Meeting the Patient Care, Education, and Research Missions: Academic Medical Centers Must Comprehensively Address Sexual and Gender Minority Health

An Education Intervention in Gastrointestinal Healthcare Workers Improves Knowledge of Sexual and Gender Minority Digestive Health

BACKGROUND

Sexual and gender minority (SGM) communities experience barriers in accessing healthcare. While literature exists in remedying SGM-related knowledge deficits in primary care, none exists for gastroenterology specialists.

AIMS

We detail a two-site experience with a focused education intervention for gastrointestinal healthcare workers on SGM digestive health.

METHODS

Gastroenterology and hepatology physicians, nurses, trainees, and staff at two academic medical centers participated. A 10-question pre-test and Likert scale questions on confidence in caring for sexual and gender minority patients were given. Participants then attended a lecture about SGM digestive health. After, they completed a post-test and 6-month follow-up assessment. Pre- and post-test averages of correct answers were compared to assess objective knowledge acquisition and identify gaps in knowledge.

RESULTS

Of 368 eligible participants, 143 (39.0%) completed the pre-test, 79 completed the post-test, and 93 completed 6-month follow-up. Pre-test average correct responses were 61%, while post-test correct responses increased to 70% (p < 0.001). At 6-month follow-up, average percent correct was 66% (p = 0.027 compared to pre-test). Confidence caring for SGM patients improved from 3.62 to 3.99. (1 = strongly disagree, 5 = strongly agree; p = .033). This persisted at 6 months (average 4.07, p = .007).

CONCLUSIONS

A lecture-based intervention results in significant and sustained improvement in confidence and knowledge surrounding digestive healthcare in SGM patients. This can be used as a starting point for curricular development at all medical education levels. Doing so may allow for more culturally inclusive care to be provided to SGM communities and foster cultural humility.

Sexual History-Taking in a Surgery Clerkship Assessment: A Stubborn Clinical Skills Gap With Reproductive Health Care Implications

PURPOSE

Patients present with sexual and reproductive health needs in various clinical settings, so knowing when and how to elicit a relevant sexual history is critical in any specialty. This work examined whether reinforcing the surgical relevance of sexual health with an integrated training improved third-year medical students' sexual history-taking.

METHOD

Third-year surgery clerkship standardized patient assessments were video coded from a 2021-2022 comparison and 2022-2023 intervention cohort (University of Louisville School of Medicine). The case used for both cohorts involved a 38-year-old patient assigned female at birth presenting with acute right lower abdominal pain. Before the assessment, the intervention cohort received an additional clerkship didactic session focused on evaluation and assessment of the acute abdomen emphasizing the importance of sexual history-taking for surgical patients. The frequency of sexual histories attempted, number of questions, topics discussed, and differential diagnoses were compared.

RESULTS

There was not a significant difference between cohorts' sexual history-taking frequency: 61% (72/119) of students in the comparison cohort, compared to 65% (86/132) in the intervention cohort. On average, students in the intervention group asked 6 questions related to sexual health, compared to 3 questions by students in the comparison group ( P < .001). Across cohorts, 66% (104/158) of students who took a sexual history considered sexual diagnoses on their differential, compared to only 23% (21/93) of students who did not take a sexual history ( P < .001).

CONCLUSIONS

Reinforcing the clinical relevance of sexual history-taking for surgical patients was associated with higher-quality histories and broader differentials but not higher rates of sexual history-taking. Because there is now variability in how reproductive health care can be delivered across the United States, medical educators must refocus on sexual history-taking skills in a variety of settings and work to address barriers preventing students from collecting this information.

Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Cardiology Physicians and Fellows in Training

Background

The number of practicing lesbian, gay, bisexual, transgender, and queer (LGBTQ+) cardiologists is unknown despite diversity initiatives focused on understanding workforce demographics.

Objectives

The aim of this study was to evaluate the prevalence, sources of mistreatment, and measures of wellness among the LGBTQ+ cardiology community.

Methods

An online survey was sent to the American College of Cardiology Fellow in Training and Early Career Professional Listservs and shared on social media sites. The survey included the Short-Negative Acts Questionnaire and LGBTQ+ -specific harassment questions. Chi-square analysis and Fisher exact tests were performed to compare responses between LGBTQ+ and non-LGBTQ+ respondents.

Results

A total of 188 respondents completed the survey (56% Fellow in Training). One-third (33%) identified as LGBTQ+. Gender identity data included: transgender (3%), nonbinary (2%), gender queer (1%), and agender (1%). LGBTQ+ physicians were less likely to agree with the statements 'LGBTQ+ patients were treated fairly' (40% vs 66%, P < 0.001), and 'leadership dealt with people demonstrating poor behavior fairly' (34% vs 51%, P = 0.029) compared to heterosexual peers. LGBTQ+ physicians were more likely to report gender policing and heterosexist harassment compared to heterosexual peers (P = 0.002). The majority of physicians (91%) were satisfied with their decision to become a cardiologist.

Conclusions

This current analysis of LGBTQ+ cardiologists in the workplace identifies opportunities to address mistreatment impacting the LGBTQ+ community. Despite experiencing mistreatment, LGBTQ+ cardiologists report high job satisfaction. Further work is necessary to create a safe space and diverse cohort of physicians required to meet the needs of LGBTQ+ patients at risk for cardiovascular disease.

Academic Physician and Trainee Occupational Well-Being by Sexual and Gender Minority Status

Importance

Few studies have explored the association between sexual and gender minority (SGM) status and occupational well-being among health care workers.

Objectives

To assess the prevalence of burnout, professional fulfillment, intent to leave, anxiety, and depression by self-reported SGM status.

Design, Setting, and Participants

This cross-sectional survey study collected data from October 2019 to July 2021, from 8 academic medical institutions participating in the Healthcare Professional Well-Being Academic Consortium. The survey, including questions on SGM status, was administered to attending physicians and trainees. Statistical analyses were performed from June 1, 2023, to February 29, 2024.

Exposure

SGM status was determined via self-reported sexual orientation and gender identity.

Main Outcomes and Measures

Primary outcomes measured were the Professional Fulfillment Index (burnout and professional fulfillment), intent to leave, and self-reported anxiety and depression using the Patient-Reported Outcomes Measurement Information System short-form 4-item measure.

Results

Of 20 541 attendings and 6900 trainees, 8376 attendings and 2564 trainees responded and provided SGM status. Of these respondents, 386 attendings (4.6%) and 212 trainees (8.3%) identified as SGM. Compared with their non-SGM peers, SGM attendings had a lower prevalence of professional fulfillment (133 of 386 [34.5%] vs 3200 of 7922 [40.4%]) and a higher prevalence of burnout (181 of 382 [47.4%] vs 2791 of 7883 [35.4%]) and intent to leave (125 of 376 [33.2%] vs 2433 of 7873 [30.9%]) (all P < .001). Compared with their non-SGM peers, SGM trainees had a lower prevalence of professional fulfillment (63 of 211 [29.9%] vs 833 of 2333 [35.7%]) and a higher prevalence of burnout (108 of 211 [51.2%] vs 954 of 2332 [40.9%]) (both P < .001). After adjusting for age and race and ethnicity, SGM attendings had higher odds of burnout than their non-SGM peers (adjusted odds ratio, 1.57 [95% CI, 1.27-1.94]; P < .001). Results for burnout were similar among the SGM trainees compared with their non-SGM peers (adjusted odds ratio, 1.47 [1.10-1.96]; P = .01).

Conclusions and Relevance

In this cross-sectional survey study of academic physicians and trainees, SGM attendings and trainees had higher levels of burnout and lower levels of professional fulfillment. SGM attendings had greater intent to leave than their non-SGM peers, but trainees did not. These disparities represent an opportunity for further exploration to retain SGM health care workers.

Structural and Social Inclusivity of Transgender and Nonbinary Students in U.S. Medical Schools and Schools of Public Health Programming

Purpose

We characterize trans-inclusive social and structural educational programming at Association of American Medical Colleges-affiliated U.S. allopathic medical and Council on Education for Public Health-accredited schools of public health using responses from deans and administrators.

Methods

Between December 2019 and February 2020, the Public Health and Medical Schools Transgender-Inclusive Educational Programming Study surveyed deans, administrators, and students via email about trans-inclusive social and structural educational programming strategies at their institution. Evaluated social programming included training topics, social events, and direct communications. Assessed structural strategies included admissions, policies, and mentorship. Descriptive statistics were performed for all variables while stratifying by medical versus public health schools. Bivariate analyses were used to examine differences between strata and chi-square or Fisher's exact tests, accordingly, to analyze programming strategies.

Results

Of 335 deans and administrators contacted, 65 completed the survey (19% response rate) and 55.4% were from public health. Most were deans (87.7%), from public institutions (69.2%), between 51 and 59 years old (44.6%), and were ciswomen (63.5%). Comparisons of medical versus public health schools demonstrated significant differences in trans-inclusive strategies such as gender competency training (58.6% vs. 36.1%); trans-inclusive lectures (44.8% vs. 30.6%); honoring trans students' names in-person (75.9% vs. 61.1%); and goals to increase trans representation as researchers (37.5% vs. 26.7%).

Conclusions

Policies aimed at creating trans-inclusive environments in these institutions should focus on bolstering affirming structural programming, encouraging prospective trans applicants, mentoring trans students' research ambitions, and consistently using students' lived names, pronouns, and gender markers in all documentation and communications.

An Analysis of Lesbian, Gay, Bisexual, Transgender, and Queer Curricula Inclusion: A National Study of Physician Assistant Programs

INTRODUCTION

The health professions education literature shows an increased focus on inclusion of lesbian, gay, bisexual, transgender, and queer (LGBTQ) content in curricula; however, it does not address hours of content or methods for content delivery. The purpose of this study was to describe the delivery of LGBTQ content in physician assistant (PA) education through a national survey of PA programs.

METHODS

In 2021, a national program survey was sent to all US-accredited PA Programs (n = 284) and had a completion rate of 71.8% (n = 204). Descriptive statistics were conducted to describe trends and make comparisons in the delivery of LGBTQ content.

RESULTS

Most PA programs are incorporating LGBTQ content into preclinical phases of PA education (81%) and describe that LGBTQ curricula align with institutional values (82%). Most report 1 to 3 hours of preclinical education for all LGBTQ population groups and cite medical interviewing courses as the most frequently used course to address LGTBQ care. Many programs (43%) do not provide instructional hours on LGBTQ content in the clinical phase, and the majority do not offer clinical rotations focused on this care. The results show variability in the level of preparedness that programs report on their students caring for LGBTQ populations.

DISCUSSION

Physician assistant programs are generally integrating the content throughout their didactic curricula; however, few offer clinical experiences focused on caring for patients who are LGBTQ. Offering clinical experiences and assessing student competencies are areas of growth in health professions education as related to LGBTQ health.

Sexual and gender minority content in undergraduate medical education in the United States and Canada: current state and changes since 2011

PURPOSE

To characterize current lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI +) health-related undergraduate medical education (UME) curricular content and associated changes since a 2011 study and to determine the frequency and extent of institutional instruction in 17 LGBTQI + health-related topics, strategies for increasing LGBTQI + health-related content, and faculty development opportunities.

METHOD

Deans of medical education (or equivalent) at 214 allopathic or osteopathic medical schools in Canada and the United States were invited to complete a 36-question, Web-based questionnaire between June 2021 and September 2022. The main outcome measured was reported hours of LGBTQI + health-related curricular content.

RESULTS

Of 214 schools, 100 (46.7%) responded, of which 85 (85.0%) fully completed the questionnaire. Compared to 5 median hours dedicated to LGBTQI + health-related in a 2011 study, the 2022 median reported time was 11 h (interquartile range [IQR], 6-16 h, p < 0.0001). Two UME institutions (2.4%; 95% CI, 0.0%-5.8%) reported 0 h during the pre-clerkship phase; 21 institutions (24.7%; CI, 15.5%-33.9%) reported 0 h during the clerkship phase; and 1 institution (1.2%; CI, 0%-3.5%) reported 0 h across the curriculum. Median US allopathic clerkship hours were significantly different from US osteopathic clerkship hours (4 h [IQR, 1-6 h] versus 0 h [IQR, 0-0 h]; p = 0.01). Suggested strategies to increase content included more curricular material focusing on LGBTQI + health and health disparities at 55 schools (64.7%; CI, 54.6%-74.9%), more faculty willing and able to teach LGBTQI + -related content at 49 schools (57.7%; CI, 47.1%-68.2%), and more evidence-based research on LGBTQI + health and health disparities at 24 schools (28.2%; CI, 18.7%-37.8%).

CONCLUSION

Compared to a 2011 study, the median reported time dedicated to LGBTQI + health-related topics in 2022 increased across US and Canadian UME institutions, but the breadth, efficacy, or quality of instruction continued to vary substantially. Despite the increased hours, this still falls short of the number of hours based on recommended LGBTQI + health competencies from the Association of American Medical Colleges. While most deans of medical education reported their institutions' coverage of LGBTQI + health as 'fair,' 'good,' or 'very good,' there continues to be a call from UME leadership to increase curricular content. This requires dedicated training for faculty and students.

Transgender Patients Report Lower Satisfaction with Care Received than Cisgender Patients Receiving Care in an Academic Medical Care System

Purpose: Transgender and gender diverse (TGD) patients experience challenges in health care settings, including stigma, lack of culturally competent providers, and suboptimal gender-affirming care. However, differences in patient satisfaction between TGD patients compared with cisgender patients have been inadequately studied. This study aimed to assess such differences in patient satisfaction with care received in a large academic medical care system in Boston, Massachusetts. Methods: Routine patient satisfaction surveys were fielded from January to December 2021 and were summarized. Logistic regression models compared low net promoter scores (NPS; ≤6) between gender identity groups (cisgender women, transmasculine and nonbinary/genderqueer people assigned female at birth [AFAB], transfeminine and nonbinary/genderqueer people assigned male at birth) relative to cisgender men, adjusting for age, race, ethnicity, education, inpatient/outpatient service delivery, and distance from medical center. Results: Of 94,810 patients, 246 (0.3%) were TGD and 94,549 (99.7%) were cisgender. The mean age was 58.3 years (standard deviation = 16.6). Of the total sample, 17.0% of patients were people of color, 6.6% were Hispanic/Latinx, 48.6% were college graduates, and 2.6% had received inpatient care. In general, patient satisfaction with health care received was lower for TGD patients than for cisgender patients (7.3% vs. 4.5% reporting low NPS; adjusted odds ratio [aOR] = 1.14; 95% confidence interval [CI] = 0.70-1.85). Transmasculine and nonbinary/genderqueer patients AFAB had elevated odds of low NPS compared with cisgender men (8.8% vs. 3.6%; aOR = 1.71; 95% CI = 1.02-2.89). Conclusion: Future research is warranted to better understand factors driving lower ratings among TGD patients. Health care quality improvement efforts are needed to address gender identity inequities in care.

Sexual and gender minority health-related content in geriatric fellowships

INTRODUCTION

Despite a growing number of older lesbian, gay, bisexual transgender, and queer (LGBTQ) adults in the United States, education on care for this vulnerable population has historically been inadequate across all levels of training. This research assessed the extent of LGBTQ education in geriatric medicine fellowship curricula across the United States.

METHODS

We designed a survey to anonymously collect information from geriatric medicine fellowship programs on LGBTQ curricular content. Eligible participants included all 160 fellowship directors on record with the American Geriatrics Society. The survey addressed demographics of the fellowship program, current state of inclusion of LGBTQ content in didactic curricula and in clinical settings, and other available training opportunities.

RESULTS

Out of those contacted, 80 (50%) completed the survey. Of the programs surveyed, 60 (75%) were housed in internal medicine, 19 (24%) were in family medicine, and one was in their own department. Forty-seven fellowships (59%) reported some formal didactic session (e.g., lecture or case based), with the majority of these programs (72%) featuring 1-2 h of formal instruction. Forty-five programs (56%) reported offering no formal clinical experiences. There was less than 50% coverage for all surveyed topics in the required curriculum (range 46% for discrimination to 9% for gender affirming care). Time and lack of expertise were cited as the main barriers to content inclusion.

CONCLUSIONS

Curricular content regarding care for LGBTQ older adults is inadequate in geriatric medicine fellowships. Faculty development of current educators and providing standardized guidelines and curricula are steps toward addressing this deficit.

The Society of General Internal Medicine's Recommendations to Improve LGBTQ + Health

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ +) individuals experience bias in healthcare with 1 in 6 LGBTQ + adults avoiding healthcare due to anticipated discrimination and overall report poorer health status compared to heterosexual and cisgendered peers. The Society of General Internal Medicine (SGIM) is a leading organization representing academic physicians and recognizes that significant physical and mental health inequities exist among LGBTQ + communities. As such, SGIM sees its role in improving LGBTQ + patient health through structural change, starting at the national policy level all the way to encouraging change in individual provider bias and personal actions. SGIM endorses a series of recommendations for policy priorities, research and data collection standards, and institutional policy changes as well as community engagement and individual practices to reduce bias and improve the well-being and health of LGBTQ + patients.

It Takes a Village: An Interdisciplinary Approach to Preparing Internal Medicine Residents to Care for Patients at the Intersection of Women's Health, Gender-Affirming Care, and Health Disparities

Objective: To create an interdisciplinary curriculum to teach key topics at the intersection of women's health, gender-affirming care, and health disparities to internal medicine (IM) residents. Materials and Methods: A core team of faculty from IM, Obstetrics and Gynecology, and Surgery partnered with faculty and fellows from other disciplines and with community experts to design and deliver the curriculum. The resulting curriculum consisted of themed half-day modules, each consisting of three to four inter-related topics, updated and repeated on an ∼3-year cycle. Health equity was a focus of all topics. Module delivery used diverse interactive learning strategies. Modules have been presented to ∼175 residents annually, beginning in 2015. To assess the curriculum, we used formative evaluation methods, using primarily anonymous, electronic surveys, and collected quantitative and qualitative data. Most surveys assessed resident learning by quantifying residents' self-reported comfort with skills taught in the module pre- and postsession. Results: Of 131 residents who completed an evaluation in 2022/23, 121 (90%) "somewhat" or "strongly" agreed with their readiness to perform a range of skills taught in the module. In all previous years where pre- and postsurveys were used to evaluate modules, we observed a consistent meaningful increase in the proportion of residents reporting high levels of comfort with the material. Residents particularly valued interactive teaching methods, and direct learning from community members and peers. Conclusion: Our interdisciplinary curriculum was feasible, valued by trainees, and increased resident learning. The curriculum provides a template to address equity issues across a spectrum of women's and gender-affirming care conditions that can be used by other institutions in implementing similar curricula.

Comparison of faculty and student perceptions of sexual and gender minority content in a preclerkship medical curriculum

BACKGROUND

Sexual and gender minority (SGM) persons experience stark health disparities. Efforts to mitigate disparities through medical education have met some success. However, evaluations have largely focused on subjective perspectives rather than objective measures. This study aimed to quantify Boston University School of Medicine's sexual and gender minority (SGM) education through surveys of course directors (CDs) and medical students regarding where SGM topics were taught in the preclerkship medical curriculum. Responses were compared to identify concordance between faculty intention and student perceptions regarding SGM education.

METHODS

A cross-sectional survey was distributed to preclerkship CDs and current medical students in Spring 2019 and 2021, respectively, regarding where in the mandatory preclerkship curriculum CDs deliberately taught and where first- and second-year students recalled having learned 10 SGM topic domains.

RESULTS

64.3% of CDs (n = 18), 47.0% of the first-year class (n = 71), and 67.3% of the second-year class (n = 101) responded to the surveys. Results indicate that, as anticipated, deliberate SGM teaching correlates with greater student recall as students recalled topics that were reported by CDs as intentionally taught at a significantly higher rate compared to those not intentionally taught (32.0% vs. 15.3%; p < 0.01). Students most commonly recalled learning SGM-related language and terminology, which is likely partly but not entirely attributed to curricular modifications and faculty development made between distribution of the faculty and student surveys, indicating the importance of all faculty being trained in appropriate SGM terminology and concepts. Discordance between faculty intention and student recall of when topics were taught reveals opportunities to enhance the intentionality and impact of SGM teaching.

CONCLUSIONS

Students perceive and recall SGM content that is not listed as learning objectives, and all faculty who utilize this material in their teachings should receive foundational training and be thoughtful about how information is framed. Faculty who intentionally teach SGM topics should be explicit and direct about the conclusions they intend students to draw from their curricular content.

Integrating LGBTQIA + Community Member Perspectives into Medical Education

ProblemLGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities) people have unique health care needs related to their sexual orientation, gender identity and expression, and sex development. However, medical education has historically excluded LGBTQIA + health-related content in formal curricula. It is common for medical students to interact with diverse patient populations through clinical rotations; however, access to and knowledge about LGBTQIA + patients is inconsistently prioritized in medical schools. This is especially true for LGBTQIA + patients with intersecting historically marginalized identities, such as people of color and people with disabilities. Learning from and listening to medically underserved community members can help both medical students and educators better understand the unique health needs of these communities, and address implicit biases to improve health care and outcomes for their patients. Intervention: To address the lack of LGBTQIA + health-related content in medical education and improve access to and knowledge about LGBTQIA + patients, LGBTQIA + community members' perspectives and lived experiences were integrated into undergraduate medical education via four primary methods: Community Advisory Groups, community panel events, standardized patients, and community member interviews. Context: LGBTQIA + community members' perspectives and lived experiences were integrated into medical education at Harvard Medical School (HMS) as part of the HMS Sexual and Gender Minority Health Equity Initiative. Impact: LGBTQIA + community members' perspectives and lived experiences were successfully integrated into multiple aspects of medical education at HMS. During this process, we navigated challenges in the following areas that can inform similar efforts at other institutions: representation of diverse identities and experiences, meeting and scheduling logistics, structural barriers in institutional processes, and implementation of community member recommendations. Lessons Learned: Based on our experiences, we offer recommendations for integrating LGBTQIA + community members' perspectives into medical education. Engaging community members and integrating their perspectives into medical education will better enable medical educators at all institutions to teach students about the health care needs of LGBTQIA + communities, and better prepare medical students to provide affirming and effective care to their future patients, particularly those who are LGBTQIA+.

Health Care Disparities Among Autistic LGBTQ+ People

Background

Lesbian, gay, bisexual, transgender, or queer (LGBTQ+) people and disabled people experience disparities in access to health care compared with others. However, we have yet to understand how health care disparities may be further exacerbated at the intersection of disability and LGBTQ+ identity, particularly among autistic people.

Objectives

The primary goals of this study were to (1) examine differences in unmet health care needs and health status between LGBTQ+ autistic people and straight/cisgender autistic people and (2) explore how state policies and demographics predict the unmet health care needs of the autistic LGBTQ+ people.

Methods

We conducted a cross-sectional analysis using data from the 2019 National Survey on Health and Disability that included a subsample of autistic participants, with 62 LGBTQ+ adults and 58 straight/cisgender adults. To address our first study goal, we used an independent samples t-test, and to address our second study goal, we used Poisson regression.

Results

The LGBTQ+ group reported significantly more days of poor physical and mental health, more co-occurring diagnoses, and more unmet health care needs than the straight/cisgender group. For LGBTQ+ people, protective state health care laws and a lower income resulted in significantly more health care needs being met.

Conclusions

Findings from this study suggest that the intersection of an LGBTQ+ identity and autism is associated with greater disparities in physical and mental health as well as unmet health care needs; however, state policies prohibiting discrimination of LGBTQ+ people may act as a protective factor and result in fewer unmet health care needs. Future research should examine additional structural factors that may mitigate health inequities for autistic LGBTQ+ people.

Graduate Medical Education Curriculum Regarding the Health and Healthcare of Older Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Adults

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) adults experience a wide variety of unique challenges accessing healthcare. These barriers may be exacerbated among older LGBTQ+ people due to intersecting, marginalized identities. To prepare physicians to address the healthcare needs of older LGBTQ+ adults, graduate medical education (GME) must include training about the specific needs of this population. Prior studies demonstrate a lack of LGBTQ+ training in GME curricula. Here, we investigated the presence of LGBTQ+ curricula in internal medicine residencies and geriatrics fellowships through a national survey. Over 62.0% of internal medicine (n = 49) and 65.6% (n = 21) of geriatric medicine fellowship program directors, responding to the survey, reported content relevant to the health of older LGBTQ+ adults. Education about LGBTQ+ health in internal medicine residencies and geriatrics fellowships is vital for the provision of culturally-competent healthcare and to create an inclusive environment for older LGBTQ+ patients.

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.

Advancing undergraduate medical education regarding the care of transgender and gender Diverse persons and communities

None

Gender and Sexual Diverse Health Education: A Needs Assessment Among Internal Medicine Residents

Purpose: The purpose of this study was to assess perception of competency and comfort level of internal medicine (IM) residents in caring for gender and sexual diverse (GSD) patients, and to identify residents' preferred educational modalities and perceived facilitators and barriers to GSD curriculum implementation. Methods: A survey was distributed among IM residents during a mandatory didactic session between November 9 and December 18, 2020. Categorical variables were analyzed using Fisher's exact test. Open-ended questions were analyzed using content and theme analysis. Results: Of 138 residents, 89 (64%) completed the survey. Residents had varying levels of comfort and perceived competence. Small group (n = 61, 69%) and case-based learning (n = 58, 66%) formats were preferred. Content and theme analysis resulted in four major themes on facilitators and three major themes on barriers to GSD curricular implementation. Conclusion: This study provides unique insight to facilitate implementation of a learner-centered and developmentally appropriate curricular approach to GSD health education.

"I just felt supported": Transgender and non-binary patient perspectives on receiving transition-related healthcare in family planning clinics

Transgender and non-binary people face challenges in accessing gender affirming hormone therapy. Family planning clinics across the United States have greatly expanded transgender care services in the last ten years offering increased access to these services. This national qualitative study describes transgender and non-binary patients' experiences of receiving transgender care in family planning clinics. We completed 34 in-depth interviews with transgender and non-binary people over age 18 who had received transition-related care at a family planning clinic in the last year from 2019-2020. We analyzed interview data in Dedoose using constant comparative analysis and inductive thematic analysis. Patients reported overwhelmingly positive experiences at family planning clinics and were especially surprised at the ease and speed of the informed consent process. Barriers to care remain for patients in rural areas, low income patients, and patients who need specialized care. Some of the barriers relate to the gender binary and transphobia built into the medical systems, which cause patients and providers to have to find "work arounds" the binary medical and insurance systems. Patients also shared their idealized visions of transition related care that center on strong referral networks and hiring of LGBTQ staff at the clinics. Family planning clinics currently provide affirming and supportive care, especially those that use the informed consent model. Family planning clinics could provide increased access to transgender healthcare outside of major metropolitan areas and for transgender and gender non-conforming clients across the lifespan.

Digestive Health in Sexual and Gender Minority Populations

It has been over 50 years since the Stonewall Inn Riots in June 1969, a seminal event for the lesbian, gay, bisexual, transgender, queer, intersex, and other sexual and gender-diverse minorities (LGBTQI+, or lesbian, gay, bisexual, transgender, queer, intersex, and everyone else) rights movement. However, sexual and gender minority (SGM) individuals still face discrimination and harassment due to their sexual orientation or gender identity. As such, the National Institute on Minority Health and Health Disparities has identified SGM communities as a "health disparity population." Broadly, there are higher rates of sexually transmitted infections, substance use and abuse, mental health conditions, obesity and eating disorders, certain cancers (breast, cervical, and anorectal), and cardiovascular disease in SGM communities. Transgender patients, especially those of color, are more likely to be uninsured, experience discrimination, and be denied health care than cisgender patients. In addition, SGM individuals have twice the risk of lifetime exposure to emotional, physical, and sexual trauma compared with heterosexuals. It is expected all these factors would negatively affect digestive health as well. This review summarizes the effects of social determinants of health and discrimination on health care access, highlights important digestive diseases to consider in the SGM population, and offers solutions to improve and prioritize the health of these communities. We aim to draw attention to SGM-specific issues that affect gastrointestinal health and spur research that is desperately lacking.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery

BACKGROUND

Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care.

AIM

The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement.

METHODS

Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations.

OUTCOMES

Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes.

RESULTS

Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235).

CLINICAL IMPLICATIONS

This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions.

STRENGTHS & LIMITATIONS

This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality.

CONCLUSION

Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.

Society for Maternal-Fetal Medicine Special Statement: Commitment to excellence in obstetrical care, research, and education for people with diverse sexual and gender identities

The Society for Maternal-Fetal Medicine seeks to ensure excellence in obstetrical outcomes for all people who desire or experience pregnancy, including people with diverse sexual and gender identities. The Society commits to the use of practices in clinical and research settings that affirm the sexual and gender identities of all people, encourages the development of undergraduate and graduate medical education curricula and training programs that address diverse pathways to pregnancy and support clinicians with diverse sexual and gender identities, and promotes the use of inclusive language that is accurate and, when possible, specific.

Representation of Sexual and Gender Minority People in Patient Nondiscrimination Policies of Cancer Centers in the United States

BACKGROUND

Sexual and gender minority (SGM) people are an underserved population who face high rates of discrimination in healthcare, including receipt of cancer treatment. Several national organizations have identified the importance of patient nondiscrimination policies that explicitly recognize SGM people in creating safe healthcare environments.

METHODS

We performed a web-based analysis of NCI-designated Cancer Centers to evaluate the landscape of patient nondiscrimination policies in major cancer centers with regard to representation of SGM people.

RESULTS

We found that 82% of cancer centers had a patient nondiscrimination policy on their website. The most commonly mentioned SGM-related term was "sex" (n=48; 89%), followed by "sexual orientation" (n=37; 69%) and "gender identity" (n=36; 67%). None of the policies included "sex assigned at birth" or "LGBTQ/SGM identity." Of the policies reviewed, 65% included protections for both sexual orientation and gender identity. Cancer centers with academic affiliations were significantly more likely to have policies that included both of these protections compared with nonacademic institutions (100% vs 79%; P=.005).

CONCLUSIONS

Our study shows that patient nondiscrimination policies across NCI-designated Cancer Centers are not always accessible to patients and their families online and do not consistently represent SGM people in their content. Because the SGM population is both at higher risk for cancer and for discrimination in the healthcare setting, it is crucial to create inclusive, safe, and equitable cancer care environments for this group. Administrators and clinicians should view the patient nondiscrimination policy as an opportunity to offer expansive protections to SGM people that extend beyond those offered in federal and state laws. Additionally, the patient nondiscrimination policy should be visible and accessible to patients seeking cancer care as a signal of safety and inclusion.

Transgender men's preferences when choosing obstetricians and gynecologists

BACKGROUND

Transgender men are a marginalized population with unique health care needs. However, their usage of health services is low because of considerable discrimination. A major factor in their avoidance is patient-provider interactions.

METHODS

This cross-sectional study included 102 transgender men who anonymously completed a 55-item questionnaire in clinic, between 10/2017 and 01/2019. In addition, 92 transgender women filled out the part about family physician's preferences. We examined which characteristics transgender men prefer in their obstetricians/gynecologists in order to promote their usage of healthcare services.

RESULTS

A small majority of the transgender men (54.1%) had no gender preference for their obstetrician/gynecologist, while 42.9% preferred a female obstetrician/gynecologist and 3.1% preferred a male obstetrician/gynecologist. Most transgender men with a same-gender preference preferred female obstetricians/gynecologists for both invasive procedures (e.g., pelvic examination, 97.4%) and non-invasive procedures (e.g., cesarean section, 60%). The reasons for preferences regarding invasive procedures were feeling comfortable, embarrassment and feeling that female obstetricians/gynecologists are gentler. Transgender men who preferred female obstetricians/gynecologists ranked ability (90.5%), sexual tolerance (92.9%) and gender identity tolerance (90.5%) as the top three desirable qualities of obstetricians/gynecologists, while the responders who did not prefer female ranked ability (94.6%), experience (92.9%) and knowledge (92.9%) as the top three qualities. Transgender men with female preferences considered female obstetricians/gynecologists to be more accepting of gender identity compared to the responders that did not prefer females (47.5% vs. 9.1%, P < .001)..

CONCLUSION

A small majority of the transgender men exhibited no gender preference when choosing an obstetrician/gynecologist, although 42.9% preferred females. The latter choice was associated with the assumption that female obstetricians/gynecologists are more tolerant towards their transgender men patients. Educating the medical staff about their special needs and establishing dedicated SGM centers staffed with high percentages of female healthcare providers are highly recommended.

Health Disparities in Recruitment and Enrollment in Research

Despite advances in thoracic oncology research, the benefits of new discoveries are not universally experienced. A lack of representation of racial/ethnic minorities and individuals of low socioeconomic status in clinical trials and thoracic research contributes to persistent health care disparities. It is critical that improved racial, ethnic, and socioeconomic diversity is achieved in our trials and research, if we are to attain generalizability of findings and reduction of health care disparities. Culturally tailored and community-based approaches can help improve recruitment and enrollment of marginalized groups in thoracic research, which is an essential step toward achieving health equity and advancing medical science.

Intersectionality and cancer survivorship: Sexual orientation and racial/ethnic differences in physical and mental health outcomes among female and male cancer survivors

BACKGROUND

Because of concerns about sexual minorities' poor cancer survivorship, this study compared cancer survivors' health outcomes in relation to multiple intersecting social positions, namely gender, sexual orientation, and race/ethnicity.

METHODS

This secondary data analysis used 2014-2019 Behavior Risk Factor Surveillance Survey data. The survey respondents consisted of 40,482 heterosexual and sexual minority men and 69,302 heterosexual and sexual minority women who identified as White, Black, or Hispanic. Logistic regression models compared White, Black, and Hispanic male and female cancer survivors' health status, depression, and health-related quality of life by sexual orientation. Models were adjusted for sociodemographic characteristics and access to care.

RESULTS

Mental health findings showed consistency, with sexual minority male and female cancer survivors having 2 to 3 times greater odds of depression and/or poor mental health among White, Black, and Hispanic survivors. Among White women, sexual minorities reported greater odds of fair or poor health, poor physical health, and poor activity days, whereas White sexual minority men showed similar odds in comparison with their heterosexual counterparts. Among Black and Hispanic sexual minority men and women, differences in the odds of fair or poor health, poor physical health, and poor activity days in comparison with their heterosexual counterparts were mostly explained by sociodemographic and access-to-care factors.

CONCLUSIONS

Physical and mental health outcomes vary in relation to sexual orientation and race/ethnicity among both female and male cancer survivors. Clinicians, researchers, and health care administrators must better understand and address the unique needs of cancer survivors in relation to multiple axes of social inequality to advance cancer equity.

Characterizing Substance Use Disorders among Transgender Adults Receiving Care at a Large Urban Safety Net Hospital

OBJECTIVES

In the midst of the opioid crisis, increasing attention has been given to assessing and addressing substance use disorders (SUDs) among transgender and gender diverse (TGD) populations. As electronic health records begin to more uniformly collect gender identity data, clinicians and public health professionals are better able to examine the prevalence of SUDs and the receipt of SUD treatment services in these populations.

METHODS

We utilized cross-sectional electronic health records data from January 2005 to December 2019 from a large safety-net hospital in Massachusetts. A cohort of TGD patients was identified using self-reported gender identity data as well as diagnostic and procedures codes associated with receipt of gender-affirming care (n = 2000). We calculated odds of SUD diagnosis and receipt of medications for SUD among TGD patients.

RESULTS

Among a cohort of 2000 TGD patients, 8.8% had a SUD diagnosis. SUD diagnoses were more common among older, Black, and transmasculine patients, as well as those holding public health insurance. SUD diagnoses were less likely among those reporting college-level education. Of those with an opioid use disorder (OUD), 46% were prescribed an FDA-approved medication for OUD.

CONCLUSIONS

SUD diagnoses among TGD patients were associated with demographic, socioeconomic, and gender-related factors. We found a modestly lower prevalence of non-tobacco SUD among our cohort of TGD patients than the national average of 7.4%. Despite a relatively better receipt of prescription treatment services than the national average, the low rate of treatment overall represents a missed opportunity to address SUDs in these vulnerable populations.

Comparative Health Status and Characteristics of Respondents of the 2019-2020 National Survey on Health and Disability by Sexual and Gender Minority Status

Purpose: We examined the health of sexual and gender minority (SGM) adults with disabilities compared with their non-SGM peers. Methods: The National Survey on Health and Disability is an internet-based survey fielded October 2019 through January 2020. We performed bivariate analyses to compare sociodemographic factors, disability type, and health behaviors between SGM and non-SGM adults. We estimated logistic regression models for dichotomous and count outcomes. Results: After adjustment, SGM adults with disabilities were more likely to report diminished measures of health status. Conclusion: SGM adults with disabilities in the United States experience disparities in self-reported health status compared with non-SGM peers.

Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement From the American Heart Association

There is growing evidence that people who are transgender and gender diverse (TGD) are impacted by disparities across a variety of cardiovascular risk factors compared with their peers who are cisgender. Prior literature has characterized disparities in cardiovascular morbidity and mortality as a result of a higher prevalence of health risk behaviors. Mounting research has revealed that cardiovascular risk factors at the individual level likely do not fully account for increased risk in cardiovascular health disparities among people who are TGD. Excess cardiovascular morbidity and mortality is hypothesized to be driven in part by psychosocial stressors across the lifespan at multiple levels, including structural violence (eg, discrimination, affordable housing, access to health care). This American Heart Association scientific statement reviews the existing literature on the cardiovascular health of people who are TGD. When applicable, the effects of gender-affirming hormone use on individual cardiovascular risk factors are also reviewed. Informed by a conceptual model building on minority stress theory, this statement identifies research gaps and provides suggestions for improving cardiovascular research and clinical care for people who are TGD, including the role of resilience-promoting factors. Advancing the cardiovascular health of people who are TGD requires a multifaceted approach that integrates best practices into research, health promotion, and cardiovascular care for this understudied population.

Building a Multidisciplinary Academic Surgical Gender-affirmation Program: Lessons Learned

Background:

Every day, we see more patients present to hospitals and clinics seeking gender-affirmation care to ameliorate the symptoms of gender dysphoria. However, to provide a multidisciplinary approach, it is important to offer an integrated clinical program that provides mental health assessment, endocrine therapy, physical therapy, research, and the full spectrum of surgical services devoted to transgender patients. This article describes our experience on building a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program.

Methods:

Herein, we describe the main and critical components on how to build a multidisciplinary academic gender-affirmation program. We share our lessons learned from this experience and describe how to overcome some of the obstacles during the process.

Results:

Building a multidisciplinary academic gender-affirmation program requires an invested team, as each and every member is essential for feedback, referrals, and to improve patient’s experience. Institutional support is essential and by far the most important component to overcome some of the obstacles during the process. Having all team members working under the same institution provides all the critical components needed to improve outcomes and patient satisfaction. In addition, the collection of prospective data with a well-structured research team will provide information needed to improve clinical services and standardize clinical protocols, while leaving space for innovation.

Conclusions:

This article describes the steps and experience needed to build a multidisciplinary holistic academic gender-affirmation program. We provide our lessons learned during the process that will help guide those who intend to start an academic gender-affirmation program.