Affirming and Inclusive Care Training for Medical Students and Residents to Reducing Health Disparities Experienced by Sexual and Gender Minorities: A Systematic Review

Nursing students and role modeled behavior while caring for LGBTQ + people: a cross-sectional, descriptive study

BACKGROUND

While efforts to improve the educational preparedness of nurses to care for lesbian, gay, bisexual, transgender, and queer (LGBTQ +) people have increased, the influence of role-modeled behaviors by healthcare professionals working with nursing students and recent graduates is not well understood. The purpose of this study is to describe the role-modeled behaviors of healthcare professionals observed by nursing students and recent graduates caring for LGBTQ + patients in clinical settings.

METHODS

A cross-sectional, online survey was conducted. Recruitment of nursing students who had completed one or more clinical rotations or were recent graduates (≤ 2 years) was performed through university emails and social media. Items included measurement of stigmatizing attitudes, observed stigmatizing behaviors, and ability to provide inclusive/affirming care for LGBTQ + patients. Open-text items prompted participants to describe observed behaviors. Data were analyzed using descriptive statistics and Wilcoxon signed rank sum tests to evaluate differences between LGB (lesbian, gay, bisexual) and T + (transgender and gender diverse) subscales. Open-text responses were analyzed using thematic analysis to identify relevant themes.

RESULTS

Participants (N = 73) had a low level of stigmatizing attitudes toward LGBTQ + people (M = 1.8, SD = 0.4), although higher stigmatizing attitudes toward T + people were reported (M = 3.0, SD = 0.2; Z = -7.254, p < .001). Half of the participants reported that they observed LGBTQ + stigmatizing behaviors role-modeled by two + healthcare professional roles; approximately one-third of participants personally engaged in one + LGBTQ + stigmatizing behaviors, most commonly toward T + people. Themes from participants' examples of observed stigmatizing behaviors included: cis-heteronormative bias, non-affirmation of chosen name/pronouns, outing patients, and rejected competency.

CONCLUSIONS

The majority of participants described observing stigmatizing behaviors toward LGBTQ + people in clinical settings. Poorer attitudes and a higher frequency of stigmatizing behaviors observed towards T + people point to deficits in healthcare provided to T + people in particular. Efforts to address LGBTQ + stigma in healthcare should be expanded to include clinical settings to address role-modeled behaviors and socialization of nurses.

Online learning modules improve confidence in providing gender affirming care for youth

PURPOSE

Healthcare providers often lack training and education in caring for gender diverse youth. We aimed to explore changes in provider confidence and behaviors following the implementation of an online learning course focused on gender affirming care for youth.

METHODS

An asynchronous, online training consisting of 2 modules was made available in October 2021. Participants were asked to complete 3 surveys for each module they completed: a pre-survey, a post-survey, and a 3-month follow-up survey. Surveys included demographic data and an assessment of provider confidence and self-reported behaviors related to the provision of gender affirming care for adolescents that were in line with the objectives outlined in each module. Paired sample t-tests were used to compare participant confidence at all timepoints.

RESULTS

Participants (n = 487) completed at least one survey from one module. There was notable diversity in provider types, including mental health providers (n = 86, 17.7%), community health workers (n = 71, 14.6%), and medical students or health professionals (n = 61, 12.5%). Participants were significantly more confident in all aspects of care provision when comparing pre-surveys and post-surveys (p < 0.001 for all survey items focused on change in provider confidence ). At 3-month follow-up after module completion, improvements in confidence were sustained in providing information and resources to adolescents and their families, and having conversations with them about gender identity along with the importance of using affirming language. However, these modules did not result in self-reported behavior change regarding provision of gender affirming hormones or puberty blockers.

CONCLUSIONS

Online learning modules may be an effective means of educating a large number of healthcare providers about caring for gender diverse youth in a variety of settings and across disciplines.

Provider preparedness to care for sexual and gender minority adolescent and young adult cancer patients: A scoping review

Objective

The purpose of the current scoping review is to explore knowledge and gaps in the literature on the preparedness of health care providers (HCPs) to deliver cancer care that addresses the needs of sexual and gender minority (SGM) adolescent and young adult (AYA) patients diagnosed with cancer between ages 15-39 years.

Methods

We conducted two comprehensive searches on OVID MEDLINE, PsycINFO, and CINAHL in February 2022 and June 2024; examined the empirical literature on HCPs who treat SGM AYA cancer patients; characterized existing research; and evaluated each contribution.

Results

A total of thirteen articles were included in the final review. The reviewed studies varied widely in sample sizes (n = 6 to n = 1253), reflecting different methodological approaches: quantitative cross-sectional (n = 3), qualitative (n = 4), and mixed methods (n = 6).

Innovation

The current scoping review piloted an innovative Quality Assessment (QA) Tool of Foundational Progress for SGM AYA Research to assess the quality of evidence, providing a new framework for evaluating and guiding future research.

Conclusion

The existing literature on provider preparedness to care for SGM AYA cancer patients is limited. Future studies are critically needed to improve providers' ability to holistically respond to the unique health care needs and concerns of this population.

Beyond stigma: Clinician bias in contraceptive counseling to sexual and gender minority youth

OBJECTIVES

Sexual and gender minority (SGM) youth experience disparities in sexual and reproductive health; however, little is known about how clinicians engage in contraceptive counseling with this patient population. This study describes pediatric clinician patterns and biases in contraceptive counseling with SGM youth.

STUDY DESIGN

We conducted 16 in-depth interviews with a convenience sample of clinicians who counsel adolescents on contraception. Participants were recruited and interviewed in-person at the American Academy of Pediatrics National Conference in October 2022. We used codebook thematic analysis.

RESULTS

When discussing contraceptive counseling among SGM youth, three major themes emerged: (1) participants' acceptance of SGM youth identities varied from support to suspicion and rejection; (2) participants' conceptualizations of their SGM youth patients' identities circumscribed the scope of the contraceptive care they provided; and (3) participants described using a universal approach to contraceptive counseling that disregarded the relevance of SGM youth identities. For transgender patients, many clinicians focused on menstrual regulation and overlooked potential pregnancy risk. When discussing sexual minority patients, clinicians overemphasized pregnancy prevention and encouraged the use of highly effective contraceptive methods rather than taking a shared decision-making approach to contraceptive care.

CONCLUSIONS

Many clinicians demonstrated bias in approaches to contraceptive care provision to SGM youth patients by holding patients accountable to normative assumptions in transgender medicine and family planning. Training and support for adolescent-facing clinicians in bias recognition and comprehensive contraceptive care are necessary to provide person-centered reproductive health care to SGM youth.

IMPLICATIONS

This qualitative study of pediatric clinicians' self-reported contraceptive care delivery revealed limited acceptance of sexual and gender minority youth identities and biased assumptions about which patients may need or desire specific contraceptive methods. Such practices overlook clinically-relevant differences among pediatric patients.

Embracing Spectrum: Celebrating LGBTQIA+ Journeys in Aesthetic Medicine: A Kaleidoscope of Identity

PURPOSE

This synaptic systemised review critically examines the provision of aesthetic medical care to LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more) individuals, assessing both the clinical practices and the educational frameworks that guide interactions with LGBTQIA+ patients in aesthetic settings.

METHODS

Following PRISMA-S guidelines, a comprehensive review was conducted, initially identifying 159 potentially relevant articles. Upon stringent full-text review, 33 studies met the inclusion criteria and were subject to an in-depth thematic analysis. The scope encompassed qualitative studies, quantitative analyses, and a cross section of interdisciplinary research, predominantly from Western settings.

RESULTS

The analysis distilled four principal themes: the imperative of identity affirmation in aesthetic interventions, substantial barriers to inclusive and empathetic care, the critical need for patient empowerment, and the existing deficiencies within medical education regarding LGBTQIA+ care. These themes highlight a complex interplay between the clinical aspirations of LGBTQIA+ individuals and the current capacity of aesthetic medicine to cater to this diversity.

CONCLUSIONS

There is a pressing need for a paradigmatic shift towards more inclusive, competent, and sensitive aesthetic medical care for LGBTQIA+ patients. It underscores the necessity of reform in medical education and advocates for policy changes that promote a more equitable healthcare environment. This research serves as a call to action, emphasizing the ethical imperative to integrate comprehensive LGBTQIA+ care competencies into aesthetic medicine curricula and practice.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Scoping Review on the Impact of COVID 19 on Vulnerable Populations: LGBTQ+ Persons, Persons Experiencing Homelessness, and Migrant Farm Workers in the US

Purpose

The goal of the National Center for Medical Education Development and Research Center (NCMEDR) is to support the education and training of medical students in the care of vulnerable populations. Access to primary care services in the US is fundamental to the health and wellness of all people regardless of their socioeconomic status. LGBQ+ persons, (lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority), Persons Experiencing Homelessness (PEH), and Migrant Farm Workers (MFW) are among the most underserved, marginalized, and socially vulnerable groups in the US. NCMEDR in the Department of Family and Community Medicine at Meharry Medical College was established in part, with funding from the Department of Health and Human Services (DHHS) and the Health Resources and Services Administration (HRSA). NCMEDR was developed to provide educational pathways for transforming medical education and clinical practice in the US by ascertaining whether medical students were being trained to provide primary care, and behavioral health services to LGBTQ+ persons, PEH, and MFW. Here we focus on the impact of the COVID-19 pandemic on these specific populations because they represent marginalized groups that have been heavily impacted by the pandemic, have poor social determinants of health (SDOH), and are more likely to be uninsured, and are less likely to engage primary care providers outside of emergency room care.

Methods

In this study, a scoping literature review was conducted to assess the impact of COVID-19 on primary care of LQBTQ+ persons, PEH, and MFW.

Results and Discussion

The pandemic provided a serious health disparities gap for the defined vulnerable populations under review by the NCMEDR. The pandemic identified the need for transformative measures for clinical practices, medical education, and health care policies required for implementation to improve health care for vulnerable groups. We make recommendations for interventions with defined populations that may influence clinical, environmental health, and SDOH in the COVID era.

Conclusions

The COVID pandemic directed the need for medical schools, health care and social organizations to intervene in new and different ways in vulnerable and marginalized communities. The recommendations provide a model for advancing health equity, access, quality, utilization, care coordination, and treatment.

Practice Makes Perfect: Objective Structured Clinical Examinations Across the UME-to-GME Continuum Improve Care of Transgender Simulated Patients

Background Residents lack confidence in caring for transgender individuals. More exposure and practice throughout training is needed. Objective To explore whether and how prior exposure to transgender health skills during medical school impacted competency with these skills during residency. Methods In 2022, all 101 internal medicine residents at New York University Grossman School of Medicine participated in an objective structured clinical examination (OSCE) station as part of their annual formative assessment where they cared for a standardized patient (SP) who identified as transgender. Three SPs who were members of the transgender community were recruited through online and social media forums. Two resident groups (continuum vs noncontinuum) differed in their prior experiences with transgender OSCEs during medical school. We analyzed SPs' ratings of resident performance using checklist data and SP open-ended feedback to compare performance between groups and resident post-OSCE evaluations to understand residents' perceptions of the educational value of the case. Results Residents with prior experience with transgender SPs (continuum) were more frequently recommended by SPs (88% [21 of 24] vs 70% [54 of 77]) to a family member or friend, were all rated professional (100% [24 of 24] vs 94% [72 of 94]) and scored better in pain information-gathering (92% vs 65%, mean summary score) and gender-affirming care skills (67% vs 52%, mean summary score). Noncontinuum residents lacked experience, missed opportunities to ask about gender identity, and needed work on demonstrating comfort and using proper language. Most residents completing a post-OSCE evaluation (80%, 41 of 51) rated the case as "very valuable." Conclusions Spaced practice and feedback through early exposure to transgender OSCEs were valuable for skill acquisition, giving continuum residents a learning advantage compared to noncontinuum residents.

Improving Family Medicine Residents' Provision of Gender-Affirming Care

BACKGROUND AND OBJECTIVES

Family physicians are uniquely poised to provide gender-affirming care (GAC) to transgender and nonbinary patients, but current undergraduate and graduate medical education in this field is lacking. Little is known about the impact of various GAC curricula on the clinical care provided by resident physicians. We aimed to assess the efficacy of a multimodal educational framework on the quality of GAC provided by residents at a large academic family medicine program.

METHODS

This pilot study used chart review to assess the impact of a multifaceted educational intervention around GAC in an academic family medicine practice. Components included faculty-specific didactics, resident feedback and didactics, standardized note templates, and compiled resources. We completed pre- and postintervention analysis of resident-led GAC encounters using a novel rubric based on standards of care and compared these results using descriptive statistics.

RESULTS

Following a multimodal educational intervention, residents demonstrated improvement in multiple domains of gender-affirming care, including documenting informed consent, counseling on pregnancy and contraception, and laboratory monitoring for patients initiating gender-affirming hormone therapy.

CONCLUSIONS

This widespread improvement suggested that a multimodal approach to resident and faculty education may help enhance the quality of GAC provided by family medicine residents. Chart review offers a feasible and effective method for identifying gaps in resident knowledge and documentation in GAC. Further research should specifically explore faculty development in this area and expanded patient-centered quality metrics and outcomes that encompass GAC.

ECHO "Bootcamp": An Innovative Training Model to Onboard Providers in the Care of Gender Diverse Patients

Purpose: Extension for Community Health Outcomes (ECHO) is a model of continuing medical education meant to connect academic medical center-based specialists with community providers to increase capacity in managing complex health conditions. The purpose of this study was to evaluate the effectiveness of a shortened "bootcamp" ECHO model in increasing participant competence with topics related to transgender and gender diverse (TGD) health care and the impact of "bootcamp" participation on enrollment in an ongoing ECHO series. Methods: An ongoing monthly ECHO series was instituted on topics of TGD health. After 2 years, the team implemented a four-session "bootcamp" for four consecutive weeks during March 2022 to introduce foundational topics for new participants who had joined or were considering joining the ongoing series. Qualitative and quantitative results were collected from self-reported pre-/post-surveys as well as from in-session quizzes. Results: There were 71 participants in the "bootcamp" including health care providers and support staff. Attendees reported a 10.3% increase (p = 0.02) in self-reported comfort providing care to transgender patients. Pre-/post-knowledge improved in areas of health inequities (50% vs. 74% correct pre/post), surgical requirements (33% vs. 74%), and effects of masculinizing (55% vs. 70%) and feminizing (64% vs. 89%) hormone therapy. Prescribing providers reported a significant change across four areas of practice competency. Among 71 "bootcamp" participants, 15 registered for the ongoing program. Conclusion: Use of a "bootcamp" highlights ways to increase participant comfort and knowledge in providing TGD health care in a shortened timeframe and recruit new participants to an ongoing ECHO curriculum.

Military Family Physicians' Readiness to Provide Gender-Affirming Care: A Serial Cross-Sectional Study

PURPOSE

Family physicians are increasingly more likely to encounter transgender and gender-diverse (TGD) patients requesting gender-affirming care. Given the significant health inequities faced by the TGD community, this study aimed to assess changes in military-affiliated clinicians' perspectives toward gender-affirming care over time.

METHODS

Using a serial cross-sectional survey design of physicians at the 2016 and 2023 Uniformed Services Academy of Family Physicians conferences, we studied participants' perception of, comfort with, and education on gender-affirming care using Fisher's Exact tests and logistic regression.

RESULTS

Response rates were 68% (n = 180) and 69% (n = 386) in 2016 and 2023, respectively. Compared to 2016, clinicians in 2023 were significantly more likely to report receiving relevant education during training, providing care to >1 patient with gender dysphoria, and being able to provide nonjudgmental care. In 2023, 26% reported an unwillingness to prescribe gender-affirming hormones (GAH) to adults due to ethical concerns. In univariable analysis, female-identifying participants were more likely to report willingness to prescribe GAH (OR = 2.6, 95%CI = 1.7-4.1) than male-identifying participants. Willingness to prescribe was also associated with ≥4 h of education (OR = 2.2, 95%CI = 1.1-4.2) compared to those with fewer than 4 h, and those who reported the ability to provide nonjudgmental care compared to those who were neutral (OR = 0.09, 95%CI = 0.04-0.2) or disagreed (OR = 0.11, 95%CI = 0.03-0.39). Female-identifying clinicians were more likely to agree additional training would benefit their practice (OR = 5.3, 95%CI = 3.3-8.5).

CONCLUSIONS

Although military-affiliated family physicians endorsed more experience with and willingness to provide nonjudgmental gender-affirming care in 2023 than 2016, profound gaps in patient experience may remain based on the assigned clinician. Additional training opportunities should be available, and clinicians unable to provide gender-affirming care should ensure timely referrals. Future research should explore trends across clinical specialties.

Beliefs and Intentions of Anesthesia Physicians Toward Providing Culturally Competent Care to Transgender Patients

Purpose

Anesthesiologists have limited relationships with their patients before delivering care and have little time for patient interactions. Yet, they should possess the knowledge and skills to treat all patients in an equitable, culturally competent manner, including transgender patients. The study's purpose was to determine behavioral factors influencing culturally competent care by anesthesia physicians with transgender patients.

Methods

A two-phase design was utilized in 2020 to examine the attitudes, subjective norms, and perceived behavioral control of anesthesia physicians, both in training and practicing independently. Phase 1 allowed exploration of themes related to facilitators and barriers of the provision of culturally competent care to transgender patients. Phase 2 involved the creation and deployment of a 51-question survey informed by phase 1 to 100 anesthesia physicians at a single academic medical center in the southeastern United States.

Results

Thematic analysis was performed on results from the phase 1 elicitation survey, which informed the creation of the survey for phase 2. One hundred phase 2 surveys were distributed, with a 70% response rate. Analyses were conducted to determine the largest influence of intent to interact with transgender patients in a culturally competent manner, as well as to establish the reliability of the tool.

Conclusion

Attitude followed by subjective norms were positive influencers of intent, while lack of knowledge was a negative influencer. Strengthening attitudes and subjective norms, while implementing programs to increase knowledge, competence, and humility, would be goals for future studies and actions toward improving healthcare of transgender individuals.

Promoting Sexual and Gender Minority Health Clinical Skills Training for All Medical Students

Despite societal, legal, and cultural improvements in their well-being, sexual and gender minority (SGM) people in the United States still face substantial physical and mental health disparities that are exacerbated by physician stigma and lack of training. Although there have been efforts at medical schools nationwide to address these disparities and interweave SGM health education into existing preclerkship courses, opportunities to practice related clinical skills during the clerkship years remain largely elective. Furthermore, national survey data from 2020 indicate that SGM Americans continue to delay or avoid medical care because of physician discrimination. By providing predominantly opt-in opportunities for hands-on SGM health clinical training, educators risk perpetuating existing structural inequities and widening health disparities. In this article, the authors advocate for required SGM health clinical training for all undergraduate medical students, regardless of intended specialty. They highlight 3 types of elective SGM health clinical training models currently in use at medical schools across the country, including student-run clinics, advanced electives, and longitudinal scholarly concentrations. Using these examples, the authors then outline ways that educators can interweave required SGM health clinical training into undergraduate medical education, including with the recruitment and retention of SGM faculty, staff, and students; required SGM standardized patient experiences; the integration of SGM clinical opportunities throughout the core clerkships; and partnerships with SGM health centers. Using these methods, medical schools can mobilize passionate students, faculty, and leaders to both counter the bigotry and hate faced by SGM populations and develop innovative strategies to improve SGM patient health outcomes and expand opportunities for SGM health scholarship.

Trends in transgender healthcare curricula in graduate medical education

Background

Recent studies have shown deficiencies in resident knowledge concerning transgender healthcare. However, there has not been an updated survey examining transgender healthcare training by medical residency directors. We assessed whether accredited residency programs in the United States and Canada were providing education on the healthcare needs of transgender patients.

Methods

We performed an exploratory descriptive survey study in 2022 of residency programs in the United States and Canada to assess residency education on transgender health using program directors listed in the website directory of the Accreditation Council for Graduate Medical Education.

Results

Out of 1680 residency program directors, 160 programs responded (response rate, 10%). Among the residency programs, education in transgender health was taught periodically throughout the curriculum (52.5%), in discrete modules (34.4%), or not taught at all (10.6%). However, 60% of residency program directors who responded reported that their program lacked any clinical rotation in which residents directly work with transgender patients. The most common areas of transgender care omitted from residency education on transgender health were barriers associated with chronic illness and mental health.

Conclusion

There remains a need for robust transgender medical training in residency programs through clinical rotations on transgender health.