Improving Family Medicine Residents’ Provision of Gender-Affirming Care

Transgender and nonbinary (TGNB) individuals experience marked health disparities compared to the general population, reflecting a complex network of extrinsic factors including discrimination, chronic traumatic stress, and limited health care access.^1-3 Multiple studies have demonstrated that gender-affirming care (GAC) improves TGNB patients’ physical and mental health. ⁴ As practitioners of comprehensive, lifelong care across diverse settings, family physicians are uniquely poised to expand access and promote equity by providing GAC within their communities. ⁵

Like any medical treatment, GAC may introduce clinical and psychosocial harm if provided without adequate training; training is particularly critical given the layers of marginalization faced by TGNB individuals. ^{1, 3} Because of the long-standing exclusion of TGNB experiences from medical education, ⁶ both new and experienced providers may lack the necessary skills to provide GAC safely, effectively, and confidently. ^{7, 8}

Medical education has begun addressing these gaps. A 2022 review identified 36 medical education studies on sexual and gender minority health, with six exclusive to resident education.⁹ In 2020, more than half of family medicine residency program directors reported including GAC in their curricula, typically via didactic sessions. ¹⁰ However, little data exist on the scope and efficacy of these curricula, such as correlation between performance on postdidactic knowledge assessments and quality of care provided. Furthermore, while lack of faculty expertise is recognized as a barrier to resident education in GAC, research on faculty development is lacking. ⁹ To that end, a 2022 study at a family medicine residency used retrospective chart review to assess providers’ adherence to GAC guidelines during clinical encounters with TGNB patients.¹¹ This technique enabled the authors not only to assess GAC as a clinical competency but also to measure the effectiveness of their intervention.

While a growing number of our program’s residents have elected to provide GAC for adult patients in their continuity panels, relatively few of our faculty currently provide GAC. This discrepancy presents a critical opportunity to pilot and assess a multimodal educational intervention for improving provision of GAC among family medicine residents. Building on the work of Urlich et al, ¹¹ we developed a novel pre- and postintervention chart review rubric to directly evaluate our intervention’s impact on quality of care and documentation within resident-led GAC encounters.

This pilot study was conducted at a large, university-affiliated family medicine residency program and comprised the development and implementation of a multifaceted GAC educational intervention, along with pre- and postintervention chart review.

Between January and May 2023, a small group of residents and faculty with professional GAC experience and lived experience within the LGBTQ+ community (including one TGNB-identifying provider) implemented an original, multifaceted GAC educational intervention (Table 1 ). Faculty attended a mandatory 90-minute didactic consisting of a lecture and case-based discussions. All residents, who had participated in a mandatory 2-hour GAC didactic earlier in the year, received an e-mail with compiled feedback on gaps identified during preintervention chart review. We also held two optional educational sessions for residents and faculty covering more advanced GAC topics and an optional 1-hour presentation on creating an affirming clinic environment.

Additionally, we developed and distributed multiple documentation templates for GAC visits, including suggested questions for new patients, standard language for hormone counseling and informed consent, and reminders about contraception, monitoring labs, medication dosing, and follow-up intervals. Lastly, we compiled dosing guidelines, counseling guides, and educational handouts into a physical binder in the residents’ workspace as well as distributed this information electronically to all resident/faculty providers.

We reviewed all resident-led GAC encounters at our central resident clinic site from January 2023 (preintervention) and May 2023 (postintervention) using an Epic (Epic Systems Corp) report of all visits associated with gender dysphoria and related diagnoses (ICD F64.0). For each January encounter, we also evaluated any other GAC encounters between that same resident and patient dating back to July 2022. We reviewed a total of 32 charts preintervention and 25 postintervention, from a total of 12 residents.

We developed a rubric to assess each encounter against GAC standards from the World Professional Association for Transgender Health and the University of California at San Francisco.^{12, 13} Rubric components included documentation of informed consent, gender dysphoria criteria, chosen name/pronouns, pregnancy risk and/or contraception (for patients assigned female at birth [AFAB]), appropriate lab orders, medication dosing, health maintenance, and timing of follow-up visits. Given our small number of participants, we compared pre- and postintervention data for each component using only descriptive statistics. Because we conducted this study as a quality improvement project, our institution’s Institutional Review Board (IRB) determined that IRB approval was not necessary.

Preintervention chart review revealed several knowledge and documentation gaps. Only three of 17 new patient encounters documented verbal or written consent prior to hormone initiation (17.6%; Figure 1). For AFAB patients, less than half of encounters (45%, n=20) included documentation of pregnancy risk and/or contraception use. Additionally, more than half of patients received unnecessary labs prior to initiation of testosterone (55%, n=11) and estrogen (60%, n=5; Figure 2).

Postintervention chart review demonstrated improvement across nearly all domains. All postintervention encounters appropriately documented patient name (n=25), pronouns (n=25), and informed consent prior to hormone initiation (n=7). Documentation of pregnancy risk and/or contraception for AFAB patients improved from 45% to 82%. Collection of appropriate baseline labs improved from 60% to 100% for Estradiol-associated encounters and from 45% to 75% for testosterone. Collection of appropriate follow-up labs remained consistent at 100% for Estradiol and improved from 70% to 89% for testosterone. The percentage of lab results within an appropriate range was consistently high pre- and postintervention.

Unlike traditional knowledge assessments, chart review may objectively assess how residents translate knowledge into practice. Our documentation templates were likely a major driver of improvement in appropriate medication dosing, lab monitoring, consent documentation, and other rubric domains by reinforcing knowledge from prior didactics. With this said, we acknowledge that quality of documentation does not always reflect quality of care, particularly when using prewritten templates. Furthermore, our evaluation approach does not assess interpersonal communication, physical exam techniques, or other skills requiring direct observation.

Additionally, our study population constituted a self-selected subgroup of residents who choose to provide GAC within their continuity clinic, limiting generalizability to all family medicine residents. This limitation reflects the practical reality that until GAC is mandatory within family medicine training, it will be provided predominantly by those with a special interest in this care. We have withheld demographic information regarding our 12 resident participants to preserve confidentiality given our small number of participants.

We look forward to expanding this single-site intervention into a full-fledged GAC curriculum for residents and faculty preceptors across all of our department’s practice sites. We plan to evaluate current and future participants longitudinally using chart review, traditional knowledge assessments, and direct clinical observation by faculty experienced in GAC, while soliciting resident, faculty, and patient feedback regarding specific intervention components.

Like many residency programs, we are navigating new educational frontiers in GAC. Despite prior didactics, our preintervention chart review identified multiple knowledge and documentation gaps, which largely improved following our multimodal educational intervention. We are excited by the potential of this intervention, along with our innovative evaluation rubric, to expand the workforce of clinicians providing high-quality GAC in service of a more inclusive, equitable future for our learners and patients alike.