HMS Completes First Phase of Sexual and Gender Minority Health Equity Initiative

Laying the foundation for this achievement required combing through the School’s MD curriculum to find areas that could be enhanced with material on SGM health and identifying assumptions or errors about sex, gender, or sexuality that needed correcting.

Once the initiative’s student–faculty committee completed that task, six SGM health curriculum faculty fellows went to work revising the material students learn before, during, and after their clinical rotations.

Among the enhancements was the hiring of local LGBTQ actors to diversify the standardized patients with whom students interact as they develop their clinical skills. Having the actors reflect real, lived experiences has increased students’ exposure to, and ease with, SGM patients as the students learn how to take sexual histories in a more sensitive, inclusive way.

Updating material throughout the entire curriculum, rather than confining the science and clinical practice of SGM health to an elective, has ensured that all HMS students receive the same rigorous training, not only those with a preexisting interest in the area, said the initiative’s principal investigator, John Dalrymple, senior associate dean for medical education at HMS.

But the initiative expanded elective opportunities, too. Adding to an existing clerkship for third- and fourth-year students called Care for Patients with Diverse Sexual Orientations, Gender Identities, and Sex Development, Keuroghlian and colleagues created a new course, Sex- and Gender-Informed Medicine: Research, Clinical Practice, and Population Health.

One of 13 advanced integrated science courses at HMS — from which students must choose at least two during their third and fourth years — it takes a pioneering approach in covering how a range of human sex-, gender-, and sexual orientation-related factors affect health, health care, and health policy and demonstrating how to conduct and critique biomedical research related to sex and gender.

When Keuroghlian and colleagues described the clerkship in LGBT Health in November 2022, they said they hoped the School’s offerings would serve as templates for other medical educators.

The initiative also has increased support and encouragement for students who choose to focus their scholarly research projects on SGM health. The “incredible number” of students pursuing scholarship in the field as a result of the initiative is “very exciting,” said Potter.

HMS students have published their findings on SGM health care, research, education, and policy in The Lancet, NEJM, JAMA Pediatrics, JAMA Surgery, and other top-tier journals, often reflecting the specialties that they plan to pursue in their careers, said Keuroghlian.

“We get to unleash the creativity of our students and strengthen their sense of self-efficacy,” he said. “They can already shape public and academic discourse and be in dialogue with the world. It only enhances their motivation to pursue careers that meaningfully incorporate SGM health.”

Although the original scope of the initiative trailed off at graduation, a grant from the American Medical Association Foundation in August 2022 is allowing initiative leaders to extend their work to include medical residents and fellows.

“There’s huge interest,” said Potter. “Our trainees didn’t receive education in SGM health when they were students.”

Potter and colleagues at HMS and Fenway Health are adapting their reworked MD curriculum to create a one-year fellowship with defined competencies and milestones that will deepen residents’ and fellows’ expertise in SGM health care.

That expertise should not only benefit patients but also get passed along to HMS students during their clinical rotations, Potter said.

“Students have this rich preclinical year and go off into their principal clinical experiences, and sometimes they’re in a climate where there’s potential for some of their SGM-related learnings to be undone, because the people who train them aren’t as skilled in these areas,” she said. “This grant will help us change that.”

Initiative leaders found early on that many HMS faculty did not feel confident in their knowledge of SGM health and research but were keen to learn.

To address those uncertainties, team members held continuing education seminars and symposia. They created a fellowship program to help early-career faculty engage in health equity initiatives, launch pilot programs, publish scholarship, and contribute in other meaningful ways.

Most notably, they crafted a multifaceted faculty development curriculum that incorporates evidence-based research and best practices as well as video testimonials from HMS students, faculty, and community members.

The mix allows faculty to “learn in a traditional academic way but also through personal narrative, which is a really important complement to the epidemiology,” said Keuroghlian.

The video narratives “bring the content to life and make it feel more real,” said Sabra Katz-Wise, HMS associate professor of pediatrics at Boston Children’s Hospital, an initiative curriculum fellow who worked on the testimonials.

Each segment “provides a concrete sense for the learner that this is an actual patient you might imagine yourself or your students seeing in the clinic, and this is their personal experience in their own words,” said Katz-Wise.

The modules are posted publicly. Initiative leaders are looking forward to determining how effectively they educate faculty via a pilot study.

“Approaching this initiative from different perspectives was the only way to work toward a holistic goal of health equity,” said Katz-Wise.

“I was amazed by how many different stakeholder groups were crucial for meaningfully engaging in this work,” echoed Keuroghlian. “Synthesizing as many points of view as possible resulted in an initiative that’s very responsive to the priorities, perspectives, and expertise of the LGBTQIA+ people we serve.”

Alongside input from HMS students, faculty, and staff, the team assembled a professional advisory committee of national leaders in LGBTQ clinical care, education, research, and policy. Most committee members were LGBTQ themselves and many were from other groups underrepresented in medicine.

Initiative leaders also convened LGBTQ youth and adult participants from local communities. Through advisory groups, panel events, and recorded interviews that were incorporated into student and faculty teachings, participants provided invaluable perspectives as patients in the health care system, said Katz-Wise.

Participation not only strengthened medical education at HMS but also benefited some advisory group members in unexpected ways, said Katz-Wise. She said some participants who hadn’t gone to the doctor in a while told her they now intended to do so, while others said they felt empowered to give constructive feedback to clinics or to advocate for themselves after having had discriminatory experiences in the past. Career-wise, one young participant built on their advisory group experience to publish a personal narrative in an academic journal; one was accepted into graduate school after asking Katz-Wise for a recommendation; and one is now co-facilitating another community advisory group at Boston Children’s under Katz-Wise’s guidance.

Katz-Wise and colleagues are now exploring ways to sustain similar advisory groups going forward.

The heavy involvement of community members within and beyond HMS proved an unusual and perhaps unique strategy in the medical education realm, said Keuroghlian.

Student leadership has been particularly inspiring, he said.

“They’re so idealistic,” he said. “They’re really in touch with where the culture is headed and how the community is evolving. That has helped us remain forward-thinking.”

The initiative has made substantive strides in raising educators’ confidence in teaching and supporting SGM health and making the learning culture more comfortable for LGBTQ students, trainees, and faculty.

Recruitment of SGM students to HMS has increased. About 20 percent of HMS MD and Harvard School of Dental Medicine students now identify as LGBTQ, a number that has risen fivefold since 2015, the team said.

Initiative leaders have broadened support for LGBTQ students from application to graduation, including by introducing entrance interviews similar to those developed for Black, Indigenous, and other students of color and by offering one-on-one advising with LGBTQ faculty throughout students’ years at HMS.

SGM students and allies can share their experiences being taught and trained at HMS, whether positive or negative, with staff members in the Office of Recruitment and Multicultural Affairs and the School’s LGBTQ student club, LAHMS. Staff can then let initiative leaders know “when something happens in a course or clerkship where we can do better,” said Keuroghlian.

Correcting missteps is done with gentleness and in a spirit of nonjudgmental collaboration and continuous quality improvement, Keuroghlian said.

“We offer ourselves as assistants, so people don’t feel criticized or shamed, and so they aren’t left wondering how to fix the problem,” he said.

In addition, the initiative has fostered a culture of mentorship for biomedical researchers working on SGM-related topics.

Brittany Charlton, HMS associate professor of population medicine at Harvard Pilgrim Health Care and an initiative curriculum fellow, and colleagues piloted a mentorship program in spring 2022 for faculty focused on LGBTQ health.

Their goals are to improve retention of underrepresented scholars and help LGBTQ researchers secure funding, in turn creating a foundation for improving patient care.

“We know that inadequate mentorship is one of the most insurmountable obstacles in a person's career, particularly for mentees who are underrepresented in medicine,” she said. “Thankfully, mentors can learn strategies for effective mentoring through evidence-based trainings.”

Charlton’s team has now received one of the inaugural awards from the National Institutes of Health for excellence in diversity, equity, and inclusion-focused mentorship, which will allow the team to expand the program to faculty and trainees at Harvard and across the country.