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Advances in Medical Education and Practice 2018:9 377–391
Advances in Medical Education and Practice Dovepress
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REVIEW
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/AMEP.S147183
Transgender health care: improving medical
students’ and residents’ training and awareness
Samuel N Dubin1,*
Ian T Nolan1,*
Carl G Streed Jr2
Richard E Greene3
Asa E Radix4
Shane D Morrison5
1NYU School of Medicine, New
York, NY, 2Department of Medicine,
Division of General Internal Medicine
and Primary Care, Brigham and
Women’s Hospital, Boston, MA,
3Department of Internal Medicine,
NYU School of Medicine, 4Callen-
Lorde Community Health Center,
New York, NY, 5Department of
Surgery, Division of Plastic Surgery,
University of Washington School of
Medicine, Seattle, WA, USA
*These authors contributed equally to
this work
Background: A growing body of research continues to elucidate health inequities experienced
by transgender individuals and further underscores the need for medical providers to be appro-
priately trained to deliver care to this population. Medical education in transgender health can
empower physicians to identify and change the systemic barriers to care that cause transgender
health inequities as well as improve knowledge about transgender-specific care.
Methods: We conducted structured searches of five databases to identify literature related
to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were
deemed relevant to predefined criteria, medical education, and transgender health topics. Citation
tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant
citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated
on December 11, 2017.
Results: Transgender health has yet to gain widespread curricular exposure, but efforts toward
incorporating transgender health into both undergraduate and graduate medical educations are
nascent. There is no consensus on the exact educational interventions that should be used to
address transgender health. Barriers to increased transgender health exposure include limited
curricular time, lack of topic-specific competency among faculty, and underwhelming institu-
tional support. All published interventions proved effective in improving attitudes, knowledge,
and/or skills necessary to achieve clinical competency with transgender patients.
Conclusion: Transgender populations experience health inequities in part due to the exclusion
of transgender-specific health needs from medical school and residency curricula. Currently,
transgender medical education is largely composed of one-time attitude and awareness-based
interventions that show significant short-term improvements but suffer methodologically.
Consensus in the existing literature supports educational efforts to shift toward pedagogical
interventions that are longitudinally integrated and clinical skills based, and we include a series
of recommendations to affirm and guide such an undertaking.
Keywords: medical education, transgender, LGBT health, medical training, residency
Introduction
In recent decades, the field of lesbian, gay, bisexual, transgender, and queer (LGBTQ)
health has become a national priority.1,2 Transgender individuals face unique health care
concerns. The term transgender, as it is used here, includes people whose gender identity
differs from their sex assigned at birth as well as those whose gender identity does not
confirm to conventional binary gender categories known as gender nonbinary or gender
nonconforming.3 Some transgender people may undergo medical interventions, such as
hormone therapy (eg, estrogen and testosterone) and gender-affirming surgeries to attain
physical characteristics that better align with their gender identity. Data from national
Correspondence: Shane D Morrison
Department of Surgery, Division of
Plastic Surgery, University of Washington
School of Medicine, 325 9th Avenue,
Mailstop #359796, Seattle, WA 98104,
USA
Tel +1 206 744 2868
Email shanedm@uw.edu
Journal name: Advances in Medical Education and Practice
Article Designation: REVIEW
Year: 2018
Volume: 9
Running head verso: Dubin et al
Running head recto: Transgender health care
DOI: http://dx.doi.org/10.2147/AMEP.S147183
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Dubin et al
surveys estimate that ~1 million Americans’ identity as trans-
gender.4 A growing body of research continues to elucidate
health inequities experienced by transgender individuals1,2,5,6
and further underscores the need for medical providers to
be appropriately trained to deliver care to this population.
Research has shown that transgender populations experience
significant health disparities such as a disproportionately
higher burden of mental health illness, including increased
rates of depression, anxiety, and suicide.7,8 Human immunode-
ficiency virus (HIV) infection is notably higher in transgender
populations, especially transgender women.9–11 Poorer health
outcomes are partially caused, and further compounded, by
socioeconomic inequities, including higher rates of unem-
ployment, poverty, legal discrimination, and harassment when
compared with cisgender people (ie, those whose sex assigned
at birth aligns with their gender identity).12,13
Notably, negative attitudes toward and lack of knowl-
edge about transgender health have manifested in reports of
transgender people being denied health care or experienc-
ing discrimination, including verbal and physical abuse, in
health care settings.14 Access to care is also affected by the
lack of insurance due to poverty or unemployment and cover-
age denials based on categorization of medically necessary
procedures such as “sex-specific”, “cosmetic”, and “experi-
mental”.7,14–17 The Patient Protection and Affordable Care Act
improved health care access for transgender Americans but
did so incompletely and does not address the lack of physician
training in transgender health care.18–22 Medical education
that improves attitudes toward and awareness of transgender
populations, provides knowledge of unique clinical concerns,
and develops skills to deliver competent care is one tool for
addressing transgender health inequities.23–25
A growing number of institutions have acknowledged
the role of education in improving care for transgender
individuals and have taken steps to address transgender
health. However, they often do so under the larger umbrella
of LGBTQ health inequities.26–28 An established body of
research merits focusing on transgender health issues as
a separate clinical skill set from lesbian, gay, and bisexual
(LGB) health. Medical education in transgender health can
empower physicians to identify and change the systemic bar-
riers to care that contribute to transgender health inequities.
It can also improve knowledge about transgender-specific
care, such as hormone therapy, gender-affirming surgical
procedures, high prevalence of gender dysphoria, and other
mental health diagnoses such as depression and anxiety.14,29
Clinicians should be trained to recognize long-term health
outcomes associated with gender-affirming interventions (eg,
dyslipidemias associated with estrogens and erythrocytosis
associated with testosterone) as well as make necessary
modifications to preventive care interventions (eg, screening
transgender women for breast cancer and osteoporosis).30
Transgender patients should have their sex assigned at birth
and current anatomical inventory recorded within the medical
record to facilitate appropriate timely delivery of preventive
care interventions, as cancer screening needs to be based on
existing anatomy.25
From systemic barriers to clinical competency, medical
education has a foundational role in equipping physicians
to address transgender health inequities. We outline various
domains within the literature and describe where consensus
or divergence of recommendations exists. We conclude with
a discussion of previous research in this area and provide
recommendations based on our findings.
Methods
We conducted structured searches of five databases (Educa-
tion Source, LGBT Life, MedEdPORTAL, PsycINFO, and
PubMed) to identify literature related to medical education
and transgender health (Figure 1 and Supplementary material).
Given the broad nature of this literature and varying method-
ologies of the studies included, our methodology is consistent
with a scoping review.31 Search results were screened for rel-
evancy and the following criteria: undergraduate and graduate,
allopathic and osteopathic medical schools in North America
published since January 1, 2000. We included publications of
primary literature, reviews, opinion pieces, and policy papers
to ensure a broad overview of the available literature. Of the
1272 papers reviewed, 119 papers were deemed relevant to
these predefined criteria and the topics of medical education
and transgender health. Citation tracking was conducted on
the 119 papers using Scopus to identify an additional 12 rel-
evant citations not retrieved in database searches (a total of
131 papers). Searches were completed on October 15, 2017
and updated on December 11, 2017.
The nature of our analysis is transgender health education
specific, yet many of our results captured LGBTQ-focused lit-
erature. Thus, our analysis focuses primarily on transgender-
specific publications and utilizes LGBTQ health research
with appropriate contextualization when needed to accurately
identify existing transgender health education research.
Results
An emerging eld with few best practices
Our literature search yielded letters to the editor, perspectives,
response articles, assessments of curricular time allotment to
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Transgender health care
transgender or LGBTQ health, and assessments of student
attitudes and knowledge around transgender health. These
were mostly focused on LGBTQ health as an aggregated
population, with few explicit mentions of the need for
educational efforts tailored to transgender topics.32–34 A
considerable number of articles, even in the last few years,
have called for increased inclusion of transgender health.34–38
They suggest that progress has yet to be made in including
transgender health as an accepted component of health pro-
fessional education. There were no explicit mentions of health
topics specific to gender nonbinary populations.
These findings reveal that efforts toward incorporating
transgender health into undergraduate and graduate medical
educations are nascent. Such programs are sparse, with only
16% of Liaison Committee on Medical Education accredited
academic practices reporting a comprehensive LGBTQ-
competency training program; more than half (52%) report
no LGBTQ training.39 Advocates for the inclusion of trans-
gender medical education widely agreed that it should begin
in medical school and continue through postgraduate train-
ing and be a part of continuing medical education, which
has been endorsed by the American College of Physicians
and echoed by other medical institutions.26,27,37,40,41 Advo-
cates also agreed that innovations in transgender medical
education are closely linked with advances in transgender
and LGB health delivery, such as improvements in the col-
lection of sexual orientation and gender identity data and
increasing LGBTQ visibility and acceptance within medical
institutions.37,42,43
Throughout these editorials, there is no consensus on the
exact educational interventions that should be used to address
transgender health. How to quantify curricular hours, account
for the “hidden curriculum”, and advocate for increased
transgender education are topics discussed without any agree-
ment of best practices.34,35,42 As one recent discussion article
said “Best practices and acceptable measures of evaluating
trainings remains unknown”.34
Barriers to implementation and efcacy
Even in the setting of validated educational interventions, the
authors of this body of literature agreed that problems will
persist given limited curricular time, lack of topic-specific
competency among faculty, and underwhelming institutional
support. The educational resources that do exist are difficult
to implement in the face of these formidable barriers. Authors
emphasize the challenges of providing faculty competent
in transgender health. Some note that having self-identified
LGBTQ faculty does not equate pedagogic or clinical
competency in LGB or transgender health issues.32 Ulti-
mately, as tools to measure educational outcomes are devel-
oped, the authors agreed on the importance of parallel efforts
in faculty development, competency, and support to create
the human capital for transgender medical education.34,44,45
If interventions are implemented, the discrete (ie, one-
time) nature of many educational interventions is a ubiqui-
tous setback to pedagogical efficacy. A review of LGBTQ
educational interventions found that the average intervention
consisted of only one to two lectures and roughly half had
a component involving patient interaction.46 Because these
were broad LGBTQ interventions, even less time was likely
devoted to transgender topics. Structural setbacks to inter-
vention assessments included that as many as a half were
Figure 1 Search algorithm for articles on transgender health.
Total studies considered
(131)
Relevant title and abstract
(119)
Total duplicates eliminated
(1272)
PsycINFO
(891)
PubMed
(155)
Education Source
(281)
MedEdPORTAL
(21)
LGBT Life
(509)
Irrelevant title
and/or abstract
(1153)
Tracked studies
using scopus
(12)
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Dubin et al
optional (resulting in potential for selection bias), response
bias, short-term nature of assessments, and lack of research
that evaluates the comparability of scales used in different
intervention assessments.46,47
Assessing the current state of
transgender medical education
The actual quantification of curricular hours devoted to
transgender health must be extrapolated from the small
number of studies that looked at LGBTQ health as a whole.
There are few studies that attempt to quantify curricular
hours and those that have used varying methods and have
disparate conclusions. One recent study, which is widely cited
throughout the literature, found that there is considerable
variation in LGBTQ health curricula between US medical
schools; the mean curricular time throughout medical school
was 5 hours, with 6.8% reporting zero preclinical hours and
33.3% reporting zero hours during clinical years.48 The most
frequently taught topics were broadly LGBTQ relevant,
such as sexual orientation, HIV, gender identity, and safer
sex; transgender-specific topics, such as transitioning and
gender-affirming procedures or surgeries, were among the
least frequently addressed.48 Regarding transgender health
specifically, 74% of medical students’ report receiving
<2 hours of curricular time devoted to transgender clinical
competency.49 Another study found that postgraduate year 1
and 2 trainees report a median of 22 hours of LGBTQ-related
content in their undergraduate curricula, with the most time
devoted to HIV, safe sex, and differences of sex develop-
ment, but is unclear to what extent any of these 22 hours
were transgender specific or related.50 This same study found
that 93% of respondents reported delivering medical care to
less than five transgender patients and 40% cared for zero
transgender patients during undergraduate training.50 Despite
varying study methodologies, transgender health has yet to
gain widespread curricular exposure.
Lack of transgender health education is reflected by
students’ lack of awareness and knowledge surrounding
transgender health. Of all LGBTQ topics, transgender health
is the least well understood. A survey of Boston University
students’ knowledge and attitudes about LGB and transgender
patients reported that compared with LGB health knowledge,
comfort and knowledge about transgender patients were
much lower.51 A larger, interschool survey echoed the same
finding, reporting that transgender-specific knowledge topics,
such as those surrounding gender-affirming surgeries, were
the worst understood of all LGBTQ health topics.52 These
results, contextualized alongside several studies that more
robustly demonstrate lower comfort and knowledge regarding
LGBTQ patients as a whole when compared with straight and
cisgender patients, elucidate the current state of transgender
health when disaggregated from LGBTQ health.53–56
The literature reviewed notes that transgender health
competency is generally poor, but precise characterization
of medical student competency in transgender health is
difficult given limitations cited by the literature. Very few
studies directly assessed medical student attitudes about
transgender patients or knowledge about transgender health
issues. Only two such studies were found, both online sur-
veys that asked medical students to subjectively report their
own attitudes and knowledge about transgender health.51,52
No objective assessments of transgender-specific attitudes,
knowledge, or clinical skills could be found. One survey
in 2017 assessed medical students at Boston University
and another in 2015 assessed students at 170 US allopathic
and osteopathic schools (4262 responses of possible 9522).
However, the latter study reports on data collected in 2010,
limiting conclusions that can be drawn regarding students’
current attitudes and knowledge given the notable increase
in transgender-related media coverage and political attention
since its publication. Therefore, characterization of medical
students’ current transgender health competency largely
depends on a single study of students at a single institution.
Current publication trends (eg, 5 in 2010 and 25 in 2015)
(Figure 2), especially in the larger context of LGBTQ educa-
tion, indicate that while remaining sparse, the publication
rate of literature addressing transgender health competency
and education has accelerated greatly in recent years. The
literature acknowledges a motivation for change. In one survey
of Canadian medical students, 95% found transgender issues
important to their health care education.57 This transgender-
specific trend is consistent with the overall trend in LGBTQ
health education attitudes in the literature. In one large survey
of 132 medical school deans, 76% rated their own LGBTQ cur-
ricula as “fair” or “poor”, with only 24% rating it as “good”.48
A smaller survey reported that medical students acknowledged
a lack of LGBTQ health education and valued its inclusion
in the larger health curriculum.58 A survey of clerkship and
course directors at the University of Louisville expressed a
desire to almost double curricular time devoted to LGBTQ
health.59 Thus, while motivation for increasing transgender
health education cannot currently be well-characterized given
the difficulty of disaggregating transgender education from the
umbrella of LGBTQ health, the literature reveals an increasing
identification of interest in increasing both transgender-specific
and LGBTQ health education.
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Transgender health care
Undergraduate medical education
interventions
A combination of factors limits consensus on best practices
for how to structure pedagogical interventions to address
transgender health education. These factors include a pau-
city of published studies, the heterogeneity of educational
interventions and assessment metrics, and the short-term
nature of outcome measurements. The general format of
interventions varies widely, including their location in the
curriculum, duration, and grouping within LGBTQ lectures
or as discrete, transgender-specific interventions.
A salient finding of our review is the general dearth of
literature regarding transgender health education, even in the
setting of a rise in LGBTQ education. Although 26 studies
published data on LGBTQ curriculum in some capacity,
only eight (31%) studies included transgender-specific con-
tent (Table 1).58,60–66 Zero papers addressed health concerns
specific for nonbinary populations. The majority of LGBTQ
studies identified did not disaggregate transgender health
issues from the larger LGBTQ umbrella in assessments of
interventions. Given the unique social considerations and
medical needs of transgender patients, the literature on
transgender medical education is limited by the predominant
approach that aggregates transgender and LGB populations.
Again, publication patterns within the literature speak
both to the newness of the field and to a rapid growth in
transgender health education interventions. While published
findings on efforts to improve transgender health educa-
tion are mostly from the last 5 years, more interventions
are published each year. This acceleration is likely due to
an increased visibility of transgender identities and health
concerns and a well-documented push from residency direc-
tors, health educators, and students to expand LGBTQ health
education broadly.59
These accelerating publication patterns are due in part
to discrete, transgender-specific educational interventions,
as well as transgender topics within a broader LGBTQ
intervention.58,61,65 Given the limited number of studies, the
literature lacked consensus as to which teaching strategy
(aggregated with LGBTQ or separated as transgender only)
is more effective at addressing attitudes, knowledge, and
skill for transgender health. Authors that support discrete
interventions argue that they allow more in-depth discussion
of transgender health issues. Yet, citing the limited resources
and time available for modifying curricula, some authors
argue that the most feasible way to include transgender topics
is to aggregate them with existing LGBTQ health education
interventions.
Figure 2 Publication rate on transgender medical education.
2008 2009
Year
10
15
5
2010 2011 2012 2013 2014 2015 2016 20172000 2001 2002 2003 2004 2005 2006 2007
25
20
30
Number of publications yielded by search method
0
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Dubin et al
The educational interventions used various formats
including optional lunchtime discussion sessions, elective
or mandatory didactic lectures, clinical observations, inter-
clerkship week lectures, and online educational modules
(Table 1).67 Interventions were placed in preclinical basic
science curricula (eg, endocrinology curricular block), in
doctoring courses geared at developing interview skills and
bedside manner, or in family medicine or pediatrics clinical
rotations. The duration of teaching time in studies also varied
considerably with format of the intervention. Mandatory
lectures were usually shorter, mostly 1 or 2 hours. Two of
the optional interventions, both lunchtime discussion series,
were much longer, with 10 or 11 hours of curricular content
in total.64,65
While no consensus has been reached as to which peda-
gogical design was more effective, there was commonality
in that all published interventions were associated with
improving attitudes, knowledge, and/or skills necessary to
achieve clinical competency with transgender patients. We
outline here the specific findings in these learning domains.
Three educational interventions were associated with
improved attitudes about transgender patients and their health
care needs. Two series of optional lunchtime electives were
associated with decreased transphobia and increased accep-
tance of transgender identities.64,65 Another intervention was
associated with a 67% decrease in the number of students
who felt uncomfortable treating transgender patients, as
well as increased acceptance of transgender health care as
“conventional medicine”.62
Three interventions were associated with increased
knowledge of trans-specific social and political concepts that
are important to transgender health care. An optional lunch-
time series was associated with increased knowledge about
federal policies impacting transgender health.64 A family
medicine clerkship module was associated with knowledge
about health disparities facing transgender patients, as well
as basic concepts relevant to transgender and LGB health,
like the distinction between sexuality and gender.60
Four interventions were associated with increased com-
fort and knowledge regarding sexual history taking, diag-
nosis of gender dysphoria, and transition-related treatment
of transgender patients. An educational module included in
the family medicine clerkship was associated with increased
comfort with transgender sexual history taking, examination,
and laboratory evaluation.60 Both an optional lunchtime series
and a mandatory module were associated with increased
awareness of transgender patients’ anatomy before and after
gender-affirmation procedures.61,64 The lunchtime series was
also associated with increased knowledge of gender dyspho-
ria diagnoses and hormone therapy. Several interventions
reported generally increased knowledge about transgender
health care.63,64,66 The family medicine clerkship module was
also associated with increased clinical performance when
interacting with transgender patients; students improved their
ability to discuss the hormone therapy and to identify the
appropriate resources and transgender-friendly practices.60
Despite some significant increase in attitudes, knowledge,
and/or skills, there were limitations noted. Authors consis-
tently observed that while interventions proved effective
when assessed in the short term, it cannot be determined
whether short-term improvements are sustained. Most studies
that assessed postinterventional knowledge did so immedi-
ately after the intervention. Authors frequently identified the
need for long-term assessments but are limited by resources
to conduct them. Additionally, authors frequently acknowl-
edged the uncertainty in how documented short-term changes
in attitudes, knowledge, or skills translate into improved clini-
cal outcomes for transgender patients. There is agreement
that long-term assessments of pedagogical interventions will
elucidate which educational interventions are most effective
in sustaining changes in attitudes, knowledge, and skills as
well as pedagogical impacts on clinical outcomes.
Graduate medical education
interventions
To our knowledge, this is the first review of graduate medical
education literature regarding transgender health. Screen-
ing for title and abstract yielded 15 papers, which included
surveys, reports on educational interventions, and editorials.
Generally, there are fewer graduate publications on transgen-
der medical education when compared with undergraduate.
Specialties found in our search include psychiatry, internal
medicine and family medicine, endocrinology, emergency
medicine (EM), plastic surgery, otolaryngology, and
urology.22,50,68–80 The residency specialties that had published
the most were plastic surgery/urology and internal medicine.
There is a consensus that transgender-specific health
education in both didactic and clinical settings is lacking.
At the graduate level, there is often no didactic or clinical
exposure, both for LGBTQ health in general and transgender
health specifically. There were no data available on nonbinary
health education. Where teaching exists, it is often minimal.
These deficiencies are consistent across all specialties for
which data exist. A 2015 dissertation on medical resident
education on sexuality showed no education to minimal edu-
cation about transgender patients (average score 1.55 of the
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Transgender health care
Table 1 Relevant studies on transgender-related health topics in medical school
Authors Year N Total time Placement in
curriculum
Format Outcomes
Braun
et al64
2017 46 Up to 10 hours Variable Optional
lunch-hour
electives
Increased knowledge of: Transgender terminology (78–87%
correct, P<0.01)
SOGI data collection (50–89% correct, P<0.01)
Awareness of DSM-V gender dysphoria diagnosis (15–59% correct,
P<0.01)
Gender-afrming medications (47–58% correct, P<0.01)
Primary care for transgender people (57–81% correct, P<0.01)
Federal policies (26–34% correct, P<0.01)
Reduced transphobia (15.9–14.1 on a 45-point scale with higher
scores indicating increased transphobia, P<0.05)
Dowshen
et al60
2013 150 1 hour Family medicine
clerkship
Mandatory
module
Increased knowledge of:
Difference between sexuality and gender concepts (P<0.05)
Poor population health outcomes in transgender communities
(P<0.001)
Increased comfort with sexual history, examination, and laboratory
evaluation (P<0.0001)
Ability to discuss hormone therapy (P<0.01)
Ability to identify appropriate resources and transgender-friendly
practices (P<0.0001)
Eriksson
and Safer63
2016 121 1 hour MS1 Mandatory
lecture
Increased knowledge of:
Etiology of gender identity (14–80% correct, P<0.001) (N=43)
Gender identity as a durable biologic phenomenon (63–93%
correct, P<0.001)
Gender identity, transgender medicine, and recognition of cross-
sex hormone therapy as a valid treatment (20–50% correct,
P<0.001) (N=56).
Grubb
et al61
2013 29 2 hours – Mandatory
module
Increased knowledge of:
Presence of prostate status post-vaginoplasty (69–95% correct,
P<0.05)
Intersex anatomy examples (52–76% correct, P<0.05)
Safer and
Pearce62
2013 66 1 hour MS2,
endocrinology
Curricular
content
Decreased discomfort with treating trans male patients (38–12.5%
uncomfortable, P<0.001)
Decreased discomfort with treating trans female patients (38–14%
uncomfortable, P = 0.0006)
Decreased unwillingness to treat a trans male patient (18–3%
uncomfortable, P = 0.02)
Decreased unwillingness to treat a trans female patient (15–3%
uncomfortable, P=0.02)
Decreased belief that health care for trans males is not
conventional medicine (7–0%)
Decreased belief that health care for trans females is not
conventional medicine (7–0%)
Sawning
et al65
2017 39 Variable, up to
11 hours
Variable Optional
lunch-hour
electives
Increased beliefs that:
Same sex behavior is normal (74–90%, P=0.019)
Transgender identities are normal (77–85%, P=0.037)
Sequeira
et al58
2012 30 4 hours (3×1 hour
lectures, 1 hour
standardized
patient
encounter).
2 hours lecture
was trans-specic
MS1 and MS2 Optional
course:
lectures and
standardized
patient
encounter
Free-text responses that indicated increased trans competency
A total of 90% reported learning something new and applicable
about hormone replacement therapy
Vance
et al66
2017 20 7 hours (2 hours
module,
5 hours clinical
observation)
Adolescent
and young
adult medicine
clerkship
Online
modules
and clinical
observation
Increased perceived knowledge and awareness of all aspects of
transgender care assessed (for each of 20 measures, P<0.001)
Abbreviations: SOGI, sexual orientation and gender identity; DSM-V, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; MS1, rst-year medical student;
MS2, second-year medical student.
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Dubin et al
5, 0 representing no education) and 83.1% reporting minimal
or no transgender health education during residency.81 The
only graduate-specific EM study found that LGBTQ topics
averaged a total of 45 minutes, which was not transgender
specific.76 Surveys of plastic surgery and urology residents
found that only 65 and 54% of respondents, respectively, had
education on or direct exposure to transgender patient care
during residency.78 The literature demonstrates a consistent
underexposure to transgender health in both the graduate
classroom and clinic.
Despite the increasing acceptance of the importance of
graduate medical education addressing transgender health,
attitudinal setbacks across specialties remain but are not
necessarily ubiquitous. One survey of psychiatry residents in
Canada found lower than expected rates of transphobia when
compared with similar studies of undergraduate students.82
One study found variation in attitudes by geographic region,
with south-eastern regions having more negative attitudes
held by residency program directors regarding the impor-
tance of transgender health education.77 In one EM study,
16% of EM residency program directors did not support the
inclusion of LGBTQ-specific education.76 As the effort to
add transgender health to undergraduate curricula changes,
the attitudinal landscape at the graduate level will likely shift
dramatically and further documentation is warranted.
Interventions that address shortcomings in resident
approaches to transgender health are primarily didactic or
policy oriented. Discrete, transgender-specific didactics for
internal medicine and family medicine residents have been
shown to increase knowledge around hormone replacement
therapy.71 One study used an observed structured clinical
encounter (OSCE) format to assess the ability of primary care
residents to care for transgender patients, finding that 61%
of residents did not consistently ask about gender identity.83
A limitation to discrete interventions was documented in
one study on psychiatry residents, where significant short-
term increases in knowledge and comfort were not sustained
when assessed with long-term follow-up.69 Multiple authors
expressed that skill-focused education at incremental cur-
ricular levels, ie, across the length of the residency rather
than a discrete modular unit, would have the best educational
impact on residents and ultimately clinical outcomes.69,75
The literature discussed interventions to both curricula
and policy that would improve graduate transgender educa-
tion. A curricular mandate from the Accreditation Council
for Graduate Medical Education (ACGME) is discussed
throughout the literature as the most pragmatic means to
the integration of transgender patient care into residency
curriculums.22,77–79 The ACMGE’s professional mandate
would standardize expectations for resident competencies in
transgender health and would move toward case log require-
ments for surgical fields and accreditation of fellowships
for highly specialized transgender-specific procedures.22,79,84
Despite the limited number of studies found for graduate
medical education and transgender health, there does appear
to be momentum toward adding more transgender health
education and clinical exposure to multiple specialties. While
a consistent lack of transgender health education is noted,
so is the belief that education should be improved. In one
study of internal medicine residents, 97% believed in the
value of learning comprehensive care skills for transgender
patients, but only 45% had any prior education on these
issues.74 In another study of endocrinology fellows, 93.8%
indicated the importance of transgender health training, but
only 72.2% of responding programs provided teaching on
transgender health.75 In their discussion sections, authors
often observed how the emerging interdisciplinary models
of care for transgender patients have yet to be critically
incorporated into the design of educational interventions in
specialist training. These authors agree that if care delivery
models change, education should change to reflect and best-
serve new care models.
Discussion
Medical education has been identified as a critical means
by which to address health inequities experienced by the
transgender community.23,27 The transgender community is
experiencing a rapid increase in visibility, through positive
media portrayals of high-profile transgender individuals,
through controversial legal battles taking place throughout
the USA, and through increased coverage of the frequent
violence experienced by the community. Recent changes in
health care laws have improved health care access for trans-
gender people both by allowing payment for gender-affirming
interventions and by addressing discriminatory practices
in health care.18 We conducted a broad literature review to
assess the state of medical education to identify emerging
best practices addressing transgender health education. To
our knowledge, we are the first to conduct a literature review
of North American medical undergraduate and graduate
educations specifically on transgender health disaggregated
from the LGBTQ umbrella.
Attitudes, knowledge, and skills are foundational
components to establish clinical competency.26 Studies
of pedagogical interventions targeting student attitudes
and knowledge of transgender health consistently show
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Transgender health care
significant improvements. However, these findings should
be considered in light of the following: 1) transgender
health is often aggregated within the larger LGB umbrella,
2) the assessments are short term with few assessing learner
outcomes at long range time points, 3) metrics are often
subject to priming or selection bias, especially with elective
curricular content, and 4) patient-related outcomes have
not been assessed. Additionally, while the general focus on
teaching to change attitudes is perhaps warranted in many
institutional cultural climates, it does not address the clinical
skills needed to begin to alleviate health inequities.46,85 The
studies that are transgender specific, with few exceptions, did
not focus on developing clinical skills that could potentially
impact patient outcomes.60,83 Further emphasis on clinical
skill development is necessary to ensure medical students
meet Association of American Medical Colleges’ clinical
competency standards. New data support the efficacy of clini-
cal exposure in improving requisite comfort and knowledge
toward transgender patients.86
The literature offers solutions to the circumscribed nature
of current pedagogical interventions. A truly effective peda-
gogical intervention has been described as one that teaches
transgender health in a way that does not create a narrative of
a medicalized or pathologized “other” but rather encourages
evaluation of the structural and cultural causes of gender
minority health inequities.47 Other structural changes in peda-
gogic delivery would benefit transgender medical education.
The literature contains an emerging consensus that modular,
ie, one time or discrete, interventions are strongly associated
with short-term improvements in attitudes. However, these
interventions lack long-term data on efficacy and are not
proven to improve transgender patient outcomes. Authors of
studies throughout this body of literature suggested incor-
porating transgender clinical competencies across the cur-
riculum rather than in one or two condensed lectures. Doing
so would reinforce topics in their relevant clinical context
with emphasis over time. A longitudinal incorporation of
transgender health topics into the standard curriculum would
also support its disaggregation from the generalized topic of
LGBTQ health. For example, this could include discussions
of sex organs as opposed to “male and female genitalia” in
anatomy, or a discussion of gender identity during lectures
on puberty. Because of the issues discussed here, one-time
interventions for transgender education are insufficient to
create sustainable learning and clinical improvements.
Our review identified the need for an increased emphasis
on clinical outcomes. In studies that looked at changes in atti-
tudes and awareness of transgender issues as well as clinical
comfort, face-to-face interactions and clinical exposure to
transgender patients were the most effective in improving
students’ metrics. In moving beyond attitudinal didactic inter-
ventions, there is evidence that observed simulated clinical
encounters are effective tools for increasing undergraduate
and graduate comfort and skill for transgender patients.60,83
Particularly at a graduate level, the need for skill-based
pedagogical interventions was ubiquitous throughout the
literature. Shifting program director attitudes, expanding
fellowship opportunities that provide skills for transgender
populations (eg, gender-affirming surgeries), and confer-
ment of credibility of these topics through accreditation
were identified as ways to build pedagogical platforms to
teach transgender-relevant clinical skills. The shift to skill-
based assessment for transgender health teachings will be
supported by increasing patient–learner interaction and
top-down acknowledgment of the topic’s importance through
accreditation and training opportunities.
The literature also details many of the challenges within
medical education on transgender health topics. Documented
perceptions of lack of time, irrelevance, or lack of competent
faculty to teach are prevalent. If the current state of trans-
gender medical education is attitude- and awareness-based
one-time interventions, then the shift to integrated and longi-
tudinal clinical skill-based interventions requires significant
human capital and institutional investment.
We include the following series of recommendations that
are meant to affirm and guide this undertaking:
1. Accreditation boards, testing boards, deans of curricu-
lum, and residency program directors must specifically
name transgender health as a required topic and identify
expectations of clinical competencies. National educa-
tional organizations and institutional leadership should
encourage allotment of curricular resources and time in
accordance with clear, agreed upon learning objectives.
A one-time lecture, which includes all aspects of LGBTQ
health, is insufficient to produce better clinical skills for
learners.
2. Separate transgender health content from the larger
LGBTQ umbrella. Gender identity is a distinct domain
from sexual orientation (LBG), and the medical concerns
relating to gender identity warrant specific attention.
Where appropriate, the transgender population should be
further individuated so that gender-based health inequities
can be more thoroughly understood, such as differences
in health outcomes between transmen, transwomen, and
gender nonbinary individuals. Integration of important
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aspects of transgender health may be appropriately placed
into lectures and other curricular content traditionally
focused on cisgender people including topics such as
breast cancer screening and fertility.
3. Incorporate pedagogical interventions that improve
attitudes toward and awareness of transgender health
inequities, which is foundational to imparting clinical
skills to address such inequities. Thus, while this type
of intervention has significant shortcomings when it is
the only intervention, it is likely necessary and founda-
tional for building clinical comfort and competency on
transgender-specific clinical concerns.86
4. Pedagogical intervention around transgender health
should provide insight into the social and legal barri-
ers that produce health inequities for this community.86
Additionally, care should be taken to ensure that curricula
content avoids the pathologization of transgender identi-
ties and acknowledges that not all transgender people seek
gender-related care. Curricular content, in an attempt to
support the transgender community, should acknowledge
its documented resilience and agency over medical initia-
tives that impact the transgender community.87
5. Pedagogical interventions must focus on the improve-
ment of students’ clinical skills and measured outcomes.
Achieving this will include an increased emphasis on
direct patient–learner interaction, likely through OSCEs,
rotations with LGBTQ-focused community health cen-
ters, or direct care of transgender individuals during
standard clinical rotations when possible. Metrics are
already in place by which to assess clinical competen-
cies for LGBTQ patients.26 It bears noting that tracking
clinical outcomes from an educational intervention is
impossible without clear and accurate gender identity
data in medical records, which is not ubiquitous at this
moment.
6. A standardized measure regarding what qualifies as trans-
gender content in undergraduate medical curricula and a
centralized and accurate reporting system to track progress
should be developed by a national institution in order to
more reliably assess curricular changes and pedagogical
best practices. Graduate medical education of transgender
health topics should also be standardized in this way but
will likely vary by which transgender health topics are most
relevant to each specialty (eg, hormone therapy for primary
care and gender-affirming procedures for urology).
Our findings are not without limitations. The scope of our
literature search was limited to undergraduate and graduate
medical educations in North America since 2000. While we
believe this to be pragmatically limited in scope, there exists
many calls for novel educational or curricular changes for
medical students that exist within the literature on a variety
of other topics. However, we focused on the current state
of transgender health education delivery and pedagogical
research rather than recommended curricular content, which
has been outlined elsewhere.88 Another limitation is our
incorporation of dissertations, opinion pieces, and letters
to the editor. While the majority of our analysis is based on
peer-reviewed publications, we include these formats to more
accurately capture the attitudes and opinions contributing to
this emerging field of research. Additionally, it is likely that
many pedagogical interventions have been implemented
without publication and are thus absent from the literature.
Our inclusion of the MedEdPORTAL database captured
some relevant studies, but our findings only speak to pub-
lished curricular changes. It merits mention that curriculum
development processes, medical education programs, and
staff trainings for transgender-specific clinical goals have
emerged but are not reviewed here due to scope.89–91
Conclusion
Transgender populations experience health inequities in part
due to the exclusion of transgender-specific health needs from
medical school and residency curricula. Currently, transgen-
der medical education is largely composed of one-time atti-
tude and awareness-based interventions that show significant
short-term improvements but suffer methodologically from
the lack of long-term assessment, the lack of emphasis on
clinical skills, or the evaluation of patient outcomes. Consen-
sus in the existing literature supports educational efforts to
shift toward pedagogical interventions that are longitudinally
integrated and clinical skills based. We believe the integra-
tion of transgender health topics into their related medical
domains, and increased emphasis on clinical skills will create
a curriculum that addresses attitudes, knowledge, and skills
and will ultimately alleviate the dire health inequities faced
by the transgender community.
Acknowledgments
We wish to acknowledge Vania Rashidi for his assistance with
making the figures. We also wish to acknowledge Dr Victoria
Harnick for her early guidance in framing this article, as well
as Joseph Nicholson for his input on our search strategy.
Disclosure
The authors report no conflicts of interest in this work.
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Supplementary material
Search databases and terms
Education Source (EBSCO)
(“Transgender Persons” OR “Transsexualism” OR “Health
Services for Transgender Persons” OR “Disorders of Sex Devel-
opment” OR “differences of sex development” OR “difference
of sex development” OR “disorders of sex development” OR
“disorder of sex development” OR “gender incongruence” OR
“gender fluidity” OR “gender reassigned” OR “gender reas-
signment” OR “gender minority” OR “gender non conformity”
OR “gender nonconformity” OR “gender nonconforming”
OR “gender non conforming” OR “gender expression” OR
“gender variance” OR “gender-variant” OR “crossgender”
OR “F2M” OR “female-to-male” OR “gender change” OR
“gender changes” OR “gender dysphoria” OR “gender dyspho-
rias” OR “gender queer” OR “gender queering” OR “gender
transition” OR “gender transitioning” OR “genderqueer” OR
“genderqueer” OR “genderqueers” OR “M2F” OR “male-to-
female” OR “sex change” OR “sex changed” OR “sex changer”
OR “sex changers” OR “sex changes” OR “sex reversal” OR
“sex reversals” OR “sex transition” OR “trans female” OR
“trans females” OR “trans male” OR “trans males” OR “trans
man” OR “trans men” OR “trans people” OR “trans woman”
OR “trans-sexuality” OR “transexual” OR “transgender” OR
“transgendered” OR “transgenders” OR “transsexual” OR
“transsexualism” OR “transsexuality” OR “transsexuals”
OR “transvestite”) AND (“medical students” OR “medical
student” OR “medical education” OR “medical college” OR
“medical curriculum” OR “clinical clerkship” OR “clinical
clerkships” OR “clinical rotation” OR “clinical rotations”
OR “clinical curriculum” OR “medical training” OR “Intern-
ship and Residency” OR “Teaching Rounds” OR “Students,
Medical” OR “Schools, Medical” OR “Education, Medical”
OR “Education, Medical, Undergraduate” OR “Education,
Medical, Graduate” OR “Education, Medical, Continuing”)
AND (“medical students” OR “medical student” OR “medical
education” OR “medical college” OR “medical curriculum”
OR “clinical clerkship” OR “clinical clerkships” OR “clinical
rotation” OR “clinical rotations” OR “clinical curriculum”
OR “medical training” OR “Internship and Residency” OR
“Teaching Rounds” OR “Students, Medical” OR “Schools,
Medical” OR “Education, Medical” OR “Education, Medi-
cal, Undergraduate” OR “Education, Medical, Graduate” OR
“Education, Medical, Continuing”)
LGBT Life (EBSCO)
(“Transgender Persons” OR “Transsexualism” OR “Health
Services for Transgender Persons” OR “Disorders of Sex
Development” OR “differences of sex development” OR
“difference of sex development” OR “disorders of sex
development” OR “disorder of sex development” OR
“gender incongruence” OR “gender fluidity” OR “gen-
der reassigned” OR “gender reassignment” OR “gender
minority” OR “gender non conformity” OR “gender non-
conformity” OR “gender nonconforming” OR “gender non
conforming” OR “gender expression” OR “gender vari-
ance” OR “gender-variant” OR “crossgender” OR “F2M”
OR “female-to-male” OR “gender change” OR “gender
changes” OR “gender dysphoria” OR “gender dysphorias”
OR “gender queer” OR “gender queering” OR “gender tran-
sition” OR “gender transitioning” OR “genderqueer” OR
“genderqueer” OR “genderqueers” OR “M2F” OR “male-
to-female” OR “sex change” OR “sex changed” OR “sex
changer” OR “sex changers” OR “sex changes” OR “sex
reversal” OR “sex reversals” OR “sex transition” OR “trans
female” OR “trans females” OR “trans male” OR “trans
males” OR “trans man” OR “trans men” OR “trans people”
OR “trans woman” OR “trans-sexuality” OR “transexual”
OR “transgender” OR “transgendered” OR “transgenders”
OR “transsexual” OR “transsexualism” OR “transsexual-
ity” OR “transsexuals” OR “transvestite”) AND (“medical
students” OR “medical student” OR “medical education”
OR “medical college” OR “medical curriculum” OR
“clinical clerkship” OR “clinical clerkships” OR “clinical
rotation” OR “clinical rotations” OR “clinical curriculum”
OR “medical training” OR “Internship and Residency” OR
“Teaching Rounds” OR “Students, Medical” OR “Schools,
Medical” OR “Education, Medical” OR “Education, Medi-
cal, Undergraduate” OR “Education, Medical, Graduate”
OR “Education, Medical, Continuing”) AND (“medical
students” OR “medical student” OR “medical education”
OR “medical college” OR “medical curriculum” OR
“clinical clerkship” OR “clinical clerkships” OR “clinical
rotation” OR “clinical rotations” OR “clinical curriculum”
OR “medical training” OR “Internship and Residency” OR
“Teaching Rounds” OR “Students, Medical” OR “Schools,
Medical” OR “Education, Medical” OR “Education, Medi-
cal, Undergraduate” OR “Education, Medical, Graduate”
OR “Education, Medical, Continuing”)
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Transgender health care
MedEdPORTAL
(“Transgender”)
PsycINFO
(“Transgender” AND “Education”)
PubMed
(((“Medical education”[Journal] OR “Academic medi-
cine: journal of the Association of American Medical
Colleges”[Journal] OR “Advances in health sciences
education: theory and practice”[Journal] OR “Medical
teacher”[Journal] OR “Academic emergency medicine:
official journal of the Society for Academic Emergency
Medicine”[Journal] OR “Simulation in healthcare: journal
of the Society for Simulation in Healthcare”[Journal] OR
“Journal of surgical education”[Journal] OR “Evaluation
& the health professions”[Journal] OR “BMC medical
education”[Journal] OR “The Journal of continuing education
in the health professions”[Journal] OR “Teaching and learn-
ing in medicine”[Journal] OR “The clinical teacher”[Journal]
OR “Education for health (Abingdon, England)”[Journal]
OR “Advances in physiology education”[Journal] OR
“Canadian medical education journal”[Journal] OR
“Journal of graduate medical education”[Journal] OR
“Medical education online”[Journal] OR “Perspectives
on medical education”[Journal] OR “Journal of research
in interprofessional practice and education”[Journal] OR
“Medical science educator”[Journal] OR “The journal of
the International Association of Medical Science Educa-
tors: JIAMSE”[Journal]))) OR (“medical students”[tiab]
OR “medical student”[tiab] OR “medical education”[tiab]
OR “medical college”[tiab] OR “medical curriculum”[tiab]
OR “clinical clerkship”[tiab] OR “clinical clerkships”[tiab]
OR “clinical rotation”[tiab] OR “clinical rotations”[tiab]
OR “clinical curriculum”[tiab] OR “medical training”[tiab]
OR “Internship and Residency”[Mesh] OR “Teaching
Rounds”[Mesh] OR “Students, Medical”[Mesh] OR
“Schools, Medical”[Mesh] OR “Education, Medical”[Mesh]
OR “Education, Medical, Undergraduate”[Mesh] OR “Edu-
cation, Medical, Graduate”[Mesh] OR “Education, Medical,
Continuing”[Mesh])
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