Chapter 2 – Literature Review
A. Introduction
The purpose of this review is to investigate the current climate related to transgender patient care among medical students and physicians and to determine how training has improved and can continue to be improved for better healthcare outcomes for the transgender population. There will be a review of literature explaining how lack of training can increase risk of poor outcomes for transgender patients. The review is limited to peer-reviewed sources, works in English, and publications within the last ten years. Initially, the review was meant to focus on the training of plastic surgery residents and attendings on transgender patient care, however, the review was extended to include physicians of all specialties and medical students in order to have an adequate quantity of data to assess. This review will begin by addressing the research supporting the need for transgender-specific medical education to be received across all specialties, concluding with a special focus on the need specifically in plastic surgery. Sources describing improving education in healthcare workers who are not medical students or physicians such as nurses, nurse practitioners, physicians’ assistants, and so forth were excluded.
The general findings from the literature review demonstrate that even though there have been several steps forward taken by the medical community to improve training for care of transgender patients, a gap in knowledge continues to exist and poses a threat on healthcare outcomes for this population. Furthermore, the review supports that medical students and physicians who have participated in educational activities, such as OSCEs, specific for improving care of transgender patients have positive outcomes and can be used as a reference for future transgender specific training. However, more research needs to be done in order to address the challenges associated with implementing these educational activities and to determine the true long-term impact on medical students and physicians using longitudinal studies.
B. Main Body
The literature findings demonstrate a strong need for transgender-inclusive healthcare education. Members of the transgender community continue to face barriers to accessing healthcare, including stigma, discrimination, and lack of understanding among healthcare professionals. A recently published manuscript reviewed reports of barriers transgender individuals face and found that of these barriers, lack of sufficient knowledge of transgender specific care among providers is the most significant (1). Of note, the majority of these findings were self-reports by transgender patients as opposed to more direct techniques such as assessing individual physician skills and knowledge of transgender specific care. Furthermore, even though this study shares that the biggest limiting step is providers’ gap of knowledge, the source of this gap is largely unknown, and future research needs to be conducted in order to determine this. The authors suggest several methods of identifying the source of this gap which should include determining current biases that exist among medical students and physicians, how much training in this field is being received and so forth (1).
While many barriers in access to healthcare among transgender patients are self-reported, there have been case reports published that describe how limited knowledge of medical care for transgender patients extends the time to make a diagnosis and treatment plan. One case report describes the presentation of a transgender male patient with nausea, vomiting and diarrhea that was complicated by his history of multiple bottom surgeries (2). The patient’s condition continued to deteriorate, and he was eventually transferred to a specialized facility where he would receive adequate medical intervention. This case demonstrates how all medical specialties will eventually come across transgender patients and will require learning basic needs of this population in order to diagnose and treat in a timely manner. Sending patients to other facilities due to lack of adequate education increases the time for risk of developing patient morbidity and mortality. The authors of this case report shared that their lack of knowledge of the management of this patient was the result of minimal exposure of this topic during their medical school education and residency training (2). A separate study was conducted in order to evaluate knowledge of transgender health management in residents and physicians at different levels of training from multiple specialties in a single institution (3). 118 surveys were completed, 66 by residents and 52 by attendings all from a wide variety of surgical, medical, and pediatric specialties. The surveys indicated that only 37.9% of residents and 46.2% of attendings felt that they could confidently provide adequate care for a transgender patient. The top two reasons respondents attributed to lack of confidence were lack of exposure working with transgender patients and lack of formal education. Lack of formal education is a direct result of poor integration of transgender specific healthcare in medical school. These studies demonstrate the need to incorporate transgender patient care into medical education.
Medical schools and residency programs can include transgender patient care in their curricula to ensure that physicians receive adequate training which can include didactic lectures, case-based learning, and hands-on experience. Even though these interventions have been proposed over the years, research demonstrates that there has been only slight implementation has been achieved. In 2018, a review of predefined criteria and medical education of transgender health in allopathic and osteopathic medical schools in North America found that education in transgender health continues to be significantly sparse (4). This study found that more than half of Liaison Committee on Medical Education accredited academic practices reported no LGBTQ-related training, and a comprehensive LGBTQ-competency training program was only available in less than one-fifth of accredited academic practices (4). When the researchers quantified curricular hours devoted to transgender-specific topics such as transitioning and gender-affirming surgeries, medical students reported receiving less than 2 hours of education (4). Since the publication of this report, there have been attempts to enhance transgender-specific training. A more recent study in 2020 reviewed original articles reporting outcomes of transgender education interventions among allopathic and osteopathic institutions in the United States and Canada (5). Some interventions that were discussed involved the improvement of transgender based education in medical students, and other interventions described extending training beyond medical school to training of residents, fellows and attendings. This review is limited in that it does not investigate all available transgender educational interventions. However, it sheds light on several recent improvements in education. When transgender-specific education was initially introduced into the medical school curriculum, it was very brief and often only measured short term improvement that may not have been retained. The majority of medical students continue to have limited exposure to transgender-specific care. However, recent literature shows that there is an increasing trend of longitudinal intervention in undergraduate medical education, meaning that they will be tested on their retention of transgender related education on multiple occasions over a long period of time as opposed to being assessed just once post their initial training (5). This form of spaced repetition increases the likelihood of comprehension and clinical application of concepts related to transgender health. The researchers found that recently options for continuing medical education online for postgraduate medical education have been made available. Again, by reviewing transgender-specific medicine, practicing physicians will be more equipped to treat and manage transgender patients. Physicians and residents will be the ones mentoring and teaching medical students during their clerkship rotations. Therefore, it is imperative for physicians and residents to remain up to date on best practices in regard to transgender health so they can pass down this information to their medical students.
In order for continuing medical education of transgender patient care to serve its purpose, practicing physicians need to have the motivation and interest to participate. One study surveyed medical providers on their motivation for seeking out training in gender-affirming care and to provide recommendations for preferred training experiences (6). The researchers found that the greatest motivators for training in gender-affirming care were to fill a need in the community and having met a transgender person in a clinical setting who requested this care, with a small percent reporting being inspired by a lecture and because it was a requirement of their training. Of the 153 providers surveyed, 148 were from the U.S., across 37 states representing all major geographic regions, and from a diverse group of specialties (6). While this study demonstrates that the majority of physicians from a number of specialties and throughout the U.S. who responded to the survey are motivated to participate in continuing medical education related to transgender patient care, it may be limited since this represents less than 1% of practicing physicians in the U.S.
Motivation amongst physicians to continue education on transgender-specific care will increase the advocacy of integrating this education into the medical school curriculum. Even though there has been research demonstrating the increase in different methods of teaching transgender medical care, there has been little mention of which approach would be most efficacious. However, there is a study that highlights the health inequities that transgender patients face and proposes key elements of providing comprehensive education on transgender health in medical schools (7). One key element includes involving members of the transgender community by having them provide input on how to improve medical school education on transgender health. A second key element is to mention and test transgender health throughout didactic learning as opposed to providing a single lecture or two about transgender health. For instance, a lecture on cholecystitis can mention risk factors in transgender females who are at increased risk due to exogenous estrogen use. A separate study tested the theory of the first key element by having gender minority simulated patients participate in an OSCE (8). Transgender OSCEs are specifically designed to assess medical students’ and practitioners’ ability to work with transgender patients by assessing their performance during scenarios that involve taking a medical history, conducting a physical examination, and discussing treatment options of a transgender patient. In this study, gender minority simulated patients were meant to measure two things, the first being medical students’ ability to provide gender-affirming care and the second being to understand the experiences and perceptions of the gender minority members who served as simulated patients. The research findings consisted of three themes which included personal connection, gap identification, and insight into medical education. The simulated patients were able to use their personal connection to provide genuine feedback by identifying specific gaps students had with management of a gender minority patient such as communication skills, assumptions, and knowledge about gender identity and gender-affirming care. Not only did medical students gain valuable insight from this experience, the gender minority simulated patients were able to appreciate the complexity of learning clinical skills and how their feedback can help overcome the obstacles faced to providing inclusive simulation (8).
Receiving feedback from transgender individuals and healthcare professionals is an invaluable tool to ensure that there is an accurate reflection of the healthcare needs of the transgender community. However, there are roadblocks in the development of effective transgender OSCEs. For instance, it is extremely difficult to find transgender patients willing to participate as simulated patients. In the aforementioned study, the simulated patients were identified as gender minorities and transgender patients only make up a small portion of the gender minority population.
The number of transgender healthcare providers who could serve as simulated patients is sparse and it is difficult to create realistic and effective scenarios without comments from transgender healthcare providers. Despite these obstacles, attempts have been made to create effective OSCEs even if only a small portion of the simulated patients identify as transgender. For example, researchers designed a transgender simulated patient to address communication challenges among fourth-year medical students (9). During the OSCE, the students would meet with a simulated patient who was portraying either a transgender woman or a transgender man who has not seen a doctor is years due to previous discriminatory experiences, however, is presenting today to appease their spouse who wants to obtain a life insurance policy. The students were being assessed on their interpersonal skills by avoiding inappropriate language such as “what were you born as?” and by obtaining pertinent information in the history such as asking if they are taking medications that are not prescribed such as buying hormones online. All 64 students were asked to complete a post-session evaluation and the researchers found that most of the students found this new case largely effective. Less than 36% of students reported feeling prepared by their medical education prior to this case and the majority felt that this experience provided them with valuable knowledge and skills to effectively provide medical care for transgender patients (9). Similar results were found in another study that was conducted to assess primary care internal medicine residents’ opinions on their comfort with treating transgender patients before and after an OSCE (10). The purpose of this study was not only to test the current skills and knowledge residents had for treating transgender patients, but to test whether this experience motivates them to fill in the gaps and learn more about proper transgender care. These OSCEs were more complex than the previous study as they not only tested the interview skills, but the ability to manage transgender patients medically. For instance, one of the cases involved the resident building rapport with the patient as well as managing the complications they are experiencing with testosterone-blocking medications (10). Following the OSCE, the residents were asked to share their experiences. The researchers found that residents who had more than one case with a transgender patient or greater past exposure rated the experience as more meaningful compared to residents who were participating in a transgender OSCE for the first time. Many of the residents also reported a lack of confidence when using affirming language and transgender care. The researchers found that most residents related that their lack of confidence was partially due to the fact that they knew they were being observed by faculty and did not want to be perceived as incompetent by their colleagues. Of note, the residents reported that their ability to devise a plan during the simulated training was not equivalent to how it would be done in a clinical setting where they have access to computers and internet sources to guide their management. Overall, the primary care internal medicine residents reported that the cases were challenging but had given them the chance to think about the skills of gender-affirming care and had inspired them to go out of their way to learn more (10).
It is of utmost importance that residents and attendings of all specialties receive education on basic transgender patient management, however, it is of even greater importance that specialists who have the most interaction with transgender patients such as endocrinologists, urologists and plastic surgeons have adequate transgender health specific training. A study from 2017 demonstrates how there is a significant lack of transgender-specific didactic and clinical training in ACGME accredited plastic surgery and urology programs (11). 145 program directors from these programs responded to the survey and it was found that on average these programs offered about 1 didactic hour and 2 clinical hours of transgender content per year. Of the program directors who responded, 18 % of plastic surgery programs offered no didactic education, and 34% offered no clinical exposure. 42 % of urology programs offered no didactic education, and 30% provided no clinical exposure. The researchers found that program directors who rated transgender education as important were significantly more likely to offer related education to the residents of their programs. Geographic location was a contributing factor since program directors of programs located in the southern U.S. compared to program directors from other parts of the U.S. were significantly less likely to rate transgender education as important which correlated to less hours of transgender education being provided to their residents (11). These results demonstrate that cultural stigma continues to exist as a barrier against training medical professionals on transgender specific care. This also shows that specialists who will have the most interaction with the transgender community are unlikely to receive the training they need to provide adequate care for their transgender patients.
Residents who do not have training dedicated to addressing transgender specific health will need to learn on the job and rely on their encounters with transgender patients to gain clinical experience. There are similar studies that support these findings. A cross-sectional study in 2022 reviewed the current state of gender transition education in US plastic surgery residency programs by assessing if accredited independent and integrated plastic surgery residency programs had incidental or structured transgender education. The findings of this study were consistent with the aforementioned study. Information about 130 independent and integrated programs was assessed based on details of curricula posted on official program websites, and through email and phone interviews with the program coordinator. The researchers found that of these programs, 74% provided exposure to gender affirming surgery, however, an estimate of how many was not provided (12). Programs that provided formal training all included didactic learning, but 86% provided clinical training. Furthermore, only 43% of these programs gave residents the opportunity to rotate on a dedicated rotation for gender transition surgery.
Based on a separate review of 186 studies across various specialties, residents who have had more education feel more comfortable providing care to transgender patients, however, the majority agree that the training providing does not provide adequate preparation (13). At this time the ACGME has no case log requirements or mandated education related to transgender health. The researchers found that residents with more hands-on experience during training were more comfortable and efficacious at treating transgender patients. Therefore, it has been proposed that residents from programs across all surgical specialty programs should record a certain number of top and bottom surgeries for transgender patients that they participated in planning, scrubbing in on and providing post-operative care/counseling (13). One of the many needs of transgender patients who want to proceed with gender affirming surgeries is affordability. By having training related to transgender based care, surgeons will be able to keep this need, among many other needs, as a priority to address. For example, male to female gender affirmation surgeries include breast augmentation, genital construction, and facial feminization surgery (FFS). Essentially, transgender patients undergo multiple operations during their transition, increasing their hospital stay and costs. One way to reduce the financial burden for transgender patients is by combining surgeries to limit number of hospitals stays. Researchers presented a study involving several transwomen undergoing both a frontal bone reduction and rhinoplasty in one visit (14). All four patients were re-assessed at 3-month, 2-year, and 4-year follow-ups and were found to have no complications and an excellent aesthetic result. This combined approach reduces hospitalizations, costs and time for transitioning. By improving medical training, plastic surgeons can safely conduct multiple surgical interventions for transgender patients at a time. Plastic surgeons can also conduct multiple surgeries alongside other specialists such as urologists. This can be done by training specialists to consult with one another and how to devise a multimodal approach as a team for the surgical treatment of transgender patients.
This type of education was proposed by several researchers who described the design of a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program (15). Surgical intervention for transgender patients requires care by a team involving nurses, social workers, physical therapists, mental health specialists, endocrinologists, gynecologists, urologists, and plastic surgeons. By training team members to develop coordinated medical care this will enhance the medical intervention transgender patients receive and will minimize the back and forth between physicians who are not equipped to provide proper care. The researchers aim for this collaborative practice to give each patient who comes in to have their needs addressed in a 1-day visit to avoid multiple trips and minimize patient dissatisfaction. The authors of this article support their claims for the importance of applying this plan, however, the limitation is that this plan has not actually been tested and implemented.
C. Conclusions
Fundamentally, transgender patients face many barriers when attempting to receive medical care which ranges from personal biases to lack of knowledge related to the management they require. This is seen across all specialties throughout the country and throughout the world. Even specialties that commonly interact with transgender patients, such as plastic surgeons, lack the training they need in order to be confident in their clinical and surgical skills required for managing transgender patients. Education should be addressed along all levels of medicine including medical students, residents, fellows, and attendings. This can be done using didactic lectures, OSCEs, continuing medical education, requiring logging a certain amount of transgender patient interactions or surgeries, and so forth. Several studies have highlighted the need for transgender-inclusive healthcare education and show that participants express feeling more capable of managing transgender patients after being involved in these experiences. There have been proposals for different types of programs, specifically those to address a multidisciplinary approach involving multiple specialists teaming up to adequately care for transgender patients. However, these have yet to be tested in actuality. Overall, improving medical professionals’, especially plastic surgeons’, training for transgender patient care requires a multi-faceted approach that includes both medical education and ongoing professional development. These strategies have the potential to improve the quality of care provided to transgender patients.
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