Three years ago, after sustaining multiple facial injuries during a bad car accident, Emily Ashcroft, went to see an ear, nose, and throat specialist about a broken nose that had healed wrong.
After an awkward interaction with clinic staff bewildered by the male name on her insurance card—she had yet to legally change her name after transitioning to female—Ashcroft says she was seen by the doctor for an endoscopy. "You could just see he was very standoffish, and... didn't want to approach me," she said. The doctor put on a face mask, glasses, and gloves to prepare for the procedure, but just as he was about to begin, he abruptly stopped and walked across the room for another pair of gloves. Ashcroft asked why.
"'It's purely a precaution,'" she said he told her, "'in a situation where I don't understand what the potential repercussions might be for me.'"
"That was upsetting," she said, still incredulous. Afterward, she explained to the doctor how marginalized and upset his actions made her feel. He apologized, but she never saw that doctor again.
Experiences like Ashcroft's are strikingly common among transgender people. In a 2015 survey conducted by the National Center for Transgender Equality (NCTE), 33 percent of transgender people who saw a physician in the past year reported a negative health care interaction related to their gender, which could include harassment, being denied treatment, and encountering unknowledgeable practitioners. Twenty-three percent of those surveyed reported having avoided seeing a doctor due to fear of mistreatment. And according to another NCTE report, issued in 2011 in collaboration with the National Gay and Lesbian Task Force, those bad experiences lead to avoidance of care and, ultimately, poorer health among transgender people.
Advocates for transgender health agree that the solution lies in producing more doctors who are "trans-competent," which translates at a minimum to treating transgender patients with the same compassion and curiosity brought to all patient encounters. And while medical educators have developed formal benchmarks for trans-competence in practice, the reality is that the way medical students are educated is taking time to catch up to those guidelines.
According to a 2011 survey published in the Journal of the American Medical Association, only 40 of 132 surveyed medical school deans reported that their curricula included content relating to gender transition. Hospitals and health care systems began to recognize that "you can't deliver [equitable care to transgender people] if you don't teach on these issues," said Dr. Jesse Ehrenfeld, who directs the Program for LGBTQ Health at Vanderbilt University.
Leaders in medical education noticed the void in resources to guide medical schools in providing that training, said Dr. Laura Castillo-Page, who directs diversity and inclusion initiatives at the American Association of Medical Colleges (AAMC). In response, the AAMC released a publication in 2014 aimed at its constituency of 147 American and Canadian medical schools and 400 teaching hospitals. It was intended to serve as a resource for medical educators seeking to change the way students learn to care for patients who are LGBTQ, gender nonconforming and born with differences of sex development.
An AAMC spokesperson said in December 2016 that in a review of 2015-2016 medical school curricula, only 30 of 144 schools included transgender-related material in their curricula. The number isn't entirely comparable to the figure from the 2011 study, in part due to the inclusion of different schools in the earlier study and its reliance on self-report by medical school deans.
And while the numbers do not seem to indicate a positive trend toward curricular inclusion of educational content related to transgender health, Ehrenfeld said there are other indicators of growing interest in and demand for the material among medical students and medical educators.
At the University of Connecticut's medical school, for example, the inclusion of an entire unit on sexual minorities and health care disparities—which revolves around a case study of a trans man with breast cancer—grew out of a faculty member's realization that the medical community at large was broadly unaware of many LGBTQ health issues.
The AAMC publication took an important first step toward helping medical schools provide transgender-related content, said co-author Dr. Kristen Eckstrand, by defining "the meaning of competence" when it comes to caring for transgender individuals.
Among those competencies are what some doctors say are universal principles of primary care: asking sensitively yet effectively about sexual anatomy, development, behavior, history, and identity; developing rapport with patients; and recognizing the historical and systemic factors underlying health care disparities. They also include an understanding of terminology used to talk about gender identity, and the basics of the medical and surgical options available to transgender people, among other skills.
Dr. Harvey Makadon, a clinical instructor focusing on LGBTQ health education at the Fenway Institute in Boston, said getting comfortable with the medical specifics of transgender care is much less important than simply getting comfortable with talking to transgender patients. "If someone's interested in doing it, there's not so much to learn that it's too complicated," he said. "It's really just an issue of feeling comfortable with the conversation."
Medical schools all over the country—and not necessarily in the most predictable places—have begun including transgender-related content in innovative ways. While schools in large, coastal urban centers such as San Francisco, New York City, and Boston led the way, said Ehrenfeld, schools in places like Texas and Alabama are also innovating. "The curricula all look surprisingly different," he said.
Teaching, said Eckstrand, isn't straightforward when the subject is a population that has historically been mistreated by the medical establishment. "We always have to strike a fine balance between training opportunities and being respectful of people who typically experience difficulty when receiving care," she said. Bedside instruction should be "done in a way that doesn't continue to marginalize transgender people when they interface with the health care system."
Fundamentally, medical education is a long way from sensitizing young physicians to the needs of transgender patients. While many schools are struggling to include transgender-related content at all, some schools that have incorporated content now struggle with how to test students on the material. And integrating trans-competency into the education of resident physicians—trainees at a later stage in their training—is still a distant goal.
Eckstrand admits the bar set by the AAMC is high, but also feels that any inclusion of transgender related material in medical school curricula likely addresses at least some of the AAMC competencies.
Regardless, she wrote in an email, "until we reach a point where we have standardized assessments that measure curricular outcomes, I don't think we can (or should) say that any school sets the gold standard."