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Discuss one diagnosis related to transgender care and how you would plan and intervene

Background

A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care.

Methods

We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017.

Results

Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients.

Conclusion

Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.

Keywords: medical education, transgender, LGBT health, medical training, residency

Introduction

In recent decades, the field of lesbian, gay, bisexual, transgender, and queer (LGBTQ) health has become a national priority.1,2 Transgender individuals face unique health care concerns. The term transgender, as it is used here, includes people whose gender identity differs from their sex assigned at birth as well as those whose gender identity does not confirm to conventional binary gender categories known as gender nonbinary or gender nonconforming.3 Some transgender people may undergo medical interventions, such as hormone therapy (eg, estrogen and testosterone) and gender-affirming surgeries to attain physical characteristics that better align with their gender identity. Data from national surveys estimate that ~1 million Americans’ identity as trans-gender.4 A growing body of research continues to elucidate health inequities experienced by transgender individuals1,2,5,6 and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Research has shown that transgender populations experience significant health disparities such as a disproportionately higher burden of mental health illness, including increased rates of depression, anxiety, and suicide.7,8 Human immunodeficiency virus (HIV) infection is notably higher in transgender populations, especially transgender women.911 Poorer health outcomes are partially caused, and further compounded, by socioeconomic inequities, including higher rates of unemployment, poverty, legal discrimination, and harassment when compared with cisgender people (ie, those whose sex assigned at birth aligns with their gender identity).12,13

Notably, negative attitudes toward and lack of knowledge about transgender health have manifested in reports of transgender people being denied health care or experiencing discrimination, including verbal and physical abuse, in health care settings.14 Access to care is also affected by the lack of insurance due to poverty or unemployment and coverage denials based on categorization of medically necessary procedures such as “sex-specific”, “cosmetic”, and “experimental”.7,1417 The Patient Protection and Affordable Care Act improved health care access for transgender Americans but did so incompletely and does not address the lack of physician training in transgender health care.1822 Medical education that improves attitudes toward and awareness of transgender populations, provides knowledge of unique clinical concerns, and develops skills to deliver competent care is one tool for addressing transgender health inequities.2325

A growing number of institutions have acknowledged the role of education in improving care for transgender individuals and have taken steps to address transgender health. However, they often do so under the larger umbrella of LGBTQ health inequities.2628 An established body of research merits focusing on transgender health issues as a separate clinical skill set from lesbian, gay, and bisexual (LGB) health. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that contribute to transgender health inequities. It can also improve knowledge about transgender-specific care, such as hormone therapy, gender-affirming surgical procedures, high prevalence of gender dysphoria, and other mental health diagnoses such as depression and anxiety.14,29 Clinicians should be trained to recognize long-term health outcomes associated with gender-affirming interventions (eg, dyslipidemias associated with estrogens and erythrocytosis associated with testosterone) as well as make necessary modifications to preventive care interventions (eg, screening transgender women for breast cancer and osteoporosis).30 Transgender patients should have their sex assigned at birth and current anatomical inventory recorded within the medical record to facilitate appropriate timely delivery of preventive care interventions, as cancer screening needs to be based on existing anatomy.25

From systemic barriers to clinical competency, medical education has a foundational role in equipping physicians to address transgender health inequities. We outline various domains within the literature and describe where consensus or divergence of recommendations exists. We conclude with a discussion of previous research in this area and provide recommendations based on our findings.

Methods

We conducted structured searches of five databases (Education Source, LGBT Life, MedEdPORTAL, PsycINFO, and PubMed) to identify literature related to medical education and transgender health (Figure 1 and Supplementary material). Given the broad nature of this literature and varying methodologies of the studies included, our methodology is consistent with a scoping review.31 Search results were screened for relevancy and the following criteria: undergraduate and graduate, allopathic and osteopathic medical schools in North America published since January 1, 2000. We included publications of primary literature, reviews, opinion pieces, and policy papers to ensure a broad overview of the available literature. Of the 1272 papers reviewed, 119 papers were deemed relevant to these predefined criteria and the topics of medical education and transgender health. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations not retrieved in database searches (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017.

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