Effectiveness of an Educational Intervention to Improve Medical Student Comfort and Familiarity With Providing Gender-Affirming Hormone Therapy

An estimated 1 million American adults identify as transgender and/or gender nonconforming (TGNC), representing 0.4% to 0.6% of the US population.1 Gender-affirming hormone therapy (GAHT) uses hormones to align secondary sex characteristics and gender identity. GAHT is a basic intervention sought by TGNC patients and is well within primary care providers’ scope of care.2 Primary care physicians can offer TGNC patients GAHT after informed consent in the outpatient setting without need for psychiatric or endocrine referral.4 However, physicians have been found to be reluctant to initiate or manage GAHT due to a lack of medical knowledge and training.3

Medications used in GAHT are commonly prescribed in the outpatient setting for other indications. Physicians first encounter these medications in the preclinical years. To effectively manage GAHT, physicians must receive adequate education on providing competent hormone care. Numerous studies have demonstrated preclinical training on the socially competent care of TGNC leads to better student understanding and comfort with TGNC patients.4-6 However, few studies have examined the effectiveness of educational interventions aimed at improving medical students’ comfort and familiarity with GAHT. In this study, we examined whether a 1-hour didactic and interactive lecture on GAHT could improve medical student comfort and familiarity with providing GAHT.

The University of Minnesota Institutional Review Board deemed this study exempt. We developed a 1-hour didactic and interactive lecture on GAHT (Appendix 1). The didactic portion of the lecture focused on the following objectives: (a) the scope of practice required to provide gender-affirming hormone therapy; (b) an informed consent model of care; and (c) the medical management of masculinizing and feminizing hormone therapy, including dosing of relevant medications (Table 1). The interactive portion of the lecture consisted of actors role-playing an office visit in which a physician initiated GAHT. The interactive lecture was designed to be stopped periodically so that audience members could be tested on concepts introduced, emulating real-time clinical decision-making.

One week prior to the optional lecture, an email announcement was sent to all second-year medical students at the University of Minnesota. Participants were given identical surveys that addressed self-perceived preparedness and comfort with learning objectives using a 5-point Likert scale (Appendix 2). The surveys were anonymous. We calculated pre- and postintervention mean scores and standard error for each survey item and then used a 2-tailed paired t test to determine significant differences between pre- and postintervention mean scores. To account for the multiple testing of the six survey items, a Bonferroni correction procedure was applied and P values were multiplied by six. We used an a of 0.05 to determine statistical significance.

Among 263 second-year medical students, all 54 (20.5%) who attended the lecture completed surveys. None of the surveys were omitted due to missing data or nonresponse. Comparing pre- and posttest survey responses, participants reported a significant increase in familiarity with GAHT dosing (mean change in response score=2.5±0.60, P<.001), common medications used in GAHT (2.3±0.21, P<.001), the use of informed consent in clinic to initiate GAHT (1.8±.20, P<.001), their confidence in finding resources to provide GAHT (1.6±.19, P<.001), providing GAHT in the primary care setting (1.4±.19, P<.001) and the difference between a legal and chosen name (0.4±.13, P<.017) after the intervention (Table 2).

Our single-institution study found that a didactic and interactive lecture on GAHT for second-year medical students resulted in significant increases in student comfort and familiarity with GAHT, including chosen names, the concept of GAHT in a primary care setting, use of informed consent to start GAHT, and the use and dosing of common medications used in GAHT. Topics discussed during the lecture, particularly the use of certain medications including spironolactone, testosterone, and GnRH agonists, were well-aligned with concepts introduced in existing endocrinology and renal curriculum and required only 1 hour of teaching time.

Our findings align with previous studies demonstrating increased trainee comfort with providing care to TGNC patients after an educational intervention.4-6 However, this study uniquely demonstrates increased trainee familiarity with GAHT, a basic element in the medical care of TGNC patients.

Participants reported significant growth surrounding their comfort with the use of medications used in GAHT and their dosing, suggesting participants were not aware which medications are used in GAHT but felt familiar after the intervention. Dosing is not routinely covered during preclinical years. However, students reported understanding the concept of dosing after the intervention. Participants felt comfortable with the difference between chosen and legal names before the intervention but there was still a significant increase in understanding after the intervention. Relatively high participant familiarity with naming could be attributed to prior education and exposure.

Our study had several limitations. This was a single-institution study with a small sample size, which limits the validity of our results. The study is likely subject to selection bias, as the lecture was optional and participants may have differences in baseline knowledge and motivation to learn about GAHT compared with nonparticipants. Further studies are needed to investigate the impact of educational interventions on actual trainee clinical performance using standardized measures and appropriate control groups.

Changes to medical school curricula are difficult given limited time for didactics in the preclinical years. We find that a 1-hour interactive lecture on GAHT increases medical students’ perceived familiarity and comfort with gender-affirming care in the primary care setting, use of informed consent to initiate GAHT, pharmacological management of GAHT, and chosen names. The elements of our curriculum could be introduced within an endocrinology unit or integrated into a more comprehensive LGBT+ curriculum. While the curriculum was designed for second-year medical students, certain elements may be adaptable for other trainees. Our findings demonstrate the feasibility of integrating GAHT into preclinical curriculum and can be used by other programs to build a holistic preclinical curriculum.