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

ABSTRACT

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.

KEYWORDS:

• Medical student
• LGBTQ+
• sexual and gender minorities
• curriculum
• medical education
• LGBT health

Introduction

The acronym ‘LGBTQ+’ describes people who identify as lesbian, gay, bisexual, transgender, queer/questioning, and other sexual/gender minorities. Some people who are born with differences in sex development or who identify as intersex identify within the LGBTQ+ community as well and are considered within the ‘LGBTQ+’ umbrella in this paper. A survey conducted in the summer of 2022 by the Pew Research Center estimates that 7% of all adults and 17% of adults younger than 30 in the USA identify as lesbian, gay, or bisexual[1]. Data from May 2022 estimate that 1.6% of all adults and 5.1% of adults younger than 30 in the US identify as transgender or non-binary[1].

LGBTQ+ identified individuals may experience discrimination in multiple areas of life, including employment, education, housing, legal, or healthcare settings. A recent study of interactions with healthcare providers among transgender, nonbinary, and gender expansive people found that 70.1% had at least one negative interaction with a healthcare provider in the past year [2]. People who pursued gender-affirming care had 8.1 times the odds of reporting a negative interaction with a healthcare provider in the past year [2].

Experiences of discrimination in healthcare settings may lead people to delay seeking care, contributing to further health disparities. A national survey of transgender individuals found that 30.8% of participants delayed or did not seek care due to discrimination [3]. More than half of respondents had to teach their providers about transgender people, and this was significantly associated with greater odds of delaying care due to discrimination [3].

Medical education has been posited as one area of intervention to address the health disparities faced by LGBTQ+ patients and improve patient healthcare experiences [4]. In 2014, the Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development published a detailed report that describes 30 competencies within eight domains to address the needs of LGBTQ+ patients in medical education [4]. Despite these recommendations, the extent to which LGBTQ+ health is covered in medical education in the USA remains variable, and often limited, across different programs [5–10].

While there are existing literature reviews that have explored medical education curricula on LGBTQ+ health [5–7,11] and transgender health [8–10,12], this review is uniquely comprehensive in that it integrates information from articles that evaluate both broad and specific curriculum items, curriculum development, as well as student knowledge and learning experiences in attempt to gain a holistic overview of this aspect of medical education, with the goal to identify common themes and opportunities for growth and development. This narrative literature review aims to explore the landscape of interventions and evaluations related to the LGBTQ+ health content that is taught and learned in medical schools in the USA with the goal of identifying critical gaps in existing curriculum and suggesting enhancements to address those gaps to better prepare future physicians.

Methods

Identification of relevant articles

The databases PubMed, ERIC, and Education Research Complete were systematically searched for peer-reviewed articles on LGBTQ+ health in medical school education in the USA written in the English language. The initial search identified articles published between 1 January 2011–19 May 2022. The search strategy was developed with the assistance of an academic librarian at our institution and the search terms utilized are available in Appendix 1.

Due to passage of time over the course of working on this review, the search was repeated for articles published between 20 May 2022–6 February 2023. The reference lists of all eligible articles were screened for additional articles for consideration.

Screening for eligible studies

The screening was completed by one author (TIJ) where areas of uncertainty were clarified with the other author (EMP). Articles were first screened by title and abstract. The inclusion criteria are displayed in Table 1. Articles that met initial inclusion criteria for further screening underwent full-text screening (see Table 1). If the title and abstract for an article did not provide sufficient information to determine if the article should proceed with full text screening, the article underwent full text screening in an effort to identify all relevant articles.

Table 1. Inclusion criteria utilized when screening for eligible articles.

Title and abstract screening	Article written in English language Article involves a medical school in the USA Article evaluates medical student education (excluding articles that include only other health professional students such as nursing or psychology students or medical trainees such as residents and fellows) Article includes a component related to LGBTQ+ health
Full text screening	Full text of article is available Article written in English language Article involves a medical school in the USA Article evaluates medical student education related to LGBTQ+ health Article involves collection and analysis of data

When considering articles that evaluated medical student education on LGBTQ+ health topics, articles that assessed medical student knowledge and comfort performing aspects of care for an LGBTQ+ patient were included. Articles that only evaluated medical student perception of a school’s acceptance of LGBTQ+ identities and without data on education or knowledge were excluded. Articles that only evaluated medical student biases toward the LGBTQ+ community were also excluded. Articles that gathered data from providers retrospectively about how much time they spent on LGBTQ+ health topics in medical school were also excluded given the variability of timeframes for their education.

Articles were only included for data abstraction if they involved the collection and analysis of new data. Commentaries, perspectives, letters to the editor, review articles, and other types of articles were excluded if they did not meet these criteria. Materials published outside of traditional commercial publishing, often referred to as ‘grey literature’, were excluded.

Data abstraction from included articles

Articles that were eligible based on full text screening underwent data abstraction. The following data were recorded in a spreadsheet: title, authors, year published, institution (if available), sample size, population studied (if applicable, e.g., first-year medical students), aim of the study, aspect of medical education studied (e.g., required clinical skills session), evaluation method (e.g., survey), intervention (if applicable, e.g., new lecture provided to students), description of LGBTQ+ health education at the medical school (if applicable), study findings, and conclusions. One author (TIJ) completed the data abstraction and conferred with the senior author (EMP) regarding any areas of uncertainty.

Articles used a variety of words to describe a method of evaluation that involved providing an instrument with questions for the participants to answer (e.g., surveys, questionnaires, evaluations, questions, forms, assessments). For consistency in this review, all of these methodologies are referred to as ‘surveys’. Additionally, some articles evaluated individual curriculum components or educational interventions, which will both be referred to as ‘interventions’ in this paper for consistency.

This review sought to characterize education in pre-clinical, clinical, or both settings. Some articles explicitly stated the type of curriculum they studied, however others did not. In some cases, the type of curriculum could be inferred based on the description. However, for some articles the type of curriculum could not be clearly identified, and this is noted as such with the article in Table 2.

Table 2. Overview of reviewed articles.

Studies that evaluate how LGBTQ+ health is covered in an existing curriculum
Author and year	Curriculum type	Methods	Key findings
DeVita, et al. (2018) [14]	Pre-clinical coverage of LGBTQI health topics	Curriculum evaluated based on 30 AAMC competencies and 31 Vanderbilt University learning objectives	Existing curriculum completely covered 7 AAMC competencies, partially covered 8, and did not cover 15 Existing curriculum completely met 12 Vanderbilt learning objectives, partially met 7, and did not meet 13 Slides made to address the gaps with partially met and unmet Vanderbilt learning objectives and were integrated into curriculum
Encandela et al. (2019) [15]	Pre-clinical and clinical coverage of SGM topics	Needs assessment using AAMC SGM health competencies, tracking of change implementation	Gap analysis showed 13 existing components that partially or completely addressed 13 of 30 AAMC SGM health competencies 12 proposals were submitted to address gaps At time of publication there were 22 SGM-related components in curriculum (12 pre-clinical, 8 clinical, 2 electives)
Park and Katz (2018) [16]	American Academy of Dermatology’s online Basic Dermatology Curriculum	Cross-sectional study of online case-based basic dermatology modules	1 of 293 (0.3%) of cases mentioned an LGBT patient (a woman with basal cell carcinoma in a same-sex marriage) No cases included a transgender patient, mentioned same-sex sexual behavior, or specified sexual orientation
Pratt-Chapman and Abon (2021) [17]	Pre-clinical coverage	Curriculum content compared to AAMC competencies and Vanderbilt University learning objectives	28 sessions found to include material specific to SGM patients The pre-clinical curriculum met 10 of the 30 AAMC competencies fully and 11 partially, and of the Vanderbilt topics: 22 were addressed; 5 were partially addressed; and 5 were not addressed
Ton et al. (2016) [18]	Pre-clinical and clinical SOGI curriculum	Retreat, review, and surveys (N=26 pre, 22 post, 18 at 6 months (MS*** in sample, not separated))	No participants were satisfied with SOGI education prior to retreat After retreat, 86% reported satisfaction with proposed curriculum 2 years after retreat, 76% of proposed competencies were addressed in curriculum
Zumwalt et al. (2022) [19]	Pre-clinical and clinical	Curriculum assessment tool developed based on AAMC competencies, this tool was used to assess curriculum	42.9% of course directors reported including any SGM content in their curriculum All 12 SGM topic areas in the tool were covered at some point in the required curriculum, but some were addressed 1-2 times SGM content was over-represented in the pre-clinical curriculum Exposure to SGM content in clinical learning was limited and dependent on a student’s site or preceptor
Studies that evaluate the impact of components of a curriculum
Author and year	Curriculum type	Methods	Key findings	Kirkpatrick model level
Bakhai, Ramos et al. (2016) [20]	Required* pre-clinical session including e-lecture, SP encounter, and small-group debrief	Survey (N=78 MS1)	After the e-lecture, 92% felt more prepared to take an inclusive sexual history with patients who identify as lesbian, gay, or bisexual; compared to 84% following the SP encounter and debrief After the SP encounter and debrief, 85% felt more comfortable discussing sexual orientation with patients and 74% felt more comfortable discussing gender identity with their patients	2
Berenson et al. (2020) [21]	Required pre-clinical** presentation, small-group, and patient panel on transgender care	Surveys (N=161 total pre/post with N=123 matched pairs, MS2)	Significant increase in average confidence describing the following related to transgender patients: health issues/disparities; medical transitioning/hormonal therapies; best practices for promoting culturally competent/affirming care Average ratings were highest for the patient panel component	1, 2
Bi et al. (2020) [22]	Required pre-clinical lecture, patient videos, and discussion on SGM health disparities and intersectionality	Surveys (N=82 pre and N=83 post MS1)	Significant increase in confidence in abilities to: identify barriers to care for LGBTQ patients and ways to help overcome them; ask LGBTQ patients about their identities	2
Cannon et al. (2021) [23]	Required* pre-clinical lecture on basics of HIV and STIs, sexual history-taking and HIV prevention [This paper also describes a variation lecture content given to other learner groups]	Survey (N=127 MS1)	Prior to lecture, 47% were not aware of or unsure if they had heard of PrEP Significant increase in knowledge after lecture	2
Christensen et al. (2019) [24]	Required pre-clinical gender and sexuality curriculum with didactic and small group parts	Surveys (N=244 MS1 pre and N=253 MS1 post)	Significantly increased agreement that: Discordance between birth sex and gender is natural LGB/T populations have unique health risks and health needs Able to empathize with the life experience of an LGB/T patient Motivated to seek opportunities to learn about LGBTQ health	2
Click et al. (2020) [25]	Required pre-clinical* session including didactic lectures, small-groups, and Q&A with transgender patient	Surveys (N=138 pre and immediate post, N=85 2-month post, MS1-2)	Significant increases in comfort with transgender patients and knowledge of transgender medicine from pre to post At 2-month follow-up: 78% felt comfortable asking patients about their gender identity; 77% agreed transgender health should be in the general medical student curriculum	1, 2
Croniger et al. (2022) [26]	Required pre-clinical problem-based learning sessions with ID cards added for each patient, including diverse identities (including LGBTQ+)	Survey (N=178 MS1)	54% reported patient ID cards helped them learn about a diverse population of patients 52% reported patient ID cards helped prepare them to deliver care to a diverse population of patients	1
Eriksson and Safer (2016) [27]	Required pre-clinical lecture about gender identity	Surveys (N=41 MS1 pre and post audience response survey, N=56 pre-exam and N=121 post-exam)	Significant number changed their answer regarding the etiology of gender identity (from ‘Hormones’ to ‘Hypothalamus/Brain’) – question answered correctly by 63% pre and 93% post Treatment question answered correctly by 20% pre and 50% post	2
Gavzy et al. (2019) [28]	Required pre-clinical** workshop including presentation and videos on LGBT health	Surveys (N=165 MS1)	Significant increase in confidence addressing all 3 learning objectives: define/compare terms; describe unique health issues/disparities; develop better practices	2
Grosz et al. (2017) [29]	Required pre-clinical LGBT health presentation, patient panel, small group, and case discussion	Surveys (N=73 MS1)	LGBT health knowledge and familiarity with LGBT terms increased significantly or remained high after the session Significant increase in confidence providing care in all areas except physical exam (which was not covered in the session)	2
Jin and Dasgupta (2017) [30]	Required pre-clinical small group with mandatory prework on LGB reproductive endocrinology and genetics	Surveys: mandatory questions (N=180 MS1) and voluntary pre (35%) and post (17%)	Some results include initially higher rates of student recommendations for assisted reproduction services for same-sex couples compared to heterosexual patients - after the session this difference disappeared, however other results showed a persistent difference or no initial difference	2
Lee et al. (2014) [31]	Required* pre-clinical** lecture and SP cases on sexual history, including LGBT health	Surveys (MS2, N not stated) and faculty debrief	Significant improvement in students reporting increased importance, confidence, and performance of a sexual history Most faculty report a positive experience teaching this session	2
Leslie et al. (2018) [32]	Required pre-clinical LGBTQI+ health equity curriculum on implicit attitudes	IATs (N=146 MS1 and 108 MS2)	Overall student IAT scores demonstrate implicit preferences for “straight” over “gay” people both pre- and post-intervention Significant decrease for MS2 from pre- to post-IAT for sexuality Significant decrease in sexuality IAT for MS1 who completed an initial IAT and debriefing session compared to MS1 that did not	2
Leslie et al. (2017) [33]	Required pre-clinical session with a lecture, community stories, interprofessional group case study discussions and case study debrief	Surveys (N=158 MS1 on teams across total of N=653 students that participated in the session)	Improvement for all LGBT self-reported knowledge items Significant changes in attitudes toward systemic and social factors that affect health for all items except for lifestyle and genetics 51% of student teams report that the top solution in a case was to refer the patient elsewhere	2
Levy et al. (2021) [34]	Required* pre-clinical case-based session on care for LGBTQ+ seniors	Surveys (N=38 MS1)	Significant increase in identification of “heterosexism” as a strong determinant of the health status Significant increases in confidence regarding knowledge of systemic barriers to health and health disparities faced by LGBTQ+ people and practices to promote culturally competent care	2
Marshal et al. (2017) [35]	Required* pre-clinical session with didactic, patient Q&A, mock patient encounter on transgender health	Survey (N=85 MS***)	73% felt more prepared to care for transgender patients In narrative comments, students described learning how to address someone who is transgender and learning about transition options	1, 2
McCave et al. (2019) [36]	Required [for majority] pre-clinical** interprofessional session with panel, SP simulation and large group debrief regarding care for transgender patients	Survey (N=278 students, including 34 MS1; MS not consistently separated in results)	93% of students found the addition of transgender individuals sharing their personal experiences useful or very useful 85% found the discharge planning meeting with SP and observation checklist useful or very useful 61% found the video simulation useful or very useful	1
Najor et al. (2020) [37]	Required pre-clinical** lecture on transgender health	Surveys (N=86 pre, 70 immediate post, and 44 1-year post, MS1)	Significant increase in comfort caring for transgender people from 76% pre to 91% post, and 89% at 1-year follow-up Significant increase in comfort with clinical scenario involving discordance of gender expression and sex listed in health record from 67% pre to 87% post, and significantly to 95% at 1-year	2
Neff and Kingery (2016) [38]	Required* pre-clinical problem-based learning session on DSD	Surveys (N=155 MS1 pre and N=144 MS1 post)	79% report the session changed their knowledge and competence regarding individuals born with a DSD 13% identify barriers to implementing their knowledge of DSD-affected individuals, including: societal norms; religion; parents; and lack of interaction with DSD-affected individuals	1, 2
Potter et al. (2016) [39]	Required* pre-clinical** flipped classroom session including prework, presentation, role-play scenarios, and small-group work on caring for SGM	Surveys (N=5 student representatives (of 175 MS1 and first year dental students) and N=14 faculty)	Increase in students’ awareness of health impacts of identity and intersectionality and clinician’s role in establishing rapport	2
Safer and Pearce (2013) [40]	Required pre-clinical lecture and follow-up small group session on healthcare for transgender people	Surveys (MS2 who took the course N=74 pre and N=66 post; baseline comparison of MS1, MS3, and MS4 not in course N=183 pre and N=168 post)	Significant decrease in percentage of MS2 reporting they would be uncomfortable providing transgender healthcare and non-significant decreases in this observed for MS1, MS3, and MS4 who did not participate in the course No MS2 and a small percent of MS1, MS3, and MS4 reported that transgender medicine was not an appropriate topic for conventional medicine	1, 2
Sanchez et al. (2022) [41]	Required* pre-clinical lecture on human sexuality with a focus on LGBTQI+ health	Surveys (N=103 MS1)	Significant increases in agreement with the statements: “bisexuality is not a choice”; “one is born transgender”; and “LGBTQI+ couples should have the right to adopt children”	2
Sell et al. (2016) [42]	Required small group case study and presentation with discussion** on HIV, including impact on gay and bisexual men	Survey and facilitator feedback (N=21 MS2 randomly selected for survey of 150 total MS2 that attended)	Mean agreement that the lecture supported student mastery of the learning objectives was 4.4 on scale of 1 = strong disagreement to 5 = strong agreement (1 of the 3 learning objectives was “analyze causes of health disparities for marginalized patient populations (e.g., LGBT persons)”)	1
Silverberg et al. (2021) [43]	Required* pre-clinical encounter with transgender SPs and panel discussion	Survey (N=126 MS2)	92% felt more confident using their patient’s identified pronouns 95% improved confidence taking history from a transgender patient Students found interaction with transgender individuals the most valuable aspect of the session	1, 2
Singh and Lee (2022) [44]	Required* pre-clinical session with didactic material and actor scenarios	Surveys (N not stated, MS1)	Significant increase in knowledge and comfort levels	2
Song et al. (2018) [45]	Required pre-clinical case-based session on social determinants of health, including LGBT health	Surveys (N=186 pre and N=111 post, MS1)	Significant increase in confidence in knowledge with terms “gender identity” and “sexual orientation” Significant increase in knowledge and comfort discussing topics covered in session with patients 94% rated the LGBT health component as “good” or “excellent”	1, 2
Stumbar et al. (2022) [46]	Required* sexual history workshop** for MS2 including lecture, small group, and SGM SP interview	Survey (N=87 MS2)	86% felt better prepared to care for transgender patients 97% reported increase in knowledge and 75% reported increase in skills on effectively providing medical care for transgender patients	2
Stumbar et al. (2021) [47]	Required pre-clinical lecture and small group SP case on inclusive sexual history	Surveys (N=110 MS2 including 73 for pre/post responses)	Significant increase in number who felt comfortable taking a sexual history from a transgender patient More than 90% felt better equipped to care for transgender patients	2
Stumbar, Garba, and Holder (2018) [48]	Required* pre-clinical** lecture, case-based learning session, and community member panel	Surveys (N=90 MS2)	Significant increase in number of students comfortable discussing sexual history related to gender and treating transgender patients 93% agreed that patient panel helped them identify their own biases when addressing issues related to sexual orientation/gender	2
Thompson H. M. et al. (2022) [49]	Required* lecture, patient panel, and small group sessions** on transgender health	Survey (N not stated, MS2)	Significant changes in student knowledge, attitudes, and perceived readiness to work with transgender patients	2
Thompson H et al. (2020) [50]	Required pre-clinical videos followed by case-based workshop and panel	Surveys (N=77 MS2)	Gender Identity Competency significantly improved Significant improvement in skills and self-reported knowledge Significantly more experience using/role-playing pronouns in a clinical setting	2
Turban et al. (2018) [51]	Required* pre-clinical and clinical sessions on transgender pediatric patient care	Survey (N=162 MS1-4)	Majority correctly answered questions about terminology, psychiatric co-morbidities, diagnostic criteria, estrogen/testosterone, and long-term benefits of interventions Gaps in knowledge existed for GnRHa and spironolactone as therapies, and time requirement for diagnostic criteria for GD 14% felt it was unethical to give hormonal interventions	2
Weingartner L et al. (2022) [52]	Required* pre-clinical SP case on gender-affirming care; students in second iteration received targeted LGBTQ+ clinical skills training prior to session	Post encounter note, preventive care survey, course director viewed encounters, and debrief with SPs in both iterations; student reflections in second iteration only	After targeted training there was a reduction in number who would refer TGD patients to endocrinology for hormones and increase in proportion willing to prescribe hormones in a primary care setting Across both iterations, 83% of TGD SPs reported being misgendered at some point during the encounter Across both iterations, 21% of students made one or more incorrect sex-specific cancer screening recommendations to TGD patients	2, 3
Wong (2014) [53]	Required* pre-clinical problem-based learning (PBL) cases	Describes rationale and process for curriculum updates	Updates to PBL case with a young male patient with two mothers New PBL case with a male-to-female transgender patient who presents to begin hormone replacement therapy	N/A
Gomez and Gisondi (2020) [54]	Elective* pre-clinical peer education program on SGM health	Surveys (N not stated, MS1 and first year PA students)	In 2019, 80% reported increase in confidence in knowledge of SGM health disparities and comfort caring for SGM patients In 2019, 100% of peer educators reported improvement in facilitation skills and understanding of SGM health issues Challenge with this is burden on SGM students to educate others	2
Greene RE et al. (2014) [55]	Elective* pre-clinical** SP encounter with debrief on transgender healthcare	Debrief discussion (N=18 MS1)	Students felt that the session was constructive and very useful for their education	1
Johnson et al. (2015) [56]	Elective pre-clinical** course on sexual health, including LGBTQI topics	Surveys (N=13 MS1)	Immediately after the course, knowledge increased on 8/15 items, decreased on 1/15, and was the same on 6/15 3 months after the course, knowledge increased on 7/15, decreased on 2/15, and the same on 6/15 Increased comfort on topics related to sexuality and sexual health	2
Kutscher and Boutin-Foster (2016) [57]	Elective pre-clinical course with community members, including LGBT people	Survey (N=16 MS1)	Satisfaction with the course was high 71% felt there was excellent applicability to medical practice 50% felt this course should be required for all MS1	1
Minturn et al. (2021) [58]	Elective pre-clinical didactic presentations, case discussions, community panel, and SP session	Survey (N=49 MS1-2)	Significant increase in self-reported confidence in actions related to LGBTQ+ healthcare Average total knowledge score improved minimally	2
Pathoulas et al. (2021) [59]	Elective pre-clinical didactic and interactive lecture on GAHT	Surveys (N=54 MS2)	Significant increases in familiarity with common medications, dosing, informed consent in clinic, and providing GAHT in primary care Significant increases in confidence finding resources for GAHT and understanding the difference between legal and chosen names	2
Sequeira et al. (2012) [60]	Elective pre-clinical didactic sessions (3) on LGBT health and followed by required LGBT SP encounter	Surveys for didactic sessions (N=35 pre-clinical MS for survey #1, 39 for #2, & 30 for #3)	After session 2, 82% could articulate how to inquire appropriately about the gender of a patient’s sexual partners After session 3, 87% agreed that the content was relevant enough to be incorporated into the required curriculum Key theme identified was current lack of exposure to LGBT content	1, 2
Wright and Campedelli (2022) [61]	Elective* pre-clinical 2-week virtual course on gynecologic care for transgender patients	Surveys (N=8 MS2-3)	Significant increase in knowledge of gynecologic needs of transgender individuals 100% “agreed” or “strongly agreed” that course built confidence in clinical care for transgender patients	2
Zheng et al. (2022) [62]	Elective pre-clinical modified jigsaw session on GAHT	Surveys (N=89 MS1-2 participants, immediate pre/post N varied by item, N=20 follow-up 1 year)	Significant increase in trans-specific topic knowledge, confidence discussing trans health with peers/patients, and confidence taking history from trans patient from pre- to immediate post-session 1-year post-session knowledge scores and comfort discussing GAHT were lower than immediately post- but higher than pre-session	2
Bakhai et al. (2016) [63]	Required clinical session on caring for SGM youth	Surveys (N=40 pre and N=39 post, MS3-4)	Significant improvement in self-reported comfort, preparedness, and skills knowledge related to care for SGM youth	2
Cooper et al. (2018) [64]	Required* didactic lecture** given to MS3 on the impact of social determinants of health on care for LGBT patients	Survey (N=63 MS3)	Significant change in mean rating of knowledge of lecture objectives (e.g. “describe the unique health risks and challenges often encountered by LGBT and gender-diverse patients”)	2
Dowshen et al. (2014) [65]	Required* lecture on transgender health in family medicine clerkship	Survey (N=204 clerkship MS)	Participants in transgender health lecture reported significantly higher levels of competency compared with non-participants Over 2 hours of instruction on transgender health associated with higher mean scores for overall self-reported knowledge and skills	2
Mayfield et al. (2017) [66]	Required* clinical lecture on taking a sexual history followed by SP encounters	Surveys (N=84 clerkship MS)	Significant increase in students’ comfort taking sexual history from patients with sexual orientation/identity different from their own Significant increase in knowledge of sexual health and practices of MSM and WSW	2
Noonan et al. (2021) [67]	Required* clinical skills session with GM SPs with rising MS3	Focus groups on SP experience (N=10 GM SPs)	SPs experiences included: microaggressions; identified benefits to community; provided informed feedback Gaps in care: communication skills; foundational SGM knowledge; cisnormative and heteronormative assumptions	N/A
Norwood et al. (2022) [68]	Required* clinical case-based session with TGD patient collaborators	Surveys (N=44 MS2 pre and N=36 MS2 post)	Significant increases in all TGD healthcare competency items except for discussing sexual health practices No significant change for perceived value of TGD healthcare training	1, 2
Ojo et al. (2022) [69]	Required clinical** case-based sessions on reproductive justice, including LGBTQIA+ health	Surveys (N=28 pre, N=31 post, N=15 both) and focus group (N=4), MS3 and MS4	No significant change in self-reported preparedness to use gender-affirming language when discussing reproductive anatomy and reproductive health with SGM Focus group theme: appreciation for intersectionality in cases	1, 2
Roth et al. (2020) [70]	Required clinical problem-based Introduction to LGBTQ Health session	Survey (N=103 MS4)	Regarding relevance, rated mean 4.8 out of 5 (1=little relevance, 5=very impactful) Total mean score 4.6/5 for first session and 4.7/5 for the second	1
Schmidt et al. (2022) [71]	Required clinical module on care for transgender and gender diverse patients	Surveys (N=65 MS3)	Significant increase in comfort caring for transgender patients Significant improvement in knowledge of healthcare maintenance and gender-affirming care	2
Underman et al. (2016) [72]	Pilot* clinical SP encounter with debrief discussion on transgender healthcare	Survey (N=64 MS4)	Almost 80% agreed or strongly agreed the session increased knowledge and skills to care for transgender patients Students discussed gaps in medical training on LGBT health and interest in more information on transgender health	1, 2
Park JA and Safer (2018) [73]	Elective clinical rotation on transgender medicine	Surveys (N=20 MS4)	Significant increase in report of ‘‘high’’ level of comfort providing care for transgender patients Significant increases in knowledge and skills caring for transgender patients (including asking about gender identity, providing general care, and providing hormone treatment)	2
Srinivasan et al. (2022) [74]	Elective clinical course on LGBTQIA+ health	Qualitative review of student experiences (N=30) and course evaluations (N=10 MS***)	Overall rating for the course on evaluations was “excellent” Students on average reported the course enhanced their interest in LGBTQIA+ health and helped them master core related knowledge	1, 2
Vance et al. (2021) [75]	Elective clinical SP encounters with e-learning on care for transgender youth in adolescent medicine rotation	Checklists by faculty and SPs and surveys by trainees (N=43 including 9 MS4)	Significant improvement in MS4 total checklists scores from case 1 to 2 Significant improvements in MS4 self-efficacy scores	2, 3
Vance et al. (2020) [76]	Elective clinical modules and observational experiences on transgender health added to adolescent medicine rotations	Surveys (for full curriculum total N=20 including 2 MS4 and for modules only total N=31 including 5 MS4; MS not consistently separated in results)	After full curriculum, participants had significant improvement in self-perceived knowledge/awareness of transgender-related considerations After the modules only, participants had significant improvements in knowledge scores and clinical self-efficacy in evaluating and counseling transgender youth High satisfaction scores with both learning experiences	1, 2
Vance et al. (2018) [77]	Elective clinical online modules on caring for pediatric transgender patients during adolescent medicine rotation	Surveys (N=28 including 5 MS4; MS not consistently separated)	Significant increases in median overall objective knowledge score, overall self-perceived knowledge score, and overall self-efficacy scores	2
Vance et al. (2017) [78]	Elective clinical modules and observational experiences on transgender health added to adolescent medicine rotation	Survey (N=20 total learners, including 2 MS4; MS not consistently separated in results)	Significant increases in knowledge and awareness scores on every queried transgender youth-related benchmark High satisfaction with the curriculum	1, 2
Alzate-Duque et al. (2021) [79]	Elective* workshop** about PrEP and communication skills including a didactic component and video-based scripted MSM patient encounter	Surveys (N=18 total across 3 sites including 9 MS***; MS not separated)	All postworkshop mean scores on agreement or confidence in learning objectives (eg “I feel comfortable identifying at-risk MSM who may benefit from PrEP”) increased, however there were only significant changes at 1 site for 4 of 7 objectives	2
Barrett et al. (2021) [80]	Elective* interactive online didactic session** on care for LGBTQ patients in dermatology	Survey (N=29 total pre with 14 MS and 18 post with 10 MS; MS responses not consistently separated)	Significant increases in mean LGBT-DOCSS overall scores as well as the self-reported clinical preparedness and basic knowledge domain scores	2
Braun, Garcia-Grossman, et al. (2017) [81]	Elective lunch-hour multidisciplinary course** in transgender health	Surveys (N=46 students pre and immediate post, including 11 MS***, N=14 students completed 3 months post, MS not separated)	Significant increase in knowledge of 11/14 transgender health topics from baseline to immediately post (N=46) Increase in knowledge immediately post to 3 months post in cultural competency, state policy, and federal policy (N=14) No significant decreases in knowledge in any category from immediately post to 3 months post (N=14)	2
Braun, Ramirez, et al. (2017) [82]	Elective LGBTI Health Forum**	Surveys (N=273 forum participants including N=39 from the school of medicine***, N=140 pre and N=192 post-surveys)	Students reported lack of LGBTQI health-related content in their core curricula (rating 2.98/6) Significant improvement in comfort interacting with LGBTQI patients and conducting accurate and inclusive medical history with LGBTQI patients following participation in Forum	1, 2
Bunting et al. (2019) [83]	Elective*, interprofessional, community-specific module** on HIV and PrEP	Survey (N=4 MS*** on the team of 11 total students who developed the module; MS not separated in results)	Overarching theme in student reflections was comfort in discussing sexual health with future patients, including addressing aspects of LGBTQ+ health care Participation in development of the module increased student knowledge about HIV risk factors and PrEP access	2
Calzo et al. (2017) [84]	Optional* interprofessional case-based modules** on LGBT adolescent health	Surveys (total N unspecified, 4 years and N of 6-10 each year, learners from medicine***, nursing, nutrition, social work, and psychology)	One year used pre and post surveys that showed an improvement in their confidence “identifying community resources for LGBT adolescents” and a slight decrease in confidence in both “taking sexual health, sexuality health, and sexuality history from adolescents” and “counseling LGBT adolescents”	2
Cherabie et al. (2018) [85]	Elective* presentation** including section by patients on transgender health	Surveys (N=163 pre (including 13 MS***), 115 post (13 MS***), 18 at 90-day follow-up (6 MS***))	Significant increase in comfort treating transgender patients from pre to post, no significant change from post to 90-day follow-up Significant increase in knowledge regarding transgender patients from pre to post, no significant change from post to 90-day follow-up	2
Congdon et al. (2021) [86]	Elective seminar** on transgender healthcare	Survey (N=100 total, includes 7 MS***)	Significant increase in self-perceived proficiency and confidence in caring gender-diverse patients	2
Gibson et al. (2020) [87]	Elective LGBTQ Health Pathway	Survey (N=6 MS in the first cohort of the pathway)	All reported the Pathway having a positive impact on their medical education and career goals as well as improved their abilities to care for LGBTQ patients	1
Grant et al. (2023) [88]	Elective modules** on PrEP, PEP, and STI/HIV testing	Surveys (N=123 pre, N=89 post: includes MS1-4+)	Increase in comfort providing sexual health care to LGBTQ individuals and perception of sexual history–taking abilities Increase in median HIV and STI screening and prevention knowledge scores	2
Guss et al. (2022) [89]	Optional video** on transgender and nonbinary health	Surveys (N=68 including 37 MS***, MS not separated)	Significant increase in knowledge on terminology and patient care Increase in agreement with feeling competent to provide primary care to a transgender patient	2
Ingraham et al. (2016) [90]	Optional training** on bias in care for lesbian and bisexual women who are overweight	Surveys (N=66 including 39 MS***, MS not separated)	Significant increase in knowledge about barriers to care and delays in care related to weight stigma for lesbian and bisexual women	2
Perucho et al. (2020) [91]	Elective* workshop** with didactic component about HIV prevention and PrEP and scripted MSM patient encounter about PrEP	Surveys (N=43 MS2-4)	Significant increase in comfort discussing sexual behaviors with MSM, identifying at-risk MSM who may benefit from PrEP, and prescribing PrEP to MSM Significant improvement in knowledge of the indications for prescribing PrEP to MSM and indications for PrEP discontinuation for MSM	2
Pfaff et al. (2020) [92]	Elective* lecture and cadaver laboratory** on facial feminization	Surveys (N=5 MS*** and N=11 residents; MS not separated in results)	Significant improvement between pre and post scores within each self-assessment category Increase on the knowledge-based section of the assessment	2
Pratt-Chapman and Phillips (2020) [93]	Optional* symposium on improving care for SGM including clinical and pre-clinical MS	Surveys (N=29 intervention including 1 pre-clinical MS and 1 clinical MS; N=134 comparison including 40 pre-clinical MS and 32 clinical MS, MS not separated)	Significant improvements in self-reported clinical preparedness to care for SGM patients and knowledge about SGM Significant improvement in overall LGBT-DOCSS scale score Those who completed the intervention had significantly higher confidence in all learning objectives and scores on LGBT-DOCSS overall and subscales for attitudes and knowledge	2
Sawning et al. (2017) [94]	Elective LGBT Health Certificate Program sessions**	Survey (N=39 MS1-4)	Significant increase in knowledge after session(s) Significant increase in agreement that same‐sex sexual behavior and transgender identities are natural After the session(s), MS reported it was more challenging to take a history with an LGB patient than a heterosexual patient	2
Thomas et al. (2020) [95]	Optional journal club** for MS1 and MS2	Surveys (N=7 MS1-2)	Increase from 71 to 100% of students that said they were familiar with LGBTQ healthcare issues Increase from 43 to 83% on confidence in ability to identify harmful medical provider practices and provide culturally competent care	2
Block et al. (2020) [96]	Educational* program** on caring for LGBTQIA+ patients	Survey, OSCE, essay (N not stated, MS***)	Significant increase in knowledge about LGBTQIA+ community, confidence engaging LGBTQIA+ patients, and comfort using correct terminology Significant increase in understanding of importance of and comfort providing culturally competent care for LGBTQIA+ patients	2
Studies that evaluate student knowledge and learning experiences
Author and year	Item assessed	Methods	Key findings	Kirkpatrick model level
Beck Dallaghan et al. (2018) [97]	Knowledge, preparedness, and attitude in caring for LGBT patients, recommendations for curriculum change, inventory of LGBT curriculum at each school	Survey and curriculum inventories (N=766 MS*** on survey with N=377 responding to qualitative questions)	96% agreed they would feel comfortable LGBT patients 55% agreed they know what to do if a patient came out as LGBT 32% agreed they know appropriate terminology for working with someone who is transgender No relationship between number of hours of LGBT curriculum and overall attitudes, knowledge, preparation, and campus climate	2
Bleasdale et al. (2022) [98]	Coverage of LGBT health topics in their curriculum	Survey (N=733 total students including 370 MS*** at 2 schools)	Overall average coverage was “too little” or “basic” for all items MS reported significantly more coverage of 10 topics in their curricula than pharmacy (PharmD) and nursing (DNP) students PharmD students reported greater coverage of HIV, safer sex, and STIs compared to MS and DNP students	1
Bidell (2017) [99]	LGBT clinical self-assessment for health and mental health providers	Surveys (Study 1 N=602 trainees, practitioners, & educators in US and UK, including 21 MS***; Study 3 N=564 including 29 MS***)	LGBT-DOCSS survey developed and validated with 3 subscales (Clinical Preparedness, Attitudinal Awareness, Basic Knowledge)	2
Bohnert et al. (2021) [100]	How GM and SM are portrayed in SP cases	Survey (N=59 schools) and follow-up interview (N=24 schools)	53% portrayed GM patients, 90% portrayed SM patients 59% knowingly used GM SPs GM cases overwhelmingly had a positive impact on learners Barriers included curriculum time, recruitment, fear of disrespecting gender minority communities, and transphobia	N/A
Bunting et al. (2022) [101]	Perceived complexity of patient and confidence in caring for patient, comprehensiveness of training in SGM health	Survey (N=665 MS1-4 across 12 schools)	Mean comprehensiveness of training about SGM health was 5.37 (1=minimal, 10=comprehensive) Gay male patient was viewed as the most medically and therapeutically complex Bisexual male was viewed as the most socially complex Perceived medical and social complexity predicted lower confidence caring for the patient	1, 2
Bunting, Chirica, et al. (2021) [102]	Comprehensiveness of medical school education on SGM health	Survey (N=1,007 MS1-4 across 12 schools)	Regarding training received on SGM health: 12.9% reported minimal training; 34.8% reported moderate training; 45.1% reported adequate training; and 7.2% reported comprehensive training	1
Bunting, Feinstein, Hazra, Sheth, et al. (2021) [103]	Knowledge about HIV and PrEP	Survey (N=2,159 MS1-4+, also N=194 pharmacy students, MS sometimes separated in results)	Mean HIV knowledge score was 79.6%, PrEP knowledge 84.1% Greater knowledge of HIV and PrEP among gay/lesbian participants compared to heterosexual Greater knowledge of HIV and PrEP among those later in their training compared to early	2
Bunting, Garber, et al. (2021) [104]	Knowledge about PrEP including questions asking about MSM, transgender women, and gay men	Survey (N=2,085 students including MS***, MS not separated)	60% MS and PA students received education about PrEP in training 78.2% of MS and PA students scored in the high knowledge range 65% of MS and PA students indicated complete/strong agreement that PrEP is effective in transgender women and 72% reported complete/strong agreement that PrEP is effective in MSM	2
Bunting, Feinstein, Hazra, Garber, et al. (2021) [105]	PrEP and HIV care for patients with various sexual orientations and gender identities	Survey (N=670 MS1-4 across 12 schools)	Less likely to identify the heterosexual female patient as a PrEP candidate (despite behavioral risk factors for HIV being identical) Reported lowest confidence caring for heterosexual female patient seeking PrEP	2
Bunting et al. (2020) [106]	PrEP awareness and education on HIV and PrEP	Survey (N=1,859 students including 902 MS1-MS4+, MS sometimes separated)	Among MS and PA students, 83.9% were taught about HIV risk, 88.6% were aware of PrEP, and 60% were taught about PrEP MSM were most frequently presented as candidate patient population for PrEP TWSM were the least frequently presented patient population indicated for PrEP	2
Calabrese et al. (2018) [107]	Likelihood of prescribing PrEP to male patients with varying condom use and sexual partners	Survey (N=111 MS1-4+)	Most willing to prescribe to patients with sustained condom use and multiple male partners (86%) and a single male partner (93%) Fewer willing to prescribe if patient had multiple partners vs. single partner with sustained condom use and sustained condom nonuse	2
Cooper RL et al. (2021) [108]	Pre-clinical and clinical regarding PrEP, focus on PrEP in MSM and transgender patients, and student preparedness to perform skills for PrEP delivery	Survey (N=71 medical school administrators)	38% of schools reported offering any PrEP content 15.4% of schools reported specific training regarding PrEP particularly for LGBT patients Lectures and problem-based learning were the most common teaching methods used	N/A
Dimant et al. (2019) [109]	Hours of formal transgender and gender nonbinary (TGNB) health education received in medical school	Survey (N=36 total including 21 current MS***, MS not sometimes separated)	20 (56%) participants received formal TGNB health education in medical school 35% received 2 hours or less 17.6% received 3 or more hours	1
Green et al. (2017) [110]	Preparedness and skillfulness at providing cross-cultural care, including LGBT patients	Survey (N=1,369 MS1-4 includes multiple responses from same individuals at different times in study)	Mean absolute percent difference between beginning fourth-year students and beginning first year students regarding caring for LGB patients was 15% and 7% for transgender patients	2
Greene MZ et al. (2018) [111]	Perspectives on curriculum and preparedness	Survey (N=1,010 total students, including 495 MS***; MS sometimes separated)	86% of all respondents felt comfortable treating LGBQ patients, 66% felt comfortable treating trans-identified patients 48% agreed their training prepared them to care for LGBTQ patients 52% report school integrated LGBTQ content in formal curriculum	1, 2
Hayes et al (2015) [112]	Comfort, knowledge, and training with sexual history taking in LGBTQ and non-LGBTQ patients	Survey (N=74 MS1-4 and N=84 residents/fellows; MS sometimes separated)	Learners were less comfortable taking a sexual history and discussing safe sexual practices with LGBTQ patients compared to other patients Decreasing level of comfort with taking a sexual history with LGBTQ patients as learners advanced through their training	2
Lapinski et al (2014) [113]	Medically relevant knowledge of the health issues of LGBT individuals	Survey (N=972 osteopathic MS1-4 across 6 schools that completed the knowledge assessment)	12.9% of MS received a passing knowledge score of 7 or greater LGB students had higher knowledge scores than heterosexual students	2
Leandre et al. (2021) [114]	Knowledge, comfort, and amount of LGBTQ+ patient interaction	Survey (N=77 MS3-4, residents and fellows; MS not separated in results)	About half of MS and residents had minimal or no interaction with LGBTQ+ patients during training Most felt comfortable treating LGBTQ+ patients Respondents who had some level of discomfort treating LGBTQ+ patients cited lack of education as a reason for this 39% did not feel that they received sufficient training	1, 2
Liang et al. (2017) [115]	Knowledge and comfort related to LGBTQI patient care	Surveys (N=218 MS1-4 in #1 and N=123 MS1-4 in #2)	Average self-reported knowledge and comfort regarding transgender and intersex health issues were lower than for LGB Students who identified as LGBTI had significantly higher knowledge for and comfort with LGB and transgender health issues Student knowledge in pre-clinical years (MS1 & MS2) was significantly lower than in clinical years (MS3 & MS4)	2
Lindberg et al. (2019) [116]	Faculty perception of adequacy of coverage LGBT concepts within curriculum	Survey and interview (N=24 faculty involved in curriculum)	Overall, curricular content on terminology, history-taking skills, preventive medicine, transgender health, use of evidence-based medicine, and prevention of discrimination in care of LGBT patients was rated as “poor” to “adequate”	N/A
Mani et al. (2018) [117]	Knowledge of HIV and HIV exposure prophylaxis with some questions including MSM and gay/bisexual men	Survey (N=459 MS1)	MS average 57.8% of knowledge questions correct Knowledge gap found for question asking to rank 3 situations from highest to lowest HIV infection risk, one of them being “An African American male engaging in unprotected sex with a male”	2
Muns et al. (2022) [118]	Knowledge, experience, and comfort regarding care for transgender patients	Survey (N=141 MS1-4+)	87% reported transgender patient care was part of their curriculum 82% reported exposure to transgender patients Students reported lack of knowledge related to surgical and hormonal aspects of gender-affirming care On average students felt comfortable working with transgender patients	1, 2
Newsom, Carter, et al. (2022) [119]	Students’ clinical practice asking about sexual orientation and gender identity (SOGI)	Survey (N=364 MS2-4)	As year in school increased, students were less likely to consistently ask patients about SOGI As year in school increased, students were more likely to cite negative influence from their attendings and question the relevance of obtaining the information as reasons for not consistently asking about SOGI	1, 2
Nowaskie and Patel (2020) [120]	LGBT-DOCSS, number LGBT patients seen, LGBT curricular hours, LGBT total hours	Survey (N=940 MS1-4+ across 3 schools)	Significantly higher Basic Knowledge than Clinical Preparedness Significantly less adequate clinical training/supervision, experience, and competence for transgender compared to LGB patients MS who cared for 35+ LGBT patients and/or received 35+ LGBT total hours had significantly higher LGBT-DOCSS scores Of the 35 total hours higher-competent MS received, 25 were extra-curricular	2
Nowaskie et al. (2020) [121]	Basic knowledge and amount of experience related to LGBTQ+ health	Survey (N=1,701 total health professional students across 3 schools, 55.3% are MS1-4+)	Significant differences among disciplines on the number of LGBT patients the student worked with annually and the number of LGBT curricular hours they received annually Number of LGBT patients and LGBT curricular hours were significant predictors for Overall LGBT-DOCSS, Clinical Preparedness, and Basic Knowledge Number of LGBT patients was a significant predictor for Attitudinal Awareness	2
Obedin-Maliver et al. (2011) [122]	Hours of LGBT curricular content and coverage of LGBT-related topics	Survey (N=132 US and Canadian medical schools, including 121 US medical schools which are sometimes separated)	Median reported pre-clinical hours dedicated to LGBT content at US medical schools was 4 hours (IQR 2-6, range 0-24) Median reported clinical hours dedicated to LGBT content at US medical schools was 2 hours (IQR 0-4, range 0-15) 63% of all schools teach at least half of the 16 LGBT-related topics	N/A
Phelan et al. (2017) [123]	Preparedness caring for LGB patient, skill at counseling LGBT patients on safer safe practices, favorability and frequency of interactions with LGBT patients	Surveys (N=3,492 MS that completed initial survey as MS1 and follow-up as MS4)	Mean score for preparedness to care for LGB patient was 4.1/5 Mean score for skill at counseling LGBT patients on safer sex practices was 3.0/5	2
Robertson (2017) [124]	Experiences in medical school, including lack of education on queer health issues	Semi-structured interviews (N=11 including N=8 MS1-4)	Expressed concern for inadequate training on queer health issues Queer health issues came up in formal curriculum related to social history or with an HIV-positive gay male patient in case studies	1
Talbott et al. (2023) [125]	Pre-clinical and clinical	Survey (N=51 medical school administrators)	13.7% of administrators reported including LGBTQ+ patients in their human trafficking curriculum	N/A
Thompson Hale M et al. (2018) [126]	Knowledge and comfort caring for LGB and transgender patients	Survey (N=137 MS1)	Significantly less knowledge of health care needs and health care issues for transgender patients compared to LGB patients Significantly lower comfort levels working with transgender patients compared to LGB patients	2
Varas-Díaz et al. (2019) [127]	Clinical practice scores in observed SP scenarios	Survey and assessment of skills in SP scenarios (N=237 MS4)	Mean physical exam score significantly worse for MSM scenario Scores for history taking, including communication, were significantly lower for scenarios with patient using IV drugs and MSM patient compared to female patient	2, 3
Vasudevan et al. (2022) [128]	Knowledge, skills, and attitudes towards healthcare for transgender patients	Survey (N=302 total students including N=178 MS1-4)	35% of MS had provided clinical care to a transgender patient 89% of MS reported “low” or “intermediate” knowledge regarding medical management of patients with gender dysphoria Among MS, self-reported knowledge about medical management and skill level in providing medical care to transgender patients increased with year in school (p = .007 and .002, respectively)	2
Warner et al. (2018) [129]	Sexual health knowledge including sexual minority health	Survey (N=1,014 MS1-4+)	63% average correct on sexual minority health section Students who learned about sexuality in a dedicated course performed significantly better than students who learned about sexuality in other courses (e.g. psychiatry, microbiology)	2
White et al. (2015) [130]	Preparedness and comfort in caring for LGBT patients	Survey (N=4,262 MS2-4+: of which 3,956 in US, 306 in Canada), focus group (N=29 MS***)	76% US DO and 65% US MD MS described curriculum as “fair,” “poor,” or “very poor” 47% US DO and 66% US MD MS felt “more prepared” by their medical education 84% all MS felt “comfortable” or “somewhat comfortable” caring for LGBT patients Required pre-clinical learning (37%), interactions with LGBT patients (25%), and personal experiences (24%) were most influential in increasing comfort with LGBT patients	1, 2
Wilson et al. (2014) [131]	Comfort caring for LGBT patients	Survey (N=975 total students including N=270 MS***)	MS responses to “It would be more challenging to gather a history from an LGBT patient than from a heterosexual patient” were an average of 3.6 (SD 1.1) (1=‘‘strongly disagree’’ - 5=‘‘strongly agree’’) MS responses to “It is more challenging to discuss sexual behavior with LGBT patients than with heterosexual patients” were average of 3.3 (SD 1.2)	2
Zelin et al. (2018) [132]	Comfort and confidence caring for SGM patients, perceived adequacy of curriculum	Survey (N=658 MS1-4)	84% somewhat/very competent in their ability to sensitively interview patients about sexual orientation, history, and practices 23% & 19% somewhat/very competent describing treatment options for patients who are transgender or have DSD, respectively 60% did not feel curriculum had adequate SGM health information 56% did not believe their curriculum adequately prepared them to comfortably and competently care for SGM patients	1, 2
Studies that describe the development of broad curriculum objectives or changes, including planning aspects
Author and year	Curriculum type	Methods	Key findings
Coleman et al. (2013) [133]	Sexual health curriculum including LGBTQI health	Summit (N not stated, US and Canadian medical educators, sexual health educators, and interested parties at the national level)	Proposed including sexual health for LGBTI populations within the sexual health curriculum Stressed need for clarification of the relationship between sexual health and LGBTI health
Coria et al. (2013) [134]	Social justice curriculum including gender and sexual identity in social determinants of health	Multidisciplinary committee developed (N=19 members including 8 MS***)	Committee compiled topics that should be included in a social justice curriculum, including gender and sexual orientation in social determinants of health Recommendations from committee implemented in existing materials, new materials, and elective social justice track
Eckstrand et al. (2016) [135]	Medical education related to care for people who are LGBT, gender nonconforming (GNC), and/or born with DSD	Identify competencies (N=9 members on AAMC Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development)	Adapted Physician Competency Reference Set (PCRS) framework to refine competencies required for care of people who are LGBT, GNC, and/or born with DSD Defined 30 qualifiers of competence for 20 PCRS competencies, including at least 1 qualifier in each of the 8 domains
Holthouser et al. (2017) [136]	Development and implementation of inclusive, comprehensive curriculum on LGBT/GNC/DSD patient care	Steering committee, involved stakeholders, evaluated gaps in curriculum to develop implementation plan and executed this	Content incorporated into 50.5 hours of required MS1-2 curriculum In pilot year 320 MS received the new curriculum and 23 faculty members taught some component of this New sessions included direct interaction with LGBT/GNC/DSD patients through patient panels and small groups
Katz-Wise et al. (2022) [137]	Integration of LGBTQIA + community experiences and perspectives into curriculum	Authors describe approach for integration including 2 community advisory groups (CAG) of young adults (N=10) and adults (N=12)	Approach detailed for integration of LGBTQIA+ community members into medical education using CAGs, community panel events, SPs, and community member interviews Main theme from CAG meetings was LGBTQIA+ education and training with subthemes of the needed education/training, patients at educators, key concepts, and learning methods Panelists discussed “What advice do you have for medical students who are still in training about caring for LGBTQIA+ people?”
Keuroghlian et al. (2022) [138]	Longitudinal SGM health curriculum (in existing curriculum and broader learning environment)	Multi-year initiative involving a core team, stakeholders, Professional Advisory Council, and Community Advisory Groups	Defined 9 core SGM health competencies mapped onto the 6 MD program competencies/objectives based on the 30 competencies in the AAMC guidelines on improving LGBTQIA+ health care Made additions to pre-clinical and clinical curriculum based on inventory of full curriculum Held 2-day symposium exploring best practices for integrating SGM health content across the curriculum
Loder et al. (2020) [139]	Reproductive justice (RJ) medical education	Delphi (N=41 RJ advocates and leaders on the expert panel)	“LGBTQI health” was noted as a core area that all physicians should receive education in Highlighted that physicians should learn about transgender healthcare and the difference between sex and gender
Matthews-Juarez et al. (2020) [140]	Broad discussion of how medical schools should train students to care for LGBTQ+ and other vulnerable groups	Community of Practice (N=62)	Created space for stakeholders to discuss how MS should be trained to provide high-quality, patient-centered care for LGBTQ+ people
Newsom, Buehler, et al. (2022) [141]	Development of student-run LGBT+-focused clinic	Previous survey of MS*** followed by needs assessment from community	Based on findings from a survey for medical students and needs assessment from community, student-run LGBT+-focused clinic developed to increase MS training and provide care for LGBT+ people in the community
Noonan et al. (2018) [142]	Overall undergraduate medical education	Community forum (N=59) and follow-up survey (N=100)	Curricula revised to include small-group sessions between MS and LGBT patients and education on specific transgender health needs Updated teaching and assessments about patient interaction to combat heteronormative and cisnormative bias in communication Integrated material on the following topics into the required curriculum: cross-gender hormone therapy, evaluation of patients for gender dysphoria, provider bias, and best practices for cancer screening in transgender patients
Pratt-Chapman (2020) [143]	Examined implementation factors that facilitated SGM health curricular integration in training for health professionals including MS at different institutions	Interviews (N=16 faculty and MS*** that were identified as champions for SGM curricular change)	Most successful interventions had a combination of student and faculty engagement Successful implementation relied on at least one institutional champion Major themes included need to increase student exposure to SGM community & how availability/lack of expertise shaped curriculum Key themes on future directions included need for evaluation tools and need to incentivize inclusion of SGM curricula
Raygani et al. (2022) [144]	LGBTQ+ health topics in pre-clinical and clinical curriculum	Topic Steward oversaw integration of LGBTQ+ content in curriculum	Pivoted from concentrated curriculum to series of facilitated discussions in LGBTQ+ health topics over 3 years Incorporated use of pronouns in first week of school Added lecture and small group on inclusive terminology, social determinants of health related to discrimination, and sexual health Added lecture and small group on inclusive sexual history taking LGBTQ+ content added to relevant existing pre-clinical lectures Expanded clerkship opportunities
Stumbar et al. (2020) [145]	Development and implementation of longitudinal, feasible, and comprehensive sexual health curricular objectives	Needs assessment including review of course syllabi and conversations with course directors, review of existing objectives	12 sexual health curricular objectives including: “sex and gender” (addressed in years 1 and 2) “skills for sexual history taking” (including inclusive sexual history, addressed in years 2 and 3) “social determinants of sexual health” (including LGBTQ communities, addressed in years 2 and 3)
Weingartner LA et al. (2022) [146]	Gender-affirming care education across medical school curriculum	Utilization of epistemic peerhood model to consider gender-affirming care in medical education at their institution	Training should include discussions of authoritative and embodied knowledge of gender-diverse patients Importance of forming partnerships between academic health centers and local gender-diverse communities Importance of including gender-diverse people as SPs
Yehia et al. (2015) [147]	Development of interprofessional program on LGBT health	Interprofessional retreat including community members	Penn Medicine Program for LGBT Health developed Includes health education area of focus, with an achievement being delivery of 10 LGBT health-themed lectures

*it was not explicitly stated in the article if the learning activity was required, or elective/optional, the label here was implied based on how the activity was described; **unspecified if this was part of a clinical or pre-clinical curriculum; ***year in medical school not specified.

Abbreviations: AAMC: Association of American Medical Colleges; DSD: differences of sex development; GAHT: gender-affirming hormone therapy; GM: gender minority; GNC: gender nonconforming; IAT: implicit association test; LGB: lesbian, gay, and bisexual; LGBT: lesbian, gay, bisexual, and transgender; LGBT-DOCSS: LGBT-Development of Clinical Skills Scale; MSM: who have sex with men; MS: medical student; MS1: first-year medical student; MS2: second-year medical student; MS3: third-year medical student; MS4: fourth-year medical student; MS4+: student that has >4 years of medical training (i.e., dual degree or research year); N/A: not applicable; PA: physician assistant; PrEP: pre-exposure prophylaxis; SGM: sexual and gender minorities; SM: sexual minority; SOGI: sexual orientation and gender identity; SP: standardized patient; TGD: transgender and gender diverse; TGWM: transgender women who have sex with men; WSW: women who have sex with women.

Articles that involved a learning outcome evaluation were also classified according to the Kirkpatrick Model of the 4 levels of evaluation [13]. Level 1 (also referred to as ‘Reaction’) in this model refers to evaluations that assess to the degree to which trainees found the educational aspect to be engaging, favorable, and relevant to their position or program. Level 2 (‘Learning’) refers to evaluations that examine the degree to which trainees acquired the intended knowledge, skills, attitude, commitment, and confidence based on their participation in the educational material. Level 3 (‘Behavior’) refers to evaluations that assess the degree to which trainees apply what they have learned to situations in their program. Level 4 (‘Results’) refers to evaluations that examine the degree to which targeted outcomes occur as a result of the trainees participating in the educational aspect studied [13].

No IRB or other ethical review was required for this project.

Results

Identification and screening of potential articles

The initial database search from 01/01/2011-05/19/2022 yielded 1,186 results (PubMed 1,048; ERIC and Education Research Complete 138). Among these, 1,097 were screened by their titles and abstracts after duplicates were removed. Subsequently, 250 articles underwent full text screening for eligibility, and 97 met inclusion criteria.

When the database search was repeated from 05/20/2022-02/06/2023, 174 unique additional articles were identified and underwent title and abstract screening. Thirty-one articles underwent full text review and 18 met inclusion criteria.

Screening of the references for all articles included following the two database searches above yielded 19 additional unique articles that met inclusion criteria. Figure 1 demonstrates the article identification and screening process.

Figure 1. Article identification and screening process.

Screening yielded 134 total articles that met inclusion criteria, all of which were subsequently reviewed. An overview of all 134 reviewed articles can be found in Table 2, including information on the sample, methods, and select results. The articles are organized by topic area: those that evaluated existing curriculum (N = 6) [14–19]; specific curriculum interventions (N = 77) [20–96]; student learning experiences and knowledge (N = 36) [97–132]; and the development of learning objectives and curricula (N = 15) [133–147]. There was a trend for a greater number of relevant articles published in recent years, shown in Figure 2. There was one article published in 2011 and in 2012. This increased to 21 (2020), 19 (2021), and 24 (2022) articles published that met inclusion criteria.

Figure 2. Frequency of articles included in review published per year. Note that only articles published through 6 February 2023 were included.

Broad evaluation of existing curriculum

Six articles (4.5%) evaluated the LGBTQ+ health content in existing curricula. Common tools for pre-clinical and/or clinical curriculum evaluations included the 2014 AAMC competencies [4,14,15,17] and learning objectives from Vanderbilt University [14,17]. Additionally, a team at Boston University developed the Sexual and Gender Minority Curriculum Assessment Tool (SGM-CAT) [19] based on the AAMC competencies [4] and used this to evaluate their curriculum [19].

Using the 2014 AAMC competenecies [4], two articles evaluated their school’s pre-clinical curriculum [14,17] and one the pre-clinical and clinical curriculum [15]. Among these articles, fifteen [14] and twenty-one [17] of the 30 competencies were partially or fully met in the pre-clinical curricula of two programs, and the pre-clinical and clinical curriculum at a different institution was found to address thirteen [15] of the 30 competencies. Two articles evaluated their pre-clinical curriculum using 31 learning objectives developed by Vanderbilt University in addition to the AAMC competencies [14,17]. These articles found their pre-clinical curricula to fully address twelve [14] and twenty-two [17], and partially address seven [14] and five [17], of the learning objectives. One article detailed the development of a 12-topic curriculum assessment tool based on the 30 AAMC competencies, named the SGM-CAT, which was then used to evaluate the pre-clinical and clinical curriculum at the institution [19]. This evaluation found that while all topics were covered at some point in the curriculum, some were addressed only a couple of times, and LGBTQ+ health content was concentrated in the pre-clinical curriculum [19]. Another team utilized a retreat to review their curriculum and develop proposed changes, which they subsequently tracked [18]. Lastly, one article evaluated the inclusion of LGBTQ+ patients in the American Academy of Dermatology’s online Basic Dermatology Curriculum, and found one of 293 cases to mention an LGBTQ+ patient [16].

Specific curriculum interventions

Seventy-seven (57%) articles evaluated the impact of specific curriculum interventions related to LGBTQ+ health. Of these, 42 (54.5%) took place in the pre-clinical curriculum, 16 (20.8%) in the clinical curriculum, and 19 (24.7%) either took place throughout both parts of the curriculum or it was unclear when they took place. Forty-three (55.8%) of the interventions were required for students to participate in, 32 (41.6%) were elective, 1 (1.3%) had both elective and required components, and for 1 (1.3%) intervention it was unspecified if it was required or elective. Table 3 displays the type and requirement of the curriculum interventions.

Table 3. The most common intervention classification was required in the pre-clinical curriculum.

Curriculum type	Required or elective for students	Number of articles (%), of 77 total
Clinical (N = 16)	Required	9 (11.7)
	Elective	6 (7.8)
	Unspecified	1 (1.3)
Pre-clinical (N = 42)	Required	33 (42.9)
	Elective	8 (10.4)
	Both elective and required elements	1 (1.3)
Unspecified or combination (N = 19)	Required	1 (1.3)
	Elective	18 (23.4)

The curriculum interventions used a variety of teaching methods and features. Forty-five (58.4%) included a lecture component, 39 (50.6%) small group activities, 32 (41.6%) direct contact with people with lived experience, 30 (39.0%) hands-on clinical skills, and 7 (9.1%) online interactive modules. Figure 3 displays the frequency of these learning features by curriculum type.

Figure 3. Frequency of teaching modalities and learning features among the studied curriculum interventions.

Of the 45 interventions that included a lecture component, 13 (28.9%) involved only lectures and 32 (71.1%) combined the lecture with additional learning activities. The 32 interventions that included direct contact with people with lived experience incorporated this aspect in the following ways: a panel in 15 (46.9%); Q&A with an individual in 3 (9.4%); interactions with patients in clinical settings in 8 (25%); interactions with LGBTQ+ standardized patients in 7 (21.9%); LGBTQ+ people leading sessions/lecture in 2 (6.3%); and community work in 1 (3.1%).

Though not all articles provided measurements of knowledge and learning following the interventions, there were statistically significant improvements in knowledge in 22 (28.6%) articles, significant improvements confidence in 13 (16.9%), and significant improvements in comfort in 15 (19.5%). Almost all interventions were evaluated with one or more surveys.

Classifying these interventions according to the Kirkpatrick Model of the 4 levels of evaluation [13], 22 (28.6%) studies involved level 1 (‘Reaction’) evaluation. Sixty-eight (88.3%) involved level 2 (‘Learning’) evaluation. Two (2.6%) included level 3 (‘Behavior’) evaluation, which in both studies occurred via evaluation of student encounters with standardized patients [52,75]. Some studies included more than one level of evaluation. None of the studies involved a level 4 evaluation (‘Results’).

While some interventions took a broader approach in looking at LGBTQ+ health, others had a more specific focus. Interventions in the pre-clinical curriculum covered a wide variety of topics, including: health disparities; barriers to care; terminology; taking an inclusive sexual history; reproductive endocrinology; sexually transmitted infections, including HIV; and care for transgender and gender diverse people (among both adult and pediatric patients). Interventions in the clinical curriculum covered similar topics, including: social determinants of health; reproductive justice; care for LGBTQ+ youth; and care for transgender and gender diverse people (among both adult and pediatric patients).

The most common topic across these interventions, described in 34 articles, was related to gender identity, care for transgender and gender diverse communities, and/or gender-affirming care. This included 19 interventions in the pre-clinical curriculum (15 of which were required) and 9 interventions in the clinical curriculum (3 of which were required). There was 1 required intervention on this topic area that involved both the pre-clinical and clinical curriculum, as well as 5 optional interventions that were not specified as occurring in a specific part of the curriculum. Among these interventions that focused on aspects related to gender identity and affirming care: 13 significantly increased knowledge [25,61,62,68,71,73,75–78,81,85,89]; 7 significantly increased comfort with aspects of providing care [25,37,47,48,71,73,85]; and 4 significantly increased confidence in providing care [21,59,62,86].

Information about HIV and pre-exposure prophylaxis (PrEP) was a topic area of focus in 6 interventions. This included 2 required pre-clinical interventions and 4 elective interventions that either took place throughout both parts of the curriculum or it was unclear when they took place. While not all studies discussed statistical significance, among these interventions that focused on HIV and PrEP, 2 studies demonstrated significantly increased knowledge on this topic [23,91], 1 study found significantly increased agreement or confidence in some learning objectives at one site in the study [79], and 1 study found significantly increased comfort discussing sexual behaviors with men who have sex with men (MSM), identifying at-risk MSM who may benefit from PrEP, and prescribing PrEP to MSM [91].

Evaluating curriculum by student knowledge, preparedness, and learning experiences

Thirty-six articles (26.9%) studied medical student knowledge, preparedness, and learning experiences. Among these, 13 (36.1%) evaluated students and student experiences at a single institution and 23 (63.9%) across multiple institutions. Thirty-one (86.1%) articles involved data collection from medical students and 5 (13.9%) from faculty or medical school administrators. The most common method of data collection used was a survey, which was used by 35 (97.2%) articles. Three (8.3%) used interviews, 1 (2.8%) focus groups, 1 (2.8%) curriculum inventories, and 1 (2.8%) coding of recorded video interactions with standardized patients. There were a variety of themes studied within these articles, the frequency of which are shown in Figure 4. This includes knowledge in 16 (44.4%), comfort in 9 (25%), preparedness in 9 (25%), specific or general curriculum components in 6 (16.7%), perceived coverage in curriculum in 5 (13.9%), amount of LGBTQ+ patient interaction in 4 (11.1%), hours of education in 4 (11.1%), comprehensiveness of training in 3 (8.3%), and confidence in 2 (5.6%).

Figure 4. Frequency of theme evaluation. ‘LGBT-DOCSS’ stands for the ‘LGBT-Development of Clinical Skills Scale’. This was developed by Bidell (2017) [99] and was used as a measurement tool in two additional studies represented in this figure [120,121]. Of note, the LGBT-DOCSS includes assessment of preparedness and knowledge, and these articles are additionally included in the frequency displayed above for the categories ‘preparedness’ and ‘knowledge’ in addition to ‘LGBT-DOCSS’.

Classifying these interventions according to the Kirkpatrick Model of the 4 levels of evaluation [13], 11 (30.6%) of these studies involved level 1 (‘Reaction’) evaluation. Twenty-seven (75%) involved level 2 (‘Learning’) evaluation. One (2.8%) used level 3 (‘Behavior’) evaluation, which in this study consisted of evaluations of students in a standardized patient encounter [127]. Some studies included more than one level of evaluation. None of the studies involved a level 4 evaluation (‘Results’).

During the period of this review, the ‘LGBT-Development of Clinical Skills Scale’ (LGBT-DOCSS) was developed by Bidell (2017) [99] and was used as a measurement tool in 4 additional studies [80,93,120,121]. This tool includes subscales on attitudinal awareness, clinical skills, and basic knowledge [99], and can be utilized to conduct evaluations at level 2 on the Kirkpatrick model, focusing on the knowledge and confidence of the learners.

Eleven studies discussed overarching gaps in LGBTQ+ health curricula at medical schools [98,101,102,109,111,114,116,118,122,124,130]. This includes a survey of medical students across 175 of the 176 medical schools in the US and Canada that found that 76% of US DO and 65% of US MD medical students described their school’s LGBT-related curriculum as ‘fair,’ ‘poor,’ or ‘very poor’ [130], a survey of medical students across two schools that described the average coverage as ‘too little’ or ‘basic’ of LGBT health items [98], a survey of medical students across 12 schools that rated the comprehensiveness of their training about sexual and gender minority (SGM) health on average to be 5.37 (on a scale of 1–10 with 1 being minimal and 10 being comprehensive) [101], and a survey of medical students across 12 schools who most commonly rated their training on SGM health as ‘moderate’ (34.8%) and ‘adequate’ (45.1%) with fewer responses on either end of the spectrum [102]. A survey of faculty found that overall, coverage of concepts related to LGBT health were rated as ‘poor’ to ‘adequate’ [116].

A study that included residents and fellows in addition to medical students found that while most respondents felt comfortable caring for LGBTQ+ patients, 39% did not feel that they received sufficient training and about half of the medical students and residents had minimal or no interaction with LGBTQ+ patients during their training [114]. Also important to note is that this study found that respondents who had some discomfort treating LGBTQ+ patients cited lack of education as a reason for this [114]. A study that surveyed medical students in addition to students in other programs found that 48% agreed their training prepared them to care for LGBTQ patients and 52% reported that their school integrated LGBTQ content into the formal curriculum [111].

A common finding, identified in eight studies, a gap in student knowledge, preparedness, and/or training related to transgender health and gender-affirming care [97,111,115,118,120,126,128,132]. Four of these studies specifically found that students had lower knowledge, comfort, and preparedness related to working with transgender patients compared to lesbian, gay, and bisexual patients [111,115,120,126]. Specific deficits included only 32% of students agreeing that they know appropriate terminology for working with someone who is transgender [97] and 23% feeling somewhat/very competent describing treatment options for patients who are transgender [132]. The amount of education about the care for transgender and gender diverse people students reported receiving was variable, as one survey of medical students at one school found that 87% reported transgender patient care was part of their curriculum, however 52.5% reported needing more information on transgender health, and on average there was a self-reported lack of sufficient knowledge related to surgical and hormonal aspects of gender-affirming care [118]. Another survey of medical students and physicians that found that only 56% participants received any formal transgender and non-binary health education in medical school [109].

Another commonly studied discrete topic was student knowledge and education on HIV care, including PrEP, which was included in nine articles [98,103–108,117,124]. A survey of medical school administrators found that 38% of schools reported offering any PrEP content and 15.4% of schools reported having specific training regarding PrEP for LGBT patients [108]. In a different survey, most (83.9%) medical and physician assistant students reported being taught about HIV risk and 60% being taught about PrEP, however 88.6% were aware of PrEP [106]. One study found health professional students to have a mean HIV knowledge score of 79.6% and PrEP knowledge score of 84.1%[103], and in a different evaluation of medical students, respondents demonstrated an average of 57.8% of questions on HIV and prophylaxis correct [117]. Interviews with medical students found that LGBTQ+ health issues came up in the formal curriculum related to social history or with an HIV-positive gay male patient in case studies [124]. Regarding findings related to HIV and PrEP in specific populations, the following findings were identified: 65% of medical and physician assistant students agreed that PrEP is effective in transgender women and 72% in MSM [104]; medical students were less likely to identify a heterosexual female patient as a PrEP candidate and reported lowest confidence caring for heterosexual female patient seeking PrEP [105]; and medical students were most willing to prescribe PrEP to patients with sustained condom use and multiple male partners (86%) and a single male partner (93%) [107]. Health professional students surveyed about their education on HIV and PrEP reported that MSM were the most frequently presented candidate patient population for PrEP and transgender women who have sex with men were the least frequently presented patient population indicated for PrEP in their education [106].

Broad curriculum and learning objective development approaches

Fifteen articles (11.2%) described approaches for broad curriculum and learning objective development. Many of these articles described the utilization of group settings as a key component, specifically including a retreat by 1 (6.7%) [147], summit by 1 (6.7%) [133], forum by 1 (6.7%) [142], community of practice by 1 (6.7%) [140], and specific committees or groups by 5 (33.3%) [134–138]. Six (40%) [136–138,140,142,147] involved community members in their development. Two (13.3%) articles utilized surveys [141,142], 1 (6.7%) interviews [143], 3 (20%) needs assessments [136,141,145], and 1 (6.7%) a Delphi process [139]. One (6.7%) article described the process by which a Topic Steward oversaw the integration of LGBTQ+ content into the curriculum [144]. One (6.7%) utilized the epistemic peerhood model to consider medical education on gender-affirming care at their institution [146].

Discussion

The aim of this review was to explore the landscape of interventions and evaluations related to the LGBTQ+ health content that is taught and learned in medical schools in the USA. We found a wide range of studies that described evaluations of the overall curriculum and specific curriculum interventions, procedures for the development of learning objectives and curricula, and evaluations of student knowledge and learning experiences related to LGBTQ+ health. In bringing the findings of these studies into conversation together, we offer insight into the current state of LGBTQ+ health medical student education with opportunities for growth and development.

Many specific curriculum interventions on LGBTQ+ health have been developed and studied over the past eleven years, which have been summarized in this review. Particular strengths demonstrated in the review include the breadth of educational interventions in the pre-clinical curriculum, variety of teaching modalities, and inclusion of LGBTQ+ community members. The educational interventions identified in this review most commonly occurred in the pre-clinical curriculum, with a little more than half of the interventions occurring exclusively during this portion of a training program (N = 42, 54.5% in pre-clinical curriculum; N = 16, 20.8% in clinical; and N = 19, 24.7% in both or unclear timing). These pre-clinical interventions provided education on a wide variety of topics, including: health disparities; barriers to care; terminology; taking an inclusive sexual history; reproductive endocrinology; sexually transmitted infections, including HIV; and care for transgender and gender diverse people (both adults and children). The breadth of topic coverage demonstrates how medical educators have integrated LGBTQ+ health into multiple didactic curricular areas. Similar to previous reviews, we found that components of teaching interventions were variable (for example, the content was sometimes delivered in lectures, small groups, panels, or online modules, among others) [5–12]. This variability in teaching modality is another strength identified through this review, as studies have found benefits to active learning, compared to the more traditional lecture model [148–150].

A third strength Identified In this review Is the Inclusion of LGBTQ+ community members. Various approaches to curriculum and learning objective development were described, and notably 6 included community members. Among curriculum interventions, 32 (41.6%) included direct contact with LGBTQ+ individuals. This is an increase in the proportion of curriculum interventions including LGBTQ+ people compared to the results reported in a review article by Sekoni et al. (2017), which found 5 of 16 (31.3%) to involve LGBTQ+ people in curriculum interventions [7]. Intergroup contact theory suggests that direct contact between members of different groups can reduce intergroup prejudice [151]. This has been shown to be true related to direct contact of students with LGBTQ+ people [142,152–154] suggesting that this could be a valuable addition to medical education. However, this should be balanced with consideration for the potential burden, often referred to as the ‘minority tax,’ that may occur when people from marginalized communities teach others about their identities, which was a concern raised in a study that involved a peer education model at one institution [54].

Despite the strengths identified among current practices of medical educators, this review found common gaps in knowledge, confidence, and preparedness for medical students related to aspects of LGBTQ+ health. Eleven articles described overarching gaps in LGBTQ+ health curricula at medical schools [98,101,102,109,111,114,116,118,122,124,130]. Overall ratings of the curricula broadly in these studies were generally adequate or lower. Specifically, these studies include surveys of medical students who described their curriculum in the following ways: LGBT-related curriculum as ‘fair,’ ‘poor,’ or ‘very poor’ by 76% of US DO and 65% of US MD students [130]; average coverage of LGBT health items as ‘too little’ or ‘basic’[98]; comprehensiveness of training about SGM health on average as 5.37 out of 10¹⁰¹; and training on SGM health as ‘moderate’ by 34.8% and ‘adequate’ by 45.1%[102]. These findings extended to faculty, as a survey found that overall they rated coverage of concepts related to LGBT health as ‘poor’ to ‘adequate’ [116].

This review also identified particular areas within LGBTQ+ health that were a common topic with lower proficiency for students. A specific topic area that was identified commonly as a gap in student training was related to gender-affirming care and the health of people who identify as transgender or gender diverse. Eight articles described gaps in student knowledge, preparedness, and training related to this topic [97,111,115,118,120,126,128,132]. Examples of specific deficits included only 32% of students agreeing that they know appropriate terminology for working with someone who is transgender [97] and 23% feeling somewhat/very competent describing treatment options for patients who are transgender [132]. This area is of particular importance to address when considering interventions to improve LGBTQ+ health education also because four studies found that medical students had lower knowledge, comfort, and preparedness related to working with transgender patients compared to lesbian, gay, and bisexual patients [111,115,120,126].

Given the high rate of negative experiences with healthcare providers among people who identify as transgender, nonbinary, and gender expansive [2,3], in addition to the health disparities faced by these patients [155–157], improving medical student education on health for these communities is critical for improving healthcare experiences and outcomes for this population. This review sheds light on educational interventions that could be utilized to address these gaps, as there were 34 studies on interventions related to the health of people who identify as transgender or gender diverse and gender-affirming care, and 19 of these studies that showed statistically significant improvement in student outcomes. These interventions had a significant impact on multiple aspects of trainees preparation: 13 significantly increased knowledge [25,61,62,68,71,73,75–78,81,85,89]; 7 significantly increased comfort with aspects of providing care [25,37,47,48,71,73,85]; and 4 significantly increased confidence in providing care [21,59,62,86]. Educational interventions on this topic area also align with the guidance in the 2014 AAMC report. For example, one competency reads, ‘Describing the special health care needs and available options for quality care for transgender patients and for patients born with DSD (e.g., specialist counseling, pubertal suppression, elective and nonelective hormone therapies, elective and nonelective surgeries, etc.)’[4]. While future physicians in some specialties may not provide direct affirming hormonal or surgical care, it should be anticipated that the vast majority of physicians across all specialties will care for transgender and gender diverse patients in their residencies and clinical practice. Given that some of the gaps identified in this area were related to fundamental aspects of clinical care such as terminology [97] or feeling comfortable caring for a patient [111,115,126], providing all medical students with more familiarity with affirming care approaches would help optimize care for these patients.

Another common discrete topic that was studied in both medical student knowledge and preparedness as well as in curriculum interventions was related to HIV and PrEP. When comparing the findings from different studies assessing the state of education on this topic and student knowledge, it appears that there is variability across institutions. Specifically, data from a sample of medical school administrators shows that 38% of schools report offering any PrEP content and 15.4% of schools report specific training regarding PrEP for LGBT patients [108]. In a different survey, 60% of medical and physician assistant students reporting being taught about PrEP [106]. It is possible that the differences in findings from administrators compared to students could be related to their position within the school or due to a difference in schools represented by the samples. Student knowledge was also variable, as one study found health professional students to have a mean HIV knowledge score of 79.6% and PrEP knowledge score of 84.1%[103], and medical students in a different evaluation had an average of 57.8% of questions on HIV and prophylaxis correct [117]. Lastly, the articles in this review shed light on the importance of considering patient representation in this setting. Health professional students surveyed about their education on HIV and PrEP reported that MSM were the most frequently presented candidate patient population for PrEP and transgender women who have sex with men were the least frequently presented patient population indicated for PrEP in their education [106]. Other studies found variability in how students responded when considering PrEP for patients of different demographics: a slightly higher percentage of medical and physician assistant students agreed that PrEP was effective in MSM (72%) compared to in transgender women (65%) [104]; and medical students were less likely to identify a heterosexual female patient as a PrEP candidate and reported lowest confidence caring for heterosexual female patient seeking PrEP [105]. While we cannot draw definitive conclusions between these findings, it is important to ensure that a diverse group of patients are portrayed in educational settings, and furthermore that stereotypes are not perpetuated in teaching materials.

Though the AAMC competencies do not explicitly reference HIV and PrEP, the report includes this topic in an example for integrating a competency (‘Explaining how homophobia, transphobia, sexism, and heterosexism affect health care inequalities, costs, and outcomes’): understanding that LGBTQ+ youth experience HIV at disproportionate rates compared to those who are not LGBTQ+[4]. It is essential that all medical students are provided with information on HIV and PrEP, as they will very likely care for a patient with HIV or who takes, or is interested in, PrEP at some point during their careers.

While there is no standard requirement for what medical school curricula should cover in regard to LGBTQ+ health, the 2014 AAMC report details 30 competency recommendations that students should accomplish by the end of medical school [4]. It appears that medical educators have responded to the guidance in this report as publications on LGBTQ+ health in medical education have steadily increased since 2014 (Figure 2). This review found that certain competencies in the report are being addressed in these efforts to enhance LGBTQ+ medical education. Specifically, a competency that was addressed across many studies within the domain of patient care describes the expected ability for graduating students to obtain an inclusive sexual history, ‘Sensitively and effectively eliciting relevant information about sex anatomy, sex development, sexual behavior, sexual history, sexual orientation, sexual identity, and gender identity from all patients in a developmentally appropriate manner.’[4] This competency was addressed by 13 interventions in this literature review [20,23,31,43,46–48,62,66,82,84,88,94]. However, there remains work to be done in this field in order to fully address all recommended competencies. Across all reviewed articles, 5 school evaluated their full pre-clinical and/or clinical curriculum [14,15,17–19]. Three institutions [14,15,17] specifically used the AAMC competencies in their evaluations [4]. These studies of curricula at individual institutions found that in the pre-clinical curriculum at two institutions partially or fully met fifteen [14] and twenty-one [17] of the 30 competencies, and the pre-clinical and clinical curriculum at a different institution addressed thirteen [15]. It is important to note that the curricular gaps related to LGBTQ+ health may vary widely between individual institutions. When comparing the findings from the two studies that evaluated their pre-clinical curriculum based on the 30 AAMC competencies, the institutions had fifteen [14] and nine [17] competencies that were not addressed, and there were only five common gaps between these programs.

Therefore, we recommend that the existing curricula at individual institutions should be evaluated to identify strengths and gaps related to LGBTQ+ health education. Educators may opt to use a variety of frameworks for evaluating their curriculum. This could involve a broader evaluation of the curriculum, for example using the AAMC competencies [4,14,15,17], learning objectives from Vanderbilt University [14,17], or the more recently published tool from Boston University, the SGM-CAT [19], which is based on the AAMC competencies [4]. The 2014 AAMC report devotes a chapter to discussing curriculum and program evaluation, including sample interventions and evaluations [4]. Educators could also follow the Kirkpatrick model of training evaluation [13], and in this case could utilize the recently developed LGBT-DOCSS tool [99], which was used in four studies in this review [80,120,121,143], and evaluates training at level 2 of the Kirkpatrick model.

Based on identified gaps in student training, knowledge, confidence, and preparedness or in the overall curriculum, specific educational activities and materials can be incorporated into the curriculum, such as those displayed in Table 2. Procedures that institutions used to evaluate and update their curricula discussed in articles in this review can also be considered in steps toward integration, such as forming specific committees or groups [134–138] or hosting an event such as a retreat [147], summit [133], or forum [142].

Based on this literature review, it is clearly evident and laudable that medical educators have developed significant content in response to the recommendations in the 2014 AAMC report. However, this review also demonstrated that gaps in student education and knowledge remain. To ensure learners are ultimately prepared to care for LGBTQ+ patients, LGBTQ+ health topics should be integrated longitudinally throughout medical school curriculum. In addition to educators evaluating the curriculum at their individual institutions, further teaching materials should be developed for the clinical curriculum. While many interventions in the pre-clinical curriculum were identified in this review, it is essential to integrate these topics throughout all aspects of a program’s curriculum. Furthermore, future studies are needed to assess the long-term implications of these educational interventions, specifically how they may impact patient care after training (in other words, addressing level 4 of the Kirkpatrick model, ‘Results’). Beyond the individual institution, building upon the competencies set forth by the 2014 AAMC report to determine standardized requirements for what students should learn about LGBTQ+ health in medical school is a critical next step in ensuring students at all institutions receive an adequate, inclusive, and holistic education that incorporates LGBTQ+ health appropriately. For instance, this may involve considering how to integrate assessment of LGBTQ+ health knowledge and skills in accreditation guidelines and assessment by national testing metrics.

Finally, in a country where sociopolitical discourse and policy create varying health care access and health equity issues for members of the LGBTQ+ community, especially as it relates to access and coverage for gender-affirming care, it is increasingly important that medical students within and across the US have more comprehensive knowledge about LGBTQ+ health issues so they are prepared to advocate for, and provide, equitable care.

Strengths and limitations

While existing reviews have studied specific curriculum aspects LGBTQ+ health [5–7] and transgender health [8–10] in medical school education, this is the first review to our knowledge that provides a comprehensive overview of studies on LGBTQ+ health education for medical students in the US that includes evaluation of specific curriculum evaluations, curriculum development procedures, and medical student learning outcomes. The broad approach taken by this review allows for the exploration of literature from multiple avenues that all contribute to our understanding of strengths and opportunities for improvement in LGBTQ+ health education for medical students.

This review is limited in that it is a narrative review that involved article reviews by one reviewer. Furthermore, 19 additional eligible articles were identified by screening reference lists of included articles, suggesting that other articles could have been missed by the search criteria we utilized. This review was limited to peer-reviewed studies and excluded grey literature, which may have prevented inclusion of relevant material. The review was also limited by the variable methodologies in the articles reviewed as many included measures of student self-reported knowledge and preparedness and some articles had mixed samples that including medical students among others. Additionally, the specific materials used in educational interventions and curricula were not consistently available with the published articles. Therefore, the way LGBTQ+ identities and topics were portrayed in these materials is not encompassed in this literature review. Future studies should include an examination of how this content is taught, to ensure that the material is presented in an inclusive manner that does not perpetuate stereotypes.

Lastly, it is important to note that this literature represents a segment of time with literature published between 1 January 2011–6 February 2023. Excitingly, additional studies in this area have been published since the conclusion of this literature review, and these will also likely prove useful to medical educators. Notably, a recent publication from medical educators across the country describes concrete strategies to promote inclusivity in language related to gender identity in pre-clinical and clinical learning spaces [158].

Conclusions

Medical student education is an important avenue to consider in addressing health disparities faced by the LGBTQ+ community. This topic has been increasingly studied in peer-reviewed literature in the USA. There have been a variety of curriculum interventions at single institutions that show promise in enhancing student knowledge and training in LGBTQ+ health. Despite these advances, multiple studies find that some students report inadequate education on this topic and there are limitations in their knowledge and preparedness to care for LGBTQ+ patients, particularly transgender and gender diverse patients. This is likely driven by how LGBTQ+ health education is variable in its coverage and depth across different institutions, and future studies and efforts should be devoted to refining a standardized requirement or minimum guidelines for the inclusion of this content in medical education.

Declarations of interest

The authors have no conflicts of interest to disclose.

Author contributions

Both authors conceived and designed the review. TIJ conducted the literature screening and analysis, based on an approach for screening and analysis as determined by both authors. EMP reviewed the analysis and areas of uncertainty were clarified through reaching consensus in discussions between both authors. TIJ wrote the first draft of the manuscript. EMP reviewed the draft and provided feedback. Both authors collaborated on editing and finalizing the manuscript. Both authors reviewed and approved the final article, including all submitted tables, figures, and appendix.

Acknowledgments

The authors would like to thank senior academic librarian Mary Hitchcock for her guidance and assistance in developing and executing the database searches for this project. We would also like to thank all of the community members, students, staff, and faculty who have and continue to contribute to the growing body of knowledge on LGBTQ+ health in medical education. We also thank the Kern National Network funded by the Kern Family Foundation that provided partial salary support for one of the authors (EMP) during the time of this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

One of the authors (EMP) received partial salary support from the Kern National Network funded by the Kern Family Foundation during the time of this study.

Appendix

1

Search terms utilized for literature search:

Search terms utilized in PubMed

((Medical[tiab]) AND (education[tiab] OR curricul*[tiab] OR knowledge[tiab] OR skill*[tiab] OR training[tiab] OR class[tiab] OR school[tiab])) OR (‘Schools, Medical’[Mesh]) OR (‘Education, Medical, Undergraduate’[Mesh] OR ‘Education, Medical’[Mesh] OR ‘medical student*’))

AND

(LGBT*[tiab] OR ‘Transgender Persons’[Mesh] OR transgender*[tiab] OR queer[tiab] OR intersex[tiab] OR ‘gender fluid’[tiab] OR gay[tiab] OR lesbian[tiab] OR bisexual*[tiab] OR homosex*[tiab] OR transsexual*[tiab] OR ‘Sexual and Gender Minorities’[Mesh] OR ‘Gender Dysphoria’[Mesh] OR gender-dysphori*[tiab] OR ‘gender dysphori*’[tiab] OR ‘gender-incongruen*’[tiab] OR non-binary[tiab] OR nonbinary[tiab])))

AND

(english[Filter])

2011–2022

Search terms utilized in ERIC & Education Research Complete (2 databases combined):

TI (LGBT* OR transgender* OR queer OR intersex OR ‘gender fluid’ OR gay OR lesbian OR bisexual* OR homosexual* OR transsexual* OR ‘Sexual and Gender Minorities’ OR ‘Gender Dysphoria’ OR gender-dysphori* OR ‘gender dysphori*’ OR ‘gender-incongruen*’ OR non-binary OR nonbinary) OR AB (LGBT* OR transgender* OR queer OR intersex OR ‘gender fluid’ OR gay OR lesbian OR bisexual* OR homosexual* OR transsexual* OR ‘Sexual and Gender Minorities’ OR ‘Gender Dysphoria’ OR gender-dysphori* OR ‘gender dysphori*’ OR ‘gender-incongruen*’ OR non-binary OR nonbinary)

AND

TI (Medical AND (education OR curricul* OR knowledge OR skill* OR training OR class OR school OR student*)) OR AB (Medical AND (education OR curricul* OR knowledge OR skill* OR training OR class OR school OR student*))

English, 2011–2022