A small group of Yale medical and public health students collaborated with faculty mentors to develop a clinical skills-based simulation session on caring for transgender and gender diverse patients, in which all MD students will participate in during their clinical year.

The initiative began in May 2022. As Yale School of Medicine (YSM) MD student Bassel Shanab explains, students were graduating “feeling uncomfortable in their ability to provide care to transgender and nonbinary patients.” Although, he says, there were pre-clinical lectures on the physiology of hormones in hormone replacement therapy, the negative and damaging effects of gender dysphoria, and societal discrimination, “we lacked the in-person clinical instruction that would ensure students can confidently serve such a marginalized group of patients."

MD student Ryan Bahar, who was involved with the initiative, adds, “Transgender and gender diverse (TGD) individuals experience alarming health disparities compared to their cisgender counterparts. While there are many reasons for this unacceptable status quo, from lack of insurance to outright discrimination, one is particularly important to grapple with in medical education: students are not sufficiently trained to provide adequate health care to TGD individuals.”

A group of students at YSM—led by MD-PhD student Kyle Gavulic—made developing curriculum to fill this gap a priority in the wake of various state-mandated restrictions on gender-affirming care. The students connected with Assistant Professor of Pediatrics Meredithe McNamara, MD, MS, and MD student Christine Lepore, who were working on evidence-based medico-legal responses to some of these bans. This led to brainstorming about enhancing YSM’s curriculum.

Creating curricular content

The group brought in John Encandela, PhD, executive director of evaluation & assessment, Center for Medical Education; Jaideep Talwalkar, MD, assistant dean for education and director of clinical skills; Beverley Sheares, MD, MS, Health Equity Thread (HET) leader; and Douglas Shenson, MD, MPH, MA, MS, HET deputy leader. The students completed a literature review of existing medical education curricula on gender-affirming care across the country, as well as a needs assessment of the YSM curricula, and developed a proposal for a "meta" curriculum, unique to YSM’s teaching model but derived from two validated curricula, on clinical skills in caring for transgender and gender diverse patients.

The group piloted the curriculum in January 2023, in partnership with HAVEN Free Clinic, training 13 medical, nursing, and PA student volunteers. The pilot demonstrated the curriculum was effective. (The project team presented their findings on a poster at YSM’s Medical Education Day in 2023.)

The conversation then shifted to where this training would fit best in the curriculum and which students would receive it. It was decided that all MD and MD-PhD clerkship students would participate during a precede, which is the orientation before each clerkship rotation. The first 40 MD students participated in the training in March 2024, and it received excellent reviews. The remaining students will participate later this year. Assuming the feedback remains positive, the training will become a permanent part of the precede curriculum.

Recruiting simulated participants

Simulated participants (SPs) are an important component of the training. Gavulic explains, “Our goal was to recruit from the local transgender and gender diverse community so that our actors possessed the lived experiences of the patient population we were aiming to empower health professional students to better care for.” Jillian Celentano, LMSW, an SP and a mentor and advocate for the trans community, “has been a very close and absolutely critical partner in this work,” Gavulic adds. “We really couldn't have pulled this off without her.” Celentano recruited all the volunteers for the pilot and was a key player in the recruitment effort to hire enough SPs to train all medical students, which was led by Barbara Hildebrand, BFA, assistant director of the Simulated Participant Program, which is part of the Yale Center for Healthcare Simulation.

Hildebrand explains they were seeking individuals “to embody fictional patients with specific gender journeys authentically. This requires staying in character, adhering to case details, providing feedback, and repeating the portrayal multiple times within a two-hour workshop.”

Leveraging YSM’s existing SP community, which included eight people who identified as transgender or gender diverse, Hildebrand embarked on an innovative recruitment strategy, which resulted in six new SPs. Partnering with Program Coordinator A Gould, they created trans-friendly recruiting posters, and Hildebrand forged partnerships with local colleges and universities through their DEI offices. Hildebrand calls Gavulic and Celentano “invaluable” partners, who were “referring applicants and connecting me with gender affirming health care practices in CT to share the job posting.”

Celentano expects most new recruits will continue as SPs “because they realize the impact they are having,” and explains, “We are petrified to go to a new medical provider. We know there is a big gap with providers who are trained to engage with gender diverse patients.”

"It is immensely gratifying for our SP Program to play a pivotal role in delivering cutting-edge curriculum to our medical students,” says Hildebrand. She adds that the SPs’ “willingness to be vulnerable creates a safe environment for students to learn and practice essential skills, ultimately shaping them into compassionate health care providers for transgender and gender diverse patients. I am incredibly proud of the SPs’ courage and the profound impact they have on our educational mission."

Impact

Encandela says he is “certain that this workshop would not exist without the steady and patient efforts of a small group of students dedicated to making this happen. They saw the gap in the curriculum; did the necessary groundwork to identify necessary resources; conducted a proof-of-concept pilot; and worked with faculty and administrative leaders in getting the workshop into the regular clerkship curriculum.” He credits Gavulic for “spearheading the effort and remaining steadfast through the process of development to implementation.”

Reflecting on the initiative, Gavulic says, it “not only tremendously advanced YSM's undergraduate medical education on trans health care, but also promises to nourish generations of graduating YSM students in feeling competent enough to provide the same quality of care to the trans and gender diverse community and to counter the spread of disinformation. This dual-pronged aim is truly what this is all about so that trans and gender diverse patients can feel safe and affirmed while seeking health care.”

Echoing these points, McNamara notes, “Trans and gender-expansive people are more visible than ever and the evidence regarding the benefits of gender-affirming care has never been stronger.” Therefore, she continues, “this is a natural time to make sure that emerging physicians are fully equipped with clinical skills to provide welcoming, evidence-based and comprehensive care to gender diverse people.” Additionally, McNamara is concerned that “the misinformation climate regarding gender-affirming care is quite virulent now,” leading to policies that restrict access to care for trans and gender-expansive people. The medical community, she says, “including emerging physicians, are powerful and credible messengers who can dispel myths and protect marginalized people.”

In addition to those mentioned in the article, the project team would like to acknowledge MD student Shamik Bhat and MPH student Sujana Nelakanti for their invaluable contributions in developing and implementing the curriculum; Manager of Clinical Medical Education Programs Gina Franco and Clerkship Director Shefali Pathy, MD, MPH, for their unwavering support in implementing this into the Clerkship curriculum; and all the faculty champions for their expertise and generosity of their time to make this a success, including Anika Anam, MD, Iman Berrahou, MD, Susan Boulware, MD, Diane Bruessow, MPAS, PA-C, Joseph Canarie, MD, Mukta Dhond, MD, Barbara Gulanski, MD, MPH, Allister Hirschmann, PA-C, Nathan Levitt, FNP-BC, MSN, RN, MA, Nicolas Meade, PsyD, Christy Olezeski, PhD, Allura Ralston, PhD, Jenn Suski, APRN, and Tristan Marvin Uy, MD, MPH.