Faculty Training on Navigating Gender and Sex in Medical Education.

Introduction: Language that assumes gender and sex are binary and aligned is pervasive in medicine and is often used when teaching on physiology and pathology. Information presented through this lens oversimplifies disease mechanisms and poorly addresses the health of gender and sexually diverse (GSD) individuals. We developed a training session to help faculty reference gender and sex in a manner that would be accurate and inclusive of GSD health. Methods: The 1-hour session for undergraduate and graduate medical educators highlighted cisgender and binary biases in medical teachings and introduced a getting-to-the-root mindset that prioritized teaching the processes underlying differences in disease profiles among gender and sex subpopulations. The training consisted of 30 minutes of didactic teaching and 20 minutes of small-group discussion. Medical education faculty attended and self-reported knowledge and awareness before and after the training. Results were compared using paired t tests. Expenses included fees for consultation and catering. Results: Forty faculty participated (pretraining survey n = 36, posttraining survey n = 21). After the training, there was a significant increase in self-reported awareness of the difference between gender and sex (p = .002), perceived relevance of gender to teachings (p = .04), and readiness to discuss physiological drivers of sex-linked disease (p = .005). Discussion: Participants reported increased understanding and consideration of gender and sex in medical education; feedback emphasized a desire for continued guidance. This easily adaptable session can provide an introduction to a series of medical teachings on gender and sex.

Assessing how frailty and healthcare delays mediate the association between sexual and gender minority status and healthcare utilization in the All of Us Research Program.

OBJECTIVES: To understand how frailty and healthcare delays differentially mediate the association between sexual and gender minority older adults (OSGM) status and healthcare utilization. MATERIALS AND METHODS: Data from the All of Us Research Program participants ≥50 years old were analyzed using marginal structural modelling to assess if frailty or healthcare delays mediated OSGM status and healthcare utilization. OSGM status, healthcare delays, and frailty were assessed using survey data. Electronic health record (EHR) data was used to measure the number of medical visits or mental health (MH) visit days, following 12 months from the calculated All of Us Frailty Index. Analyses adjusted for age, race and ethnicity, income, HIV, marital status ± general MH (only MH analyses). RESULTS: Compared to non-OSGM, OSGM adults have higher rates of medical visits (adjusted rate ratio [aRR]: 1.14; 95% CI: 1.03, 1.24) and MH visits (aRR: 1.85; 95% CI: 1.07, 2.91). Frailty mediated the association between OSGM status medical visits (Controlled direct effect [Rcde] aRR: 1.03, 95% CI [0.87, 1.22]), but not MH visits (Rcde aRR: 0.37 [95% CI: 0.06, 1.47]). Delays mediated the association between OSGM status and MH visit days (Rcde aRR: 2.27, 95% CI [1.15, 3.76]), but not medical visits (Rcde aRR: 1.06 [95% CI: 0.97, 1.17]). DISCUSSION: Frailty represents a need for medical care among OSGM adults, highlighting the importance of addressing it to improve health and healthcare utilization disparities. In contrast, healthcare delays are a barrier to MH care, underscoring the necessity of targeted strategies to ensure timely MH care for OSGM adults.

Disparities in cancer incidence by sexual orientation.

INTRODUCTION: Cancer risk factors are more common among sexual minority populations (e.g., lesbian, bisexual) than their heterosexual peers, yet little is known about cancer incidence across sexual orientation groups. METHODS: The 1989-2017 data from the Nurses' Health Study II, a longitudinal cohort of female nurses across the United States, were analyzed (N = 101,543). Sexual orientation-related cancer disparities were quantified by comparing any cancer incidence among four sexual minority groups based on self-disclosure-(1) heterosexual with past same-sex attractions/partners/identity; (2) mostly heterosexual; (3) bisexual; and (4) lesbian women-to completely heterosexual women using age-adjusted incidence rate ratios (aIRR) calculated by the Mantel-Haenszel method. Additionally, subanalyses at 21 cancer disease sites (e.g., breast, colon/rectum) were conducted. RESULTS: For all-cancer analyses, there were no statistically significant differences in cancer incidence at the 5% type I error cutoff among sexual minority groups when compared to completely heterosexual women; the aIRR was 1.17 (95% CI,0.99-1.38) among lesbian women and 0.80 (0.58-1.10) among bisexual women. For the site-specific analyses, incidences at multiple sites were significantly higher among lesbian women compared to completely heterosexual women: thyroid cancer (aIRR, 1.87 [1.03-3.41]), basal cell carcinoma (aIRR, 1.85 [1.09-3.14]), and non-Hodgkin lymphoma (aIRR, 2.13 [1.10-4.12]). CONCLUSION: Lesbian women may be disproportionately burdened by cancer relative to their heterosexual peers. Sexual minority populations must be explicitly included in cancer prevention efforts. Comprehensive and standardized sexual orientation data must be systematically collected so nuanced sexual orientation-related cancer disparities can be accurately assessed for both common and rare cancers.

Sexual and gender minority content in undergraduate medical education in the United States and Canada: current state and changes since 2011.

PURPOSE: To characterize current lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI +) health-related undergraduate medical education (UME) curricular content and associated changes since a 2011 study and to determine the frequency and extent of institutional instruction in 17 LGBTQI + health-related topics, strategies for increasing LGBTQI + health-related content, and faculty development opportunities. METHOD: Deans of medical education (or equivalent) at 214 allopathic or osteopathic medical schools in Canada and the United States were invited to complete a 36-question, Web-based questionnaire between June 2021 and September 2022. The main outcome measured was reported hours of LGBTQI + health-related curricular content. RESULTS: Of 214 schools, 100 (46.7%) responded, of which 85 (85.0%) fully completed the questionnaire. Compared to 5 median hours dedicated to LGBTQI + health-related in a 2011 study, the 2022 median reported time was 11 h (interquartile range [IQR], 6-16 h, p < 0.0001). Two UME institutions (2.4%; 95% CI, 0.0%-5.8%) reported 0 h during the pre-clerkship phase; 21 institutions (24.7%; CI, 15.5%-33.9%) reported 0 h during the clerkship phase; and 1 institution (1.2%; CI, 0%-3.5%) reported 0 h across the curriculum. Median US allopathic clerkship hours were significantly different from US osteopathic clerkship hours (4 h [IQR, 1-6 h] versus 0 h [IQR, 0-0 h]; p = 0.01). Suggested strategies to increase content included more curricular material focusing on LGBTQI + health and health disparities at 55 schools (64.7%; CI, 54.6%-74.9%), more faculty willing and able to teach LGBTQI + -related content at 49 schools (57.7%; CI, 47.1%-68.2%), and more evidence-based research on LGBTQI + health and health disparities at 24 schools (28.2%; CI, 18.7%-37.8%). CONCLUSION: Compared to a 2011 study, the median reported time dedicated to LGBTQI + health-related topics in 2022 increased across US and Canadian UME institutions, but the breadth, efficacy, or quality of instruction continued to vary substantially. Despite the increased hours, this still falls short of the number of hours based on recommended LGBTQI + health competencies from the Association of American Medical Colleges. While most deans of medical education reported their institutions' coverage of LGBTQI + health as 'fair,' 'good,' or 'very good,' there continues to be a call from UME leadership to increase curricular content. This requires dedicated training for faculty and students.

Gender-Affirming Hormone Therapy and Cervical Cancer Screening Rates in Transgender Men and Nonbinary People: A Cross-Sectional Study from a Boston Community Health Center.

Purpose: Clinical monitoring for patients receiving gender-affirming hormone therapy (GAHT) has the potential to facilitate their receipt of preventive health services. We aimed to determine whether GAHT is associated with increased utilization of cervical cancer screening among transgender men (TM) and nonbinary persons assigned female at birth (NB-AFAB). Methods: We conducted a cross-sectional observational study of a single community health center in Boston. Persons of all gender identities eligible for cervical cancer screening during 2008-2019 were assessed. The outcome of interest was receipt of cervical cancer screening based on U.S. Preventive Services Task Force recommendations. We compared the proportion of persons who received cervical cancer screening by prescription of GAHT. Results: We identified 13,267 eligible persons. This cohort included 10,547 (79.5%) cisgender women, 1547 (11.7%) TM, and 1173 (8.8%) NB-AFAB persons. Among all persons eligible for cervical cancer screening, TM and NB-AFAB persons were less likely to receive screening than cisgender women (56.2% and 56.1% vs. 60.5% respectively; odds ratio [OR] = 0.84; 95% confidence interval [CI] = 0.75-0.93; OR = 0.84; 95% CI = 0.74-0.94, respectively). Among TM, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (57.9% vs. 48.2%, OR = 1.47; 95% CI = 1.14-1.92). Among NB-AFAB adults, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (61.9% vs. 51.5%, OR = 1.53; 95% CI = 1.21-1.93). Conclusions: The benefits of engagement in care to access GAHT may extend beyond the hormonal intervention to preventive health services.

Development of a mentor training curriculum to support LGBTQIA+ health professionals.

While mentors can learn general strategies for effective mentoring, existing mentorship curricula do not comprehensively address how to support marginalized mentees, including LGBTQIA+ mentees. After identifying best mentoring practices and existing evidence-based curricula, we adapted these to create the Harvard Sexual and Gender Minority Health Mentoring Program. The primary goal was to address the needs of underrepresented health professionals in two overlapping groups: (1) LGBTQIA+ mentees and (2) any mentees focused on LGBTQIA+ health. An inaugural cohort (N = 12) of early-, mid-, and late-career faculty piloted this curriculum in spring 2022 during six 90-minute sessions. We evaluated the program using confidential surveys after each session and at the program's conclusion as well as with focus groups. Faculty were highly satisfied with the program and reported skill gains and behavioral changes. Our findings suggest this novel curriculum can effectively prepare mentors to support mentees with identities different from their own; the whole curriculum, or parts, could be integrated into other trainings to enhance inclusive mentoring. Our adaptations are also a model for how mentorship curricula can be tailored to a particular focus (i.e., LGBTQIA+ health). Ideally, such mentor trainings can help create more inclusive environments throughout academic medicine.

Sexual and gender minority health-related content in geriatric fellowships.

INTRODUCTION: Despite a growing number of older lesbian, gay, bisexual transgender, and queer (LGBTQ) adults in the United States, education on care for this vulnerable population has historically been inadequate across all levels of training. This research assessed the extent of LGBTQ education in geriatric medicine fellowship curricula across the United States. METHODS: We designed a survey to anonymously collect information from geriatric medicine fellowship programs on LGBTQ curricular content. Eligible participants included all 160 fellowship directors on record with the American Geriatrics Society. The survey addressed demographics of the fellowship program, current state of inclusion of LGBTQ content in didactic curricula and in clinical settings, and other available training opportunities. RESULTS: Out of those contacted, 80 (50%) completed the survey. Of the programs surveyed, 60 (75%) were housed in internal medicine, 19 (24%) were in family medicine, and one was in their own department. Forty-seven fellowships (59%) reported some formal didactic session (e.g., lecture or case based), with the majority of these programs (72%) featuring 1-2 h of formal instruction. Forty-five programs (56%) reported offering no formal clinical experiences. There was less than 50% coverage for all surveyed topics in the required curriculum (range 46% for discrimination to 9% for gender affirming care). Time and lack of expertise were cited as the main barriers to content inclusion. CONCLUSIONS: Curricular content regarding care for LGBTQ older adults is inadequate in geriatric medicine fellowships. Faculty development of current educators and providing standardized guidelines and curricula are steps toward addressing this deficit.

The Society of General Internal Medicine's Recommendations to Improve LGBTQ + Health.

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ +) individuals experience bias in healthcare with 1 in 6 LGBTQ + adults avoiding healthcare due to anticipated discrimination and overall report poorer health status compared to heterosexual and cisgendered peers. The Society of General Internal Medicine (SGIM) is a leading organization representing academic physicians and recognizes that significant physical and mental health inequities exist among LGBTQ + communities. As such, SGIM sees its role in improving LGBTQ + patient health through structural change, starting at the national policy level all the way to encouraging change in individual provider bias and personal actions. SGIM endorses a series of recommendations for policy priorities, research and data collection standards, and institutional policy changes as well as community engagement and individual practices to reduce bias and improve the well-being and health of LGBTQ + patients.

Gender Diversity, Disability, and Well-Being: Impact of Delayed and Foregone Care Because of COVID-19.

Purpose: This study explored the impact of delayed and foregone care due to COVID-19 on well-being among disabled and gender diverse adults. Methods: Using data from the 2021 National Survey on Health and Disability and logistic regression modeling we assessed the impact of delayed or foregone care due to COVID-19 on well-being among disabled people (n = 1638), with comparisons between cisgender (n = 1538) and gender diverse (n = 100) people with disabilities. We report odds ratios (OR) and confidence intervals (CI). Results: Disabled people reported high rates of delayed (79.36%) and foregone (67.83%) care and subsequent negative effects on well-being (72.07%). Gender diverse disabled people were over four times more likely to have delayed any care (OR 4.45, 95% CI 1.86-10.77) and three times more likely to have foregone any care (OR 3.14, 95% CI 1.71-5.79) due to COVID-19 compared to cisgender disabled people. They were three times more likely to report any negative impact on their health and well-being because of delayed and foregone care (OR 2.78, 95% CI 1.43-5.39). Conclusion: The COVID-19 pandemic affected the health care utilization of disabled people, resulting in high rates of delayed care, foregone care, and negative impacts on well-being. These effects were intensified at the intersection of disability and marginalized gender identity, with gender diverse disabled people having higher odds of delayed and foregone care and negative effects on well-being, including physical health, mental health, pain levels, and overall level of functioning.

Effects of Race and Gender Classifications on Atherosclerotic Cardiovascular Disease Risk Estimates for Clinical Decision-Making in a Cohort of Black Transgender Women.

Introduction: Despite their dynamic, socially constructed, and imprecise nature, both race and gender are included in common risk calculators used for clinical decision-making about statin therapy for atherosclerotic cardiovascular disease (ASCVD) prevention. Methods and Materials: We assessed the effect of manipulating six different race-gender categories on ASCVD risk scores among 90 Black transgender women. Results: Risk scores varied by operationalization of race and gender and affected the proportion for whom statins were recommended. Discussion: Race and gender are social constructs underpinning racialized and gendered health inequities. Their rote use in ASCVD risk calculators may reinforce and perpetuate existing inequities.

Comparison of faculty and student perceptions of sexual and gender minority content in a preclerkship medical curriculum.

BACKGROUND: Sexual and gender minority (SGM) persons experience stark health disparities. Efforts to mitigate disparities through medical education have met some success. However, evaluations have largely focused on subjective perspectives rather than objective measures. This study aimed to quantify Boston University School of Medicine's sexual and gender minority (SGM) education through surveys of course directors (CDs) and medical students regarding where SGM topics were taught in the preclerkship medical curriculum. Responses were compared to identify concordance between faculty intention and student perceptions regarding SGM education. METHODS: A cross-sectional survey was distributed to preclerkship CDs and current medical students in Spring 2019 and 2021, respectively, regarding where in the mandatory preclerkship curriculum CDs deliberately taught and where first- and second-year students recalled having learned 10 SGM topic domains. RESULTS: 64.3% of CDs (n = 18), 47.0% of the first-year class (n = 71), and 67.3% of the second-year class (n = 101) responded to the surveys. Results indicate that, as anticipated, deliberate SGM teaching correlates with greater student recall as students recalled topics that were reported by CDs as intentionally taught at a significantly higher rate compared to those not intentionally taught (32.0% vs. 15.3%; p < 0.01). Students most commonly recalled learning SGM-related language and terminology, which is likely partly but not entirely attributed to curricular modifications and faculty development made between distribution of the faculty and student surveys, indicating the importance of all faculty being trained in appropriate SGM terminology and concepts. Discordance between faculty intention and student recall of when topics were taught reveals opportunities to enhance the intentionality and impact of SGM teaching. CONCLUSIONS: Students perceive and recall SGM content that is not listed as learning objectives, and all faculty who utilize this material in their teachings should receive foundational training and be thoughtful about how information is framed. Faculty who intentionally teach SGM topics should be explicit and direct about the conclusions they intend students to draw from their curricular content.