An audit of the medical pre-clinical curriculum at an urban university: sexual and gender minority health content

Figures & data

Table 1. Medical school curricular alignment with association of American medical colleges competencies to improve health care for LGBTQI individuals

	Met	Partially met	Not met
Competency Domain: Patient Care Gather essential and accurate information about patients and their conditions through history taking, physical examination, and the use of laboratory data, imaging, and other tests by:
1. 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.	✓
2. 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).		✓
Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment by:
3. 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.).		✓
Counsel and educate patients and their families to empower them to participate in their care and enable shared decision-making by:
4. Assessing unique needs and tailoring the physical exam and counseling and treatment recommendations to any of the individuals described above, taking into account any special needs, impairments, or disabilities.	✓
5. 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.	✓
Provide health care services to patients, families, and communities aimed at preventing health problems or maintaining health by:
6. 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).		✓
Competency Domain: Knowledge for Practice Apply established and emerging biophysical scientific principles fundamental to health care for patients and populations by:
7. 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.	✓
8. Understanding typical (male and female) sex development and knowing the main etiologies of atypical sex development.	✓
9. 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.		✓
Apply principles of social-behavioral sciences to the provision of patient care, including assessment of the impact of psychosocial and cultural influences on health, disease, care seeking, care compliance, and barriers to and attitudes toward care by:
10. Understanding and describing historical, political, institutional, and sociocultural factors that may underlie health care disparities experienced by the populations described above.		✓
Demonstrate an investigatory and analytic approach to clinical situations by:
11. 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.		✓
Competency Domain: Practice-Based Learning and Improvement Identify strengths, deficiencies, and limits in one’s knowledge and expertise by:
12. 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.		✓
13. 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.).	✓
Locate, appraise, and assimilate evidence from scientific studies related to patients’ health problems by:
14. 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.			✓
Competency Domain: Interpersonal and Communication Skills Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds by:
15. 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.	✓
16. 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.			✓
Demonstrate insight and understanding about emotions and human responses to emotions that allow one to develop and manage interpersonal interactions by:
17. 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.	✓
18. 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.	✓
Competency Domain: Professionalism Demonstrate sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation by:
19. 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.			✓
20. 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.
Demonstrate accountability to patients, society, and the profession by:
21. Accepting shared responsibility for eliminating disparities, overt bias (e.g., discrimination), and developing policies and procedures that respect all patients’ rights to self-determination.			✓
22. 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.).			✓
Competency Domain: Systems-Based Practice Advocate for quality patient care and optimal patient care systems by:
23. 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.			✓
Coordinate patient care within the health care system relevant to one’s clinical specialty by:
24. 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).			✓
25. Identifying and partnering with community resources that provide support to the individuals described above (e.g., treatment centers, care providers, community activists, support groups, legal advocates) to help eliminate bias from health care and address community needs.			✓
Participate in identifying system errors and implementing potential systems solutions by:
26. Explaining how homophobia, transphobia, heterosexism, and sexism affect health care inequalities, costs, and outcomes.	✓
27. 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.			✓
Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care by:
28. 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 pre-pubertal gender nonconforming children, or families with pubertal gender nonconforming adolescents.		✓
Competency Domain: Interprofessional Collaboration
29. Work with other health professionals to establish and maintain a climate of mutual respect, dignity, diversity, ethical integrity, and trust by: 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.		✓
Competency Domain: Personal and Professional Development
30. Practice flexibility and maturity in adjusting to change with the capacity to alter one’s behavior by: 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.		✓

Table 2. Partially covered AAMC competencies

Competency	Covered	Not covered
2	Gender expression not equating to anatomy	Repeat genital exams by multiple providers traumatizing to intersex patients
3	Hormonal and surgical options for transgender individuals	Multidisciplinary specialty referral for transgender individuals
6	Cancer screening based on anatomy and hepatitis vaccinations for individuals who engage in anal sex	Indications for hormonal replacement among intersex patients
9	Adolescent transgender content was provided including anxiety or loneliness stemming from social isolation or family rejection	Counseling needs of families with intersex children
10	Medical pathology of homosexuality and laws that discriminate against same-sex benefits	Analyzing clinical practices to address the needs of intersex patients
11	Dangers of conversion therapy and mental health benefits of affirming-transgender care	Lack of evidence to support genital ‘normalization’ for intersex patients
12	Awareness of power imbalance between providers and genderqueer adolescents	Shared decision-making with parents of intersex children
20	Patient confidentiality and adolescent-specific concerns	Concerns and risks of disclosure of SGM patient information
28	Dangers of conversion therapy	Social transition for transgender youth with patients, weighing pros and cons of pubertal suppression for transgender youth, and assisting families with understanding the medical management implications for intersex patients
29	Working with a multidisciplinary team for appropriate transgender care	Working with a multidisciplinary team to address appropriate intersex care, bullying directed toward LGBTQI youth, substance abuse treatment for SGM, and care coordination
30	Recognizing that biology and identity do not always align	Self-reflection on assumptions about necessary care and suspending judgment about patient behavioral risks

Table 3. Medical school curricular alignment with Vanderbilt topics for LGBTQI health

SGM-Specific Health Topic	Addressed?	Explanation
Communication/Interview Skills	Yes	Addressed in ‘LGBTQ Health Basics’ in Foundations block and in ‘Sexual History Interviewing’ in Reproduction and Endocrinology block
Intake Forms (gender identity, sexual orientation, relationship status, parentage)	Yes	Discussed how to build a culture of respect and openness which included slides showing intake forms in ‘LGBTQ Health Basics’
Assumptions/Biases	Partially	The presence of assumptions and biases are discussed in lectures, but students are not given time to explore or reflect on their own biases specific to SGM populations.
Depression Screening	Yes	Addressed increased prevalence of depression in LGBTQ population in ‘LGBTQ Health Basics.’ Depression screening taught in Brain and Behavior block.
Substance Abuse Screening	Yes	Addressed increased prevalence of substance abuse in ‘LGBTQ Health Basics.’ Substance use disorder screening taught in Brain and Behavior block.
SGM Standardized Patient Cases	Partially	There are five lesbian or gay standardized patient scenarios and one bisexual patient scenario throughout the curriculum (bisexual patient newly added). There are no transgender, gender-nonconforming, nor intersex patient scenarios. Two transgender cases have subsequently been developed for fellows and practitioners, but they are not integrated with student curricula.
PBL (Problem Based Learning) Integration	Yes	Addressed by use of lesbian or gay standardized patients and in Clinical Public Health Summit on HIV/AIDS
Embryology: Disorders of Sex Development	Partially	‘Mechanisms of Sex Determination’ lecture in Reproduction and Endocrinology block. However, this lecture was taught by research faculty and focused on physiology. Lacked discussion on clinical care and interdisciplinary teams needed to care for intersex patients.
Embryology: Gender vs. Sex	Yes	Presentations in ‘LGBTQ Health Basics’ and various lectures in Reproduction and Endocrinology block
Embryology: Changing Terminology	Yes	Presentations in ‘LGBTQ Health Basics’ and various lectures in Reproduction and Endocrinology block
Infectious Disease: Sexually Transmitted Infections in in lesbians	No	Was not in curriculum prior to 2018, but has been added.
Infectious Disease: Vaginitis in lesbians	No	Not covered.
Infectious Disease: STI recommendations in MSM	Partially	Guidelines in pre-session readings in ‘Introduction to Cultural Competency,’ but not discussed in lecture
HIV in Men who have Sex with Men (MSM)	Yes	HIV-specific lectures in Immunohematology and Infection block and in Clinical Public Health Summit on HIV/AIDS
Availability/ efficacy of rectal microbicides	No	Not covered.
Exclusive Women who have Sex with Women (WSW): Pap, Breast Exams, HPV screening	Yes	Addressed in LGTBQ Healthcare 1 lecture.
Anal Paps	No	Not covered.
MSMs and need of Hep A/ HPV shot	Yes	‘Infectious Causes of Liver Disease’ lecture in Immunohematology and Infection block
Hormone Therapy Pharmacology	Yes	Readings and lecture for ‘Transgender Medicine’ in Reproduction and Endocrinology block
Transitioning Options and Associated Risks	Yes	Readings and lecture for ‘Transgender Medicine’ in Reproduction and Endocrinology block
Puberty suppression in trans youth	Yes	Readings and lecture for ‘Transgender Medicine’ in Reproduction and Endocrinology block
Lesbian obesity	Yes	Readings and lecture for ‘Transgender Medicine’ in Reproduction and Endocrinology block
Increased heart disease rate in lesbians	Yes	Addressed in LGTBQ Healthcare 1 lecture
Anal cancer, risk, treatment in MSM	No	Not covered.
Lesbian nulliparity and risk of breast/ ovarian/ cervical cancer	Yes	Addressed in LGTBQ Healthcare 1 lecture
Psychological/ sexual/ coming out/ identity development	Yes	Discussed in ‘LGBT Health Basics’ and ‘Transgender Medicine’
Gay couples and fertility options	Yes	Focus of LGBQ Health II during Reproduction and Endocrinology block with panel including gay/lesbian parents and a Reproductive Endocrinology and Infertility clinician
Gender dysphoria vs. transgender	Yes	Discussed in various lectures- LGBTQ Health Basics (Foundations block), Brain and Sex (Brain and Behavior block), and Transgender Medicine (Reproduction and Endocrinology block)
Depression and suicide rates in LGBTQI teens/adults	Yes	Discussed in ‘Intro to Cultural Competency’ and ‘LGBT Health Basics’ lectures in Foundations block
Eating disorders in MSM	Partially	In ‘Eating Disorders’ (GI-Liver block) pre-session readings, but not in lecture
LGBTQI patients and having children (medical options and legal concerns)	Yes	Focus of ‘LGBQ Health’ during Reproduction and Endocrinology block with panel including gay/lesbian parents and a Reproductive Endocrinology and Infertility clinician
LGBT Teen Issues	Yes	Covered in sexually active adolescent panel discussion.