Imagine not speaking to a long-term patient with whom you’ve built a relationship, about “life.” How’s their spouse/partners? The kids? Everything going okay with work? How’s your stress level? Are you sleeping okay? These are all important everyday life conversations that impact a patient’s general well-being, and subsequently, their health. We ask these questions on most visits. It’s part of who they are and we want to know about that. There are other integral parts of our patients’ lives we may not ask or think to ask about. Why not ask about the components of their gender identity or sexual orientation? It is not something we routinely do, possibly because we have never been properly taught how and why to. As increasing awareness of variations in orientation and gender identity come into mainstream life, we as educators are tasked with educating students and residents (learners) on populations for which our own knowledge may be limited.
To best understand this discussion moving forward, it is useful to define some terms. Gender identity is one’s internal concept of self as male/female, neither, or a combination of both. A transgender person is a person whose gender identity is different from their biological gender assigned at birth (eg, an individual born a female with a male gender identity is a transgender man). Transgender is also an umbrella term that includes nonbinary or genderqueer persons. Genderqueer/nonbinary is a subtype of a transgender person who feels their gender identity cannot be described in a binary manner (ie, male or female).
Health and Health Care Disparities for Transgender and Gender Nonconforming Individuals
There are an estimated 1.4 million transgender individuals in the United States,1 many of whom do not seek regular medical care due to fear and stigma, among other societal reasons. In the National Transgender Discrimination Survey,2 28% of respondents reported postponing care due to discrimination based on gender identity, and 19% reported refusal of care. Lack of provider knowledge was reported by 50% of respondents, noting having to teach their providers about transgender care. And sadly, 41% reported attempting suicide at some point in their life. In our own community of Charleston, South Carolina, a tri-county survey of the metropolitan area of LGBTQ residents found that one in four had thought about suicide and 50% of noncisgender respondents reported that their doctors did not know their gender identity.3
Do students and residents know these startling statistics? We believe they care and want to. You may think this patient population is not likely to come to your practice, but most physicians will see transgender patients at some point. Students, residents, and other learners should hold us to account for not teaching this content well when we know they will see these patients.
Over the past couple of decades, our understanding about health risks and disparities experienced by gay and lesbian cisgender individuals has increased thanks to research and changes in societal norms such as marriage equality for same-gender couples. Yet large disparities remain. For example, HIV transmission rates remain highest amongst African American men who sleep with men.4 There is much left to do. Health care inequalities for transgender and gender nonbinary individuals are less widely known and are worse than those of their cisgender counterparts. In 2014 the CDC added gender identity questions to the Behavioral Risk Factors Surveillance System (BRFSS) and showed that gender-minority adults compared to cisgender adults were more likely to report fair/poor health, unmet medical care due to cost, being overweight, and symptoms of depression.5
Limitations in Education on Transgender and Gender-Nonbinary Health
In medical school curricula and postgraduate training, education on LGTBQ topics as a whole are limited.7,8 Teaching on transgender topics is even less established and often combined with LGB topics, though there are distinctly different sets of disparities and skills needed to address these patients. And this is not because providers are unwilling to see transgender patients. In one study of internal medicine residents, 97% believed in the value of learning comprehensive care skills for transgender patients, but only 45% had any prior education on these issues.8 Another study in 2018 surveyed general internal and family medicine clinicians working in a large Midwest integrated health system; 85.7% of respondents noted a willingness to provide care to transgender patients. And though there was likely a selection bias (53% response rate), respondents still noted barriers related to training and competence. Forty-eight percent reported lack of training as a barrier, and another 31% reported not feeling capable of providing routine care to transgender patients.9
What Educators and Programs Can Do
How best to teach and address transgender health in medical education is not well known. Studies are limited and there is no agreement on best practices. Being transgender or gender nonbinary is not a disease to study or a disorder to treat; it simply is. Yet there are pressing issues that nonbinary individuals face because of larger societal discrimination and lack of knowledge that relate directly to their health and their interactions with the health care system. The American Academy of Family Physicians offers curriculum guidelines on LGBT health for programs looking for resources and guidance on teaching this content,10 but such training is not mandatory by accrediting bodies. The days of a 1- or 2-hour didactic session on LGBTQ health should be a relic of the past. As educators, we should be more engaged to provide educational content and patient experiences with transgender and other gender minorities in a longitudinal, integrated approach whether or not it is currently required. Transgender health and health care issues should be addressed separately from issues of sexual orientation. Further, we must develop tools to measure educational outcomes and develop mechanisms to support research in this sort of specified curriculum development and evaluation. Lectures provide some short-term knowledge gains, but longitudinal assessments like objective structured clinical exams11 and direct clinical experience can provide more in-depth learning experiences.12
While eliminating health and health care disparities for transgender individuals will require structural changes at many levels of society, it is already within our power to ameliorate these disparities by implementing required curricula at all levels of medical education. If we fail to teach incoming generations of students and residents the terminology, culture, economic discrimination, and unique health needs of transgender and gender nonbinary people, we will inevitably allow barriers to their health care and poorer health outcomes to continue. We believe students and residents desire this education, and that patients deserve it. The time to provide it is now.
- Flores AR, Herman JL, Gates GJ, Brown TNT. How Many Adults Identify as Transgender in the United States? Los Angeles: Williams Institute; 2016.
- Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.
- Glenn C, Titus A, Stewart K, Giblin J, et al. Tri-county Area LGBTQ Community Needs Assessment. Charlston, SC: Alliance for Full Acceptance; 2019. https://www.affa-sc.org/wp-content/uploads/AFFA_AssessmentReport_2019_Singles.pdf. Accessed May 1, 2020.
- Centers for Disease Control and Prevention. HIV in the United States and Dependent Areas. 2020. https://www.cdc.gov/hiv/statistics/overview/ataglance.html. Accessed May 1, 2020.
- Streed CG Jr, McCarthy EP, Haas JS. Association between gender minority status and self-reported physical and mental health in the United States. JAMA Intern Med. 2017;177(8):1210-1212. https://doi.org/10.1001/jamainternmed.2017.1460
- Khalili J, Leung LB, Diamant AL. Finding the perfect doctor: identifying lesbian, gay, bisexual, and transgender-competent physicians. Am J Public Health. 2015;105(6):1114-1119. https://doi.org/10.2105/AJPH.2014.302448
- Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Adv Med Educ Pract. 2018;9(9):377-391. https://doi.org/10.2147/AMEP.S147183
- Johnston CD, Shearer LS. Internal medicine resident attitudes, prior education, comfort, and knowledge regarding delivering comprehensive primary care to transgender patients. Transgend Health. 2017;2(1):91-95. https://doi.org/10.1089/trgh.2017.0007
- Shires DA, Stroumsa D, Jaffee KD, Woodford MR. Primary Care Clinicians’ Willingness to Care for Transgender Patients. Ann Fam Med. 2018;16(6):555-558. https://doi.org/10.1370/afm.2298
- American Academy of Family Physicians. Recommended LGBT Curriculum Guidelines for Family Medicine Residents. AAFP Reprint No. 289D, 2016. Leawood, KS: AAFP. https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint289D_LGBT.pdf. Accessed May 1, 2020.
- Greene RE, Hanley K, Cook TE, Gillespie C, Zabar S. Meeting the primary care needs of transgender patients through simulation. J Grad Med Educ. 2017; 9(3): 380–381. https://doi.org/10.4300/JGME-D-16-00770.1
- Park JA, Safer JD. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: a key addition to the Boston University Model for Teaching Transgender Healthcare. Transgend Health. 2018;3(1):10-16. https://doi.org/10.1089/trgh.2017.0047