As an increasing proportion of Americans identify as LGBTQ, leaders in sexual and gender minority health care say that the nation’s medical schools are largely failing to adequately prepare the next generation of doctors to properly care for this population.
The need is critical, according to experts in medical education and LGBTQ care. Lesbian, gay, bisexual, transgender and queer people, as stigmatized minorities, often have difficulty accessing health care that properly addresses their health concerns, that is sensitive to their sexual and gender identities and that is not flat-out discriminatory, researchers have found.
“It’s terrible that there’s a whole population of people who aren’t getting the health care they need,” said Ann Zumwalt, an associate professor of anatomy and neurobiology at the Boston University Chobanian & Avedisian School of Medicine and a leader in the effort to improve medical school curricula pertaining to LGBTQ care.
In 2014, the Association of American Medical Colleges, or AAMC, released a call for the 158 U.S. and Canadian medical schools to provide comprehensive training in caring for LGBTQ people and those born with sex-development differences.
Since then, the need for such instruction has only ballooned, given the dramatic increase in LGBTQ identification among young people in particular.
“The current political and social climates are unfortunately leading to many, many health care-professional students and residents feeling uncertain and frightened to engage in LGBTQ+ education and training.”
DR. DUSTIN NOWASKIE, OUTCARE HEALTH
A constellation of medical schools has heeded the AAMC’s call — progress that inspires hope among queer-health advocates. But the schools’ adoption of comprehensive LGBTQ-focused curricula are the exceptions to the rule. The organization’s call, which was buttressed by a 300-page roadmap for reform but lacked the teeth of a mandate, has mostly gone unheeded nearly a decade later.
Progress at medical schools has been stymied by a myriad of factors, including the lack of LGBTQ-related content in medical licensing exams; inadequate or nonexistent knowledge and clinical experience among educators; administrators and the medical old guard’s resistance to change and concerns about competing educational priorities; and outside political pressures as conservatives seize upon transition-related care for minors and diversity policies as wedge issues and as they scrutinize higher education.
Dr. Alex S. Keuroghlian, director of education and training at the LGBTQ-focused Fenway Institute in Boston, and six other medical educators who asked to remain anonymous out of fear of the very reprisals they described told NBC News that recent state-level efforts to restrict diversity programs in education and transition-related health care for transgender minors have instilled fear in some medical schools that their LGBTQ-related medical training could draw increased scrutiny and punitive attacks from legislators.
Keuroghlian, who is also an associate professor of psychiatry at Harvard Medical School, said that the recent state gender-care bans would likely have a chilling effect “on our ability to teach in an evidence-based way that is grounded in human rights and autonomy.”
Where are the needs?
Researchers who have assessed the capacity of the nation’s health care workforce to serve the specific needs of LGBTQ Americans have found them woefully unprepared, especially to care for transgender people. And LGBTQ people remain in dire need of improved physical and mental health care, according to a trove of studies.
Despite the population skewing younger, 23% of LGBTQ people report being in poor health, compared with 14% of the non-LGBTQ population, according to the health-care analysis nonprofit KFF. And research finds that as many as 1 in 5 LGBTQ people have experienced discrimination during health care encounters, including refusals to prescribe medication and even verbal attacks.
Resulting alienation from the health care system, researchers say, is a key driver of the various health disparities that plague LGBTQ Americans. Such apparent consequences include elevated rates of heart disease, cancer, depression and anxiety, substance use disorders and risk of suicide. These disparate outcomes, according to researchers, are likely also fueled by the damage that being a member of a stigmatized minority can apparently inflict upon the mind and body. These are pervasive problems that the health care establishment would ideally mitigate, not exacerbate.
And yet a 2011 survey of 176 U.S. and Canadian medical schools found that their students received a median of just five hours of LGBT-related training. One in 3 schools devoted no such time during clinical rotations.
Dr. Dustin Nowaskie is the founder and president of OutCare Health, a nonprofit LGBTQ health-equity organization that is at the forefront of a growing movement to improve medical training on this front and has developed queer-medicine training programs for both medical students and physicians. Nowaskie, who uses gender neutral pronouns, argued in a 2020 paper that medical schools should, in fact, provide at least 35 hours of such training. This instruction, according to Nowaskie, should start with basic terminology and cultural sensitivity and expand to issues such as health conditions that occur at higher rates among LGBTQ people, including sexually transmitted infections and skin cancer.
“These skills should absolutely be required,” Nowaskie said, because of the expanding LGBTQ population and the inevitability that doctors will frequently treat such patients. Nowaskie said they consistently hear from medical students nationwide that LGBTQ-specific instruction is “often minimal,” and that it is “very outdated,” relying on language, terminology and an overall understanding of queer people that has otherwise been retired thanks to recent social progress.
A recent Gallup poll found that over the past decade, the proportion of Americans openly identifying as LGBTQ has doubled, to 7.2%, and that 1 in 5 young adults say they identify as something other than a cisgender heterosexual. The Williams Institute at UCLA Law recently estimated that 0.5% of older adults identify as transgender, compared with 1.4% of adolescents and 1.3% of young adults.
A team directed by Dr. Carl Streed, research lead for the Center for Transgender Medicine and Surgery at Boston Medical Center, is preparing to publish an update of the 2011 medical school survey. Streed was keen to highlight medical schools that have adopted comprehensive LGBTQ-related curricula — including, among many others, the University of Kentucky at Louisville, Stanford University and Boston University, where Streed is an assistant professor. But Streed tempered expectations that his team would identify much of an uptick in overall training.
“Who ends up being remotely comfortable and competent” in caring for sexual and gender minorities, Streed said, “is a matter of wherethey trained rather than whether they’ve been trained.”
Any progress over the past decade has transpired against a split-screen backdrop of sweeping advances for LGBTQ civil rights and, in response, a fierce backlash against transgender rights, in particular. At least 20 states have now passed various restrictions on transition-related care for minors — a legislative effort that even many physicians who express misgivings about the science backing such treatment say they oppose.
“The current political and social climates are unfortunately leading to many, many health care-professional students and residents feeling uncertain and frightened to engage in LGBTQ+ education and training,” Nowaskie said.
“At the same time,” Nowaskie said, “these climates are perpetuating health care stigma among biased, discriminatory providers.”
How medicine can fail LGBTQ people
Delia M. Sosa, a first-year medical student in Ohio, wants to focus on LGBTQ care. Sosa, who uses gender-neutral pronouns, said they are motivated, in part, by their own alienating encounter with the medical old guard.
After growing up in what they described as a conformist Christian community in New England, Sosa came into their trans and nonbinary identity in their early 20s. At 21, they sought to establish a relationship with a primary care physician in their hometown in hopes of eventually having a double mastectomy, or what’s known in trans medical care as top surgery. But after Sosa disclosed to the doctor their queer identity and the fact that they were dating a nonbinary person, they recalled, “she looked at me with a look of confusion” that was also “mixed with frustration.”
“Medicine is playing catch-up in a lot of ways. … I get some really seasoned, experienced physicians who come up to me and say, ‘I never had a chance to learn about this, yet I know this is something I need to learn.’”
DR. SARAH PICKLE
Sosa said they spent the bulk of the appointment providing the doctor a trans-identity 101 tutorial, including breaking down the difference between gender and sex, what it means to be nonbinary, what gender neutral pronouns are and how sexual orientation can be fluid with respect to the gender of partners. They found the experience so off-putting, they let three years pass before seeking surgery again, which they ultimately had last year.
Dr. Sarah Pickle, a family physician and medical educator in Ohio, is a leading proponent of medical schools cultivating a deft hand in up-and-coming physicians in how to care for LGBTQ people. Pickle insists that such training, which focuses, for example, on speaking with sensitivity and inclusivity regarding queer people’s differences, can be crucial in keeping LGBTQ people engaged in care.
“Medicine is playing catch-up in a lot of ways,” Pickle said. “I get some really seasoned, experienced physicians who come up to me and say, ‘I never had a chance to learn about this, yet I know this is something I need to learn.’”
Sosa discovered their own evidence of the potential perils of physicians’ lack of knowledge about treating LGBTQ patients when researching trans people’s experiences with cancer care. Some oncologists, Sosa found, were confounded over how to manage such treatment in a patient taking cross-sex hormones.
“I can’t tell you how many stories I heard of trans folks where they had delayed care because an oncologist didn’t know what to do with them,” Sosa said.
One expert in LGBTQ medicine, who preferred to remain anonymous because of attacks from the far right, described an often cavalier attitude among specialists toward trans patients’ hormone therapy. A cardiologist, they said, might advise a patient to simply go off hormones due to cardiovascular risk, rather than thoroughly reviewing the risks versus benefits of a therapy that is fundamental to many trans people’s sense of self and well-being.
This health care provider and medical educator expressed frustration that such doctors often remain ignorant to studies that provide insight into managing hormonal therapy in the context of certain health problems.
Who is leading the change?
Keuroghlian stands at the vanguard of the movement to train doctors in caring for trans and gay patients.
At Harvard, he and a team of colleagues led a three-year effort to design and implement a new curriculum that provides comprehensive training in such care.
The curriculum, which other schools are free to adopt, permits all professors, regardless of their own identity or experience, to weave LGBTQ themes and practices into their own instruction. So, for example, a course on endocrinology would include instruction on cross-sex hormonal treatment and an embryology course would teach about intersex variations.
Bringing a broad swath of medical educators up to speed is crucial, Keuroghlian said. A major roadblock to progress has been the fact that the professors, who are meant to pass on their own acquired knowledge, have typically never received their own training in sexual and gender minority care. So, in addition to the four-hour training he helped craft for Harvard faculty about how to teach this subject, Keuroghlian is among the educational pioneers, a group that includes Nowaskie, who are designing medical education seminars to train other health care providers nationwide.
Dr. Christopher Terndrup, an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tennessee, noted that most demand for LGBTQ health education “is actually pushed by the medical students themselves.”
But such eagerness from the new generation can hit old bureaucratic walls, according to Dr. Nelson Sanchez, an associate professor of clinical medicine at Weill Cornell Medicine and the chair of the annual LGBT Health Workforce Conference. Sanchez said administrators often resist calls for such curriculum by insisting that a zero-sum game governs all medical-school education hours.
Dr. Lily Rolfe, who recently graduated from Rush Medical College in Chicago and is matriculating to a residency in family medicine, with a focus on caring for LGBTQ patients, at Swedish Hospital in Seattle, conducted an informal survey of students at Chicago area medical schools about the quality of their education in caring for LGBTQ people.
“It’s always, ‘The gay guy has HIV,’” Rolfe quipped regarding the typical way the respondents characterized their limited education on this front.
“HIV is important,” Rolfe said. “We should learn about it. But that shouldn’t be the entirety of LGBT health.”
Otherwise, the Chicago students said that social determinants of health pertaining to sexual and gender minorities were commonly addressed. But the survey respondents, Rolfe said, “noticed a lack of discussion about trans people, including gender dysphoria; gender euphoria; medical, social, legal and surgical transitioning; and a lack of the discussion of the over pathologization of trans people.”
Harvard’s LGBTQ curriculum, meanwhile, goes beyond just infectious disease, including basic concepts and terminology about gender and sexuality; stigma’s impacts on health inequities; major health concerns that are more common in LGBTQ people, such as anal cancer in gay men or breast cancer in lesbians; effective doctor-patient communication methods; navigating power imbalances and implicit bias; addressing microaggressions; and how to generate learning opportunities if an LGBTQ patient responds negatively to a physician’s words or actions.
Other med schools that have also established substantial training efforts on such subjects include Louisiana State University, the University of Mississippi at Jackson, the University of Wisconsin at Madison, Vanderbilt University, the University of Pennsylvania and Cedars-Sinai in Los Angeles.
The current hostile political environment notwithstanding, Keuroghlian said he remains optimistic for how well prepared the next generation of doctors will be.
“People in medical school are increasingly passionate about doing this work, because there’s more understanding for the need for skilled, culturally responsive care,” Keuroghlian said of sexual and gender minority care.
“There’s also a sense of social justice and health equity that drives young people to do this work,” he said. “They see this as one of the major health rights issues of their generation, and that’s very engaging for them.”
But, he acknowledged, “we have a long way to go.”