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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
interaction—can 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 development—four 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
cancer—a fatal decision—may 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.
References
1 Institute of Medicine Committee on Lesbian,
Gay, Bisexual, and Transgender Health,
Issues, Research, Gaps, & Opportunities.
The Health of Lesbian, Gay, Bisexual, and
Transgender People: Building a Foundation
for Better Understanding. Washington, DC:
National Academies Press; 2011.
2 Tillery B, Fazer S, Hirshman R. When Health
Care Isn’t Caring: Lambda Legal’s Survey on
Discrimination Against LGBT People and
People With HIV. New York, NY: Lambda
Legal; 2010.
3 Hatzenbuehler ML, Bellatorre A, Lee Y, Finch
BK, Muennig P, Fiscella K. Structural stigma
and all-cause mortality in sexual minority
populations. Soc Sci Med. 2014;103:33–41.
4 Perez-Brumer A, Hatzenbuehler ML,
Oldenburg CE, Bockting W. Individual-
and structural-level risk factors for suicide
attempts among transgender adults. Behav
Med. 2015;41:164–171.
5 Eckstrand KL, Potter J, Bayer CR, Englander
R. Giving context to the physician
competency reference set: Adapting to the
needs of diverse populations. Acad Med.
2016;91:930–935.
6 Hollenbach AD, Eckstrand KL, Dreger AD.
Implementing Curricular and Institutional
Climate Changes to Improve Health Care
for Individuals Who Are LGBT, Gender
Nonconforming, or Born With DSD: A
Resource for Medical Educators. Washington,
DC: Association of American Medical
Colleges; 2014.
7 Metzl JM. Structural competency. Am Q.
2012;64:213–218.
8 Metzl JM, Hansen H. Structural competency:
Theorizing a new medical engagement
with stigma and inequality. Soc Sci Med.
2014;103:126–133.
9 Englander R, Cameron T, Ballard AJ, Dodge J,
Bull J, Aschenbrener CA. Toward a common
taxonomy of competency domains for the
health professions and competencies for
physicians. Acad Med. 2013;88:1088–1094.
10 Obedin-Maliver J, Goldsmith ES, Stewart L,
et al. Lesbian, gay, bisexual, and transgender-
related content in undergraduate medical
education. JAMA. 2011;306:971–977.
11 White W, Brenman S, Paradis E, et al. Lesbian,
gay, bisexual, and transgender patient care:
Medical students’ preparedness and comfort.
Teach Learn Med. 2015;27:254–263.
12 Kleinman A, Benson P. Anthropology in the
clinic: The problem of cultural competency
and how to fix it. PLoS Med. 2006;3:e294.
doi: 10.1371/journal.pmed.0030294.
13 Metzl JM, Roberts DE. Structural
competency meets structural racism:
Race, politics, and the structure of medical
knowledge. Virtual Mentor. 2014;16:674–690.
14 Kumagai AK, Lypson ML. Beyond cultural
competence: Critical consciousness, social
justice, and multicultural education. Acad
Med. 2009;84:782–787.
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Academic Medicine, Vol. 92, No. 3 / March 2017
350
15 Fallin-Bennett K. Implicit bias against sexual
minorities in medicine: Cycles of professional
influence and the role of the hidden
curriculum. Acad Med. 2015;90:549–552.
16 Fullilove MT, Wallace R. Serial forced
displacement in American cities, 1916–2010.
J Urban Health. 2011;88:381–389.
17 Bonilla-Silva E. Rethinking racism: Toward
a structural interpretation. Am Sociol Rev.
1997;62:465–480.
18 Hatzenbuehler ML, Link BG. Introduction
to the special issue on structural stigma and
health. Soc Sci Med. 2014;103:1–6.
19 Potter J. Scenario 8: A transgender man
with a pelvic mass. In: Hollenbach AD,
Eckstrand KL, Dreger AD, etc. Implementing
Curricular and Institutional Climate Changes
to Improve Health Care for Individuals
Who Are LGBT, Gender Nonconforming,
or Born With DSD: A Resource for Medical
Educators. Washington, DC: Association of
American Medical Colleges; 2014:151–153.
20 Forcier MKLE, Potter JE. Genitourinary
care for transgender men. MedEdPORTAL
iCollaborative. July 17, 2015. https://
www.mededportal.org/icollaborative/
resource/4084. Accessed November 3, 2016.
21 Crenshaw K. Demarginalizing the
intersection of race and sex: A black
feminist critique of antidiscrimination
doctrine, feminist theory and
antiracist politics. Univ Chic Leg
Forum. 1989;1989(1):139–167. http://
chicagounbound.uchicago.edu/cgi/
viewcontent.cgi?article=1052&context=uc
lf. Accessed November 3, 2016.
22 Collins PH. Black Feminist Thought:
Knowledge, Consciousness, and the Politics
of Empowerment. New York, NY: Routledge;
2000.
23 Levine-Rasky C. Intersectionality theory
applied to whiteness and middle-classness.
Soc Identities. 2011;17(2):239–253.
24 Meyer IH. Prejudice, social stress, and
mental health in lesbian, gay, and bisexual
populations: Conceptual issues and research
evidence. Psychol Bull. 2003;129:674–697.
25 Goffman E. Stigma: Notes on the
Management of Spoiled Identity. New York,
NY: Simon and Schuster; 2009.
26 Steele CM, Aronson J. Stereotype threat
and the intellectual test performance of
African Americans. J Pers Soc Psychol.
1995;69:797–811.
27 Greenwald AG, Banaji MR. Implicit social
cognition: Attitudes, self-esteem, and
stereotypes. Psychol Rev. 1995;102:4–27.
28 Sekaquaptewa D, Espinoza P, Thompson
M, Vargas P, von Hippel W. Stereotypic
explanatory bias: Implicit stereotyping as
a predictor of discrimination. J Exp Soc
Psychol. 2003;39(1):75–82.
29 Sciolla AF, Eckstrand K, Potter J. Integrating
trauma-related curricular content into
medical education and training. Acad Med.
2016;91:896–898.
30 Markoff LS, Reed BG, Fallot RD, Elliott DE,
Bjelajac P. Implementing trauma-informed
alcohol and other drug and mental health
services for women: Lessons learned in
a multisite demonstration project. Am J
Orthopsychiatry. 2005;75:525–539.
31 Levins H. The cost-saving potential of
trauma-informed primary care. University
of Pennsylvania Leonard Davis Institute
of Health Economics Web site. http://ldi.
upenn.edu/news/cost-saving-potential-
trauma-informed-primary-care. Published
November 2015. Accessed November 3,
2016.
32 Vanderbilt University School of Medicine.
Trans Buddy Program. https://medschool.
vanderbilt.edu/lgbti/trans-buddy-program.
Accessed November 3, 2016.
33 Columbia University Medical Center. $1.5
million cooperative agreement to expand
lesbian, gay, bisexual, and transgender
(LGBT) health services in New York
City. September 25, 2014. http://nursing.
columbia.edu/15-million-cooperative-
agreement-expand-lesbian-gay-bisexual-and-
transgender-lgbt-health-services. Accessed
November 3, 2016.
