Addressing Gender-Nonconforming Invisibility in Medical Education's Creation of a Culturally Competent Clinician
———————————————————————————————————— Alexandra R. Williams, M.Ed email: [email protected]
“...if you are not like everybody else, then you are abnormal, if you are abnormal , then you are sick. These three categories, not being like everybody else, not being normal and being sick are in fact very different but have been reduced to the same thing” ― Michel Foucault1
The transgender community is a distinct population with specialized needs and concerns, not simply physiological, but also psychological and sociocultural. This population is often underserved both in clinical practice and in medical education. The existing disparity of care in clinical practice has its roots in medical school as LGBT (Lesbian, Gay, Bisexual, and Transgender) curriculum is typically minimal or altogether absent. This omission has the result of creating a population of medical professionals who lack the cultural competency necessary to treat gender non-conforming patients. There is a push for greater inclusion of LGBT curriculum from major medical organizations, however change is costly, time consuming and wrought with political implications. Often, LGBT instruction is student-led and organized; this results in extra-curricular and inconsistent application across the course of education, rather than faculty/ administratively coordinated implementation as a part of the core curriculum. Looking to correct this invisibility in the current curriculum requires addressing the roots of the
Michel Foucault, and Valerio Marchetti. Abnormal: Lectures at the Collège De France, 1974-1975. New York: Picador, 2003. 2
invisibility as well as asking how and where LGBT content should be included in medical education. On the sexual health spectrum, queer2 individuals differ from the heterosexual community in a variety of ways. Differences in sexual orientation and gender identity/ expression require a differentiation in sex education and sexual health needs. Necessary information on sexual health, safe sex and HIV prevention/treatment often differs from what is widely available, as the widely available material is designed for the needs of heterosexual individuals and is written in the context of cultural heteronormativity. This is especially true for those who identify as transgender. Sexual health care within this group can vary greatly, and is often widely different from the general population as it can concern issues such as hormone use, the various degrees of surgical transition, and preventative and routine care relating to transition and expression. However, the needs of the queer community do not stop at sexual health. The LGBT community suffers from higher percentages of violence (both intimate partner and stranger), homelessness, unemployment, lack of health insurance/access to care, dangers of illegal sex work, depression, addiction, suicide, and social stigma than the general population. Additionally, family members and questioning persons are often overlooked as they often struggle with obtaining resources and assistance. Accessing Care 2
I use the term ‘queer’ here and through out the piece as a collective, inclusionary umbrella term for Gay, Lesbian, Bisexual, Transgender, Intersex, and Asexual individuals. I use it as a means to extend the range of terminology beyond the sexual classifications into which GLBTIA individuals are often divided. I respect the right of all individuals to self-identify. 3
The gender-nonconforming population is often underserved in clinical practice. The specialized needs of the transgender population make the disparity in care even more detrimental. Disparity in care is compounded by both the difficulty in accessing quality care and specialized needs outside the heteronormative spectrum. Lack of insurance coverage and inability to pay outright are obstacles, as is discrimination in healthcare. This ranges from harassment, denial of treatment/care, lack of provider knowledge, and even violence in the care setting. Care settings frequently fail to be safe spaces; 28% of surveyed transgender individuals reported postponing care due to discrimination in the National Transgender Discrimination Survey. 2% polled had been victims of violence in the care setting, 50% reported having to teach their clinician about transgender issues, 3 and 19% were denied care outright.4 Xavier et al. posited that the principle cause of the disparities in care for the transgender community is the social stigma of transgenderism. 5 Stigmatized groups are vulnerable to negative labeling, deviant status, and social devaluation. 6 Stigma is one of 3Jaime
M. Grant, Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. 4
The Affordable Care Act prohibits discrimination on the basis of sex or gender identity. Care providers receiving federal funds cannot discriminate based on gender identity or perceived nonconformity to gender norms, regardless of the actual gender identity of those involved. 5
Jessica Xavier, Judith Bradford, Michael Hendricks, Lauretta Safford, Ryan Mckee, Elaine Martin, and Julie A. Honnold. "Transgender Health Care Access in Virginia: A Qualitative Study." International Journal of Transgenderism 14 (2013): 3-17. 6Saul
M. Kassin, and Steven Fein. "Attitudes." In Social Psychology. 7th ed. Boston: Houghton Mifflin, 2008. 4
the primary reasons for refusal of care, such as in the experiences of Naya Taylor and Leslie Feinberg. Taylor is a transgender woman who was refused access to hormone therapy treatment by a physician and was subsequently told by the clinic that they did not have “to treat people like you”. The clinic provided hormone treatment to nontransgender patients but refused to do so for Taylor due to her transgender status.7 For Leslie Feinberg, this stigma almost caused death when s/he entered an emergency room very ill with a high fever and signs of an serious infection. After the staff had begun treating the fever it was discovered that s/he was anatomically female. The doctor made several snide remarks about what ‘normal sexuality’ entailed, unhooked Leslie from all monitoring devices and medical equipment, told then Leslie to leave and never return. Had s/he not been able to receive timely treatment elsewhere this would have been fatal —s/he had endocarditis. As s/he wrote in the book TransLiberation, “Bigotry extracts a toll in flesh and blood. And left unchecked and unchallenged, prejudices create a poisonous climate for us all.”8 Leslie’s words sum up perfectly just why cultural competence is so important. Cultural Competence One of the primary goals of medical education is the creation of a culturally competent clinician. In 1994, The American Medical Association defined cultural competence as “the knowledge and interpersonal skills that allow providers to 7
"Lambda Legal Sues Doctor and Clinic for Denying Medical Care to Transgender Woman." Out & About Nashville. April 27, 2014. Accessed October 27, 2014. http:// www.outandaboutnashville.com/story/lambda-legal-sues-doctor-and-clinicdenying#.VITrN4tWclI. 8
understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences; self-awareness; knowledge of the patient’s culture; and adaptation of skills.”9 When every clinical encounter has the likelihood of being a cross-cultural experience, cultural competence is supremely important. Lack of cultural competency feeds disparity in care settings, but luckily it is an area where improvement is possible and would have great impact. One of the key factors in cultural competence is the ability to operate in the clinical setting with out the construction of assumptions.10 Unfortunately, our current medical model is built on an assumption—that of heteronormativity. In this model, sexuality, sexual orientation, and gender exist in finite categories; the only natural sexual orientation is heterosexuality, with sexuality normally transpiring only between those of different genders; and it is expected (if not demanded) that individuals will respect the dichotomy of masculine and feminine norms. All others are considered unnatural, infrequent, and deviant.11 In order to access care, those deviating from the heteronormative model in terms of gender identity often find themselves being diagnosed with a disorder, Gender Dysphoria. This is a relatively new diagnosis, corresponding with the issue of the most
Delivering Culturally Effective Health Care to Adolescents. Chicago, IL: American Medical Association, 2002. 10Robin
M. Mathy,”A Nonclinical Comparison of Transgender Identity and Sexual Orientation: A Framework for Multicultural Competence." Journal Of Psychology & Human Sexuality 13, no. 1 (March 2001): 31. 11Katrina Alicia
Karkazis. Fixing Sex: Intersex, Medical Authority, and Lived Experience. Durham: Duke University Press, 2008. 6
recent version (V) of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Previously, in DSM IV, Gender Identity Disorder was the diagnosis. The DSM V removed Gender Identity Disorder and replaced it with Gender Dysphoria, in an effort to more accurately reflect gender non-conforming individuals and “avoid stigma…and provide a diagnostic term that protects their access to care and won’t be used against them in social, occupational, or legal areas”.12 Prior to the change in the DSM, in 2010, a work group from the World Professional Association for Transgender Health (WPATH) published a report13 with recommendations to the proposed changes for the DSM V. Within the report they reference the history of diagnosis as a means to exclude and discriminate, and discuss the clinician as ‘gatekeeper’, where often in the past the focus has been more on the terminology and context of the DSM criteria and less on the well-being of the transgender person being treated. Within the options the committee considered when drafting their report, was an option for removing the terminology used to classify transgender patients completely. They objected to this, citing it as possibly erasing the transgender experience entirely— thereby maximizing invisibility in the healthcare institution and causing a greater disparity in care. They recommended a change to the terminology that reflected Friere’s 12
"American Psychiatric Association DSM-5 Development." American Psychiatric Association. Accessed October 23, 2014. http://www.dsm5.org/. 13
Trevor A. Corneil, Justus H. Eisfeld, and Marsha Botzer. "Proposed Changes to Diagnoses Related to Gender Identity in The: A World Professional Association for Transgender Health Consensus Paper Regarding the Potential Impact on Access to Health Care for Transgender Persons." International Journal of Transgenderism 12 (2010): 107-14. 7
pedagogy14—where they hoped that working with the transgender community in constructing new terminology would result in the redefining of the transgender experience through a normative lens, giving transgender persons agency over their identities, reducing stigma, and improving the current disparity and barriers in accessing care.15 Even with these well-intentioned changes, the DSM V still classifies them as symptoms (which most commonly linguistically denotes an illness—placing those with non-conforming gender identities as outside the frame of the “norm”, the gender binary— by which continuing to uphold and enforce the heteronormative model). The diagnosis of gender dysphoria is, in itself, a stigmatization based on the heteronormative model, as it (the diagnosis, as well as simply the general inclusion in the DSM itself) denotes an abnormality, a sickness, some form of deviation from the heteronormative expectation, rather than an acknowledgement of the spectrum of identities present in individuals. 16 As Judith Butler has stated, The diagnosis…assumes that certain gender norms have not been properly embodied and that an error and a failure have taken place,…it seeks to uphold the gender norms of the world as it is currently constituted and tends to pathologize 14
Paulo Freire. Pedagogy of the Oppressed. 30th Anniversary ed. New York: Continuum, 2000. 15
Trevor A. Corneil, Justus H. Eisfeld, and Marsha Botzer. "Proposed Changes to Diagnoses Related to Gender Identity in The: A World Professional Association for Transgender Health Consensus Paper Regarding the Potential Impact on Access to Health Care for Transgender Persons." International Journal of Transgenderism 12 (2010): 107-14. 16
Judith Butler. “Undiagnosing Gender,” in Transgender Rights, ed. Paisley Currah, Richard M. Juang, and Shannon Price Minter, (Minneapolis: University of Minnesota Press, 2006), 275. 8
any effort to produce gender in ways that fail to conform to existing norms (or to a certain dominant fantasy of what existing norms actually are).17 While it is encouraging that standards and terminology can change over time, this issue still remains controversial and highly debated—one not likely to reach a conclusion anytime soon. For this to be as productive as possible we need not only the involvement of the transgender community but also of culturally competent clinicians. Cultural Curriculum This begins within medical education, as one of the first places a clinician will address cultural competence is within the culture of the medical education organization. The culture within educational organizations, healthcare settings, and clinicians has a great impact on the level of cultural competence a community will see in its care. In 2011, the Journal of the American Medical Association (JAMA) published an article detailing findings about LGBT curriculum in medical education18. Surveys were sent to all 176 medical schools in the US and Canada, with 150 of the 176 schools responding. 132 of those 150 completed the questionnaire in its entirety. In this study, the median reported amount of dedicated LGBT programming was 5 hours. In this reported time, more of the LGBT curriculum was found in the pre-clinical areas of education than the clinical areas. Out of the 132 respondents, 44 reported having no LGBT-related clinical content, and 9 reported no LBGT-related content in the pre-
Ibid. p 275/6.
J. Obedin-Maliver, E. S. Goldsmith, L. Stewart, W. White, E. Tran, S. Brenman, M. Wells, D. M. Fetterman, G. Garcia, and M. R. Lunn. "Lesbian, Gay, Bisexual, And Transgender-Related Content In Undergraduate Medical Education." JAMA: The Journal of the American Medical Association 306, no. 9 (2011): 971-77. 9
clinical years. The study obtained responses from the deans as to whether or not their curricula covered 16 core LGBT topics19, and then their evaluation of the degree of coverage of the 16 core topics. Only 32 schools responded having taught LGBT-related material in units specifically targeted to LGBT care. Clinical sites focused on LGBT care and curriculum were not offered in 103 of the respondents, but were available as electives at 12 and required at 7 schools. Evaluation of teaching in LGBT areas varied and 38 schools did not evaluate at all. Only a small amount of schools reported teaching all 16 core areas, and some schools reported teaching LGBT topics as part of the required curriculum that covered various primary care areas, however they were a minority of the responses.20 When present, LGBT curriculum often focuses on one of two areas: the sexual nature of LGBT issues, or the the mental nature. Focusing on the sexual aspects of LGBT issues often reduces complex issues to simplistic, hypersexualized themes and ignores the effects of intersectionality with issues such as race and class. Sometimes these themed models of study unintentionally act to reinforce stereotypical
Core topics: Sexual Orientation, HIV, Gender Identity, STI, Safer Sex, DSD/Intersex (Disorders of sex development), Barriers to care, Mental Health Issues, LGBT Adolescents, Coming Out, Unhealthy relationships/IPV, Substance Abuse, Chronic Disease Risk, SRS (sex reassignment surgery), Body Image, Transitioning 20
This study notes that it cannot account for any instruction that may occur in a sporadic or unplanned fashion through out the curriculum. There are also difficulties in relating certain types of instruction/evaluation, such as problem-based learning (pbl) and standardized patients to the same metric of measure. 10
representations of LGBT people.21 For example, consider the inclusion of LGBT subject matter only when discussing the risks of gay/bisexual men concerning HIV/AIDS or when covering gender dysphoria in mental health curriculum. In this example, this ensures that the only visibility in the curriculum for LGBT persons is as hyper-sexed and/or mentally ill individuals. It also runs the risk of not addressing the intersectionality of other areas of life, such as stigma leading to unemployment that may force individuals in the LGBT community (not just gay/bisexual men) into alternate forms of employment (such as sex work) that leads to greater risk for STI, HIV infection, depression, and violence (and will affect the types and availability of treatment). There is available guidance and a push for greater inclusion from major medical organizations, such as the Association of American Medical Colleges (AAMC). AAMC has put out a self-assessment tool for medical schools to by which to gauge their programs. There are 18 standards with associated targets that cover such topics such as curricular content in each year of instruction, in-depth electives, dedicated staff for LGBT curriculum, admissions procedures, and educational materials, among others. 22 AAMC is also developing the AAMC Sexual Orientation, Gender Identity and Sex Development Project23, a repository of materials and resources for use in medical education focusing on 21
Jessica Guh. "Do Medical School Curricula Hypersexualize the LGBT Population?" Slate Magazine. September 9, 2011. http://www.slate.com/blogs/xx_factor/2011/09/09/ does_medical_school_curricula_hypersexualize_the_lgbt_population.html. 22
"LGBT PEOPLE & ISSUES IN MEDICAL SCHOOLS: A TOOL FOR INSTITUTIONAL SELF-ASSESSMENT." American Association of Medical Colleges. https://www.aamc.org/linkableblob/54770-10/data/lgbtinstitutionalselfassessmentdata.pdf. 23
the health of LGBT individuals, to include gender non-conforming and those with differences of sex development. AAMC also provides a recommendations guide on curriculum, policies, and services for LGBT students and patients. 24 However, there is no requirement for programs to self-evaluate, no independent evaluation, no standardization in curriculum requirements, and no requirement for reporting. Currently, for many organizations the bulk of instruction/interaction is student-led and organized and often extra-curricular, rather than faculty and administratively coordinated and a part of the core curriculum. A popular method for student-led instruction is the use of panel speakers for block sessions. In these sessions, part of the block is devoted to panel members speaking on a subject and is followed by question/ answer sessions between attendees and panel members. Unfortunately, speakers are often asked to tackle broad areas of information—often without specific focus, limited time, and little to no prior knowledge of the subject by the attendees. While offering the possibility of interaction between students and facilitators which is often beneficial to overall educational goals, these short sessions pose a problem where it is very likely and possible that students will draw overreaching and possibly unrealistic perceptions of a larger group of people by their brief interactions with a small few. Rather than making these short supplementary panel sessions/provider trainings part of a special topic or
"Informational Guide to Effective Practices for Gay, Lesbian, Bisexual, and Transgender (GLBT) Students and Patients - Group on Student Affairs (GSA) - Member Center - AAMC." American Association of Medical Colleges.. http://www.aamc.org/ members/gsa/54702/gsa_glbt.html. 12
session, the issue can be better addressed by making them part the larger curriculum as a component of dedicated courses and lectures.25 The American Association of Medical Students (AAMS) has recognized that the attitudes and clinical competency of providers can play a large part in the quality and availability of care that the LGBT population receives. They believe that interventions in the current medical education curriculum can improve the ability of the clinician to treat and support LGBT community members. 26 AAMS developed and published a guide to help students lobby for an increase in the amount of LGBT health curriculum called the “Guide to the Plus One Initiative”. The Plus One Initiative27 is a campaign by the AAMS to address the disparity in LGBT curriculum by getting medical students to advocate for an increase in LGBT-related content by taking part in curriculum development and student-led proposals. The Plus One Guide offers steps to creating curriculum based on the ADDIE model and has listed resources and curricular tools beneficial to those looking to increase the amount of LGBT programming in their curriculum. Curriculum Ideas Safe Space 25
Christoph Hanssmann. “Training Disservice: The Productive Potential and Structural Limitations of Health as a Terrain for Trans Activism” in Transfeminist Perspectives: In and Beyond Transgender and Gender Studies, ed. Anne Enke, (Philadelphia: Temple University Press, 2012), 113, 117. 26
"Guide to the Plus One Initiative." American Medical Student Association. http:// www.amsa.org/AMSA/Libraries/Committee_Docs/Plus_One_Initiative_Guide.sflb.ashx. 27
This isn’t to be confused with student-designed electives or peer teaching, as they are often credit-bearing and faculty overseen. AAMS also has a ‘Preclinical Elective Planning Checklist’ that helps students to design preclinical electives that is a great resource and could be used to plan LGBT focused elective courses. 13
From the standpoint of creating a base level of understanding and exposure to LGBT topics, the I believe the best way to begin is by creating mandatory safe space training as part of first year orientation or shortly after orientation. (Additionally, all faculty and staff should be trained as well.) Safe Space training is a LGBT-related training program focusing on teaching awareness and knowledge of LGBT issues and providing resources to support equality, diversity, and inclusion in the educational environment.28 Often training will include panel discussions, terminology, and best practices. Many universities already have programs in place to provide safe space training; medical schools need just to reach out and coordinate the training. A refresher session added between the clinical and pre-clinical years would also be beneficial, as clerkship directors have noted students are often unequipped to handle and appreciate the impact of cultural differences in clinical practice when beginning the clerkship years.29 Leveraging 4th Year Electives and Peer Teaching in Transitional Phases To leverage currently available options in the curriculum I would suggest the creation of a second term 4th year elective in parallel with a transitional cultural competency course that bridges the pre-clinical and clinical years. This course should focus on the perspectives, knowledge, and clinical skills of students as they interact with culturally diverse populations, to include LGBT communities. 4th year students would be
Wright State University Safe Space Program Ally Manual, 2010
Julie Taylor, Paul George, Marina MacNamara, Dana Zink, Nilay Patel, Jamie Gainor, and Richard Dollase. "A New Clinical Skills Clerkship for Medical Students." Family Medicine 46, no. 6 (2014): 433-9. 14
working with the soon-to-be clinical students to address the above areas while imparting their own experiences in their clinical years. The relationship between the second and fourth year students is often more collaborative and less authoritarian, possibly allowing for a more personable and comfortable experience as well as a brief respite from the structured core of their traditional classes. Additionally, peer teaching has been shown to be beneficial to not only the student but also to the peer educator. 30 “Cinemeducation”31 The use of video provides a flexible tool for introducing directed and focused materials for student learning. Video is a multimodal method of instruction that delivers information through verbal and visual means that can facilitate and reinforce learning.32 Video can be used in a myriad of ways—individually, in small or large groups, basic overviews or focused clips, asynchronous or synchronous, depending on how the content would fit best with the course objectives. Videos are often used in tandem with discussion and/or critical reflection. Critical reflection itself is a desired skill in a clinician, often described as a self awareness that fosters and drives compassion and empathy. 33Video can be used as a starting point for providing provoking and challenging experiences to 30
Florence Bretelle et al., “Medical students as sexual health peer educators: who benefits more?,” BMC Medical Education 14, no. 1 (2014): 162. 31
Matthew Alexander, and Dael Waxman. "Cinemeducation: Teaching Family Systems through the Movies." Families, Systems, & Health: 455-66. 32
Gurvinder Kalra. "Using Cinema to Train Mental Health Care Trainees in Transgender Issues." International Journal of Transgenderism 14 (2013): 39-48. 33
Linda Lewin, Nancy J Robert, John Raczek, Carol Carraccio, and Patricia J Hicks. “An online evidence based medicine exercise prompts reflection in third year medical students.” BMC Medical Education 14, no. 1 (2014): 164. 15
analyze in critical reflection. Video can also be used as an effective method of fronting information to students prior to discussion classes, where students are asked to first view the film and then develop questions to be used in group discussions. Video is a good choice when wanting to provide personal narratives and experiences while protecting patient confidentiality and/or provide realistic depictions of personal hardship, difficult situations, and hard choices. Clips can be used to drive focused discussions, and documentaries can shed light on difficult subjects within stigmatized communities. For example, the documentary Southern Comfort follows the last year in the life of a transman who developed ovarian cancer and was denied treatment by 2 dozen doctors, leading to his death. 34 It is an excellent example of a video highlighting a non-fictional narrative of disparities in care for the transgender population. Specific Focus on Sexual History Documentation Sexual history documentation is an important part of adequate screening and medical care. When looked at in 2009, a small study found that a little over half the surveyed students felt comfortable taking a sexual history. Further research has shown that while many residents are comfortable asking broad questions concerning sexual history taking, few are comfortable with more specific or probing questions. Some of the cited reasons for this discomfort were embarrassment (their own and their patient’s) or being afraid of offending their patient.35 In the LGBT community, assessing sexual
Southern Comfort, directed by Kate Davis (2001, HBO Documentary)
Loeb, Eva M. Aagaard, Steve R. Cali, and Rita S. Lee. "Modest Impact of a Brief Curricular Intervention on Poor Documentation of Sexual History in UniversityBased Resident Internal Medicine Clinics." The Journal of Sexual Medicine: 3315-321. 16
behavior, sexual identity, and gender identity correctly is necessary to determine risk and necessary counseling. As part of cultural competency and clinical skills, clinicians must be comfortable with asking questions about these topics, and must make them a routine part of their history taking. Being upfront and proactive about these topics is an important step in helping LGBT individuals in seeking and receiving necessary care.36 A provider who can broach these topics in a compassionate and straight forward way offer a safe space for LGBT individuals to ask questions and access care. More attention should be taken through out the course of medical education to ensure students become comfortable with a wide range of sexual inquiries, starting with basic history taking in the first year and later focusing on specific questions and topics. Students should be able to take accurate sexual histories with compassion and empathy, and without coming across as being judgmental. Self Paced Web Based Learning Modules With the prevalence of online learning and asynchronous course materials, students should have the ability to learn about health issues affecting transgender individuals and the larger LGBT populations in detail via web-based training modules. These modules should be developed collaboratively with upper-level students, clinicians, transgender patients and LGBT health activists. They should address best practices in primary care for the transgender population as well as social determinants and legal issues.
H.J. Makadon. "Ending LGBT Invisibility in Health Care: The First Step in Ensuring Equitable Care." Cleveland Clinic Journal of Medicine: 220-24. 17
Leveraging current resources Whenever possible, effort should also be made to leverage current available resources from outside sources to both compliment curriculum and provide students with further reading or information. Many organizations have taken great care and effort to put together and to post a comprehensive library of resources, ranging from a general informational perspective to more in-depth and specific topics. A great many resources are available without charge and some organizations will provide specialized training and continuing education credits. Reading lists, videos, powerpoint presentations, and guided activities are just a fraction of the resources available. There are resources available that are appropriate for all levels of education, one must just go looking for them (and with the ubiquity of today’s internet, we are fortunate to not have to look too far). Organizations such as The Fenway Institute (www.thefenwayinstitute.org), The World Professional Association for Transgender Heath (www.wpath.org), Vancouver Coastal Health (transhealth.vch.ca) and GLAAD's Transgender Media and Education Program (http://www.glaad.org/transgender) are good places to start.
As research by Nelson Sanchez37 and his team is quick to point out, determining and quantifying just what constitutes adequate curriculum for LGBT-related content is very difficult. However, they also noted that the more access to LGBT related education and clinical encounters a student had, the less negative their attitude and behaviors
Nelson Sanchez, et al.,"Medical Students' Ability to Care for Lesbian, Gay, Bisexual, and Transgendered Patients." Medical Student Education 38, no. 1 (2010): 25. 18
towards LGBT-related issues and persons. 38As Mitchell Lunn, M.D., who co-founded Stanford’s LGBT Medical Education Research Group states, “having LGBT instruction in the curriculum improves the social and educational climate through direct education,” Lunn said. “This yields greater understanding and awareness.”39 Education and awareness clearly make a difference in the lives and care of queer individuals. With the positive impact this education can make and the variety of applications and available resources, there is no acceptable reason for delaying widespread improvements in LGBT curriculum and giving queer individuals, particularly those who are transgender, visibility and voice.
Prescott. Changing Times for LGBT Population Affect Medical Schools and Teaching Hospitals, February 2011, AAMC Reporter Newsroom. 19
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