Queering medical education: systematically assessing LGBTQI health competency and implementing reform

Figures & data

Table 1. AAMC competencies.

Met	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.
	Understanding typical (male and female) sex development and knowing the main etiologies of atypical sex development.
	Developing rapport with all individuals (patient, families, and/or members of the health care team) regardless of others’ gender identities, gender expressions, body types, sexual identities, or sexual orientations, to promote respectful and affirming interpersonal exchanges, including by staying current with evolving terminology.
	Recognizing and respecting the sensitivity of certain clinical information pertaining to the care of the patient populations described above, and involving the patient (or the guardian of a pediatric patient) in the decision of when and how to communicate such information to others.
	Recognizing the unique aspects of confidentiality regarding gender, sex, and sexuality issues, especially for the patients described above, across the developmental spectrum, and by employing appropriate consent and assent practices.
	Valuing the importance of interprofessional communication and collaboration in providing culturally competent, patient-centered care to the individuals described above and participating effectively as a member of an interdisciplinary health care team.
	Identifying important clinical questions as they emerge in the context of caring for the individuals described above, and using technology to find evidence from scientific studies in the literature and/or existing clinical guidelines to inform clinical decision making and improve health outcomes.
Partially Met	Performing a complete and accurate physical exam with sensitivity to issues specific to the individuals described above at stages across the lifespan. This includes knowing when particulars of the exam are essential and when they may be unnecessarily traumatizing (as may be the case, for example, with repeated genital exams by multiple providers)
	Recognizing the unique health risks and challenges often encountered by the individuals described above, as well as their resources, and tailoring health messages and counseling efforts to boost resilience and reduce high-risk behaviors.
	Providing effective primary care and anticipatory guidance by utilizing screening tests, preventive interventions, and health care maintenance for the populations described above (e.g., screening all individuals for inter-partner violence and abuse; assessing suicide risk in all youth who are gender nonconforming and/or identify as gay, lesbian, bisexual and/or transgender; and conducting screenings for transgender patients as appropriate to each patient’s anatomical, physiological, and behavioral histories).
	Defining and describing the differences among: sex and gender; gender expression and gender identity; gender discordance, gender nonconformity, and gender dysphoria; and sexual orientation, sexual identity, and sexual behavior.
	Identifying communication patterns in the health care setting that may adversely affect care of the described populations, and learning to effectively address those situations in order to protect patients from the harmful effects of implicit bias or acts of discrimination.
	Critically recognizing, assessing, and developing strategies to mitigate one’s own implicit (i.e., automatic or unconscious) biases in providing care to the individuals described above and recognizing the contribution of bias to increased iatrogenic risk and health disparities.
	Understanding and addressing the special challenges faced by health professionals who identify with one or more of the populations described above in order to advance a health care environment that promotes the use of policies that eliminate disparities (e.g., employee nondiscrimination policies, comprehensive domestic partner benefits, etc.).
Unmet	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.)
	Understanding and explaining how stages of physical and identity development across the lifespan affect the above-described populations and how health care needs and clinical practice are affected by these processes.
	Understanding and describing historical, political, institutional, and sociocultural factors that may underlie health care disparities experienced by the populations described above.
	Recognizing the gaps in scientific knowledge (e.g., efficacy of various interventions for DSD in childhood; efficacy of various interventions for gender dysphoria in childhood) and identifying various harmful practices (e.g., historical practice of using ‘reparative’ therapy to attempt to change sexual orientation; withholding hormone therapy from transgender individuals) that perpetuate the health disparities for patients in the populations described above.
	Critically recognizing, assessing, and developing strategies to mitigate the inherent power imbalance between physician and patient or between physician and parent/guardian, and recognizing how this imbalance may negatively affect the clinical encounter and health care outcomes for the individuals described above.
	Demonstrating the ability to elicit feedback from the individuals described above about their experience in health care systems and with practitioners, and identifying opportunities to incorporate this feedback as a means to improve care (e.g., modification of intake forms, providing access to single-stall, gender-neutral bathrooms, etc.)
	Understanding that implicit (i.e., automatic or unconscious) bias and assumptions about sexuality, gender, and sex anatomy may adversely affect verbal, nonverbal, and/or written communication strategies involved in patient care, and engaging in effective corrective self- reflection processes to mitigate those effects.
	Recognizing and sensitively addressing all patients’ and families’ healing traditions and beliefs, including health-related beliefs, and understanding how these might shape reactions to diverse forms of sexuality, sexual behavior, sexual orientation, gender identity, gender expression, and sex development.
	Accepting shared responsibility for eliminating disparities, overt bias (e.g., discrimination), and developing policies and procedures that respect all patients’ rights to self-determination
	Explaining and demonstrating how to navigate the special legal and policy issues (e.g., insurance limitations, lack of partner benefits, visitation and nondiscrimination policies, discrimination against children of same-sex parents, school bullying policies) encountered by the populations described above.
	Identifying and appropriately using special resources available to support the health of the individuals described above (e.g., targeted smoking cessation programs, substance abuse treatment, and psychological support).
	Explaining how homophobia, transphobia, heterosexism, and sexism affect health care inequalities, costs, and outcomes.
	Describing strategies that can be used to enact reform within existing health care institutions to improve care to the populations described above, such as forming an LGBT support network, revising outdated nondiscrimination and employee benefits policies, developing dedicated care teams to work with patients who were born with DSD, etc.
	Demonstrating the ability to perform an appropriate risk/benefit analysis for interventions where evidence-based practice is lacking, such as when assisting families with children born with some forms of DSD, families with prepubertal gender nonconforming children, or families with pubertal gender nonconforming adolescents.

Table 2. Vanderbilt learning objectives.

Met	Communication/Interview Skills
	Intake Forms (gender identity, sexual orientation, relationship status, parentage)
	PBL Integration
	Embryology – Gender vs. Sex
	STIs in lesbians
	STI recommendations in MSM
	HIV in MSM
	Exclusive WSWs: Paps, Breast Exams, and HPV Screening
	MSMs and need of HepA/HPV shot
	Lesbian Obesity
	Increased heart disease rate in lesbians
	Eating disorders in MSM
Partially Met	Assumptions/Biases
	Substance Abuse Screening
	Standardized Patient Cases
	Embryology—Changing Terminology
	Anal Paps
	Anal Cancer Risks, Tx, Anal Pap in MSM
	Lesbian nulliparity and risk of breast/ovarian/cervical cancer
Unmet	Depression screening
	Embryology—Disorders of Sex Development (What are they? What are the current thoughts on treatment options? What are gender assignments?)
	Vaginitis spread in lesbians
	Availability/Efficacy of Rectal Microbicides
	Hormone Therapy Pharmacology
	Transitioning options and associated risks
	Puberty suppression in management of trans youth
	Gay teen issues (psychological/sexual/coming out/identity development/schooling)
	Gay couples and fertility options
	Gender dysphoria vs. transgender
	Depression and Suicide Rates in LGBTQI teens/adults
	LGBTQI patients and having children (medical options and legal concerns)
	LGBT Teen Issues

Figure 1. Comparison of AAMC competencies and Vanderbilt learning objectives.

Figure 1. Continue.

Figure 1. Continue.

Figure 1. Continue.