The Irrelevance Narrative: Queer (In)Visibility in Medical Education and Practice

LGBTQ+ health education for medical students in the United States: a narrative literature review

INTRODUCTION

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and other sexual/gender minorities (LGBTQ+) may experience discrimination when seeking healthcare. Medical students should be trained in inclusive and affirming care for LGBTQ+ patients. This narrative literature review explores the landscape of interventions and evaluations related to LGBTQ+ health content taught in medical schools in the USA and suggests strategies for further curriculum development.

METHODS

PubMed, ERIC, and Education Research Complete databases were systematically searched for peer-reviewed articles on LGBTQ+ health in medical student education in the USA published between 1 January 2011-6 February 2023. Articles were screened for eligibility and data was abstracted from all eligible articles. Data abstraction included the type of intervention or evaluation, sample population and size, and key outcomes.

RESULTS

One hundred thirty-four articles met inclusion criteria and were reviewed. This includes 6 (4.5%) that evaluate existing curriculum, 77 (57.5%) study the impact of curriculum components and interventions, 36 (26.9%) evaluate student knowledge and learning experiences, and 15 (11.2%) describe the development of broad learning objectives and curriculum. Eight studies identified student knowledge gaps related to gender identity and affirming care and these topics were covered in 34 curriculum interventions.

CONCLUSION

Medical student education is important to address health disparities faced by the LGBTQ+ community, and has been an increasingly studied topic in the USA. A variety of curriculum interventions at single institutions show promise in enhancing student knowledge and training in LGBTQ+ health. Despite this, multiple studies indicate that students report inadequate education on certain topics with limitations in their knowledge and preparedness to care for LGBTQ+ patients, particularly transgender and gender diverse patients. Additional integration of LGBTQ+ curriculum content in areas of perceived deficits could help better prepare future physicians to care for LGBTQ+ patients and populations.

Seeing the invisible: extracurricular learning processes and learning outcome as experienced by student volunteers accompanying persons in a socially vulnerable situation to healthcare appointments-an ethnographic study

Becoming a healthcare professional is a complex process, where learning occurs in various ways. This study explores an extracurricular learning approach, called the Social Health Bridge-Building Programme, designed to address health inequities. Student volunteers accompany persons in a socially vulnerable situation to healthcare appointments. Operating outside the realms of health education, the programme intends to provide an alternative road to training healthcare students to become capable of engaging with diverse populations, and reducing barriers to healthcare access. Based on an ethnographic fieldwork, using interviews and participant observation ("walking along") as methods, the aim of the study was to explore the learning processes and learning outcomes associated with bridge-building, as experienced by students. Our findings show that this extracurricular learning complemented the formal curriculum, and bridged the gap from theoretical knowledge to practice and to real persons, preparing students for their future roles. The particular positioning of walking alongside or sitting beside persons made the invisible visible, enabling student volunteers to see the variety of persons in need of bridge-building, ways of living in a socially vulnerable situation, inequity in health, and see the persons, beyond initial impression, fostering a deeper understanding and empathy among the students. Learning outcomes included communicational, relational, and observations skills, and a more comprehensive grasp of the healthcare system's complexity. We conclude that a non-governmental organization, independent of the healthcare system, may have found a novel way of providing extracurricular learning about health inequity to students. Demonstrating how the Social Health Bridge-Building Programme complements formal curricula, the concept could be applicable in other settings.

'I'm looking as white and as straight as possible at all times': a qualitative study exploring the intersectional experiences of BAME LGBTQ+ medical students in the UK

OBJECTIVES

The positive formation of professional identity is considered crucial in how medical students begin to feel and act as clinicians. Although, awareness of how Professional Identity Formation (PIF) may be affected among minoritised groups is increasing, understanding from an intersectional lens remains limited. The aim of this study was to explore the experiences of Black, Asian, Minoritised Ethnic (BAME) and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) medical students in the undergraduate Bachelor of Medicine, Bachelor of Science programme.

DESIGN

Based on the methodology of phenomenography, all medical students identifying as BAME and LGBTQ+ were eligible for participation. Semistructured interviews were conducted with data collection continuing until theoretical saturation was reached. The coding framework was developed independently by the principal researcher and supervisor before being compared to create a shared analytical framework.

SETTING

University College London Medical School (UCLMS) between October 2022 and February 2023.

PARTICIPANTS

Six UCLMS students were recruited, one of whom was in the 'early' years (years 1-3) with the remainder in the 'later' years (years 4-6) RESULTS: Six main themes emerged from the data, which were categorised into three main areas: challenges to intersectionality, benefits to intersectionality and protective factors. Challenges to intersectionality included three themes, 'The BAME identity interacting with the LGBTQ+identity', 'BAME background influencing LGBTQ+identity exploration' and 'no true safe spaces for BAME and LGBTQ+ students to be themselves'. Benefits to intersectionality included 'greater insight into the self' and protective factors included two themes of 'peer support networks' and 'visibility within the university and clinical environments.'

CONCLUSION

By exploring PIF among medical students from an intersectional lens, this study highlights the increased emotional burden faced by those who identify as BAME and LGBTQ+, as they attempt to reconcile both these identities with becoming a future doctor, affecting their sense of belonging socially and within the profession. Despite being based at a single medical school, it highlights the importance of creating a truly inclusive environment through positive role modelling and increased visibility among the BAME, LGBTQ+ community in the undergraduate programme.

Queer(ing) medical spaces: queer theory as a framework for transformative social change in anesthesiology and critical care medicine

Queer theory is a disruptive lens that can be adopted by researchers, educators, clinicians, and administrators to effect transformative social change. It offers opportunities for anesthesiologists, critical care physicians, and medical practitioners to more broadly understand what it means to think queerly and how queering anesthesiology and critical care medicine spaces improves workplace culture and patient outcomes. This article grapples with the cis-heteronormative medical gaze and queer people's apprehensions of violence in medical settings to offer new ways of thinking about structural changes needed in medicine, medical language, and the dehumanizing application of medical modes of care. Using a series of clinical vignettes, this article outlines the historical context underlying queer peoples' distrust of medicine, a primer in queer theory, and an understanding of how to begin to "queer" medical spaces using this critical framework.

Hetero- and cisnormativity-UK pharmacy education as a queer opponent

INTRODUCTION

Queer pedagogy is a lens through which the hegemonic discourses of curricula and the heterosexual assumptions within them can be made visible. Using this lens, sexuality and gender norms incorporated in undergraduate medical and health curricula can be located and the lived experience of a curriculum examined. This paper seeks to determine the extent of hetero/cisnormativity within UK pharmacy education with the aim of problematising the normalisation of heterosexuality; following this, strategies to disrupt structured hetero/cisnormativity are considered.

METHODS

Online cross-sectional surveys were distributed to course leads (n = 29) and students enrolled on undergraduate pharmacy (MPharm) programmes. Surveys captured quantitative data on curriculum design and perceived barriers to implementation of inclusive curriculum design (the espoused LGBTQI+ curriculum), as well qualitative data on the lived experience of the hidden curriculum. Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed thematically.

RESULTS

Responses were received from 19 course leads and students from 25 MPharm programmes, representing varying completion rates. Findings suggest the shared values and goals of pharmacy education act to normalise and legitimise hetero and cis identities within curriculum design that othering as a consequence of heterosexual normativity is experienced and that pharmacy education is an LGBTQI+ opponent and does not adopt an ally attitude. Moreover, both educator and student data suggest that the enacted and experienced curriculum fails to prepare learners to care for LGBTQI+ people.

DISCUSSION

Despite findings suggesting the espoused or enacted curriculum absents LGBTQI+ people, and the hidden curriculum is experienced as homonegative, learners are questioning, resisting and disrupting the hetero- and cisnormative benevolent heterosexism within UK pharmacy curricula. This method of curricula interrogation can be adopted across health professions education as a means for ongoing problematising and disruption of normativity in clinical education.

Articulating the canon: The sociology of medical education from 1980 to 2000

An exciting development in the sociology of medical education has been its recent return as a distinct scholarly conversation in medical sociology. During the 1980s and 1990s, the sociology of medical education, an historically prominent subfield in sociology, seemed to disappear from the scholarly conversation despite ongoing development in this area. In this narrative review I describe this "missing period" of sociology of medical education, discussing complementary explanations for why it receded and describing what research activity did take place during those decades. In reviewing this work, I argue that articulating theoretical advances made within sociology of medical education research during these decades allows us to link foundational research from the 1950s and 1960s with the renaissance of this subfield in the early 2000s. Fundamentally, understanding the intellectual history and development of this subfield supports a broader movement to understand the import of studies of medical training for exploring questions of interest in general sociology.

Factors influencing LGBTQ+ disclosure decision-making by Canadian health professionals: A qualitative study

Disclosure of LGBTQ+ identities at work may reap benefits, but may also exacerbate harms. Faced with ambiguous outcomes, people engage in complex concealment/disclosure decision-making. For health professionals, in contexts of pervasive heteronormativity where disclosure to patients/clients is deemed to violate professional boundaries, stakes are high. This qualitative study with 13 LGBTQ+ health professionals across Canada used semi-structured interviews to explore factors affecting disclosure decision-making, particularly attending to power structures at multiple levels. Most participants engaged in constant risk-benefit assessment, disclosing strategically to colleagues, rarely to clients/patients. At the individual level they were affected by degree of LGBTQ+ visibility. At the institutional level they were affected by the culture of particular professional fields and practice settings, including type of care and type of patients/clients, as well as colleague interactions. Professional power-held by them, and held by others over them-directly affected disclosures. Finally, intersections of queer identities with other privileged or marginalized identities complicated disclosures. Power relations in the health professions shape LGBTQ+ identity disclosures in complex ways, with unpredictable outcomes. Concepts of professionalism are infused with heteronormativity, serving to regulate the gender and sexual identity expression of queer professionals. Disrupting heteronormativity is essential to forge more open professional cultures.

"Ah, it's best not to mention that here:" Experiences of LGBTQ+ health professionals in (heteronormative) workplaces in Canada

Introduction

Despite human rights protections for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people, LGBTQ+ professionals may continue to experience discrimination working in heteronormative systems and spaces.

Methods

In this qualitative study 13 health professionals (nurses, occupational therapists, and physicians) from across Canada participated in in-depth qualitative interviews to explore their experiences with work-related microaggressions and heteronormativity.

Results

Heterosexist microaggressions from both patients/clients and colleagues were the norm, perpetuating and bolstered by heteronormative workplace and professional cultures. In turn, LGBTQ+ professionals navigated disclosure-decision-making, in power-laden contexts where all options carried potential negative consequences.

Discussion

Drawing on the notion of "heteroprofessionalism," we argue that the concept of professional carries encoded within it demands that the occupant of that category be-or present as-heterosexual, an unmarked status that can be readily desexualized. Acknowledging sex and sexuality disrupts "professionalism." We argue that such disruption, indeed dissention, is necessary to open (hetero)professional spaces to LGBTQ+ workers.

Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators

Health disparities faced by transgender people are partly explained by barriers to trans-inclusive healthcare, which in turn are linked to a lack of transgender health education in medical school curricula. We carried out a theory-driven systematic review with the aim to (1) provide an overview of key characteristics of training initiatives and pedagogical features, and (2) analyze barriers and facilitators to implementing this training in medical education. We used queer theory to contextualize our findings. We searched the PubMed/Ovid MEDLINE database (October 2009 to December 2021) for original studies that reported on transgender content within medical schools and residency programs (N = 46). We performed a thematic analysis to identify training characteristics, pedagogical features, barriers and facilitators. Most training consisted of single-session interventions, with varying modes of delivery. Most interventions were facilitated by instructors with a range of professional experience and half covered general LGBT+-content. Thematic analysis highlighted barriers including lack of educational materials, lack of faculty expertise, time/costs constraints, and challenges in recruiting and compensating transgender guest speakers. Facilitators included scaffolding learning throughout the curriculum, drawing on expertise of transgender people and engaging learners in skills-based training. Sustainable implementation of transgender-health objectives in medical education faces persistent institutional barriers. These barriers are rooted in normative biases inherent to biomedical knowledge production, and an understanding of categories of sex and gender as uncomplicated. Medical schools should facilitate trans-inclusive educational strategies to combat transgender-health inequities, which should include a critical stance toward binary conceptualizations of sex and gender throughout the curriculum.

Coming out or staying in? Disclosure experiences of lesbian and gay radiation therapists in practice

INTRODUCTION

The healthcare environment reflects and embeds sociocultural norms, including heteronormativity. Coming out for sexual and gender minority (SGM) people is often a process of continual identity management. There is evidence that lesbian and gay people (LG), both patients and healthcare professionals, engage in significant emotional work to manage who they tell about their sexual identity, and when. This qualitative study explored the experiences of LG radiation therapists (RTs) managing their sexual identity at work, and how this impacts relationships with co-workers and patients.

METHODS

The research used an authoethnographic narrative inquiry approach. Narrative inquiry incorporates story-based methods to acquire a deep understanding of how individuals make sense of events. Autoethnography uses personal experience to understand and reflect on a broader culture. Three LG participants from a Canadian urban cancer centre worked with the researcher to co-construct stories of coming out at work using their shared personal histories.

RESULTS

The co-constructed stories included fictionalised narratives of coming out at work, relationships with patients/peers, the experiences of sexual minority patients and the researcher's accompanying embodied research journey. They were written in a variety of genres and from a number of different perspectives. The results showed the participants engaged in highly contextualised and continual identity management which depended on a series of different strategies or tools. Additionally, it was clear that both the discourse around professionalism, and the pervasive biomedical healthcare culture served to further inhibit disclosure at work. Purposeful disclosure to LG patients was uncommon.

CONCLUSION

Coming out at work might be a risky business for some lesbian and gay RTs. However, focused attention on improving the work environment so RTs can be open about their identities in the professional setting would be beneficial for patients and staff.

IMPLICATIONS FOR PRACTICE

LG RTs who are out at work can be a source of support and comfort to SGM patients. They may also feel more satisfied and engaged at work. Organizations should ensure they provide overt support for SGM RTs from frontline staff to leadership roles.

Hungarian Medical Students' Knowledge About and Attitude Toward Homosexual, Bisexual, and Transsexual Individuals

Discrimination that LGBTQ individuals experience in health care settings might affect their health and intention of using health care services. However, health needs of LGBTQ patients are still inappropriately addressed in the medical curriculum. First-, third-, and fourth-year medical students (N = 569) from the four Hungarian medical universities participated in a study in 2017 to assess knowledge about homosexuality, homonegativity, and their attitude as health care professionals toward sexual minorities. We found that higher levels of knowledge about homosexuality were associated with lower levels of homonegativity, upper-grade level in university, not being religious, and having close LGBTQ acquaintances. Our results suggest that it may be necessary to introduce LGBTQ themes in the medical curricula (not only in Hungary, but also in other countries) in order to improve the knowledge and attitude of medical students and thereby improve the health care of LGBTQ individuals.

Are all LGBTQI+ patients white and male? Good practices and curriculum gaps in sexual and gender minority health issues in a Dutch medical curriculum

Objectives: People marginalized based on their sexual and gender identity face specific health risks and experience barriers to culturally competent care. Insight into how Dutch medical schools address LGBTQI+ health-related learning objectives is scarce. We therefore examined how LGBTQI+ health issues are integrated in the Amsterdam UMC-VUmc medical curriculum by evaluating the year-two course 'Sex, Sexuality and Relationships' for LGBTQI+ content. Methods/Design: We examined written course content (course syllabus, lecture notes, and course literature) of the 2016-2017 course. We used a framework for essential LGBTQI+ content in medical education and an intersectional approach to examine which LGBTQI+ themes and subthemes were addressed. Results: Several essential LGBTQI+ health issues were adequately addressed and integrated into the Amsterdam UMC-VUmc curriculum, but we also identified curriculum gaps. The needs of patients with lesbian, bisexual, or gender non-conforming identities were marginally addressed, and issues related to intersections of minoritized sexual and gender identities with other aspects of diversity such as ethnicity, age and class remained unexplored. The course discussed gender and sexuality as fixed and mainly binary constructs, and only addressed biomedical explanatory models of sex, gender and sexuality. Discussion and conclusion: The absence of complex patient identities in relation to sex, gender and sexuality does not adequately prepare students to provide LGBTQI+ responsive care. If not designed and taught competently, LGBTQI+-related curriculum content may reproduce bias and stereotypes, and contribute to a medical climate where both LGBTQI+ patients, students, and doctors conceal their identities. Further implementation of LGBTQI+ health issues is required in (continuing) medical education to secure culturally competent clinical environments. Educational research is needed to understand how medical education contributes to marginalization of LGBTQI+ identities and thus, to health disparities.

The Hidden Curricula of Medical Education: A Scoping Review

PURPOSE

To analyze the plural definitions and applications of the term "hidden curriculum" within the medical education literature and to propose a conceptual framework for conducting future research on the topic.

METHOD

The authors conducted a literature search of nine online databases, seeking articles published on the hidden, informal, or implicit curriculum in medical education prior to March 2017. Two reviewers independently screened articles with set inclusion criteria and performed kappa coefficient tests to evaluate interreviewer reliability. They extracted, coded, and analyzed key data, using grounded theory methodology.

RESULTS

The authors uncovered 3,747 articles relating to the hidden curriculum in medical education. Of these, they selected 197 articles for full review. Use of the term "hidden curriculum" has expanded substantially since 2012. U.S. and Canadian medical schools are the focus of two-thirds of the empirical hidden curriculum studies; data from African and South American schools are nearly absent. Few quantitative techniques to measure the hidden curriculum exist. The "hidden curriculum" is understood as a mostly negative concept. Its definition varies widely, but can be understood via four conceptual boundaries: (1) institutional-organizational, (2) interpersonal-social, (3) contextual-cultural, and/or (4) motivational-psychological.

CONCLUSIONS

Future medical education researchers should make clear the conceptual boundary or boundaries they are applying to the term "hidden curriculum," move away from general musings on its effects, and focus on specific methods for improving the powerful hidden curriculum.

Academic Medicine and Medical Professionalism: A Legacy and a Portal Into an Evolving Field of Educational Scholarship

In this Invited Commentary, the author examines two curated Academic Medicine volumes showcasing foundational research and key writings on professionalism in medicine and medical education, collectively spanning from 1994 to 2016. The author reviews the beginnings of the medical professionalism movement and examines how the trends and themes reflected in the first volume-specifically the work to define, assess, and institutionalize professionalism-capture key elements in this movement. He then examines how the trends and themes in the second volume align with and build on those from the first, noting two themes that extend across a number of second volume articles: a unit-of-analysis issue and the challenge of context. The author identifies several topics that have yet to be adequately mined and calls attention to two bridge-spanning articles in the second volume that, respectively, take us into the future (around the topic of identify formation) and back to the past (on the hidden curriculum). Finally, the author reflects on "directions home" in medicine's noble search for its moral core and collective identity.

'Believe it or not': the medical framing of rectal foreign bodies

Medical and lay attention to and intervention for rectal foreign bodies, the presence of an object in the rectum most often via insertion through the anus, has long been a source of humour and suspicion in both medical and public discourses. How do the ways medical providers write and talk to each other about rectal foreign bodies shape and reflect understandings of gender, sexuality and the (im)proper use of the anus and rectum? This paper examines the medical literature on rectal foreign bodies to shed light on the ways in which medical providers frame rectal foreign bodies. It develops a set of six frames that demonstrate how the medical literature on rectal foreign bodies (re)produces a variety of normative assumptions about and sociocultural values concerning bodies and sexuality, danger, shame, deception, mental illness and medical professionalism. It concludes with a discussion of how these framings of rectal foreign bodies might potentially contribute to the ongoing stigmatisation not only of rectal foreign body patients, but of non-heteronormative sexualities in general.