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Queer Frontiers in Medicine: A Structural Competency Approach

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Abstract

In 2014, the Association of American Medical Colleges (AAMC) published a report proposing qualifiers of competence to guide medical educators towards training physicians to appropriately care for individuals who are or may be lesbian, gay, bisexual, transgender (LGBT); gender nonconforming (GNC); and/or born with differences in sex development (DSD). These qualifiers provide content and context to an existing framework heavily used in competency-based medical education, emphasizing individual and interpersonal abilities to enhance care delivered to individuals identifying as LGBT, GNC, and/or born with DSD. However, systemic and societal forces including health insurance, implicit bias, and legal protections significantly impact the health of these communities. The concept of structural competency proposes that it is necessary to consider these larger forces contributing to and sustaining disease and health in order to fully address identity-based health needs. Competing competency frameworks for addressing diversity may be counterproductive to the ultimate goal of improving health outcomes among diverse communities. In this article, frameworks are reconciled by proposing structural competency as one approach for teaching identity-based health-related competencies that can be feasibly implemented for medical educators seeking to comply with the AAMC's recommendations. This article aims to "queer"-or to open up-possibilities in medical education in an effort to ultimately support the provision of equitable and responsible health care to people who are LGBT, GNC, and/or born with DSD through the use of innovative frameworks and teaching materials. (C) 2016 by the Association of American Medical Colleges
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Academic Medicine, Vol. 92, No. 3 / March 2017 345
Article
Over recent years, the experiences
of individuals with diverse sexual
orientations, gender identities, and sex
developments have received increasing
attention. This attention has led to
activism, initiative, and change across all
realms of society, including health care,
to better accommodate and serve these
communities. However, health equity
is not yet a reality for many people who
are lesbian, gay, bisexual, transgender
(LGBT); gender nonconforming
(GNC); and/or born with differences
in sex development (DSD). Significant
causes of morbidity—and subsequent
mortality—remain disproportionally
prevalent among the aforementioned
populations.1 These health disparities are
not inherent to individuals with diverse
sexual orientations, gender identities,
and sex developments but stem from
structural factors including federal and
statewide nondiscrimination policies,
interpersonal factors such as family and
social discrimination, and individual
barriers such as internalized homophobia/
transphobia. These factors, combined
with the challenge of accessing affirming,
responsible health care, can lead to a delay
in necessary and routine care.2
Significant research has focused on the
detrimental effect that interpersonal and
individual factors have on the health of
individuals who are LGBT, GNC, and/
or born with DSD1; however, a parallel,
emerging body of research highlights
the importance of considering structural
factors when conceptualizing health of the
aforementioned populations. For example,
comparing all-cause mortality between
lesbian, gay, and bisexual individuals
in communities with high versus low
antigay prejudice, the individuals living
in high-prejudice communities had
a shorter life expectancy by 12 years.3
Similarly, high levels of structural stigma
are further associated with greater lifetime
suicide attempts among transgender
adults.4 These upstream social and
structural factors must be considered
when conceptualizing health care for the
aforementioned communities.
To improve access to care and
health outcomes, it is critical that
medical education for current and
future providers include training to
appropriately address sexual orientation,
gender identity, and sex development
with all patients. The Association of
American Medical Colleges (AAMC)
recently qualified a competency-
based medical education framework
to facilitate training and assessment
of individual provider competence
in providing responsible care for the
aforementioned populations5; however, if
general upstream factors underlie health
inequities among these communities,
training providers to address these
structural factors is similarly necessary
to alleviate health disparities.6 Whether
to use a population-specific or structural
competency approach to curriculum
remains unclear.
In this article, we propose that these
frameworks can work symbiotically,
where the theoretical framework of
structural competency—the consideration
of forces that influence health
outcomes at the level above individual
interactioncan serve as an approach
to teaching the AAMC’s professional
competencies to improve health care for
people who are or may be LGBT, GNC,
and/or born with DSD.6–8 While both
frameworks endeavor to increase medical
provider competency, they differ in scope;
the AAMC’s recommendations qualify an
existing competency-based framework9
to ensure that individual providers
Acad Med. 2013;92:345–350
Abstract
In 2014, the Association of American
Medical Colleges (AAMC) published a
report proposing qualifiers of competence
to guide medical educators towards
training physicians to appropriately care
for individuals who are or may be lesbian,
gay, bisexual, transgender (LGBT); gender
nonconforming (GNC); and/or born with
differences in sex development (DSD).
These qualifiers provide content and
context to an existing framework heavily
used in competency-based medical
education, emphasizing individual and
interpersonal abilities to enhance care
delivered to individuals identifying as
LGBT, GNC, and/or born with DSD.
However, systemic and societal forces
including health insurance, implicit
bias, and legal protections significantly
impact the health of these communities.
The concept of structural competency
proposes that it is necessary to consider
these larger forces contributing to
and sustaining disease and health in
order to fully address identity-based
health needs. Competing competency
frameworks for addressing diversity may
be counterproductive to the ultimate goal
of improving health outcomes among
diverse communities. In this article,
frameworks are reconciled by proposing
structural competency as one approach
for teaching identity-based health-
related competencies that can be feasibly
implemented for medical educators
seeking to comply with the AAMC’s
recommendations. This article aims to
“queer”—or to open up—possibilities
in medical education in an effort to
ultimately support the provision of
equitable and responsible health care to
people who are LGBT, GNC, and/or born
with DSD through the use of innovative
frameworks and teaching materials.
Acad Med. 2017;92:345–350.
First published online December 20, 2016
doi: 10.1097/ACM.0000000000001533
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Cameron A.
Donald, University of California San Francisco, School
of Medicine; telephone: (707) 349-0041; e-mail:
Cameron.Donald@ucsf.edu.
Queer Frontiers in Medicine: A Structural
Competency Approach
Cameron A. Donald, MS, Sayantani DasGupta, MD, MPH, Jonathan M. Metzl, MD, PhD,
and Kristen L. Eckstrand, MD, PhD
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Academic Medicine, Vol. 92, No. 3 / March 2017
346
ensure appropriate care to patients
who are LGBT, GNC, and/or born with
DSD, whereas structural competency
emphasizes forces beyond individual
and interpersonal interactions as critical
for achieving and maintaining health.
Combined, these two frameworks address
health across individual, interpersonal,
and structural factors of health.
Here, these frameworks are compared
to demonstrate how the two schemes
symbiotically enhance medical education
on identity-specific health topics by
addressing individual, interpersonal,
and structural factors contributing
to the health of the aforementioned
populations. As there is an emerging need
for addressing structural determinants of
health, we then use a narrative approach
to demonstrate teaching population-
specific structural determinants of health
for individuals who are LGBT, GNC,
or born with DSD within the AAMC
framework.
AAMC LGBT/GNC/DSD
Competency Qualifiers
As of 2010, the median reported time
dedicated to teaching LGBT-related
content in the entire curriculum among
medical schools across the United States
and Canada was five hours; one-third of
the schools reported zero hours.10 Two -
thirds of these schools’ students rated
their schools’ LGBT-related curriculum
as “fair, “poor,” or “very poor.11 Further,
very few studies have addressed medical
students’ ability to deliver appropriate
care to individuals identifying as LGBT,
GNC, or DSD affected. To date, the
most promising international medical
education effort seeking to address these
gaps in knowledge, skills, and attitudes
is the chapter “Professional Competency
Objectives to Improve Health Care for
People Who Are or May Be LGBT, Gender
Nonconforming, and/or Born with
DSD” published by the AAMC Advisory
Committee on Sexual Orientation,
Gender Identity, and Sex Development
in the AAMC’s medical education guide
on providing care to the aforementioned
communities.6 These competencies
qualify those from the Physician
Competency Reference Set, the standard
set of competencies used in medical
education, to provide a framework for
teaching and assessing competence for
providing care to individuals with diverse
sexual orientations, gender identities, and
sex developments,5 and thus ensure that
current and future health care providers
are able to deliver appropriate care
inclusive of these topics. Importantly,
these qualifiers address the competence
of individual providers and their
interpersonal interactions with patients,
with colleagues, and within the larger
health care system. In-depth explanation
of these competencies, and associated
recommendations for curricular
integration and assessment, can be found
in the AAMC’s original publication.6
There is an overwhelming curricular
need in medical training to address
how patients who are LGBT, GNC, and/
or born with DSD can be seen in their
human complexity, to understand their
health as a product of biopsychosocial
development, intersecting identities,
societal and personal ideologies, and
structural/geographic resources and
barriers. As such, these recommendations
represent a new frontier in medical
education that attempts to redefine health
to be inclusive of sexual orientation,
gender identity, gender expression,
and sex developmentfour intrinsic
components of personhood. The
interarticulation of these components
with other aspects of identity and culture
across the life span creates the spectrum
of diversity among people who are
or may be LGBT, GNC, and/or born
with DSD, and thus contribute to each
individual’s unique health needs.
Structural Competency
Metzl and Hansen8 define structural
competency as
the trained ability to discern how a host
of issues defined clinically as symptoms,
attitudes, or disease also present the
downstream implications of a number of
upstream decisions about such matters
as health care and food delivery systems,
zoning laws, urban and rural infrastructures,
medicalization, or even about the very
definitions of illness and health.
Within this theoretical framework exist
five core skills: (1) recognition that
structures shape clinical interactions,
(2) development of an extraclinical
language of structure, (3) rearticulation
of “cultural” formations in structural
terms, (4) ability to observe and imagine
structural interventions, and (5)
cultivation of structural humility.8
Structural competency builds upon
and complements an already heavily
relied-upon concept in medical
education: cultural competency.
Cultural competency implies the trained
ability to identify and address cultural
manifestations of illness and health.12
Under a cultural competency model,
clinical professionals learn approaches to
communication, diagnosis, and treatment
that take into account culturally specific
sources of stigma within the clinical
encounter. Yet cultural competency
alone does not provide individuals the
skills, values, or perspective necessary
to adequately consider the health needs
of various communities and identities.
Not only is it impossible to memorize
all aspects of “culturally specific”
information that could be important for
an individual patient’s care, but operating
solely under a culturally competent
framework reinforces reductive
understandings of identity markers
without consideration of context.13
It is necessary to integrate training that
includes the health needs of diverse
communities into the provision of
medicine. Integral to this training is a
broader consideration of the impact
that stigma and bias have on treatment
decisions14 and the self-reflective ability
of providers to manage their roles in
perpetuating ideas and systems that
facilitate or preclude patients’ ability to
thrive.15 Culture and access to resources
are mediated and often limited by social,
economic, legal, and political structures
that marginalized individuals rarely have
agency in constructing or controlling.
Structural competency operates under
the understanding that stigma and
health disparity are not simply the
product of interpersonal encounters
but also are the result of structural
inequity.16 For example, as previously
mentioned, structural determinants of
health impacting individuals who are
LGBT are associated with morbidity and
mortality.1 Thus, oft-invisible structural-
level determinants, biases, inequities, and
blind spots shape definitions of health
and illness before the clinical providers
or patients enter examination rooms.8 If
clinicians are to impact stigma-related
health inequalities, clinical training must
redirect its attention from an exclusive
focus on “cultural elements” of the
clinical encounter to also include the
organization of institutions and policies,
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Academic Medicine, Vol. 92, No. 3 / March 2017 347
as well as of geography and access to
essential resources.17,18
The structure of medical education
and the provision of health care must
continue interrogating their own
culpability in invisibly reinforcing social
injustices and must develop effective
strategies for mitigating those injustices.
Structural competency affords health care
professionals the opportunity to develop
new policies, practices, and political
agendas that address broader structural
factors impacting health in a dynamic
and meaningful fashion. As medicine
continues to actively address disparities
within the health of and treatment
provided to individuals and communities
who are LGBT, GNC, and/or born with
DSD, there must be specific focus on the
unique structural factors contributing
to the health of the aforementioned
communities and how these same
institutions can begin dismantling
outside paradigms that perpetuate
structural determinants of health
among these persons and communities.
Structural competency has been most
extensively applied to considerations
of race and racial health disparities in
medical education13; however, the model’s
relevance to sexual orientation, gender
identity, and sex development has not
been fully analyzed.
Comparing AAMC and Structural
Competency Approaches
We assessed compatibility between the
AAMC6 and structural competence8
approaches by comparing how the
components of each converge. Given the
scope of the AAMC’s aforementioned
recommendations, elements of structural
competency were naturally encapsulated
in the AAMC’s proposed learning
competencies. Table 1 demonstrates
where these two models overlap.
Teaching Structural Competence
Based on Sexual Orientation,
Gender Identity, and Sex
Development
Table 1 provides a visual representation
of how the AAMC’s6 and Metzl and
Hansen’s8 approaches can be applied
synchronously, allowing for the teaching
and assessment of structural competence
as it relates to sexual orientation,
gender identity, and sex development
in alignment within an existing medical
education framework. In this section,
we explore a previously published
narrative patient case to illustrate how
the two approaches can be applied in a
hypothetical practice situation.
First, we will rearticulate into structural
terms a narrative-based patient case
study published by Potter19 in the AAMC
implementation guide, thereby unifying
individual, interpersonal, and structural
approaches to provide a multilevel
understanding to individualized patient
care. This reframing also adds further
depth and structural context to Forcier
and Potter’s20 AAMC competency-specific
assessment of the same vignette.
In the case by Potter, a 65-year-old
female-to-male transgender man, Mikal
Brown, presents alone at a gynecology
oncology clinic for treatment planning
after being diagnosed with a pelvic
mass consistent with stage IIIB cervical
cancer. The mass was found during
an ER visit prompted by intermittent
bloody discharge on his underwear and
recent-onset pelvic pain. By the time
Mikal enters the oncology clinic’s exam
room to be attended to by the physician,
he is frustrated and scared, as he has
encountered two instances of misnaming
during clinic intake and has been
additionally told, “This is a gynecology
clinic; we only see women here” by
medical support staff. In the exam room,
Mikal tells the physician that he is not
sure he wants to stay for the remainder
of his appointment and is having second
thoughts about pursuing evaluation and
treatment because “What difference will it
make, anyway?”19
The first step in developing structural
competency is to consider the forces
that shaped the clinical interaction and
resultant gaps in care. Mikal’s initial
statement wherein he voices thoughts
of not pursuing treatment for cervical
cancera fatal decisionmay have been
influenced by discrimination throughout
the clinic including misnaming,
misgendering, and denial of access to
care by support staff due to normative
and gendered understandings of
gynecological health. What could have led
to the reactions of Mikal and clinic staff?
Mikal’s medical record provides
additional insight: Mikal lives alone, as
his romantic partner left him when he
came out as transgender 20 years ago;
he works at a relatively low-paying job
as an information technician; he has
experienced traumatic life events; and
he has not sought primary care services
in years. The record elaborates, noting
that pelvic exams reawaken for Mikal the
trauma of an adolescent sexual assault,
and that “he is [loath] to reveal genitalia
discordant with his gender identity.19
Because Mikal is an older individual
who transitioned later in life, it is
unclear who remains in his family and
support system, and how transphobia
has affected those relationships. Or, if
he is engaged in community support,
how might community misinformation
about whether transmen need Pap
tests have changed Mikal’s thoughts on
receiving care? Chronic experiences of
victimization and rejection, including
those in the clinic, certainly challenge
the ability of individuals who have
experienced trauma to revisit similar,
triggering contexts. Lack of legal
protections based on gender identity
could also have impacted Mikal’s
prospects for employment and economic
opportunity (or ability to take time
off work), access to affordable health
insurance, and/or ability to undergo
transition without exorbitant financial
burden. Isolation, expectation of
rejection, and lack of social and financial
support may further influence Mikal’s
ability and willingness to continue
seeking necessary medical care. Finally,
Mikal may be receiving care at a clinic
that does not require its front desk
or clinical staff to receive training in
providing safe and affirmative care such
that the discrimination Mikal faced
could have been entirely avoided. Indeed,
Mikal’s health history and current clinical
interactions have been influenced by
economic, physical, and sociopolitical
forces.
Identification of extraclinical structure
makes explicit that Mikal’s experience
extends beyond the clinic. Mikal’s
disposition and health status are not
a cultural phenomenon inherent to
“transgender men” but are in fact
facilitated by stigma, trauma, and
transphobia; strict understandings
of gender and health; inadequate
provider training; and sociopolitical
and economic systems facilitating
ongoing discrimination and decreased
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Academic Medicine, Vol. 92, No. 3 / March 2017
348
access to care. Referring to the work of
Crenshaw,21 Collins,22 and Levine-Rasky23
in intersectionality, we can additionally
acknowledge that minority stress24
may affect Mikal not only through his
transgender status but also as a person
of color.25 As a masculine-appearing
person of color, Mikal may also face daily
stereotype threat.26 Again, considering
the clinical context, might the likelihood
of rejection from front desk staff also
be due to the staff’s own implicit fears27
about black men?28 Identifying factors
facilitating Mikal’s ability to thrive and
the rearticulation of these factors into
structural terms can enhance the ability
of health care providers to better support
Mikal.
As health status becomes understood
as a product of these many factors,
imagining structural interventions
becomes necessary to ultimately improve
health and access to care. For Mikal,
this would require a paradigm shift
inside and outside of health care. For
example, this shift could occur within
institutions providing gynecological
care, where gynecology is not narrowly
referent (symbolically or explicitly) to
feminine gender but is instead inclusive
and cognizant of all people necessitating
gynecological health examination
and treatment. This ideological shift
can manifest in the changing of built
environments like the clinic waiting
Table 1
Uniting Structural and LGBT/GNC/DSD Competence
Structural competence
componentaLGBT/GNC/DSD competency qualifierb
1. Recognizing the
structures that shape
clinical interactions
Knowledge for Practice #4: 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 understanding and describing historical, political, institutional, and sociocultural
factors that may underlie health care disparities experienced by the populations described above (i.e., LGBT/GNC/DSD
populations).
Systems Based Practice #1: Advocate for quality patient care and optimal patient care systems by 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.
2. Developing an
extraclinical language of
structure
Patient Care #5: Counsel and educate patients and their families to empower them to participate in their care and
enable shared decision-making by 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.
3. Rearticulating “cultural”
presentations in structural
terms
Systems Based Practice #4–5: Participate in identifying system errors and implementing potential systems solutions by (1)
Explaining how homophobia, transphobia, heterosexism, and sexism affect health care inequalities, costs, and outcomes
and (2) Describing strategies that can be used to enact reform within existing health care institutions to improve care to
the populations described above.
4. Observing and imagining
structural intervention
Systems Based Practice #1: Advocate for quality patient care and optimal patient care systems by 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.
Systems Based Practice #2–3: Coordinate patient care within the health care system relevant to one’s clinical specialty by:
(1) 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) and (2) 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.
Professionalism #4: Mitigating structural barriers for patients through 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.).
5. Developing structural
humility
Practice-Based Learning and Improvement #1: Identify strengths, deficiencies, and limits in one’s knowledge and
expertise by 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.
Interprofessional Collaboration #1: Maintaining agency to address structural factors that facilitate health despite deficits
in knowledge through actively engaging interprofessional communication and collaboration with medical support staff,
administrators, policy makers and government officials, laywers, landlords, etc.
Professionalism #3 and Personal Development #1: Demonstrate accountability to patients, society, and the profession by
accepting shared responsibility for eliminating disparities, overt bias (e.g., discrimination), and developing policies and
procedures that respect all patients’ rights to self-determination [and] Critically recognizing, assessing, and developing
strategies to mitigate one’s own implicit (i.e., automatic or unconscious) biases [shaped by prevailing social, cultural and
structural ideologies] in providing care to the individuals described above and recognizing the contribution of bias to
increased iatrogenic risk and health disparities.
Abbreviations: LGBT indicates lesbian, gay, bisexual, transgender; GNC, gender nonconforming; DSD, born with differences in sex development; SO, sexual orientation; GI,
gender identity; SD, sex difference; SES, socioeconomic status.
aStructural competence components referenced from Metzl and Hansen.8
bLGBT/GNC/DSD competency qualifiers referenced from Eckstrand et al5 and Hollenbach et al.6 Italicized text represents summarized material from Hollenbach et al.6
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Academic Medicine, Vol. 92, No. 3 / March 2017 349
room, where reading materials and health
promotion pamphlets can attempt to
inclusively reflect all patient populations
accessing care. For example, Pap tests and
mammography screening pamphlets,
in addition to other patient education
materials, can reflect various genders,
family structures, romantic partnerships,
and racial makeups. Electronic health
records may make explicit affirming
information such as a person’s preferred
name (versus legal name) and gender
pronoun. Education on the structural
considerations regarding individuals
identifying as LGBT, GNC, and/or born
with DSD, and ways to better support
these individuals, must be provided to all
employees of the medical system across
the training continuum.
Finally, structural interventions require
health care institutions and providers
to be cognizant of, or create, structural
resources that address the many
sociopolitical, economic, and geographic
barriers and traumas that many sexual
and gender minorities face. The clinic
Mikal is accessing could begin offering
a cancer support group for transgender
individuals to better serve people of
diverse gender identities. Similarly,
given the prevalence of trauma, trauma-
informed care should be provided at all
sites where patients are seen29,30 (e.g.,
the PurPLE Clinic, a trauma-informed
primary care clinic).31 Structural
support could also come from specific
transgender patient advocacy programs
(e.g., the Trans Buddy program)32
wherein a patient advocate assists
patients through in-person and resource
support. Finally, health care and support
could be tailored based on Mikal’s age
and life experience (e.g., Elderly LGBT
Interprofessional Care Collaborative).33
Throughout these efforts, structural
humility—the awareness that structural
competence alone is an incomplete
solution—must be employed. It is with
this humility that we can value and
affirm Mikal’s knowledge and humbly
seek to understand what has motivated
him to seek care, maintain his job, and
remain in a long-term relationship.
Identification of Mikal’s resilience
simultaneously clarifies opportunities
for health care to further support his
ability to thrive in new—or “queered”—
ways. Indeed, it is with this humility
that we recommend this proposed
synergy of competency frameworks
to enhance individual, interpersonal,
and structural aspects supporting
responsible and appropriate care for
patients who are LGBT, GNC, and/or
born with DSD.
Conclusion
Competing competency frameworks
aimed at addressing the health of
underserved communities can ultimately
prohibit the inclusion of such material
in health professions curricula. In an
effort to advance continued education
and training in providing quality health
care for people who are LGBT, GNC,
and/or born with DSD, using the AAMC
and structural competency frameworks
synergistically can facilitate opportunities
for improving health care across
individual, interpersonal, and structural
levels. Although future work is necessary
to develop assessment strategies for
students and providers across the training
continuum, myriad examples exist
nationwide that model implementation
of these approaches to appropriate and
responsible provision of care to these
communities. Through the lenses and
models outlined in this paper, new and
opened-up—or “queered”—modalities
for attending to vulnerable patients who
are LGBT, GNC, and/or born with DSD
are offered as informants that guide
improved medical training on these
topics.
Acknowledgments: The authors wish to thank
Edgar Rivera-Colon; Vanderbilt Medical Center’s
Program for Lesbian Gay Bisexual, Transgender
and Intersex Health; the Trans Buddy Program;
the Elder LGBT Interprofessional Collaborative
Care Program at Columbia University Medical
Center; and Columbia University’s Narrative
Medicine Program for their encouragement and
support for the writing of this article.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
C. Donald is a first-year medical student, University
of California, San Francisco, School of Medicine, San
Francisco, California.
S. DasGupta is a faculty member, Graduate
Program in Narrative Medicine, Center for the Study
of Ethnicity and Race, and Institute for Comparative
Literature and Society, Columbia University, New
York, New York.
J.M. Metzl is Frederick B. Rentschler II Professor
of Sociology and Psychiatry and director, Center for
Medicine, Health, and Society, Vanderbilt University,
Nashville, Tennessee.
K.L. Eckstrand is founding chair, Advisory
Committee on Sexual Orientation, Gender Identity,
and Sex Development, Association of American
Medical Colleges, Washington, DC, and a second-
year psychiatry resident, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania.
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... Social histories precede individuals who are then socialized to existing norms and the latter shapes the former accordingly (Razack, 1998). The historical precedence for the ongoing exclusion and invisibility of 2SLGBTQ populations in medical and health professions curricula and training complicate how stigmatization is experienced by individuals within health care and society more broadly (Donald et al., 2017). Distress felt across generations of stigmatized groups connects individuals across time; at their expense, those with relatively more power are afforded better choices (Collins & Bilge, 2020;Haraway, 2016;McGovern & Vinjamuri, 2016). ...
... Stigma served as a point of entry for the investigation because it is is a socio-structural process that is embedded in practices across cultures (Donald et al., 2017;Kleinman & Hall-Clifford, 2009). Stigma thus afforded an exploration of health-related practices that are influenced by socially constructed differences between (eg. ...
... This issue is not limited to nursing and highlights the socio-structural nature of stigma; it has an impact on individuals (future HSPs) by way of a lack of content on stigmatized populations in formal training and education. There is a paucity of training on 2SLGBTQ in medical schools across Canada and the United States and physicians are frustrated by their lack of training on the social causes of illness (Donald et al., 2017;Hansen & Metzl, 2017 (Meyer, 2003;Spurlin, 2019). Obscuring these socio-structural factors, which include discrimination in the workplace and education system, food and housing insecurity, rurality, and legal factors, results in unequal treatment under the law and a failure to appreciate the broader social context of negative health outcomes. ...
Thesis
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This study was designed to generate theory that works to further understandings of the processes and factors influencing the conditions under which primary care services are delivered to diverse 2SLGBTQ populations in Nova Scotia. This Constructivist Grounded Theory study employed Intersectional and Critical lenses, complicated the notion of identity in a broadly inclusive manner, and gained insight into socio-structural factors that influence access to health services in primary care settings across Nova Scotia. By conducting a preliminary literature review, stigma was identified as significant to the health outcomes of 2SLGBTQ populations, justifying its use as a starting point for the investigation. Upon REB approval, a diverse sample population was recruited; variation was maximized across categories of identity (sexual orientation, gender, race, (dis)ability, and citizenship), geographies, and professional scope of practice/role. Sampling purposively from historically underrepresented groups so they were overrepresented in the sample population created points of comparison for the purpose of enhancing data analysis and generation of a robust grounded theory. The sample population (n=30) was comprised of three subgroups: 2SLGBTQ health service users (HSUs) (n=10), 2SLGBTQ health service providers (HSPs) (n=10), and non-2SLGBTQ HSPs (n=10). Semi-structured interviews lasting up to 90 minutes were conducted with each participant using video-conferencing software. Participants confirmed that stigma was a meaningful construct; its significance was substantiated throughout the data collection process. Conceiving stigma as a socio-structural process that determines health outcomes allowed for an exploration of 2SLGBTQ stigmatization in health care by investigating the delivery of primary care services to 2SLGBTQ populations across a provincial health system. Data analysis started with its collection by way of constant comparison, and continued through coding methods, memo-writing, diagramming, and writing this dissertation. As such, the level of abstraction was raised and a substantive theory of Working Through Stigma was co-created. The main concern of participants was that stigma causes individuals to experience power relations differently and the experiences of those with relatively less power are often disproportionately negative. The theory depicts what participants are doing about their concerns and involves three interrelated processes: depending on context, resolving histories, and surviving the situation.
... Social scientists, in contrast, have highlighted the embeddedness of heteronormativity within biomedicine, as reflected in curricular priorities within health professions education, the demographic makeup of medical staff, and organizational segregation between sites of care (Cruz, 2014(Cruz, , 2020. Medical students' uneven basic knowledge of SOGI (such as the distinction between SO and GI, and the multiple dimensions of identity, behavior, and embodiment) and low levels of comfort interacting with SGM patients is due in part to the absence of such topics within formal curricula (Obedin-Maliver et al., 2011;Carabez et al., 2015;Donald et al., 2017;Banerjee et al., 2018). Negative experiences in medical school, including implicit and explicit bias contributing to provider concealment of their own SGM identities, may inform future care disparities when providers enter the workforce (Wittlin et al., 2019;Phelan et al., 2017;Mansh et al., 2015). ...
... We find standard data may promote visibility of "social factors" in certain clinical settings, yet can also constrain clinical utility among providers and staff with greater knowledge and experience with related domains (Gaspar et al., 2020;Thompson, 2020). We further illustrate how data reporting may result in limited attenuation of health inequities, despite broad expectations of clinical change (Institute of Medicine, 2014: 17; Douglas et al., 2015;Zhang et al., 2017): evidence from our two sites illuminates how entrenched inequities actively inform organizational asymmetries in serving different communities (Paine, 2021a(Paine, , 2021bMartos et al., 2017;Ingraham and Rodriguez, 2021), discussing related topics with patients as a part of care (Cruz, 2020;Carabez et al., 2015;Banerjee et al., 2018), and establishing provider and staff knowledge and experience in redressing social problems (Donald et al., 2017;Mansh et al., 2015). Our fieldwork "on the inside" of clinical settings thus reveals a much more fundamental set of stakes at play with data standardization, beyond implementation and associated technical challenges (Cruz, 2021). ...
Article
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In effort to address fundamental causes and reduce health disparities, public programs increasingly mandate sites of care to capture patient data on social and behavioral domains within Electronic Health Records (EHRs). Data reporting drawing from EHRs plays an essential role in public management of social problems, and data on social factors are commonly cited as foundational for eliminating health inequities. Yet one major shortcoming of these data-centered initiatives is their limited attention to social context, including the institutional conditions of biomedical stratification and variation of care provision across clinical settings. In this article, we leverage comparative fieldwork to examine provider and system responses to mandated data collection on patient sexual orientation and gender identity (SOGI), highlighting unequal clinical contexts as they appear across a large county safety-net institution and an LGBTQ-oriented health organization. Although point of care data collection is commonly justified for governance in the aggregate (e.g., disparity monitoring), we find standardized data on social domains presents a double-edged sword in clinical settings: formal categories promote visibility where certain issues remain hidden, yet constrain clinical utility in sites with greater knowledge and experience with related topics. We further illustrate how data standardization captures patient identities yet fundamentally misses these unequal contexts, resulting in limited attenuation of inequity despite broad expectations of clinical change. By revealing the often-invisible contexts of care that elude standard measurement, our findings underline the strengths of qualitative social science in accounting for the complex dynamics of enduring social problems. We call for deeper engagement with the unequal contexts of biomedical stratification, especially in light of increasing pressure to quantify the social amidst the rising tide of data-driven care.
... When 'queer' is used in post-graduate and graduate medical education research, it refers to curriculum gaps, patient identities in relation to culturally safe care and physician competencies, and the experiences of LGBT+-students (Baker & Beagan, 2014;Donald et al., 2017;MacCormick & George, 2020;Muntinga et al., 2020;Streed et al., 2019;Tollemache et al., 2021). Applying a queer lens to medical education has led authors to suggest the existence of a global discursive and systemic invisibility of queer narratives and needs, and a widespread refusal to label sexual and gender minority status as medically significant -a situation Müller (2018) identifies as an active process of erasure. ...
Article
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Health disparities faced by transgender people are partly explained by barriers to trans-inclusive healthcare, which in turn are linked to a lack of transgender health education in medical school curricula. We carried out a theory-driven systematic review with the aim to (1) provide an overview of key characteristics of training initiatives and pedagogical features, and (2) analyze barriers and facilitators to implementing this training in medical education. We used queer theory to contextualize our findings. We searched the PubMed/Ovid MEDLINE database (October 2009 to December 2021) for original studies that reported on transgender content within medical schools and residency programs ( N = 46). We performed a thematic analysis to identify training characteristics, pedagogical features, barriers and facilitators. Most training consisted of single-session interventions, with varying modes of delivery. Most interventions were facilitated by instructors with a range of professional experience and half covered general LGBT+-content. Thematic analysis highlighted barriers including lack of educational materials, lack of faculty expertise, time/costs constraints, and challenges in recruiting and compensating transgender guest speakers. Facilitators included scaffolding learning throughout the curriculum, drawing on expertise of transgender people and engaging learners in skills-based training. Sustainable implementation of transgender-health objectives in medical education faces persistent institutional barriers. These barriers are rooted in normative biases inherent to biomedical knowledge production, and an understanding of categories of sex and gender as uncomplicated. Medical schools should facilitate trans-inclusive educational strategies to combat transgender-health inequities, which should include a critical stance toward binary conceptualizations of sex and gender throughout the curriculum.
... Medical students learn professional skills through memorization and modeling of clinical preceptors, including case presentation formats; the importance of this educational process should not be underestimated. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] The process that allows physicians to quickly diagnose patients can activate implicit bias, especially if identifiers used for patients are not thoughtfully selected. This can result in disparities in care along a variety of axes of identity. ...
Article
Background and objectives: Patient identifiers are used in the opening lines of case presentations and written documentation in health care and medical education settings. These identifiers can reflect physicians' implicit biases, which are known to impact patient care. Yet, no clear recommendations for the use of patient identifiers to reduce bias and stigma in patient care and medical education learning environments currently exist. We describe a process and outcomes for articulating such recommendations. Methods: The University of Washington School of Medicine convened a group of diverse stakeholders to create patient identifier recommendations for use in the undergraduate medical education program. After a literature review, 22 recommendations for the use of patient identifiers were articulated. These underwent public comment periods reaching 11,150 potential respondents across our 5-state institution. Feedback from 437 respondents informed modifications to the recommendations. We used consensus methodology with three rounds of surveys and an expert group of 27 stakeholders to adopt recommendations with an a priori threshold of 90% agreeing the recommendation should be used. Results: We adopted 12 recommendations for patient identifiers for age, gender/sex, race/ethnicity, sexual orientation, ability, size, and stigma; nine in round one, three in round two, and none in the third round. Discussion: Our institution vetted these patient identifier recommendations via public comment and consensus methodology. Next steps include implementation across the undergraduate medical education program, including classroom and clinical settings. Other institutions could consider similar processes as key steps to reduce bias and stigma in their medical education programs.
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Existing curricula and recommendations on the incorporation of structural competency and vulnerability into medical education have not provided clear guidance on how best to do so within emergency medicine (EM). The goal of this scoping review and consensus building process was to provide a comprehensive overview of structural competency, link structural competency to educational and patient care outcomes, and identify existing gaps in the literature to inform curricular implementation and future research in EM. A scoping review focused on structural competency and vulnerability following Arksey and O’Malley’s six‐step framework was performed in concurrence with a multistep consensus process culminating in the 2021 SAEM Consensus Conference. Feedback was incorporated in developing a framework for a national structural competency curriculum in EM. A literature search identified 291 articles that underwent initial screening. Of these, 51 were determined to be relevant to EM education. The papers consistently conceptualized structural competency as an interdisciplinary framework that requires learners and educators to consider historical power and privilege to develop a professional commitment to justice. However, the papers varied in their operationalization, and no consensus existed on how to observe or measure the effects of structural competency on learners or patients. None of the studies examined the structural constraints of the learners studied. Findings emphasize the need for training structurally competent physicians via national structural competency curricula focusing on standardized core competency proficiencies. Moreover, the findings highlight the need to assess the impact of such curricula on patient outcomes and learners’ knowledge, attitudes, and clinical care delivery. The framework aims to standardize EM education while highlighting the need for further research in how structural competency interventions would translate to an ED setting and affect patient outcomes and experiences.
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The COVID-19 pandemic and murder of Mr George Floyd served as catalysts for examining antiracism efforts in psychiatry training programs and health care systems. Our recruitment and retention of Black, Indigenous, and other racial/ethnic minority psychiatry trainees has not met the demand for care and does not represent the communities served. Training directors at a critical juncture in creating systemic changes to recruitment, retention, policies, and curricular competencies to address ongoing inequities and disparities in health care. We describe several strategies and considerations for training directors in supporting a diverse psychiatric workforce.
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There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.
It is possible and necessary to provide trans and gender nonconforming (TGNC) individuals with gender-affirming care (GAC) in primary care settings. A known risk of increased suicidality among TGNC individuals and a lack of provider training on prescribing gender-affirming hormones (GAH) in the Canadian province of Nova Scotia highlighted a need for building capacity around GAC delivery. A referral network was established across the province, which reduced wait times to access GAH by several months.
Article
Background The LGBTQ health disparities literature documents barriers to comprehensive and queer-inclusive care. Queer cisgender women and gender expansive individuals assigned female at birth experience myriad health disparities related to reproductive health, in part owing to the health care system. However, few studies have examined how queer individuals cope with and overcome barriers to queer-competent reproductive health care. This study aims to understand the strategies queer cisgender women and gender expansive individuals use to meet their reproductive health needs. Methods Investigators conducted interviews with 22 queer cisgender women and gender expansive individuals assigned female at birth about their experiences seeking reproductive health care services. We used inductive coding and thematic analysis to identify themes related to meeting reproductive health and health care needs. Results Findings highlight the prevalence of negative and harmful experiences while seeking reproductive health care. In response to these negative experiences, individuals developed active strategies to meet their health needs, including seeking information and community, seeking alternative models of care, and managing identity disclosure. Importantly, these strategies varied in effectiveness, depending on participants' social and economic advantage. Conclusions Queer individuals face numerous barriers to queer-competent reproductive health care when seeking reproductive health services. While queer patients are often resilient and creative, developing strategies to get their needs met, the presence of such strategies highlights the need for structural changes in the health system to better serve queer patients.
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There are over one million transgender people living in the United States and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.
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Delineating the requisite competencies of a 21st-century physician is the first step in the paradigm shift to competency-based medical education. Over the past two decades, more than 150 lists of competencies have emerged. In a synthesis of these lists, the Physician Competency Reference Set (PCRS) provided a unifying framework of competencies that define the general physician. The PCRS is not context or population specific; however, competently caring for certain underrepresented populations or specific medical conditions can require more specific context. Previously developed competency lists describing care for these populations have been disconnected from an overarching competency framework, limiting their uptake. To address this gap, the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development adapted the PCRS by adding context- and content-specific qualifying statements to existing PCRS competencies to better meet the needs of diverse patient populations. This Article describes the committee's process in developing these qualifiers of competence. To facilitate widespread adoption of the contextualized competencies in U.S. medical schools, the committee used an established competency framework to develop qualifiers of competence to improve the health of individuals who are lesbian, gay, bisexual, transgender; gender nonconforming; or born with differences in sexual development. This process can be applied to other underrepresented populations or medical conditions, ensuring that relevant topics are included in medical education and, ultimately, health care outcomes are improved for all patients inclusive of diversity, background, and ability.
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In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
Article
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Phenomenon: Lesbian, gay, bisexual, and transgender (LGBT) individuals face significant barriers in accessing appropriate and comprehensive medical care. Medical students' level of preparedness and comfort caring for LGBT patients is unknown. An online questionnaire (2009-2010) was distributed to students (n = 9,522) at 176 allopathic and osteopathic medical schools in Canada and the United States, followed by focus groups (2010) with students (n = 35) at five medical schools. The objective of this study was to characterize LGBT-related medical curricula, to determine medical students' assessments of their institutions' LGBT-related curricular content, and to evaluate their comfort and preparedness in caring for LGBT patients. Of 9,522 survey respondents, 4,262 from 170 schools were included in the final analysis. Most medical students (2,866/4,262; 67.3%) evaluated their LGBT-related curriculum as "fair" or worse. Students most often felt prepared addressing human immunodeficiency virus (HIV; 3,254/4,147; 78.5%) and non-HIV sexually transmitted infections (2,851/4,136; 68.9%). They felt least prepared discussing sex reassignment surgery (1,061/4,070; 26.1%) and gender transitioning (1,141/4,068; 28.0%). Medical education helped 62.6% (2,669/4,262) of students feel "more prepared" and 46.3% (1,972/4,262) of students feel "more comfortable" to care for LGBT patients. Four focus group sessions with 29 students were transcribed and analyzed. Qualitative analysis suggested students have significant concerns in addressing certain aspects of LGBT health, specifically with transgender patients. Insights: Medical students thought LGBT-specific curricula could be improved, consistent with the findings from a survey of deans of medical education. They felt comfortable, but not fully prepared, to care for LGBT patients. Increasing curricular coverage of LGBT-related topics is indicated with emphasis on exposing students to LGBT patients in clinical settings.
Article
This study assessed individual (ie, internalized transphobia) and structural forms of stigma as risk factors for suicide attempts among transgender adults. Internalized transphobia was assessed through a 26-item scale including four dimensions: pride, passing, alienation, and shame. State-level structural stigma was operationalized as a composite index, including density of same-sex couples; proportion of Gay-Straight Alliances per public high school; 5 policies related to sexual orientation discrimination; and aggregated public opinion toward homosexuality. Multivariable logistic generalized estimating equation models assessed associations of interest among an online sample of transgender adults (N = 1,229) representing 48 states and the District of Columbia. Lower levels of structural stigma were associated with fewer lifetime suicide attempts (AOR 0.96, 95% CI 0.92-0.997), and a higher score on the internalized transphobia scale was associated with greater lifetime suicide attempts (AOR 1.18, 95% CI 1.04-1.33). Addressing stigma at multiple levels is necessary to reduce the vulnerability of suicide attempts among transgender adults.
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Despite many recent advances in rights for sexual and gender minorities in the United States, bias against lesbian, gay, bisexual, and transgender (LGBT) people still exists. In this Commentary, the author briefly reviews disparities with regard to LGBT health, in both health care and medical education, and discusses the implications of Burke and colleagues' study of implicit and explicit biases against lesbian and gay people among heterosexual first-year medical students, published in this issue of Academic Medicine.Emphasis is placed on the ways in which physicians' implicit bias against LGBT people can create a cycle that perpetuates a professional climate reinforcing the bias. The hidden curriculum in academic health centers is discussed as both a cause of this cycle and as a starting point for a research and intervention agenda. The findings from Burke and colleagues' study, as well as other evidence, support raising awareness of LGBT discrimination, increasing exposure to LGBT individuals as colleagues and role models in academic health centers, and modifying medical education curricula as methods to break the cycle of implicit bias in medicine.
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The call for structural competency encourages medicine to broaden its approach to matters of race and culture so that it might better address both individual-level doctor and patient characteristics and institutional factors.