Doctors call for queer curriculum in medical schools

When a British Columbian recently sought support for depression, a doctor misunderstood and told them their sexuality seemed to be the larger issue.

"I'm asexual, but this one  doctor I had just kept thinking I had a low libido, and when I wanted something to help my depression, he wouldn't prescribe me anything because a common side effect was low libido,'' wrote a participant in a recent report on queer and transgender healthcare in B.C.

"It just seems like he got to say that was a worse issue—even though my sexuality isn't an issue—than my depression.'' They left without a prescription or future care plan.

Access to competent and inclusive healthcare makes a huge difference in the lives of queer and transgender people, not to mention all marginalized communities in Canada.

But as the 2020 report found, respectful care is sorely lacking in British Columbia, particularly in rural areas and for those who are Indigenous, Black and people of colour.

Now a group of medical residents and researchers has launched a campaign to make queer and trans-specific training mandatory in medical schools and residencies across the country.

It's just one part of sweeping transformative change they say medicine needs to undergo in order to help end health inequities created by homophobia and transphobia.

"If we don't formalize these competencies specific to queer and trans health, they're going to continue to be neglected at a systemic level,'' said Miranda Schreiber, a researcher at the University of Toronto's faculty of medicine.

Schreiber recently co-wrote an article published in the Canadian Medical Association Journal calling for Canadian medical schools—supported by colleges and the Association of Faculties of Medicine—to implement a national curriculum standard to include queer and trans health training in the licensing and assessment process.

Currently, "bodies such as the Association of Faculties of Medicine of Canada, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada have no explicit assessment objectives mandating that graduating residents and medical trainees must show knowledge or management skills specifically related to healthcare for 2SLGBTQIA+ patients,'' the article states.

A petition addressed to the association and national regulatory colleges that Schreiber helped launch currently has more than 3,700 signatories expressing their support for the change.

Integrating queer and trans health skills into assessments is key to signal how important so-called "soft skills'' are in healthcare, because they impact the care and health outcomes of a patient, says Dr. Elise Jackson.

"There's this disparity between what is seen as sort of hard medical science knowledge and the more kind of social and human-oriented aspects of medicine that are often not taken quite as seriously,'' said Dr. Jackson, a third-year internal medicine resident at the University of British Columbia who founded the Social Justice in Medical Education club during medical school at the University of Toronto.

The club challenges instructors to examine whether their course materials are sufficiently diverse, asking them to consider the nuances used to describe various identities, if they inadvertently reinforce prejudices around marginalized people, whether they place blame on patients for their health status, and other systemic biases that perpetuate health inequities.

A 2019 report to the House of Commons found that 2SLGBTQIA+ people are more likely to live with chronic health conditions but less likely to have a family doctor or be able to afford basic and gender-affirming healthcare.

Being judged, misgendered or poorly treated by health-care providers is a barrier that makes these issues worse, discouraging people from seeking care when they need it or preventative care to stay well, the report adds.

Simple shifts, such as training focused on using correct pronouns and gender-inclusive language, gives physicians the skills and awareness to build trust with patients, Dr. Jackson said.

"We know how damaging that can be coming from a health-care provider, and someone who should be treating you with respect and empathy and compassion,'' said Dr. Jackson, who as the chief internal medicine resident at Vancouver General Hospital leads resident education.

But it's not just a doctor's bedside manner and attentiveness that matters. Physicians—and all health-care providers for that matter—should be familiar with queer and trans-specific health needs so they can provide the best medical advice possible in a judgment-free way, Dr. Jackson said.

In a 2016 survey of medical students, just 10% felt they were knowledgeable enough to provide queer and trans-specific healthcare at all. Many queer and trans patients report educating doctors about their specific health needs when seeking gender-affirming care such as hormone therapies or surgery.

Cervical cancer screenings, for example, are important for trans men and some non-binary people, but many doctors haven't been trained on how to perform a risk assessment for someone who is not a cis woman.

"That's actually one of the driving causes of the increased risk for cervical cancer in trans communities,'' said Schreiber, adding that education therefore needs to not just be additive to the status quo, but used as a way to reinterpret common practices and assumptions in medicine that exclude the needs and realities of queer and trans people.

Developing a standard for national medical curricula is complicated by a lack of consistent and reliable data on the specific health concerns of queer and trans communities. However, those working for change say there is a lot that can be done as data collection improves.

In her internal medicine residency, Dr. Jackson has worked with administrators and fellow students to create a practical examination scenario in which the patient is trans. Residents were graded based on their ability to take a medical history, respect the person's gender identity and provide trans-specific care recommendations.

Embedding trans and queer-specific care skills in assessments is an important signal that these skills aren't optional for physicians caring for a diverse population.

"That's such an interesting way to really incorporate and make queer and trans health a benchmark for medical knowledge,'' said Dr. Jackson.

Dr. Jackson also hopes to see anti-oppression training embedded in the pre-residency "bootcamp'' residents take, as well as the lecture series they attend throughout their residencies.

Seeing changes in her residency has been rewarding, Dr. Jackson says, but the onus shouldn't fall on passionate residents and professors to make changes. A national standard would make comprehensive education for queer and trans healthcare the standard, not the exception.

Both Schreiber and Dr. Jackson agree that better training isn't the only solution to medical discrimination, as other social determinants of health—such as housing and income inequality, racism and colonialism—persist.

"Training and education is part of it, but I think the provision of concrete services, like funding more gender-affirming surgeries and shortening the waitlist, is also really important,'' said Dr. Jackson.

Schreiber believes doctors can be a formidable force in making medicine a safer place for marginalized communities—one patient at a time.

Poverty, colonialism, racism, homophobia and transphobia "are ultimately creating health gaps, like the one we're trying to address, so this will be very much a partial solution,'' said Schreiber of improving medical training. "But it's still part of a series of actions we can take right now.''