ArticlePDF Available

Queer Frontiers in Medicine: A Structural Competency Approach



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
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
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:
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.
Academic Medicine, Vol. 92, No. 3 / March 2017
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
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.
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
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
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.
Academic Medicine, Vol. 92, No. 3 / March 2017
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
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
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
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
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
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.
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.
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
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.
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.
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.
8 Metzl JM, Hansen H. Structural competency:
Theorizing a new medical engagement
with stigma and inequality. Soc Sci Med.
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.
Academic Medicine, Vol. 92, No. 3 / March 2017
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.
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://
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://
lf. Accessed November 3, 2016.
22 Collins PH. Black Feminist Thought:
Knowledge, Consciousness, and the Politics
of Empowerment. New York, NY: Routledge;
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.
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.
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.
trauma-informed-primary-care. Published
November 2015. Accessed November 3,
32 Vanderbilt University School of Medicine.
Trans Buddy Program. https://medschool.
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.
transgender-lgbt-health-services. Accessed
November 3, 2016.
... Healthcare settings represent situated contexts that are reflective of broader cultural milieux, across which SGM are subjected to various human rights violations, including mutilation, torture, corrective rape, murder, unequal legal protections, and conversion therapy despite a lack of evidence to support its practice (United Nations, 2011). Existing within all cultures and experiencing health disparities that are well documented in the literature, SGM have been historically pathologized within health care, as evidenced by a legacy of stigmatization that can be traced in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Canada, 2019;Cohen et al., 2007;Donald et al., 2017;Drescher, 2015bDrescher, , 2015aFlores et al., 2018;Hatzenbuehler, 2009Hatzenbuehler, , 2014Hatzenbuehler, , 2016Hatzenbuehler et al., 2017; House of Commons of Canada, 2019; Lick et al., 2013;Meyer, 2003;Spurlin, 2019). ...
... Stigma connects us all, across contexts; citizens of all societies internalize stigma, but its impacts and externalization depend on the sociocultural context, personal circumstances, and the interplay there between. Stigmatizing social structures cause minorities to experience stress, which is recognized as a cause of health disparities, particularly among SGM (Donald et al., 2017;Flentje, 2020;Hatzenbuehler, 2009Hatzenbuehler, , 2014Metzl & Hansen, 2014;Meyer, 2003;Spurlin, 2019). The impacts of stigma-related stress can be influenced, but opportunities to mediate these risks are often concealed from those who are best positioned to transform causal imbalanced power relations. ...
Previous research inadequately explores processes and factors influencing the delivery of health services to sexual and gender minorities in ways that equitably attend to the infinite diversity held by these groups. This study employed Intersectionality and Critical Theories to inform Constructivist Grounded Theory methods and methodology; social categories of identity were strategically adopted to explore domains of power operating across multiple forms of oppression, think through subjective realities, and generate a nuanced rendering of power relations influencing health service delivery to diverse 2SLGBTQ populations in a Canadian province. Semi-structured interviews were conducted and the co-constructed theory of Working Through Stigma, with three interrelated concepts, depending on context, resolving histories, and surviving the situation, was generated. The theory depicts the concerns of participants and what they do about power relations influencing health service delivery and broader social contexts. While the negative impacts of stigma were widely and diversely experienced by patients and providers, ways of working within power relations emerged that would be impossible if stigma was not present, highlighting opportunities to positively impact those from stigmatized groups. As such, Working Through Stigma is a theory that flouts the tradition of stigma research; it offers theoretical knowledge that can be used to work within power relations upholding stigma in ways that increase access to quality health services for those whose historical underservicing can be attributed to stigma. In doing so, the stigma script is flipped and strategies for working against practices and behaviours that uphold cultural supremacies may be realized.
... Notably, there was little evidence of student reflection on power and systems of oppression and privilege. Moving students' critical thinking beyond individual actions is vital as they move to work in the heteronormative and cisnormative context of established health services (Beagan et al., 2012;Donald et al., 2017). Students highlighted the importance of 'diversity' and acknowledged differences, but not disadvantage. ...
Background In order to avoid perpetuating inequities faced by lesbian, gay, bisexual, transgender, queer, intersex, and other minority (LGBTQI+) communities, future nurses need to recognize and resist discriminatory, oppressive, heteronormative and cisnormative health and social systems. Objectives To share the development, embedding, and formative evaluation of an interdisciplinary project to improve LGBTQI+ health content across an undergraduate nursing curriculum. Methods This paper describes a collaborative interdisciplinary project to embed LGBTQI+ health content across a 3-year undergraduate nursing degree. An anonymous cross-sectional online survey was sent to 87 student nurses enrolled in the final semester of their undergraduate degree. The survey included six Likert scale-type questions and five open-ended questions. Qualitative data were analyzed by inductive, reflexive thematic analysis. Results Most students rated the topic relevant ‘extremely’ relevant (77 %) to nursing. Students' self-reported comfort discussing LGBTQI+ health in class varied from ‘extremely’ (42 %) through to ‘not at all’ (6 %). Thematic analysis of student responses to open-ended questions identified five themes: (1) Becoming aware of LGBTQI+ diversity; (2) Personal values and beliefs; (3) Learning in order to improve clinical encounters; (4) Inconsistency and a lack of incorporation across the curriculum; and (5) (Dis)comfort in the learning environment. Conclusions Opportunities to better embed LGBTQI+ competency included clear acknowledgement of wider systems of power and oppression, integration and consistent modeling by nursing faculty, and linkage of content to other equity issues to address the intersectional nature of inequities.
... 49 The structural competency approach has also been described in relation to lesbian, gay, bisexual, transgender, gender nonconforming, and those with differences in sex development. 50 Although much of the initial training in structural competency may be didactic through understanding systemic forces, integrating opportunities for modeling action-oriented interventions expands this work from merely academic to transformative through advocacy. 51 As more psychiatry training programs seek to adopt structural competency training as part of their programs, psychiatry and national training organizations (e.g., AADPRT) must also provide continuing education and support for training directors to be sucessful in change managment. ...
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.
Queer theory is a disruptive lens that can be adopted by researchers, educators, clinicians, and administrators to effect transformative social change. It offers opportunities for anesthesiologists, critical care physicians, and medical practitioners to more broadly understand what it means to think queerly and how queering anesthesiology and critical care medicine spaces improves workplace culture and patient outcomes. This article grapples with the cis-heteronormative medical gaze and queer people's apprehensions of violence in medical settings to offer new ways of thinking about structural changes needed in medicine, medical language, and the dehumanizing application of medical modes of care. Using a series of clinical vignettes, this article outlines the historical context underlying queer peoples' distrust of medicine, a primer in queer theory, and an understanding of how to begin to "queer" medical spaces using this critical framework.
Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults experience significant health disparities. Examining these disparities has become an international research priority, but gaps remain. In this review article, we summarize major contributions of and ongoing gaps in health disparities research among LGBTQ+ older adults, while focusing on four major content areas: (a) social determinants of health disparities, (b) mental, cognitive, and physical health disparities, (c) reproductive and sexual health disparities, and (d) seeking LGBTQ+-affirming and age-friendly care. Using a structural competency approach, we develop a four-part agenda for this research area that enhances our understanding of how macro-level systems, institutions, and structures drive health disparities among aging LGBTQ+ communities. We also outline future research on structural competency in LGBTQ+ older adult health, while providing recommendations for researchers and clinicians. These recommendations illuminate potential best practices for bettering the health and quality of life of LGBTQ+ older populations.
Full-text available
Background: Despite broad social and policy changes over the past several decades, many LGBTQ+ people face barriers to healthcare and report mistreatment and disrespect in healthcare settings. Few health systems level interventions have been shown to improve sexuality- and gender-related health disparities. Using the Community Readiness Model, we developed and implemented a rigorous assessment and priority-setting intervention at one mid-sized health system in the midwestern US. We evaluated the system’s readiness to provide LGBTQ+ healthcare and developed immediate action steps that are responsive to local context. We engaged diverse stakeholder groups throughout the process. Methods: Led by the Community Readiness Model, we identified key groups within the health system and conductedstructured interviews with 4-6 key informants from each group. Two trained scorers external to the study team individually scored each interview on a numerical scale ranging from 1 (no awareness of the problem) to 9 (community ownership of the problem) and discussed and reconciled scores. Group scores were averaged for each dimension of readiness and overall readiness, and then triangulated with stakeholders to ensure they reflected lived experiences. Finally, specific recommendations were generated to match the needs of the system and move them towards higher levels of readiness. Results: We convened an advisory committee of LGBTQ+ patients of the health system and a panel of local experts on LGBTQ+ wellness. Both groups contributed significantly to research processes. 28 interviews across 6 staff subcommunities indicated readiness levels ranging from “3: Vague Awareness” of the issue, and the “4: Preplanning” stage. Discrepancies across staff groups and dimensions of readiness suggested areas of focus for the health system. The evaluation process led to immediately actionable recommendations for the health system. Conclusions: This pilot study demonstrates the potential impact of the Community Readiness Model on improving health systems’ readiness to provide LGBTQ+ healthcare. This model combines strengths from community-based research and implementation science approaches to form an intervention that can be widely disseminated and maintain the flexibility and agility to meet local needs. Future research will evaluate changes in readiness at the same health system and test the process in additional health systems.
Structural competency is a concept that offers a way to understand and respond to health inequities and work toward antiracism in health care. This article undertakes a concept analysis of structural competency using Rodgers' evolutionary method. Based on this analysis, structural competency refers to the ability to recognize and act on structural inequities, skill development, multidisciplinary collaboration, and the reproduction of inequity over time. The meanings and use of this concept differ among disciplines. Multidisciplinary applications of structural competency offer insight into how this concept can foster health equity and antiracism in nursing care, education, research, and health services delivery.
Full-text available
Key concepts and theories that are taught in order to develop cultural competency skills are often introduced to medical students throughout behavioral and social science (BSS) learning content. BSS represents a core component of medical education in the United Kingdom. In this paper, we examine, through (auto)ethnographic data and reflections, the experiences of BSS in medical education. The empirical data and insights have been collected in two ways: (1) through long-term ethnographic fieldwork among medical students and (2) via autoethnographic reflexive practice undertaken by the co-authors who studied, worked, examined, and collaborated with colleagues at different UK medical schools. Our findings indicate that despite BSS constituting a mandatory, essential component of the medical curriculum, medical students did not always perceive BSS as useful for their future practice as doctors, nor did they find it to be clinically relevant, in comparison to the biomedical learning content. We suggest that it is paramount for all stakeholders to commit to cultivating and developing cultural competency skills in medical education, through robustly embedding BSS learning content across the undergraduate medical curriculum. We conclude with recommendations for a wide range of educational practices that would ensure a full integration of BSS in the medical curriculum.
Objectives: 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. Methods: 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. Results: 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. Conclusions: 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.
Purpose: To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD). Method: The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020. Results: of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation. Conclusions: Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.
Full-text available
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.
Full-text available
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.
Full-text available
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.
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.
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.
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.