Education Columns

By Joshua St. Louis, MD, MPH, AAHIVS, Greater Lawrence Family Health Center Program, Lawrence, MA; and Amy L. Lee, MD; Tufts University School of Medicine, Department of Family Medicine, Boston, MA

Introduction

Curricular teaching on the health and primary care of LGBTQ patients is frequently neglected in medical school education, with some medical schools providing no instruction on the subject. A policy document by the Association of American Medical Colleges (AAMC) in 2014 provided guidelines on integration of LGBTQ health into medical school education.¹ However, few medical schools have made significant progress. The same document found that many existing LGBTQ health curricula place an untoward focus on sexual health while often neglecting common primary care concerns. This focus subconsciously teaches medical students to consider gender identity and sexual orientation only when patients present with concerns related to sexual health. Teaching about the care of these patients in a more holistic primary care-focused fashion can help to avoid such an outcome. With this in mind, starting in 2017, we integrated a 1-hour educational session on the primary care of transgender patients into one of 6 didactic days in the required third-year family medicine clerkship at Tufts University School of Medicine. These didactic days cover core topics in primary care in a small group setting of about 20 students. The primary care of transgender patients was integrated into a didactic day focused on the care of an urban underserved population, including topics related to global health, family medicine obstetrics, addiction medicine, HIV primary care, and homeless medicine. 

Didactic Content

Medical students are assigned two short readings prior to the didactic day that review basic terminology related to caring for LGBTQ patients in addition to providing a basic overview of gender-affirming hormone therapy.^2,3 The small group interactive session begins with learning and practicing correct terminology that pertains to sexual and gender minority patients with a particular focus on transgender and gender nonconforming patients. Significant group discussion is spent workshopping interview techniques for ascertaining this information and addressing medical student discomfort in asking these questions. The faculty facilitator then provides an overview of the health concerns that disproportionately affect the transgender community including sexually transmitted infections, elevated rates of certain cancers due to decreased rates of screening, and increased rates of certain mental health disorders.^2,4-5 Patient-centered communication techniques, and use of respectful terminology is emphasized as a means of providing high quality primary care. The session concludes with a basic overview of gender-affirming hormone therapy, including eligibility criteria, medications that may be used, and the risks and benefits of these treatments.⁶

Results

Our transgender care education session was first integrated into the family medicine clerkship didactic day in July 2017. Assigned readings were added in early 2018, and an exam question about appropriate and respectful terminology based upon the readings and reinforced by the live session was added to the family medicine clerkship exam in May 2018. Student evaluations of the session have been favorable; anonymous aggregated feedback from over 200 students to date have, on average, rated the usefulness of the topic at 3.83 out of 4 on a Likert scale, and have rated the facilitator as effective at 3.59 out of 4. Performance on the related exam question has also been positive with the percentage correct being in line with the overall exam average. 

Conclusion

Incorporating this interactive educational session on the health of transgender patients into a family medicine clerkship didactic day has been an effective way of integrating this topic in a way that is consistent with the 2014 recommendations of the AAMC. Furthermore, this approach has been well received by medical students and has led to effective performance on end-of-clerkship testing. As we continue to work toward improved integration of LGBTQ health into our medical school curriculum, we will further adjust our clerkship session on transgender care. We have recently added more teaching related to respectful communication with sexual and gender minority patients in the first year course on medical interviewing. When these students enter the family medicine clerkship in 2 years, we plan to spend a shorter time reviewing terminology and interviewing techniques, so that we can explore health concerns and gender-affirming treatment options for transgender patients in more detail. As medical school educators consider how best to integrate these important topics into their curricula, we suggest the family medicine clerkship as an ideal place to focus on patient-centered, holistic care of transgender patients.

References

1. Hollenbach A, Eckstrand K, Dreger A. “mplementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD. Association of American Medical Colleges Policy Document;
2. Klein DA, Paradise SL, Goodwin ET. Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know. Am Fam Physician. 2018;98(11):645-653.
3. National LGBT Health Education Center. Affirmative Care for Transgender and Gender Non-Conforming People: Best Practices for Front-line Health Care Staff. Fall 2016.
4. Grant J, Mottet JD, et al. National Transgender Discrimination Survey (NTDS) Report on Health and Health Care. October 2010.
5. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; March 31, 2011.
6. Deutsch MB, Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Center of Excellence for Transgender Health, University of California San Francisco; June 17, 2016.