When Perry Cohen experienced an urgent health concern earlier this year, his town’s only care provider who specializes in working with LGBTQ (lesbian, gay, bisexual, transgender and queer) patients wasn’t available to see him.
He went to a different doctor, then to a second. Both times, when the providers learned that Cohen is transgender, “their faces fell,” he recalled.
“It wasn’t about malice; it wasn’t about not affirming me,” he said, “but rather, they had this look of, ‘Oh, no, I don’t know if I’ll be able to help this patient.’ They didn’t want to get it wrong, but they were out of their element.”
Cohen’s confidence in both doctors ebbed.
“I felt that their fear of messing up on a cultural or emotional level hampered their ability to do their usual rigorous critical thinking,” he said.
Too often, for Cohen and countless other LGBTQ patients across the country, the problem begins not in the exam room but in the classroom: Physicians lack sufficient training in how to provide competent, affirming care for patients who identify as members of sexual and gender minority (SGM) groups, especially for transgender people.
This educational gap has led to alarming health disparities for SGM patients, experts report. According to Healthy People 2020, a program of the U.S. Department of Health and Human Services, transgender people alone experience disproportionate rates of suicide, homelessness, substance use, HIV and other sexually transmitted diseases, mental health disorders and victimization, yet they also confront barriers to accessing effective health care.
Students, faculty and staff at Harvard Medical School are joining forces to change that.
This fall, HMS launched the Sexual and Gender Minorities Health Equity Initiative, a three-year plan to amend the core MD curriculum so that all students and faculty clinicians can become exceptionally well equipped to provide high-quality, holistic health care for sexual and gender minority patients of all ages.
The plan encompasses curriculum reform, faculty development, continuous quality assessment and global dissemination, as well as increased efforts to recruit and support students, faculty and staff with interests or experience in SGM health.
“The most powerful vehicle to effect durable, meaningful change across current and future generations of clinicians in all specialties caring for LGBTQ patients is singular: education,” said Ed Hundert, dean for medical education at HMS.
“We are immensely grateful to be able to embark on this exciting and important initiative, which allows us to transform longitudinal medical education for students, teachers, researchers and care providers at HMS and our affiliated institutions, and also share our curriculum, faculty development programming and lessons learned with medical schools worldwide,” he said.
“Our faculty, staff and students are eager to do this work and to help right the health inequities that sexual and gender minorities confront throughout their lives,” said HMS Dean George Q. Daley. “We firmly believe that Harvard Medical School must lead this widespread change in medicine.”
The initiative was made possible by a $1.5 million gift from the Cohen and Bull-Cohen families.
“We’re hoping this becomes part of a broader way of looking at transgender people and transgender health care across the U.S.,” said Cohen. “If we can train medical students, then they can go out into not just the few major hospitals that are doing great work for transgender patients but also into local community hospitals and places further afield and bring high-quality care to transgender patients who might not live on the coasts.
“We want transgender people to not feel so scared to go to the doctor,” he said.
How do you conduct routine physical exams that respect the dignity of transgender or gender nonconforming patients? What’s the best way to take thorough sexual histories for all patients? What are the unique cancer screening needs of transgender men and women?
“When I came to HMS as an LGBT student 30 years ago, there was no curriculum about LGBT health,” said John Dalrymple, MD ’91, the Dr. Mark and Karen Lawrence Director of Humanism in Medicine and associate dean for medical education quality improvement at HMS. “Just being ‘out’ was a difficult circumstance.”
“It means a lot to me to see how far HMS has come and how far medical education has evolved, to the point that we’re not adding small components on SGM health but doing it in a global, transparent, candid, integrated and meaningful way,” he said. “I’m thrilled.”
Dalrymple now serves as principal investigator for the initiative. His co-faculty directors are Jennifer Potter, MD ’87, advisory dean and director of the William Bosworth Castle Society at HMS and co-chair of the Fenway Institute in Boston, and Alex Keuroghlian, director of the psychiatry gender identity and sexual orientation program at Massachusetts General Hospital, course director for the fourth-year clerkship Care for Patients with Diverse Sexual Orientations and Gender Identities at HMS and director of the National LGBT Health Education Center at the Fenway Institute.
Together they will usher the initiative through its multiple components.
First, the team is leading a committee of students and faculty members in conducting a comprehensive review of the School’s four-year curriculum and identifying areas that are ripe for enhancement with material on SGM health or that contain assumptions or errors about sex and gender, such as conflating sexual orientation with gender identity, presuming gender is immutable or treating heterosexuality as a default.
“This initiative isn’t about ‘adding more stuff’ to an already full curriculum,” said committee member Jessica Halem, the LGBT program director at HMS. “It’s about unearthing where wrong ideas are unwittingly getting cemented in people’s heads and correcting them from the beginning so they don’t have to be unlearned later. It’s about rewriting the stories and the language we use, built around a better understanding of how sex and gender really work in people’s lives.”
The committee will then create a map of learning objectives and add explicit requirements related to SGM health for the six core competencies HMS students must demonstrate in order to graduate.
When the plan is complete, a group of Curriculum Faculty Fellows will develop the new components and integrate them throughout preclerkship courses, including the practice of medicine, basic science and population and social science; the principal clinical experience, when students are likely to encounter SGM health issues in specialties such as medicine, surgery, pediatrics, obstetrics and gynecology and psychiatry; and the post-clerkship curriculum, expanding opportunities for students to take elective courses and pursue scholarly research projects focused on SGM health.
In this way, every student earning an MD from HMS will undergo rigorous training in the science and clinical practice of sexual and gender minority health, “not only those with a preexisting interest in caring for this segment of the population,” said Dalrymple.
Students at the Helm
When Michael Fuchs matriculated at HMS in 2016, he studied not only his course material, but also the curriculum itself.
“As a former educator, I was fascinated by how we teach, and I had a particular interest in how we teach LGBTQ health,” said Fuchs, now in his third year.
He constructed a schematic of existing components related to SGM health, which “illuminated some of the strengths in our curriculum and showed ways we could bolster an already strong commitment,” he said.
Fuchs’ project attracted the attention of educational leaders at HMS. A working group took shape that included Fuchs and fellow students Jordan Said and Aliya Feroe as well as Dalrymple, Potter, Keuroghlian and Halem. They looked for ways to build on the initial assessment and identify areas ripe for improvement.
When the new gift was announced, the team was poised to scale up its efforts.
“There’s so much interest and willingness at HMS in doing LGBT work, but we haven’t had the resources to implement them. This gift is exciting because it’s enabled us to take these fleshed-out ideas that have student and faculty backing and really get going on them,” said Said. “For Aliya and me, it’s incredible as second-year students to see change like this happening so early in our careers. I can’t wait to see where it’s going.”
“I’ve been impressed by the first-year class already and where they’re taking these efforts,” agreed Feroe. “The next generations of HMS students will help build this culture.”
Teaching the teachers
The initiative’s educational component doesn’t end with students. Dalrymple’s team will also teach the teachers.
Barbara Cockrill, recently appointed as the School’s director of faculty development for the Program in Medical Education, will create and work with a faculty interest group on SGM health in the HMS Academy to design seminars, retreats and online modules that prepare faculty educators at HMS and its hospital affiliates to teach the new curriculum objectives.
In addition, the team will help clinicians across the HMS community increase their competence and confidence in caring for SGM patients.
“Clinicians have the enthusiasm and compassion needed for health equity, but often lack the knowledge and skills because most of us had minimal exposure to gender and sexual minority health principles and practices as medical students,” said Keuroghlian. “We will provide opportunities for training in best practices as well as how to create inclusive and affirming health care environments.”
To ensure that the initiative achieves its goals, the team will conduct outcome studies and recommend any needed adjustments. Dalrymple is prepared to lead this effort as faculty head of the Office of Educational Quality Improvement at HMS.
“The MD curriculum at HMS is designed to perpetually evolve through iterative improvements and regular evaluation of its effectiveness,” said Hundert. “It is precisely this spirit of continuous improvement that allows us to integrate critical new material and ensure its effectiveness for current students and generations of physicians to come.”
Dalrymple and colleagues will share their findings with clinicians and leaders in medical education at national and international meetings. HMS will also make all curricular and faculty development materials freely available online for other medical schools to use.
It’s about the people
Last but not least, the initiative will aid HMS in recruiting more students, faculty and staff from SGM populations or those who have interests or experience in SGM health, and in supporting and retaining those individuals.
“This project interweaves with multiple efforts going on across HMS and our affiliated hospitals, including other health equity curriculum enhancements,” said Potter, who is also faculty advisor for LAHMS, the LGBT, queer and allies student organization at HMS. “It’s a collaborative piece with value-adds for everyone.”
“This grant to rewrite the way we train doctors works because it’s backed by five years of preparation at HMS,” said Halem. “Faculty members have been engaged and are excited to take this on. The student body has a large and growing interest in SGM health. Our affiliate hospitals have dramatically increased clinical care and outreach for LGBTQ populations. Federal and insurance policies have changed. The national conversation has evolved. We’re fitting in the final puzzle piece.”
Alongside further diversification of the faculty and student body, the team plans to engage more people from SGM populations in the curriculum-enrichment process as guest speakers in preclinical courses and as actual patients in clinical rotations.
“If you want to reduce health inequities, you have to engage members of those populations in the effort of education and research,” said Potter. “We don’t want to base our decisions on what we think they need. Plus, studies show that students learn best when they meet authentic members of the community.”
Along the way, the team hopes to change the learning environment for faculty and students so that those who identify as sexual and gender minorities feel heard and respected, while others grow comfortable with SGM health topics that may be new to them, Potter said.
“Understanding our differences makes everyone better,” said Dalrymple. “We learn better, we provide better care.”
Dalrymple also anticipates that the initiative will inspire faculty to seek additional opportunities to innovate in SGM health education and research and lead more students to choose SGM health as their focus.“We’re just scratching the surface of what the impact could be,” he said.