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Transgender Healthcare: Development of an Illustrated eLearning Tool for Medical Education
... poor, yet standardized curricula for professional training and continued education are lacking (Alpert et al., 2017;Bohnert et al., 2020;Congdon et al., 2021;Hana et al., 2021;Pratt-Chapman, 2020;Young et al., 2021). Studies have demonstrated that transphobia rather than education predicts provider knowledge of transgender healthcare (Bohnert et al., 2020;Noonan et al., 2021;Pathoulas et al., 2021;Stroumsa et al., 2019). ...
The aim of this project is to determine the state of representation of transgender, intersex, and
gender-nonconforming (TIGNC) people in acupuncture and East Asian Medicine (AEAM) research literature.
Introduction: There is recent and growing research literature on the advancement of representation of TIGNC populations; however, the definitions and measures within AEAM research and clinical practice do not consider the complex physiological sex characteristics and socially constructed gender, fostering underrepresentation and use with these populations. Current AEAM research literature was reviewed for representation of TIGNC populations. Key issues for consideration in future research and clinical practice were critically summarized.
Methods: A systematized review was conducted of TIGNC representation in AEAM research in English language, peer-reviewed journals, published 1900-2021. A secondary grey literature search was conducted. Key details from studies were extracted and described.
Results: The systematized review yielded no studies that met all inclusion criteria for the review. The secondary grey literature review yielded three studies that met all inclusion criteria; all three results were academic papers centering transgender and/or gender-nonconforming people and acupuncture and/or East Asian Medicine.
Conclusions: The findings suggest a high need for ongoing public health attention. Recommendations are offered to improve future AEAM research and clinical practice with transgender, intersex, and gender-nonconforming populations, such as being explicit as to whether and how sex and/or gender are operationalized and relevant for the research question.
Keywords: ‘transgender,’ ‘intersex,’ ‘gender nonconformity,’ ‘LGBTQIA+,’ ‘sexual and gender minorities,’ ‘acupuncture,’ ‘Traditional Chinese Medicine,’ ‘East Asian Traditional Medicine’
Background
Health care professionals often face challenges in providing affirming and culturally competent care to transgender, nonbinary, and intersex (TNBI) patients due to a lack of understanding and training in TNBI health care. This gap highlights the opportunity for tailored educational resources to enhance health care professionals’ interactions with TNBI individuals.
Objective
This study aimed to explore health care professionals’ perspectives on education and awareness of health issues related to TNBI individuals. Specifically, it aimed to identify their needs, challenges, and preferences in accessing and using digital educational resources to enhance their knowledge and competence in providing inclusive and effective care for this population.
Methods
A qualitative research approach was used in this study. In total, 15 health care professionals were recruited via convenience sampling to participate in semistructured interviews. Thematic analysis was applied to identify recurring codes and themes.
Results
The study identified several themes and subthemes related to gender diversity awareness, inclusive communication and understanding the needs of TNBI individuals, societal and structural challenges, regulatory gaps in training and support infrastructure, education and training needs for health care professionals on TNBI care, educational resources and training tools for TNBI care, challenges and design considerations for eHealth tools integrations, and evaluating eHealth impact. Participants identified communication barriers, the need for health care providers to use inclusive language, and gaps in both health care system infrastructure and specialized training for gender-affirming care. In addition, participants expressed a need for comprehensive education on transgender and nonbinary health issues, resources for mental health professionals, user-friendly design, and accessibility features in eHealth tools.
Conclusions
The study revealed substantial deficiencies in health care professionals’ knowledge of gender diversity, cultural competency, and the importance of inclusive communication. Addressing the identified barriers and challenges through targeted interventions, such as providing training and support for health care professionals, investing in user-friendly design and data security, and promoting cultural competence in TNBI health care, is essential. Despite integration challenges, eHealth tools have the potential to improve patient–health care professional relationships and access to care.
Objectives
Gender dysphoria is defined as a conflict between the biological gender and the gender with which the person identifies. Gender reassignment therapy can alter external sexual features to resemble those of the desired gender and are broadly classified into two types, female to male (FTM) and male to female (MTF). In this paper we describe expected findings and complications of gender reassignment therapy.
Methods
Collaborative multi-institutional project supported by Ovarian and Uterine Cancer Disease Focused panel of Society of Abdominal Radiology.
Results
Gender dysphoria is defined as a conflict between the biological gender and the gender with which the person identifies. Gender reassignment therapy can alter external sexual features to resemble those of the desired gender and are broadly classified into two types, female to male (FTM) and male to female (MTF). These therapies include hormonal treatment as well as surgical procedures. FTM genital reconstructive therapy includes creation of a neophallus, which can be achieved by metoidioplasty or phalloplasty with mastectomy, along with testosterone administration. MTF gender reassignment surgery includes complete removal of external genitalia with penectomy and orchiectomy, with vaginoplasty, clitoroplasty, labiaplasty, and breast augmentation along with estrogen supplements.
Conclusion
Surgical techniques alter the standard anatomy and make imaging interpretation challenging if radiologists are unfamiliar with expected post-operative appearances. It is important to recognize the complications related to surgical and non-surgical treatment of gender dysphoria to avoid interpretation errors. Furthermore, increasing the prevalence of transgender patients requires increased sensitivity when interpreting imaging studies to reduce the potential for misdiagnoses in reporting due to frequently incomplete available clinical history.
Problem: Sexual and gender minority patients face well-documented health disparities. One strategy to help overcome disparities is preparing medical trainees to competently provide care for sexual and gender minority patients. The Association of American Medical Colleges has identified professional competencies that medical students should develop to meet sexual and gender minority health needs. However, challenges in the medical education environment may hinder the adoption and implementation of curricular interventions to foster these competencies. Intervention: Our medical education community engaged in curriculum evaluation and subsequently developed a sexual and gender minority topical sequence to promote student development of these competencies. This process was guided by explicit principles and curriculum development practices. Context: This work began at the Yale University School of Medicine in 2014, shortly after the Association of American Medical Colleges published sexual and gender minority health competencies and amidst the development and implementation of a new curriculum at the institution. Impact: We identified core principles and practices to guide the development of an integrated sexual and gender minority health sequence. This process resulted in successful creation of an integrated curricular sequence. At this time, 9 new or enhanced curricular components have been adopted through our process—5 in preclinical, 3 in the clinical, and 1 in the elective, curricula—in addition to the 13 preexisting components that have been updated as appropriate. Feedback about the process from students and faculty has been overwhelmingly positive. Evaluation of curricular components and their effectiveness as an integrated sequence is ongoing. Lessons Learned: Core principles consisted of including a wide range of stakeholders to build consensus, establishing complementary student and faculty roles, using the “language of collaboration” rather than the “language of demand,” presenting sexual and gender minority content in an intersectional manner whenever possible, and balancing sexual and gender minority components across the curriculum. Key practices included mapping curriculum to identify gaps; developing curriculum “pitches”; identifying early and potential later “adopters” among faculty; focusing on faculty ownership of curriculum to facilitate institutionalization; and performing ongoing tracking, assessment, and revision of curriculum.
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 appropriately 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 institutional 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.
Background: Sexual and gender minority (SGM) individuals experience high rates of harassment and discrimination when seeking healthcare, which contributes to substantial healthcare disparities. Improving physician training about gender identity, sexual orientation, and the healthcare needs of SGM patients has been identified as a critical strategy for mitigating these disparities. In 2014, the Association of American Medical Colleges (AAMC) published medical education competencies to guide undergraduate medical education on SGM topics.
Objective: Conduct pilot study to investigate medical student comfort and competence about SGM health competencies outlined by the AAMC and evaluate curricular coverage of SGM topics.
Design: Six-hundred and fifty-eight students at New England allopathic medical schools (response rate 21.2%) completed an anonymous, online survey evaluating self-reported comfort and competence regarding SGM health competencies, and coverage of SGM health in the medical curriculum.
Results: 92.7% of students felt somewhat or very comfortable treating sexual minorities; 68.4% felt comfortable treating gender minorities. Most respondents felt not competent or somewhat not competent with medical treatment of gender minority patients (76.7%) and patients with a difference of sex development (81%). At seven schools, more than 50% of students indicated that the curriculum neither adequately covers SGM-specific topics nor adequately prepares students to serve SGM patients.
Conclusions: The prevalence of self-reported comfort is greater than that of self-reported competence serving SGM patients in a convenience sample of New England allopathic medical students. The majority of participants reported insufficient curricular preparation to achieve the competencies necessary to care for SGM patients. This multi-institution pilot study provides preliminary evidence that further curriculum development may be needed to enable medical students to achieve core competencies in SGM health, as defined by AAMC. Further mixed methods research is necessary to substantiate and expand upon the findings of this pilot study. This pilot study also demonstrates the importance of creating specific evaluation tools to assess medical student achievement of competencies established by the AAMC.
Introduction
There is a recognized and articulated need for health professionals to understand the definitions, health disparities, and medical management of transgender patients. This recognition comes organically from students requesting more information, and top-down from governing bodies such as the AAMC or the Liaison Committee on Medical Education. Surveys of North American medical schools indicate that training in transgender medicine (specifically, the process of transition) is infrequent and inadequate. One problem underlying this trend may be the lack of resources to help conceptualize and roll out a transgender medicine curriculum.
Methods
Here, we report the integration of training in transgender medicine into the organ system–based course Endocrine-Reproduction. This transgender curriculum includes coverage of basic science, clinical management, ethics, and clinical skills. The curriculum leverages an already existing, health care disparity–focused curriculum but adds (1) a didactic component for dissemination and discussion of basic science principles applied to transgender patients and (2) a mock initial encounter between a physician and patient with gender dysphoria.
Results
Following the first-time implementation of the transgender curriculum, students were surveyed, with a large majority reporting feeling more prepared to care for transgender patients.
Discussion
We conclude that including a multidisciplinary transgender medicine curriculum in medical school advances the goal of creating safe, effective physicians by providing fundamental knowledge about an underserved population of patients, as well as exampled application of that knowledge.
Despite recent notable advances in societal equality for lesbian, gay, bisexual, and transgender (LGBT) individuals, youth who identify as trans* or gender nonconforming, in particular, continue to experience significant challenges accessing the services they need to grow into healthy adults. This policy perspective first offers background information describing this population, their unique healthcare needs, and obstacles when seeking care, including case study examples. The authors then provide recommendations for medical education, health systems, and insurance payers, as well as recommendations for school systems and broader public policy changes to improve the health and well-being of gender nonconforming youth.
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 literature review illustrates the various ways images are used in teaching and the evidence appertaining to it and advice regarding permissions and use. Four databases were searched, 23 papers were retained out of 135 abstracts found for the study. Images are frequently used to motivate an audience to listen to a lecture or to note key medical findings. Images can promote observation skills when linked with learning outcomes, but the timing and relevance of the images is important - it appears they must be congruent with the dialogue. Student reflection can be encouraged by asking students to actually draw their own impressions of a course as an integral part of course feedback. Careful structured use of images improve attention, cognition, reflection and possibly memory retention.
Lesbian, gay, bisexual, and transgender (LGBT) individuals experience health and health care disparities and have specific health care needs. Medical education organizations have called for LGBT-sensitive training, but how and to what extent schools educate students to deliver comprehensive LGBT patient care is unknown.
To characterize LGBT-related medical curricula and associated curricular development practices and to determine deans' assessments of their institutions' LGBT-related curricular content.
Deans of medical education (or equivalent) at 176 allopathic or osteopathic medical schools in Canada and the United States were surveyed to complete a 13-question, Web-based questionnaire between May 2009 and March 2010.
Reported hours of LGBT-related curricular content.
Of 176 schools, 150 (85.2%) responded, and 132 (75.0%) fully completed the questionnaire. The median reported time dedicated to teaching LGBT-related content in the entire curriculum was 5 hours (interquartile range [IQR], 3-8 hours). Of the 132 respondents, 9 (6.8%; 95% CI, 2.5%-11.1%) reported 0 hours taught during preclinical years and 44 (33.3%; 95% CI, 25.3%-41.4%) reported 0 hours during clinical years. Median US allopathic clinical hours were significantly different from US osteopathic clinical hours (2 hours [IQR, 0-4 hours] vs 0 hours [IQR, 0-2 hours]; P = .008). Although 128 of the schools (97.0%; 95% CI, 94.0%-99.9%) taught students to ask patients if they "have sex with men, women, or both" when obtaining a sexual history, the reported teaching frequency of 16 LGBT-specific topic areas in the required curriculum was lower: at least 8 topics at 83 schools (62.9%; 95% CI, 54.6%-71.1%) and all topics at 11 schools (8.3%; 95% CI, 3.6%-13.0%). The institutions' LGBT content was rated as "fair" at 58 schools (43.9%; 95% CI, 35.5%-52.4%). Suggested successful strategies to increase content included curricular material focusing on LGBT-related health and health disparities at 77 schools (58.3%, 95% CI, 49.9%-66.7%) and faculty willing and able to teach LGBT-related curricular content at 67 schools (50.8%, 95% CI, 42.2%-59.3%).
The median reported time dedicated to LGBT-related topics in 2009-2010 was small across US and Canadian medical schools, but the quantity, content covered, and perceived quality of instruction varied substantially.
This chapter provides an overview of the Standards of Care (SOC) of the World Professional Association for Transgender Health. The chapter describes the underlying principles of the SOC and highlights key issues which the clinician faces in providing the best possible care. The basic competencies for clinicians are described as well as the criteria for hormonal and surgical treatment. This chapter is a useful introduction and summary of essential elements of the SOC. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.
Background:
Lesbian, gay, bisexual, transgender, and intersex (LGBTI) patients face many well-documented disparities in care which among transgender and intersex people can often be traced to providers' lack of knowledge.
Methods:
We administered surveys to examine the self-assessed knowledge and attitudes of all medical students at Boston University regarding different LGBTI subpopulations. Survey questions were based on a Likert scale from 1-5; analysis was conducted with Wilcoxon rank sum test.
Results:
Overall there was a response rate of 24%, with the number of responses varying by class. Three of the four surveyed classes reported lower knowledge about transgender health than LGB health. Every class reported significantly lower knowledge of intersex health in comparison to LGB. Comfort with transgender or with intersex patients was lower than with LGB patients for all surveyed classes. Students across all self-identified groups (LGBTI, ally, not an ally) reported significantly lower average responses for knowledge and comfort regarding transgender or intersex health in comparison to that of LGB. Students in their preclinical years reported lower levels of knowledge in comparison with students in their clinical years. Students who identified as LGBTI reported significantly higher knowledge and comfort with only LGB and transgender health when compared with students who didn't identify as LGBTI. Respondents more frequently requested additional learning opportunities in transgender and intersex health than in LGB health.
Conclusion:
Self-reported knowledge of transgender and intersex health lags behind knowledge of LGB health, though these deficits appear responsive in part to targeted educational intervention.
Body modification, hormones and surgery for the treatment of transsexualism, first found traction in the early 20th century. Once known as the Einstein of Sexuality, Dr. Hirschfeld described cross-dressing worked to elucidate the chemical nature of hormones, experimented with gonadal transplantation, and began rudimentary treatment of transsexual individuals. Penile inversion surgical template became the de facto model for the most prevalent and preferred modern methods of male-to-female genital confirmation surgery (GCS). This chapter's author, Dr. Bowers, has performed more than 1,200 male-to-female (MTF) vaginoplasties. The chapter details and shares this work. She is the only current gynecologist to herself perform genital reassignment surgery (GRS). The cosmetic surgical management of MTF transsexualism is best approached as a one-stage, modified penile inversion technique with scrotal grafting. Retention of neurovascular structures of the natal penis allows the new vulva to attain a highly functional and visually aesthetic state.
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