' knowledge, attitudes, and clinical care delivery. The framework aims to standardize EM education while highlighting the need for further research in how structural competency interventions would translate to an ED setting and affect patient outcomes and experiences.

Transgender data collection in the electronic health record: Current concepts and issues

There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.

Using Queer Phenomenology to Disrupt Heteronormativity and Deconstruct Homosexuality

Stigma is structurally embedded and preexists a person's involvement in-the-world. This is understood to create the conditions necessary for what is described here as a priori homophobia, which is defined as a projection of structurally embedded stigma that extends into the mind of 2SLGBTQ individuals and causes them to hide their identities out of fear. With this in mind and by way of queer phenomenology, heteronormativity will be disrupted and the inherently negative notion of "homosexuality" will be deconstructed to understand the role of stigma as a root cause of 2SLGBTQ mental health disparities. Implications for practice are offered so health service providers can understand heteronormativity as a source of everyday harm for 2SLGBTQ and be responsive to the ways in which stigma influences 2SLGBTQ mental health outcomes.

"The Health System Just Wasn't Built for Us": Queer Cisgender Women and Gender Expansive Individuals' Strategies for Navigating Reproductive Health Care

BACKGROUND

The LGBTQ health disparities literature documents barriers to comprehensive and queer-inclusive care. Queer cisgender women and gender expansive individuals assigned female at birth experience myriad health disparities related to reproductive health, in part owing to the health care system. However, few studies have examined how queer individuals cope with and overcome barriers to queer-competent reproductive health care. This study aims to understand the strategies queer cisgender women and gender expansive individuals use to meet their reproductive health needs.

METHODS

Investigators conducted interviews with 22 queer cisgender women and gender expansive individuals assigned female at birth about their experiences seeking reproductive health care services. We used inductive coding and thematic analysis to identify themes related to meeting reproductive health and health care needs.

RESULTS

Findings highlight the prevalence of negative and harmful experiences while seeking reproductive health care. In response to these negative experiences, individuals developed active strategies to meet their health needs, including seeking information and community, seeking alternative models of care, and managing identity disclosure. Importantly, these strategies varied in effectiveness, depending on participants' social and economic advantage.

CONCLUSIONS

Queer individuals face numerous barriers to queer-competent reproductive health care when seeking reproductive health services. While queer patients are often resilient and creative, developing strategies to get their needs met, the presence of such strategies highlights the need for structural changes in the health system to better serve queer patients.

Capturing patients, missing inequities: Data standardization on sexual orientation and gender identity across unequal clinical contexts

In effort to address fundamental causes and reduce health disparities, public programs increasingly mandate sites of care to capture patient data on social and behavioral domains within Electronic Health Records (EHRs). Data reporting drawing from EHRs plays an essential role in public management of social problems, and data on social factors are commonly cited as foundational for eliminating health inequities. Yet one major shortcoming of these data-centered initiatives is their limited attention to social context, including the institutional conditions of biomedical stratification and variation of care provision across clinical settings. In this article, we leverage comparative fieldwork to examine provider and system responses to mandated data collection on patient sexual orientation and gender identity (SOGI), highlighting unequal clinical contexts as they appear across a large county safety-net institution and an LGBTQ-oriented health organization. Although point of care data collection is commonly justified for governance in the aggregate (e.g., disparity monitoring), we find standardized data on social domains presents a double-edged sword in clinical settings: formal categories promote visibility where certain issues remain hidden, yet constrain clinical utility in sites with greater knowledge and experience with related topics. We further illustrate how data standardization captures patient identities yet fundamentally misses these unequal contexts, resulting in limited attenuation of inequity despite broad expectations of clinical change. By revealing the often-invisible contexts of care that elude standard measurement, our findings underline the strengths of qualitative social science in accounting for the complex dynamics of enduring social problems. We call for deeper engagement with the unequal contexts of biomedical stratification, especially in light of increasing pressure to quantify the social amidst the rising tide of data-driven care.

Using Kern's 6-Step Approach to Integrate Health Systems Science Curricula Into Medical Education

The term "health systems science" (HSS) has recently emerged as a unifying label for competencies in health care delivery and in population and community health. Despite strong evidence that HSS competencies are needed in the current and future health care workforce, heretofore the integration of HSS into medical education has been slow or fragmented-due, in part, to a lack of evidence that these curricula improve education or population outcomes. The recent COVID-19 pandemic and the national reckoning with racial inequities in the United States further highlight the time-sensitive imperative to integrate HSS content across the medical education continuum. While acknowledging challenges, the authors highlight the unique opportunities inherent in an HSS curriculum and present an elaborated curricular framework for incorporating health care delivery and population health into undergraduate medical education. This framework includes competencies previously left out of medical education, increases the scope of faculty development, and allows for evidence of effectiveness beyond traditional learner-centric metrics. The authors apply a widely adopted 6-step approach to curriculum development to address the unique challenges of incorporating HSS. Two examples-of a module on quality improvement (health care delivery) and of an introductory course on health equity (population and community health)-illustrate how the 6-step approach can be used to build HSS curricula. The Supplemental Digital Appendix (at http://links.lww.com/ACADMED/B106) outlines this approach and provides specific examples and resources. Adapting these resources within local environments to build HSS curricula will allow medical educators to ensure future graduates have the expertise and commitment necessary to effect health systems change and to advocate for their communities, while also building the much-needed evidence for such curricula.

Establishing a province-wide referral network to improve access to gender-affirming primary healthcare services

ABSTRACT

It is possible and necessary to provide trans and gender nonconforming (TGNC) individuals with gender-affirming care (GAC) in primary care settings. A known risk of increased suicidality among TGNC individuals and a lack of provider training on prescribing gender-affirming hormones (GAH) in the Canadian province of Nova Scotia highlighted a need for building capacity around GAC delivery. A referral network was established across the province, which reduced wait times to access GAH by several months.

A Call for LGBTQ Content in Graduate Medical Education Program Requirements

A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.

Transgender health in medical education

Transforming our world the 2030 agenda for sustainable development is working towards a world that reflects equity, with universal respect for human dignity, pledging to leave no one behind. However, transgender and gender-diverse individuals experience significant health inequities, including negative health outcomes and multiple barriers to accessing care. In this article, we first highlight the health inequities that transgender and gender-diverse people face globally. We describe important aspects of transgender and gender-diverse health care, including the design and provision of health services, epidemiological considerations, transition-related care, changes in transition-related goals, cultural considerations, and political and legal issues. We then review the existing global literature on incorporating transgender health into medical curricula. We make a case for prioritizing improved education in medical schools on the specific health needs of transgender and gender-diverse people as part of addressing global health inequities in care. Our recommendations for comprehensive education on transgender health include cultural humility and anti-oppression training; involvement of transgender and gender-diverse community members; integration of transgender and gender-diverse health into curricula; practice-focused and in situ training; staff development in medical schools; and improving access to careers in medicine for transgender and gender-diverse people.

Centering Patients, Revealing Structures: The Health Humanities Portrait Approach

This paper introduces an innovative curricular approach-the Health Humanities Portrait Approach (Portrait Approach)-and its pedagogical tool-the Health Humanities Portrait (HHP). Both enable health professions learners to examine pressing social issues that shape, and are shaped by, experiences of health and illness. The Portrait Approach is grounded in a set of "critical portraiture" principles that foster humanities-driven analytical skills. The HHP's architecture is distinctively framed around a pressing social theme and utilizes a first-person narrative and scholarship to explore how the dimensions of the personal and the structural are mutually constituted. We argue that when creator-educators adopt the Portrait Approach and its critical portraiture principles to design and teach the HHP, they enable learners to become proficient in synthesizing and analyzing-with both depth and breadth-the human and social dimensions of patients' lives. This inventive curricular intervention provides a needed contribution to health professions education in that it utilizes health humanities methodologies to elucidate the multiple aspects of health, illness, disability, and healthcare.

Applying a Structural-Competency Framework to the Implementation of Strategies to Reduce Disparities for Sexual and Gender Minority Youth

BACKGROUND

Sexual and gender minority youth (SGMY) are at high risk for adverse health outcomes. Safer schools decrease this risk. The US Centers for Disease Control and Prevention has identified 6 practices that can make schools safer for SGMY, yet few US schools implement them all. We apply a structural competency framework to elucidate factors contributing to this implementation gap.

METHODS

We conducted 75 interviews and 32 focus groups with school professionals in 18 New Mexico high schools to assess factors impacting implementation of the practices over 2 years. We analyzed data using iterative coding, thematic identification techniques, and the sensitizing concept of structural competency.

RESULTS

Themes included: rendering an invisible population visible; critical thinking about LGBTQ inequalities; building school personnel capacity; intersecting cultural, religious, and political conflicts; and tackling community-based sources of stigma and discrimination.

CONCLUSIONS

Underlying cultural and structural forces render SGMY invisible and constrain what schools can accomplish. Professional development encouraging critical thinking about structural inequities is foundational, but efforts to close the implementation gap must attend to structural forces producing disparities for SGMY. Structural competency can strengthen the ability of the Whole School, Whole Community, and Whole Child model's cross-sector coordination of policy and process to meet the needs of every student.

The TOLERance Model for Promoting Structural Competency in Nursing

BACKGROUND

Structural competency is the trained ability to recognize how social, political, economic, and legal structures shape diseases and symptoms. Although structural competency has become an increasingly accepted framework for training and teaching, it usually has not addressed nursing students and has not included marginalized patients as trainers.

METHOD

This article analyzes a structural competency training model for nursing students that includes five components: Theory, Observations, Learning from patients, Engagement, and Research (the TOLERance model).

RESULTS

The TOLERance model increases the understanding of the interrelation between the individual clinical level and the sociopolitical structural level. It encourages nursing students to actively engage in social, political, and policy issues that affect their patients' health and to advocate for policy change.

CONCLUSION

The moral and professional commitment of nurses to their patients demands that they do not ignore the structural forces that are detrimental to their patients' health. The TOLERance model provides nursing students with skills and competencies that help them to fulfill this commitment. [J Nurs Educ. 2020;59(8):425-432.].

Learning by chance: Investigating gaps in transgender care education amongst family medicine, endocrinology, psychiatry and urology residents

BACKGROUND

The transgender (trans) population is one of the most underserved in health care. Not only do they face discrimination and stigma from society as a whole, they also have difficulty accessing transition-related care, leading to adverse outcomes such as suicide. We aimed to increase understanding on how our current postgraduate education system contributes to a lack of care for trans patients.

METHODS

Our study consisted of 11 semi-structured interviews conducted in 2016 with residents in the following specialties: family medicine (3), endocrinology (3), psychiatry (3), and urology (2). We used Framework Analysis to qualitatively analyze our data.

RESULTS

Residents described a lack of trans care education in the core curriculum, in part due to a lack of exposure to experts in this area. They also expressed discomfort when dealing with trans patients, due to inexperience and lack of knowledge. Furthermore, residents in each specialty had false assumptions that other specialties had sufficient knowledge and expertise in trans care.

DISCUSSION

This study highlights how the lack of teaching and clinical experiences with trans patients during residency contributes to the poor access to healthcare. By systematically embedding trans care in the curriculum, medical education can play a prominent role in addressing the healthcare disparities of this underserved population.

Are all LGBTQI+ patients white and male? Good practices and curriculum gaps in sexual and gender minority health issues in a Dutch medical curriculum

Objectives: People marginalized based on their sexual and gender identity face specific health risks and experience barriers to culturally competent care. Insight into how Dutch medical schools address LGBTQI+ health-related learning objectives is scarce. We therefore examined how LGBTQI+ health issues are integrated in the Amsterdam UMC-VUmc medical curriculum by evaluating the year-two course 'Sex, Sexuality and Relationships' for LGBTQI+ content. Methods/Design: We examined written course content (course syllabus, lecture notes, and course literature) of the 2016-2017 course. We used a framework for essential LGBTQI+ content in medical education and an intersectional approach to examine which LGBTQI+ themes and subthemes were addressed. Results: Several essential LGBTQI+ health issues were adequately addressed and integrated into the Amsterdam UMC-VUmc curriculum, but we also identified curriculum gaps. The needs of patients with lesbian, bisexual, or gender non-conforming identities were marginally addressed, and issues related to intersections of minoritized sexual and gender identities with other aspects of diversity such as ethnicity, age and class remained unexplored. The course discussed gender and sexuality as fixed and mainly binary constructs, and only addressed biomedical explanatory models of sex, gender and sexuality. Discussion and conclusion: The absence of complex patient identities in relation to sex, gender and sexuality does not adequately prepare students to provide LGBTQI+ responsive care. If not designed and taught competently, LGBTQI+-related curriculum content may reproduce bias and stereotypes, and contribute to a medical climate where both LGBTQI+ patients, students, and doctors conceal their identities. Further implementation of LGBTQI+ health issues is required in (continuing) medical education to secure culturally competent clinical environments. Educational research is needed to understand how medical education contributes to marginalization of LGBTQI+ identities and thus, to health disparities.

Structural Competency of Pre-health Students: Can a Single Course Lead to Meaningful Change?

Scholars within the medical sciences recently have called on undergraduate educators to incorporate the social sciences in order to teach pre-health students structural competencies - or the ability to articulate how social structures produce racial, ethnic, gender, class, and other disparities - in order to better serve these populations medically. Authors used a semester-long course to assess how experiential learning focused on the topic of structural inequities improves structural competency. In Fall 2018, 27 students completed a hands-on, experiential, course focused on structural factors and health disparities. The authors conducted a mixed-methods, pre-/post-test design to solicit data on students' views on the reasons for high rates of obesity, gender pay disparities, and racial/ethnic housing segregation. Using systematic qualitative data analysis and statistical analysis of coded answers, the authors were able to detect pre-/post-test differences in the number of times students identified structural reasons for the disparities. Statistical analysis showed that students were able to identify an average of 4.63 structural reasons at pre-test, and that increased to 5.93 reasons at post-test (statically significant (p = 0.007)), indicating an increase in structural awareness after participation in the course. Qualitative analysis, using systematic methods of coding and a modified constant comparison method, demonstrated that students' ability to articulate structural reasons for inequality greatly improved. This experiential learning course, while relatively short, was found to increase students' ability to identify structural factors and articulate them with deeper understandings. Future curriculum development should consider incorporating experiential learning to promote structural competency, rather than a more traditional passive, content-delivery method of training.

Debate: Why should gender-affirming health care be included in health science curricula?

BACKGROUND

Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse people have experienced significant marginalization and discrimination in health care settings. Health professionals are generally not adequately prepared by current curricula to provide appropriate healthcare to trans and gender diverse people. This strongly implies that health care students would benefit from curricula which facilitate learning about gender-affirming health care.

MAIN BODY

Trans and gender diverse people have been pathologized by the medical profession, through classifications of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). Although this is changing in the new ICD-11, tension remains between depathologization discourses and access to gender-affirming health care. Trans and gender diverse people experience significant health disparities and an increased burden of disease, specifically in the areas of mental health, Human Immunodeficiency Virus, violence and victimisation. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professional ignorance. This paper will outline gaps in health science curricula that have been described in different contexts, and specific educational interventions that have attempted to improve awareness, knowledge and skills related to gender-affirming health care. The education of primary care providers is critical, as in much of the world, specialist services for gender-affirming health care are not widely available. The ethics of the gatekeeping model, where service providers decide who can access care, will be discussed and contrasted with the informed-consent model that upholds autonomy by empowering patients to make their own health care decisions.

CONCLUSION

There is an ethical imperative for health professionals to reduce health care disparities of trans and gender diverse people and practice within the health care values of social justice and cultural humility. As health science educators, we have an ethical duty to include gender-affirming health in health science curricula in order to prevent harm to the trans and gender diverse patients that our students will provide care for in the future.

Structures of Sexuality: Sexual Stigma, Disclosure, and HIV Risk with Primary Female Partners Among Behaviorally Bisexual Black Men

HIV continues to disproportionately impact bisexual Black men, as well as their female partners, in the U.S. There is a need to better understand how stigma and disclosure affect sexual risk for men and their female partners. This article describes the relationship between sexual stigma and HIV risk with primary female partners among a sample of 121 behaviorally bisexual Black men of mixed HIV status in the San Francisco Bay Area. Multivariate analyses tested to see if each of three stigma measures (bisexual stigma, internalized homophobia, difficulty with bisexual identity) would have any effect on participants' condom use. Quantitative analyses found that sexual stigma increased men's sexual risk through inhibiting disclosure of their sexual activity with men to their female partners. Men who reported higher levels of bisexual stigma and internalized homophobia reported that it was harder to disclose having sex with men to their primary female partner, which was significantly related to lower levels of condom use. Stigma reduction HIV prevention interventions are needed that address bisexual stigma experienced by Black men. HIV prevention interventions, including stigma reduction programs, must target both men and women to effectively reduce bisexual stigma and address the structural and relationship contexts of HIV.

Compulsory Heterosexuality and Lesbian Invisibility in Nursing

Lesbian nurses have historically been silenced, but diversity initiatives within professional health programs suggest a need to initiate scholarly discussions that explore heteronormativity as increasing the risk of harm for nonheterosexual nurses as compared to their heterosexual counterparts. Nurses can reflect on relative privilege within the profession to better understand the ways in which normative health practices perpetuate adverse health outcomes among vulnerable patient populations. Nurses from diverse backgrounds, such as this lesbian author, offer insight into how the nursing profession might illuminate relational aspects of privilege. As such, the nursing profession could uncover solutions to systemic vulnerabilities which are inadvertently perpetuated within our profession, the health-care system, and society more broadly. The notion of compulsory heterosexuality is discussed in relation to nursing in this opinion piece with an aim to render structural harms visible that have been obscured by the institutionalization of heteronormativity in health care, to build awareness of the ways in which systemic vulnerabilities are unknowingly perpetuated despite health-care professionals being well-intended in their practice.

Queer Phenomenology, the Disruption of Heteronormativity, and Structurally Responsive Care

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) health disparities persist and reflect larger structural inequities that negatively impact the health of historically marginalized communities. By way of using queer phenomenology, the author analyzes a personal experience that was harmful to her as a lesbian patient who required emergency medical attention. Also a registered nurse, the author draws on her lived experiences to reveal heteronormativity as a prevalent, but largely unacknowledged, source of structural harms for LGBTQ patients. This aims to bring about an appreciation among nurses and other health care professionals to locate themselves within systems of privilege and oppression and gain an awareness on how they might better respond to ongoing structural harms that are disproportionately experienced by vulnerable patient populations.

Twelve tips for incorporating and teaching sexual and gender minority health in medical school curricula

The World Health Organization has identified many barriers to improving the health of lesbian, gay, bisexual, and transgender (LGBT) patients, including challenges to incorporating and teaching about healthcare for such patients, which we call "sexual and gender minority" (SGM) health content. These challenges include structural and logistical barriers to incorporating SGM health content into undergraduate medical curricula, as well as lack of support in identifying high-quality pedagogical methods for teaching this material. Here, we provide twelve tips for incorporating and teaching SGM health curricular content in undergraduate medical education, including resources and strategies to support individual educators. Based on our success in developing and implementing this content, we believe that our approach can be effectively used by individual educators aiming to incorporate SGM health curricular material into their teaching, and to support individuals or groups championing the inclusion of a SGM health topical sequence in medical curricula.

Structural competency in emergency medicine services for transgender and gender non-conforming patients

In this formative qualitative research, we draw upon the concepts of structural vulnerability and structural competency to examine how transgender and gender non-conforming (TGGNC) patients and healthcare personnel experience service delivery in Emergency Departments (EDs), and how this experience can be improved upon. Between October 2016 and June 2017, we undertook 31 semi-structured interviews with TGGNC patients (n = 11) and physicians (n = 6), nurses (n = 7), and non-clinical staff (n = 7) in four community-based EDs in New Mexico. Our iterative coding and analysis process resulted in eight sets of findings: (1) reasons why TGGNC patients seek care from EDs; (2) perceptions about and experiences of TGGNC patients; (3) relevance of gender identity and sex at birth; (4) bureaucracy and communication; (5) spatial considerations; (6) preparing providers and staff to care for TGGNC patients; (7) the lack of resources for structural prescriptions; and (8) respect, humanity, and sameness. Findings suggest that structural issues adversely impact the health and wellbeing of TGGNC patients and service-delivery practices in the ED. We describe study implications for training ED personnel and modifying this practice setting to prevent delayed care and ensure appropriate services for TGGNC patients in need of structurally competent emergency medicine.

Comparing medical, dental, and nursing students' preparedness to address lesbian, gay, bisexual, transgender, and queer health

Background

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations face multiple health disparities including barriers to healthcare. Few studies have examined healthcare trainees’ perceptions of their preparedness to care for LGBTQ populations and none have compared perceptions of training across medicine, dental medicine, and nursing. We aimed to understand variations across disciplines in LGBTQ health by assessing medical, dental, and nursing students’ perceptions of preparedness across three domains: comfort levels, attitudes, and formal training.

Methods

We developed a 12-item survey with an interprofessional panel of LGBTQ students from the schools of medicine, dental medicine, and nursing at a top-tier private university in the United States. Any student enrolled full time in any of the three schools were eligible to respond. We performed descriptive statistical analyses and examined patterns in responses using Kruskal-Wallis tests and an ordered logistic regression model.

Results

1,010 students from the Schools of Medicine, Dental Medicine, and Nursing responded to the survey for an overall response rate of 43%. While 70–74% of all student respondents felt comfortable treating LGBTQ patients, fewer than 50% agreed that their formal training had prepared them to do so. Overall, 71–81% of students reported interest in receiving formal LGBTQ health education, though dental students were significantly less likely than medical students to report this interest (OR 0.53, p<0.01). Respondents who identified as LGBQ were significantly less likely than heterosexual students to agree that training was effective (OR 0.55, p<0.01) and that their instructors were competent in LGBTQ health (OR 0.56, p<0.01).

Conclusion

Despite high comfort levels and positive attitudes towards LGBTQ health, most student respondents did not report adequate formal preparation. There were some significant differences between disciplines, but significant gaps in training exist across disciplines. Health professional schools should develop formal content on LGBTQ health and utilize this content as an opportunity for interprofessional training.

Commentary: Racism and Bias in Health Professions Education: How Educators, Faculty Developers, and Researchers Can Make a Difference

The Research in Medical Education (RIME) Program Planning Committee is committed to advancing scholarship in and promoting dialogue about the critical issues of racism and bias in health professions education (HPE). From the call for studies focused on underrepresented learners and faculty in medicine to the invited 2016 RIME plenary address by Dr. Camara Jones, the committee strongly believes that dismantling racism is critical to the future of HPE.The evidence is glaring: Dramatic racial and ethnic health disparities persist in the United States, people of color remain deeply underrepresented in medical school and academic health systems as faculty, learner experiences across the medical education continuum are fraught with bias, and current approaches to teaching perpetuate stereotypes and insufficiently challenge structural inequities. To achieve racial justice in HPE, academic medicine must commit to leveraging positions of influence and contributing from these positions. In this Commentary, the authors consider three roles (educator, faculty developer, and researcher) represented by the community of scholars and pose potential research questions as well as suggestions for advancing educational research relevant to eliminating racism and bias in HPE.

Using a structural competency framework to teach structural racism in pre-health education

The inclusion of structural competency training in pre-health undergraduate programs may offer significant benefits to future healthcare professionals. This paper presents the results of a comparative study of an interdisciplinary pre-health curriculum based in structural competency with a traditional premedical curriculum. The authors describe the interdisciplinary pre-health curriculum, titled Medicine, Health, and Society (MHS) at Vanderbilt University. The authors then use a new survey tool, the Structural Foundations of Health Survey, to evaluate structural skills and sensibilities. The analysis compares MHS majors (n = 185) with premed science majors (n = 63) and first-semester freshmen (n = 91), with particular attention to understanding how structural factors shape health. Research was conducted from August 2015 to December 2016. Results suggest that MHS majors identified and analyzed relationships between structural factors and health outcomes at higher rates and in deeper ways than did premed science majors and freshmen, and also demonstrated higher understanding of structural and implicit racism and health disparities. The skills that MHS students exhibited represent proficiencies increasingly stressed by the MCAT, the AAMC, and other educational bodies that emphasize how contextual factors shape expressions of health and illness.