In October of 2015, the Center for Medicare and Medicaid Services—the agency responsible for covering a third of the U.S. population and dictating U.S. health care practices—issued a mandate requiring that all electronic health records include specific fields about gender identity and sexual orientation. This unprecedented move means that virtually all future medical records must address the spectrum of sexual and gender issues. With this decision, the government has guaranteed that physicians will have to ask all their patients about their gender identity and sexual orientation during medical visits.
The mandate comes as a response to the frequent omission of these issues and the resultant lower-quality medical care received by LGBT patients—a 2010 National Transgender Discrimination Survey of 7,000 transgender and gender non-conforming people revealed that only 28 percent of respondents were out to their medical providers, and 50 percent said they had to teach their providers about transgender care. A Lambda Legal survey performed the same year uncovered that 56 percent of lesbian, gay, and bisexual respondents and 70 percent of transgender and gender-nonconforming respondents had experienced barriers to health care, including being denied care and experiencing physical or linguistic abuse.
But how have medical schools been doing in educating students on LGBT-related topics? A 2011 study published in JAMA suggests that the answer is not very well. Surveying 176 schools in the United States and Canada, Stanford researchers attempted to determine the amount of LGBT-related education that medical students received throughout their four years in school. According to their results, an average of only five hours was dedicated to LGBT-related content. The majority of the LGBT-specific instruction centered on sexual orientation—“men, women, or both?”—while less than half of medical schools broached more nuanced topics like transitioning, body image, sex reassignment surgery, chronic disease risk, substance abuse, unhealthy relationships, and coming out. At the same time, there appeared to be a reluctance on the part of school administrators to make major curricular change since, as the JAMA study further revealed, 68.1 percent of medical school deans reported that they believed their LGBT education to be either “fair,” “good,” or “very good.” So if medical schools were waiting for a reason to revamp their LGBT education, the new electronic-health-record rule appears to have provided a good one.
Fortunately, a blueprint for revamping medical education was recently offered by the Association of American Medical Colleges—the body overseeing student applications to medical schools and residency programs. In 2014, the AAMC’s Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development released a 314-page comprehensive guideline titled “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” the goal of the which is to “provide education about the health needs of individuals who are LGBT, gender nonconforming, and/or born with DSD [disorders of sexual development].” The 30 competencies identified in the AAMC document seek to address a health care disparity that exists for these patients. Falling under eight domains, including patient care, knowledge and practice, interpersonal skills, professionalism, and personal and professional development, the competencies strive to improve medical education around the four axes of human experience: sexual orientation, gender identity, gender expression, and biological sex development.
Together, these changes signal a recognition by medical school and health care governing bodies of the need to revamp not only medical school and residency training but the health care system as a whole. It is important to note that several schools have already implemented progressive and integrated LGBT medical education programs into their curricula (notable programs include Vanderbilt, Vermont, UCSF, and the pilot eQuality program at the Louisville medical school), but many schools still lag behind. As more institutions continue to address their educational gaps, curricular changes will have to be both widespread and innovative.
At the Georgetown University School of Medicine, where I work, large sections of the Human Sexuality module taught to second-year medical students center on LGBT issues. The instruction is multimodal, consisting of panel discussions, lectures and small groups. A big effort is directed toward pushing against conventional ideas and boundaries and at teaching medical students to pose meaningful and open-ended questions to their patients: What does sex mean to you? What role does sexuality play in your everyday life? At the end of the module, students obtain a dedicated sexual history using a mock patient interaction and are graded on their proficiency in addressing the issues of human sexuality.
The innovative aspect of Georgetown’s approach to starting the conversation about LGBT-related issues begins before students ever set foot in the classroom. Accepted students are assigned one book to read before they enter school in August: Jeffrey Eugenides’ Middlesex. The Pulitzer Prize-winning novel tells the story of Cal Stephanides, an intersex Greek man who is born with a 5-alpha-reductase deficiency and raised as a girl named Callie. Upon starting school, the new medical students write a reflection on the book and attend a panel discussion that includes a primary care physician, an ethicist, a psychiatrist, and an endocrinologist, exploring the complexities of gender and sexuality both within Middlesex and beyond it. Linking an intricate and emotionally stirring narrative to expert discussions humanizes the subject in a way that scientific textbooks cannot. Middlesex, after all, is about Cal, not about a gene mutation. In this way, the school helps frame these and future discussions as something more than scientific questions—these are profoundly human issues. Though other texts might be able to achieve a similar effect, Georgetown has only experimented with using Middlesex so far.
Middlesex will not be the answer for every school; nor will the panels. Each institution will have to find its own method for revamping the curriculum. But one thing is certain: LGBT education in medical schools needs to be vast, and it needs to begin early. Educating students on LGBT-related issues is no longer just ethical; it is becoming mandatory.