Clinical exposure key to closing education gap in transgender care
Substantial strides have been made in physician education and cultural competency in caring for transgender patients, but gaps remain in the areas of familiarity and comfort with this population, according to Joshua D. Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery and senior faculty member at the Icahn School of Medicine at Mount Sinai.
“It’s been known for a number of years now that when asked to describe the barriers to [transgender] care, the No. 1 problem isn’t insurance, or any of those other issues you might expect,” Safer told Endocrine Today. “It’s a lack of physicians who know what they’re doing.”
The need to improve medical education in the area of transgender care has been recognized and prioritized by various training entities, Safer said. Curriculum inventory data collected in 2016-2017 from 131 U.S. medical schools and released by the Association of American Medical Colleges (AAMC) revealed that more than 65% of medical schools offer some form of transgender-related education, and more than 80% of those schools present this education through required courses.
Additionally, the AAMC has called for improvement in transgender care and has partnered with Fenway Health, a health care system dedicated to the well-being of the LGBT community, to develop better medical school curricula.
Although transgender care is recognized as important, Safer said, the focus has not sufficiently increased providers’ comfort level in treating this population.
“Those curricula focused heavily on understanding typical experiences with patients in those communities, learning the pronouns and learning some of the health care disparities. In my view, that still left an enormous gap,” Safer said.
“That type of training may help with seeing people on the street, or maybe even interacting in the waiting room, but what I was still observing as a practitioner was that people trained in these curricula still tended to send me their patients. Basically, the barrier was not addressed,” Safer said.
Seeking to fill in the “missing piece” that remained in transgender care, Safer began teaching the topic at Boston University in a more evidence-based manner, similar to the way other medical topics were being addressed.
“At BU, it is now the case that when students learn about normal physiology, they have a small section on how much we understand about the biology underlying gender identity,” Safer said.
When students learn about endocrinology and hormones, the curriculum addresses hormone therapy for transgender patients. For each section in the curriculum, Safer said, he began to see improvement in the students’ comfort level.
“[AAMC guidelines] were already teaching pronouns and how to approach patients in a respectful fashion, so the students had that as a baseline,” he said. “Then, if they went on to learn gender identity as a biological phenomenon, and to learn about the hormone regimen, we saw we could improve on their relative comfort level.”
Still lagging behind
Although his efforts to improve transgender education through evidence-based medicine yielded some improvements in comfort level, Safer said, a survey of Boston University medical students found room for improvement.
In the study, Jennifer J. Liang, MS, and colleagues administered a questionnaire to medical students in their first through fourth years about their self-reported knowledge and attitudes regarding different subpopulations of the LGBT and intersex community. They found that in addition to three of the four surveyed classes reporting lower knowledge of transgender health vs. LGB health, all surveyed classes expressed lower comfort levels with transgender patients vs. LGB patients. Notably, the survey respondents requested additional learning opportunities regarding transgender and intersex health vs. the other subpopulations.
“The ‘T’ still lagged behind ‘LGB’ in LGBT education,” Jason Andrew Park, a medical student at Boston University who conducted a later study on transgender care, told Endocrine Today. “When it came to everything from being comfortable to asking questions, there was a greater comfort level in talking to a lesbian, gay or bisexual person.”
According to Safer, the study showed that evidence-based learning is valuable in teaching transgender care, but there was a need to go one step further to familiarize students with this population.
“Part of what makes an American education so good is how well we implement experiential education, which is what you think of as the medical students being on the floor in their white coats,” he said. “It’s all well and good to learn things in lectures and in virtual scenarios, but to get out into the real world and take care of patients under the supervision of more experienced people is the ultimate in the training model.”
Value of clinical exposure
With the goal of eliminating the remaining educational disparity, Safer and colleagues introduced a transgender medicine elective at Boston University in which fourth-year medical students could rotate on clinical care services for transgender patients. Before and after completing the rotation, the students filled out surveys assessing their levels of comfort.
“In the fourth-year rotation, students would have 4 weeks of exposure to transgender medicine in an integrated way. It’s not siloed where we’re just endocrinology and transgender patients come in,” Park said. “It’s the whole gamut, from pediatric to internal medicine to endocrinology to just general care. It goes to pretransition, during transitioning, or post-transitioning, at all ranges.”
Park said the students who chose the transgender medicine rotation were those who already had an interest in transgender care. However, according to baseline pre-rotation surveys, even these students lacked comfort and confidence with the topic.
“They felt it was something that needs to be taught and learned, they advocated for trans education, but they were not comfortable,” he said. “They didn’t really know how to ask a transgender individual about their gender identity, their sexual identity, anything.”
Park said he and colleagues found this surprising because these students had learned about these topics during the first 2 years of medical school.
“They didn’t know how to use it in practice, though, because there was no exposure,” Park said.
All 20 students in the study completed the pre- and postelective surveys. After the rotation, the percentage of students who expressed “high” comfort with transgender care rose from 45% to 80% (P = .04). Additionally, the percentage of students reporting high knowledge regarding the management of these patients increased from zero to 85% (P < .001). Similarly, the proportion of students who reported having “low” skills providing general care decreased from 35% to zero (P = .04), and the percentage of students reporting low skills in providing hormone treatments for transgender patients decreased from more than 50% to 5% (P < .001).
The researchers concluded that evidence-based training is important, but it is no substitute for the confidence gained from regular exposure to transgender patients.
“As medical students, when we first go and interview, we don’t know what we’re doing, and we’re afraid we’re going to do something wrong,” Park said. “But then, because we do it so often, it gets natural.”
Park, who also works with transgender youths in other settings, said he learned a great deal from time spent with transgender people.
“One thing I learned is that, when you accidentally say the wrong pronoun, or you say something you worry is offensive, don’t harp on it,” he said. “You apologize, acknowledge it, and move on. Someone told me it’s similar to when you get someone’s name wrong. It’s good to apologize, but no one wants you to annoy them by saying ‘I’m sorry,’ over and over again. Acknowledge it and be respectful, but everyone makes mistakes.”
Park said he hopes to see such an elective become a part of the regular curriculum.
“The capacity and ability is easier at BU. There are people who want to come to BU for this rotation,” Park said. “In some other places, where the transgender population is not that large, it will be more difficult.”
Park noted that in any other area of medicine, a rotation would be necessary before the medical student or physician is tasked with treating a patient.
“For example, we learn about cardiology in our didactic,” Park said. “We’re not going to be asked to suddenly take care of someone with heart failure before doing a cardiology rotation. So, transgender health is like anything else — we want to normalize it.” – by Jennifer Byrne
Eriksson SE, et al. Endocr Pract. 2016;doi:10.4158/EP151141.OR.
Liang JJ, et al. Endocr Pract. 2017;doi:10.4158/EP171758.OR.
Park JA, et al. Transgend Health. 2018;doi:10.1089/trgh.2017.0047.
Safer JD, et al. Endocr Pract. 2013;doi:10.4158/EP13014.OR.
For more information:
Jason Andrew Park can be reached at 732 Harrison Ave., Second Floor, Boston, MA; email: email@example.com.
Joshua Safer, MD, can be reached at 1 Gustave L. Levy Place, New York, NY 10029; email: firstname.lastname@example.org.
Disclosures: Park and Safer report no relevant financial disclosures.