At Issue

Should medical schools require transgender health education?

Routine transgender health education is not common in U.S. medical schools. At Harvard Medical School and the University of California, San Francisco — two universities that have placed a premium on transgender health — the subject is currently covered only in elective courses. Infectious Disease News asked Katherine L. Margo, MD, associate professor of family medicine and community health in the Perelman School of Medicine at the University of Pennsylvania, if transgender health education should be required in medical school curricula.

Katherine L. Margo

Given the 1 million to 1.4 million transgender people in the United States, most physicians will have transgender patients at some point as part of their practice. Until recently, this interaction often caused consternation and embarrassment for both the patient and the physician. I have had transgender patients tell me that a particular specialist “doesn’t take care of people like me.” This lack of knowledge and comfort is changing with more and more publicity about transgender people through social media, TV and movies. In addition, millennials are much more fluid in their understanding and expression of gender, and most medical students I encounter now have had a friend or acquaintance who is transgender or gender nonbinary.

Medical students and residents are asking for more curriculum about how to care for transgender patients. Given the vulnerability and poor access to health care with resultant poor outcomes in this population, the learners are right. Just as all students learn about hepatitis C, HIV and other infections, they all need to understand how to assess the increased risk for these infections in this population. A study in JAMA in 2011 showed that 5 was the mean number of LGBT-related content hours among 150 medical schools who completed a survey. The quality of the instruction was variable, much of it rated as poor. A more recent article in Teaching and Learning in Medicine showed that students still rated their LGBT education as “fair.” They felt the least prepared in knowledge of transgender care. In a study published in 2014 in the American Journal of Public Health, we showed after implementing curriculum in a family medicine clerkship that 2 hours or less of focused lectures on transgender care improved their competency.

Transgender health care needs to be included as an integral part of the medical student curriculum in an ongoing manner and not only be relegated to an elective for those with a special interest. Asking students to participate in creating that curriculum has made it more creative and useful. Doctor-patient relationship strategies for these patients should be addressed. Courses that discuss psychosocial issues should address transgender patients’ common mental health issues resulting from, in many cases, bias, rejection by families and bullying. Everyone should know that 41% of transgender women of color have attempted suicide. Sexuality and reproductive health in this population present unique challenges. Like so many lesbian and gay couples, many couples with one or two transgender people want to have children. The rate of HIV infection in transgender women is high, requiring a thorough knowledge of PrEP and special fertilization methods. Hormone treatment is straightforward and should be taught as part of a primary care curriculum. Special cancer screening needs should be included. Educating health care providers to take good care of this group is overdue and needs to be prioritized.

Disclosure: Margo reports no relevant financial disclosures.

Routine transgender health education is not common in U.S. medical schools. At Harvard Medical School and the University of California, San Francisco — two universities that have placed a premium on transgender health — the subject is currently covered only in elective courses. Infectious Disease News asked Katherine L. Margo, MD, associate professor of family medicine and community health in the Perelman School of Medicine at the University of Pennsylvania, if transgender health education should be required in medical school curricula.

Katherine L. Margo

Given the 1 million to 1.4 million transgender people in the United States, most physicians will have transgender patients at some point as part of their practice. Until recently, this interaction often caused consternation and embarrassment for both the patient and the physician. I have had transgender patients tell me that a particular specialist “doesn’t take care of people like me.” This lack of knowledge and comfort is changing with more and more publicity about transgender people through social media, TV and movies. In addition, millennials are much more fluid in their understanding and expression of gender, and most medical students I encounter now have had a friend or acquaintance who is transgender or gender nonbinary.

Medical students and residents are asking for more curriculum about how to care for transgender patients. Given the vulnerability and poor access to health care with resultant poor outcomes in this population, the learners are right. Just as all students learn about hepatitis C, HIV and other infections, they all need to understand how to assess the increased risk for these infections in this population. A study in JAMA in 2011 showed that 5 was the mean number of LGBT-related content hours among 150 medical schools who completed a survey. The quality of the instruction was variable, much of it rated as poor. A more recent article in Teaching and Learning in Medicine showed that students still rated their LGBT education as “fair.” They felt the least prepared in knowledge of transgender care. In a study published in 2014 in the American Journal of Public Health, we showed after implementing curriculum in a family medicine clerkship that 2 hours or less of focused lectures on transgender care improved their competency.

Transgender health care needs to be included as an integral part of the medical student curriculum in an ongoing manner and not only be relegated to an elective for those with a special interest. Asking students to participate in creating that curriculum has made it more creative and useful. Doctor-patient relationship strategies for these patients should be addressed. Courses that discuss psychosocial issues should address transgender patients’ common mental health issues resulting from, in many cases, bias, rejection by families and bullying. Everyone should know that 41% of transgender women of color have attempted suicide. Sexuality and reproductive health in this population present unique challenges. Like so many lesbian and gay couples, many couples with one or two transgender people want to have children. The rate of HIV infection in transgender women is high, requiring a thorough knowledge of PrEP and special fertilization methods. Hormone treatment is straightforward and should be taught as part of a primary care curriculum. Special cancer screening needs should be included. Educating health care providers to take good care of this group is overdue and needs to be prioritized.

Disclosure: Margo reports no relevant financial disclosures.