A woman, who was assigned male at birth, is diagnosed with prostate cancer. This was a recent clinical training exercise from Yale’s Physician Assistant Online (PA Online) Program involving standardized patients who are transgender women. At Yale School of Medicine (YSM), MD, PA Online, and Physician Associate (PA) degree programs incorporate curricular content to train students to care for transgender and non-binary patients competently and compassionately. Importantly, the programs are committed to ongoing curricular assessment and revisions.
YSM began the process of meaningfully including such content into its MD curriculum in 2014, as part of a larger collaborative effort between students and faculty to evaluate and increase content related to sexual and gender minority (SGM) medicine. This involved carefully examining the curriculum to determine what was and was not being covered, based on nationally established competencies provided by the Association of American Medical Colleges. Faculty were provided guidance and resources for incorporating missing content into the curriculum. A key principle was developing unified, intersectional learning activities that focused on the experiences and needs of all patients to address the multifaceted nature of patient identities and health care concerns.
Relevant content is now embedded in a number of pre-clerkship courses and several clerkships, such as an Ob-Gyn shared decision-making workshop using a case study of a male assigned female at birth with cervical cancer.
MD students can participate in a Family & Transgender Medicine elective at a clinic in Oneonta, New York, where YSM alumni, Carolyn Wolf-Gould, MD ‘90 and Christopher Wolf-Gould, MD ’90, serve as preceptors. Michael Solotke, MD-MBA ’21, spent two weeks seeing only transgender and non-binary pediatric and adult patients during the elective. Because these patients are some of the must underserved in our health care system, he explains, “it was extremely valuable for my education to have the chance to learn in an environment that centers their needs.” Solotke praises the Wolf-Goulds as truly outstanding preceptors who “modeled how to provide care that is structurally informed, evidence based, humble, and community engaged.”
The travel restrictions during the COVID-19 pandemic underscored that an equivalent opportunity does not yet exist in New Haven, though the Pediatric Gender Program created a temporary opportunity for students to participate in a transgender and non-binary medicine elective.
The YSM Dean’s Council for LGBTQI+ Affairs was born out of the 2014 MD curriculum review. Since its creation in 2015, it has included representatives from the MD, PA, and PA Online Programs, as well as the Yale Schools of Nursing and Public Health. It not only focuses on curricula, but a range of Lesbian, Gay, Bisexual, Transgender, Intersex, and Queer+ (LGBTQI+) issues, as well as organizing events. In January 2021, the Council created an official Education/Curriculum Working Group to provide curricular advice to YSM’s Dean Nancy J. Brown, MD, C.N.H. Long Professor of Internal Medicine, and other educational leaders.
In 2020, the MD Program added a four-year Health Equity Thread (HET) to its curriculum, with the goal that by 2023, 50% of the curriculum incorporates health equity in a meaningful way. Associate Dean for Curriculum Michael Schwartz, PhD, anticipates that as the strong content related to the appropriate and meaningful care and treatment of transgender and non-binary patients is incorporated within the HET, students will gain even greater exposure to this important facet of health care delivery.
As of September 2020, the Accreditation Review Commission on Education for the Physician Assistant required accredited PA programs to prepare their graduates to provide care for SGM patients. (There is not yet an equivalent accreditation requirement for medical schools.) Both of YSM’s PA programs were meeting this requirement prior to its adoption. PA Online faculty member Diane Bruessow, PA-C, DFAAPA, credits PA Online Program Director James Van Rhee, MS, PA-C, with ensuring the topic’s inclusion in the curriculum when Yale welcomed its first class in January 2018.
Transgender health material is woven throughout the PA Online patient assessment course. For example, the musculoskeletal system curriculum includes a discussion of how sex steroids, particularly estrogen, influence bone health, and how that relates to pubertal suppression and hormone therapies. When studying the pulmonary system, PA Online students learn about pulmonary risks associated with some chest binding techniques—a non-medical/surgical alternative to top surgery that transmasculine individuals may engage in to create a masculine presenting chest.
During the multi-institutional Virtual Interprofessional Education (VIPE) program, PA Online students work through clinical cases in small interprofessional groups. In one scenario, the patient is a young transgender woman of color who presents with a musculoskeletal issue and abuse is uncovered. Additionally, many PA Online students participate in the program’s virtual clinical elective on SGM health, designed to help students understand and apply the scientific constructs of sexual orientation and gender identity and expression to patient assessment and clinical decision-making.
Bruessow, who has expertise in transgender and non-binary medicine, spent the last year authoring chapters on transgender health for medical textbooks, with the aim of enabling other programs to teach this content as well.
The PA Program similarly has material woven into its didactic and clinical curriculum. Interspersed throughout the first year is content on approaches to treatment and care including hormone therapies, implicit bias, gynecological care, psychiatric impact, diversity, and inclusion. Additionally, students take a class on Healthcare of Gender Variant Youth, and participate in a session on LGBTQ health disparities, focusing on identifying major barriers in accessing health care and the health disparities and risk factors that this community experiences. Students learn about providing primary care to LGBTQ patients, including developing a clinically inclusive and empathic approach to providing optimal medical care.
In their shared medical decision-making sessions with standardized patients, PA students have a case with a transgender male who is making decisions about having children with his partner. They also can participate in clinical rotations at the Nathan Smith Clinic in New Haven, which provides care for patients, including transgender and non-binary individuals, with HIV. Clinical electives are available at the interdisciplinary Yale Gender Program and the Walter–Whitman Clinic in Washington, DC, both of which have a focus on transgender and non-binary health care.
YSM Deputy Dean for Education Jessica Illuzzi, MD, MS, professor of Obstetrics, Gynecology and Reproductive Sciences, says it is vital that students are trained to care for transgender and non-binary individuals to ensure this segment of the population receives the care they need and deserve in a supportive, understanding, and inclusive environment. “Recognizing and minimizing bias in caring for our patients is critical. This is at the core of our mission and, therefore, our curriculum.”