The Equal Curriculum: The Student and Educator Guide to LGBTQ Health [1st ed. 2020] 978-3-030-24024-0, 978-3-030-24025-7

Table of contents :
Front Matter ....Pages i-xxiii
Language and History of the LGBTQ Community (Michael Haymer, Smitty Buckler-Amabilis, Katherine Lawrence, Marcus Tye)....Pages 1-12
LGBTQ Health Disparities (Jeremy Connors, Maria Carolina Casares, Michael C. Honigberg, John A. Davis)....Pages 13-31
The LGBTQ-Friendly Clinic Encounter (Brian A. Nuyen, Maria Carolina Casares, Eric Fifield, Kevin Johnson, Rita S. Lee)....Pages 33-55
Interdisciplinary Approach to Care (Brian A. Nuyen, Jason D. Domogauer, Laura Jennings, Julie Kinzel, Michele J. Eliason)....Pages 57-70
Prevention (Brian A. Nuyen, Florence Doo, Philipp Hannan, Ronni Hayon)....Pages 71-90
Child and Adolescent Medicine (Jeremy Connors, Laura Irastorza, Aron Janssen, Bobby Kelly)....Pages 91-105
Adult Primary Care (Carl G. Streed Jr., Melanie Adams, Christopher Terndrup, Andrew Petroll)....Pages 107-129
Sexual Health (Carl G. Streed Jr., Ivy H. Gardner, Kara Malone, Brent C. Monseur)....Pages 131-151
Transgender Health (James R. Lehman, Lydia A. Fein, Elan L. Horesh, Marina Petsalis, Erryn E. Tappy, Christopher Estes et al.)....Pages 153-179
Emergency Medicine (Carl G. Streed Jr., Elizabeth A. Samuels, Joyce Rosenfeld)....Pages 181-198
HIV/AIDS (Brian A. Nuyen, Jennifer L. Glick, Vanessa Ferrel, W. Christopher Mathews)....Pages 199-221
Psychiatry and Neurology (James R. Lehman, Ashley Rae Martinez, A. Ning Zhou, Stephan Carlson)....Pages 223-252
Data Collection and Research (Michael Haymer, Nadejda Bespalova, Laura Jennings, Brandyn D. Lau)....Pages 253-260
Topics in Global LGBTQ Health (Shilpen Patel, C. Nicholas Cuneo, John R. Power, Chris Beyrer)....Pages 261-288
Back Matter ....Pages 289-317

Citation preview

The Equal Curriculum The Student and Educator Guide to LGBTQ Health James R. Lehman Kristine Diaz Henry Ng Elizabeth M. Petty Meena Thatikunta Kristen Eckstrand  Editors

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The Equal Curriculum

James R. Lehman Kristine Diaz  •  Henry Ng Elizabeth M. Petty Meena Thatikunta • Kristen Eckstrand Editors

The Equal Curriculum The Student and Educator Guide to LGBTQ Health

Editors James R. Lehman Department of Psychiatry University of Wisconsin–Madison Madison, WI USA Henry Ng MetroHealth Medical Center The MetroHealth System Cleveland, OH USA Meena Thatikunta University of Louisville Louisville, KY USA

Kristine Diaz Medical Directorate Defense Health Agency-National Capital Bethesda, MD USA Elizabeth M. Petty UW School of Medicine and Public Health University of Wisconsin–Madison Madison, WI USA Kristen Eckstrand Department of Psychiatry University of Pittsburgh Pittsburgh, PA USA

ISBN 978-3-030-24024-0    ISBN 978-3-030-24025-7 (eBook) https://doi.org/10.1007/978-3-030-24025-7 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

To our patients, who are resilient through health and hardship.

Ignorance as a Public Health Threat There are an estimated 8.8 million LGBT-identifying individuals in the United States. (The use of LGBT versus LGBTQ – adding the Q for queer or questioning – in this text depends on the specific context of their use.) For our health care system to systematically ignore and at times abuse millions because of their identity and health needs is unjust. Through silence, ignorance, and hate we have created a second-class citizenry whose members suffer emotionally, physically, and mentally because they cannot obtain adequate health care. According to the Center for American Progress, the LGBT population experiences significant health disparities that are attributable to a lack of quality health education and subsequent professional unpreparedness. A JAMA study found that 33.3% of medical schools dedicated zero hours of their curriculum to LGBT health. On average, medical schools dedicated just five hours to LGBT health education. The quality of this education varied widely; most is focused on HIV/AIDS, which represents just a sliver of the LGBTQ health spectrum. Ninety-two percent of medical students reported at least one clinical encounter with an (openly) LGBT-identifying patient. Despite predictable contact with LGBTQ patient(s), 46% of heterosexual medical students displayed explicit bias, defined as consciously expressed attitudes or beliefs, against gay men and lesbian women. Eighty-one percent of students displayed implicit bias, defined as subconscious attitudes or beliefs, against gay men and lesbian women. Furthermore, in a study of 1,335 medical students, a mere 12.9% passed a test assessing medical knowledge relevant to LGBT patient care. These statistics are alarming: the respondents represent the brightest students of our nation and future health care workforce. Medical education has so far left its students unprepared and the prognosis of the LGBTQ population’s health rather grim.

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Learning the Hard Way Students often lament that the first time they realize how truly unprepared they were to care for LGBTQ patients is, not surprisingly, the first time they care for an LGBTQ patient. That experience came early for my own class in our second year of medical school. Northeast Ohio Medical University (NEOMED), my alma mater, is unique in that it provides a lecture-based curriculum and experiential opportunities to interact with LGBTQ-identifying patients before clinical rotations. In one saturday session, we had four hours in which we organized into groups of four students and collectively interviewed a series of LGBTQ-­identifying patients. There was no chief complaint, just a conversation about anything the students are curious. We were ill-prepared for such a situation. Why? First, there was no chief complaint, leaving us wondering what to explore. Second, the preparatory lecture meant to teach us about sexual orientation and gender identity lacked substantive recommendations. Therefore, we didn’t know what was medically relevant to ask. Most students were flummoxed. Embarrassed. Quiet. I wouldn’t have expected much more since we were so ill-equipped for the situation. We were unprepared to care for an LGBTQidentifying patient, and we learned that lesson the hard way. (The curriculum has since been revised to better prepare students.) Medical education is in clear need of reform.

A More Equal Curriculum When reading a book, pay attention to what is said. Pay equal attention to what is not said.

This pearl from my high school English teacher, Ms. Connie Smith, has always stuck with me – it’s part of being a critical learner, physician, and citizen. Analyze everything for what it is and for what it is not. That wisdom stayed with me even in medical school. Early on at Northeast Ohio Medical University (NEOMED), I realized that my education left me unprepared to care for an LGBTQ-identifying patient, leaving potential for patient discrimination, morbidity, and mortality. This is something that was, as Ms. Smith would say, “not said.” An unspoken injustice. “But, why? Why?” The question ran through my mind often. There was no good answer for me. I had grown up with a good number of friends and colleagues who identified with varying sexual orientations and gender identities. To me, it was normal and healthy to have this kind of diversity in one’s life. It bothered me that medical education did not have the same expectations, especially for the LGBTQ population. So again, I asked, “Why is medical education ignoring this population?” No system is free of bias or injustice, even a system as altruistic as medical education. As it stood, the curriculum was unequal – teaching about some diseases and some populations and not others, simply because of ignorance. It was a medical education I could not swallow. I had discovered an inconvenient truth, and it gnawed at my conscience.

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We needed a more equal curriculum. I started looking at the data and ongoing efforts across the country. This “unequal curriculum” was actually a national problem. I saw a few people making effective headway at their own institutions, but no one effort was national in scope. The problem seemed unsolved to me. In order to gather more insight, I called leaders in LGBTQ health medical education. Essentially, I asked the same questions on every call, “What are we doing about this nationally? Why isn’t there a widespread curriculum?” Most said, “Sure it makes sense to do something, but no one has. We are all at our own institutions fighting battles here to teach LGBTQ health effectively.” It was true; I was doing the same at NEOMED. I consulted the incredible leaders I had met across the country on how to do this the right way at NEOMED.

Introducing Educational Reform The first step was trying to understand the barriers to introducing LGBTQ health curriculum at any institution. I’ve briefly summarized those conversations into a list of considerations I had to make before I began the reform process: • New territory. Only within the last decade have major organizations pushed for LGBTQ health competency as an educational standard. Additionally, we are still in the infancy stages of defining what those competencies even are. • Few qualified, institutional advocates. Think of your own faculty. If they have never been taught LGBTQ health, it’s unlikely that they will be able to teach it themselves. It is a cycle of ignorance and silence. • Insufficient comprehensive, introductory teaching resources. Imagine again your faculty trying to teach themselves this topic so they can in turn teach you. Without introductory and summative learning resources, this is a challenging task indeed. • Limited curricular time. Medical education is already saturated with material. How can we add on yet another competency area? • Stigma. Medical education still has discriminatory practices related to race, gender, religion, age, socioeconomic class, sexual orientation, etc. Worse yet is medical education’s “sweep under the rug” culture; medical education continues to be a risk-averse environment in which addressing controversial issues is not welcomed. The educational leaders I consulted insisted that barriers should be acknowledged and addressed head on. We had a group of five truly passionate students who continued to push to reform and introduce new curriculum. In fact, the more we pushed, the more we received. The student feedback on the curriculum was incredible! We made a difference at NEOMED. Still my wheels turned. The LGBTQ population is suffering because we haven’t educated health care providers en masse. Widespread, national curriculum was the answer. Paul Farmer, MD writes in his book Infections and

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Inequalities about a patient to whom he administers antibiotics for tuberculosis. Were it not for his volunteer service, she would have likely died of the disease. Those observing thought her recovery was a miracle. Dr. Farmer bluntly writes, "When she received⋯[the antibiotics], she soon began to respond  – almost as if she had a treatable infectious disease.” Dr. Farmer means this is not rocket science; this is a problem with a concrete solution. Here the solution is a widely accessible, comprehensive educational resource⋯which is a tangible goal⋯Doable. Then, what were we waiting for? We know the LGBTQ population is suffering within the health care system. LGBTQ-identifying individuals need and deserve quality care from well-taught health professionals. It is our duty to help patients thrive despite injustice, invisibility, stigma, and abuse.

Committed Citizens Never doubt that a small group of thoughtful, committed citizens can change the world; indeed it is the only thing that ever has. – Margaret Mead

I was ready to start, and I called on leaders in LGBTQ health medical education to join me. Some thought I might be crazy. Most were intrigued. A few thought I might actually be on to something. It was those few who grew into our current team – initially over seventy some folks from all across the world. We all believed in this singular idea. That it was doable. Ah, how incredible. Henry Ng, MD, MPH was one of my earliest teammates. I drove to his office in Cleveland to glean some insights and hopefully win him over. His career exemplifies such integrity, bravery, and justice; he is a real-life hero. Eventually, Dr. Ng joined as a Senior Editor. At that time, I still had no concrete strategy, just Dr. Ng’s support. I kept going. I had heard much about Kristen Eckstrand, PhD – now MD, PhD – a fellow medical student. She had her finger on what seemed like every LGBTQ health medical education initiative in the country. Kristen joined as a Senior Editor. I met her in-person a few months later at a conference. I offered to shake her hand; she refused and leaned in for a hug. It is one of the most meaningful hugs I have ever received. Kristen connected me with Kristine Diaz, PsyD, and insisted that Kristine needed to be a Senior Editor as well. Kristine adds a much-needed perspective on the psychosocial aspects of LGBTQ health, as well as innovative approaches to medical education. She is a rare and powerful combination. James R Lehman, MPH – now MD, MPH – a fellow medical student and advocate, came out of the blue. James found my online Prezi (a pitch for the project) and immediately understood the potential impact of The Equal Curriculum. Since then, James has been something of a secret weapon, ­making progress against all odds. He was an Associate Editor, then became the Managing Editor, then a Senior Editor. James connected me with Elizabeth M. Petty, MD and insisted that she needed to be a Senior Editor. Dr. Petty knows medical education and knows

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medical students. It’s an effective combination for leadership, especially on this project. Next we gathered our most instrumental players, our many Associate Editors and primary authors. Many of them were students, which was by design. One of the barriers to LGBTQ health medical education reform is lack of faculty to teach such curricula. That faculty will come  – they are today’s students. The Equal Curriculum is an opportunity for students to lead and teach others. Moreover, The Equal Curriculum is a revolutionary effort to reform medical education nationally, and was humbly made possible by “thoughtful, committed citizens” who joined together.

Renewed Duty I hope that you will read this text with a sense of duty. There are patients who need your help. Be knowledgeable. Be compassionate. Teach others, too. It is within your power to open minds and change systems. May you heal patients and our ailing health care system. This text addresses only one barrier to LGBTQ health medical education reform: lack of comprehensive educational resources. It is a novel substrate but you are the catalyst. With your help we can galvanize LGBTQ medical education reform across the country, one institution at a time. Share this book with your peers, your faculty, and institutional leadership. Encourage them to read it and reform curricula. Together, we can come to expect an equal curriculum. Thank you for all that you do. Meena Thatikunta, MD Founding Executive Director, Senior Editor

Acknowledgments Thank you to the many physicians (Keisa Bennett, Mitchell Lunn, Greg Blaschke, Abbas Hyderi, William O’Byrne, Baligh Yehia, and others) who listened to my pitch for this project, offered advice, and connected me with other movers and shakers. Thank you to the entire The Equal Curriculum team for inspiring me with your sense of duty and daily work. I am so glad to have met all of you and to have created this work together. May you go on to do even greater things. Lastly, but certainly not the least, we are also grateful to NEOMED and its then College of Medicine Dean, Jeffrey Susman, MD, for their institutional and financial support of this project in its early stages.

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References Burke S, Dovidio J, Przedworski J et al. Do contact and empathy mitigate bias against gay and lesbian people among heterosexual first-year medical students? A report from the Medical Student CHANGE Study. Acad Med. 2015;90(5):645–51. Center for American Progress. How to close the LGBT health disparities gap: 2009. Lapinski J, Sexton P, Barker L.  Acceptance of lesbian, gay, bisexual, and transgender patients, attitudes about their treatment, and related medical knowledge among osteopathic medical students. JAOA. 2014;114(10):788–96. Obedin-Maliver J, Goldsmith E, Stewart L et al. Lesbian, gay, bisexual, and transgender related content in undergraduate medical education. JAMA. 2011;306(9). Sanchez N, Rabatin J, Sanchez J, Hubbard S, Kalet A. Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. J Fam Med. 2006;38(1):22. The Williams Institute. How many people are lesbian, gay, bisexual and transgender?: 2011.

Foreword

Preface

It has been 50 years since the Stonewall Riots, regarded by many as the most significant event in LGBTQ history during the previous century. Since then, the story of LGBTQ Americans has had many twists and turns, from the HIV/ AIDS epidemic, to policies like “Don’t Ask, Don’t Tell,” and most recently, universal civil marriage equality. While organizations devoted to the health of sexual and gender minorities have labored for decades through these changes, it is only in the last several years that many government offices and mainstream health care organizations have openly acknowledged LGBTQ health as a priority. Health care has had a parallel story. There is no shortage of examples of hostility and abuse – both interpersonal and structural – toward LGBTQ people. Though instances of severe abuse in the health system grow rarer, treatment and education practices have been sluggish in the realm of LGBTQ health. Where medicine previously grappled with tolerance, it now must evolve to provide treatment that is fully inclusive and equitable. Many organizations, instructors, and trainees have started to develop and implement teaching about LGBTQ health. While these efforts have been excellent, they tend to address the needs of a specific time, place, and audience. The Association of American Medical Colleges has developed core competencies for LGBTQ medical education, giving educators – including us – a common concept of appropriate training outcomes. In writing The Equal Curriculum, we have tried to create a comprehensive, high-quality resource that can serve as a foundation for LGBTQ health education across multiple disciplines. The subject matter has been organized for integration into preclinical work and clinical rotations, with careful attention to breadth and depth. Our hope is that a new generation of health professionals will have the tools that they need to deliver thoughtful and informed care to persons of all sexual orientations and gender identities.

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Dozens of hardworking people contributed to this text. We would particularly like to thank our early phase copy-editor Kerry Bailey and our graphic designer Trent Waterman (https://www.trentwaterman.com), who were instrumental in making this work accessible and digestible for time-strapped trainees. Washington, DC, USA Kristine Diaz Pittsburgh, PA, USA Kristen Eckstrand Madison, WI, USA James R. Lehman Berea, OH, USA Henry Ng Madison, WI, USA Elizabeth M. Petty Louisville, KY, USA Meena Thatikunta 

Preface

Contents

1 Language and History of the LGBTQ Community����������������������   1 Michael Haymer, Smitty Buckler-Amabilis, Katherine Lawrence, and Marcus Tye 2 LGBTQ Health Disparities ������������������������������������������������������������  13 Jeremy Connors, Maria Carolina Casares, Michael C. Honigberg, and John A. Davis 3 The LGBTQ-Friendly Clinic Encounter ��������������������������������������  33 Brian A. Nuyen, Maria Carolina Casares, Eric Fifield, Kevin Johnson, and Rita S. Lee 4 Interdisciplinary Approach to Care ����������������������������������������������  57 Brian A. Nuyen, Jason D. Domogauer, Laura Jennings, Julie Kinzel, and Michele J. Eliason 5 Prevention ����������������������������������������������������������������������������������������  71 Brian A. Nuyen, Florence Doo, Philipp Hannan, and Ronni Hayon 6 Child and Adolescent Medicine������������������������������������������������������  91 Jeremy Connors, Laura Irastorza, Aron Janssen, and Bobby Kelly 7 Adult Primary Care ������������������������������������������������������������������������ 107 Carl G. Streed Jr., Melanie Adams, Christopher Terndrup, and Andrew Petroll 8 Sexual Health������������������������������������������������������������������������������������ 131 Carl G. Streed Jr., Ivy H. Gardner, Kara Malone, and Brent C. Monseur 9 Transgender Health ������������������������������������������������������������������������ 153 James R. Lehman, Lydia A. Fein, Elan L. Horesh, Marina Petsalis, Erryn E. Tappy, Christopher Estes, and Christopher J. Salgado 10 Emergency Medicine ���������������������������������������������������������������������� 181 Carl G. Streed Jr., Elizabeth A. Samuels, and Joyce Rosenfeld

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11 HIV/AIDS ���������������������������������������������������������������������������������������� 199 Brian A. Nuyen, Jennifer L. Glick, Vanessa Ferrel, and W. Christopher Mathews 12 Psychiatry and Neurology �������������������������������������������������������������� 223 James R. Lehman, Ashley Rae Martinez, A. Ning Zhou, and Stephan Carlson 13 Data Collection and Research�������������������������������������������������������� 253 Michael Haymer, Nadejda Bespalova, Laura Jennings, and Brandyn D. Lau 14 Topics in Global LGBTQ Health���������������������������������������������������� 261 Shilpen Patel, C. Nicholas Cuneo, John R. Power, and Chris Beyrer Appendix 1: Resources for LGBTQ Patients���������������������������������������� 289 Appendix 2: National Support Organizations�������������������������������������� 295 Appendix 3: Glossary������������������������������������������������������������������������������ 299 Appendix 4: AAMC Competencies�������������������������������������������������������� 305 Appendix 5: Recommended Reading by Profession and Clerkship �������� 309 Index ������������������������������������������������������������������������������������������ 311

Contents

Contributors

Melanie Adams, MD  Cape Breton Regional Hospital, Sydney, NS, Canada Nadejda  Bespalova, MD  NYU Langone Medical Center, New York, NY, USA Chris  Beyrer, MD, MPH Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Smitty Buckler-Amabilis  Rad Care, Seattle, WA, USA Stephan Carlson, MD  Brookdale Hospital Medical Center, Brooklyn, NY, USA Maria  Carolina  Casares, MD, MPH Georgia State University, Atlanta, GA, USA Jeremy Connors, MD  Rutgers New Jersey Medical School, Department of Medicine, Newark, NJ, USA C. Nicholas Cuneo, MD  Brigham and Women’s Hospital, Boston Children’s Hospital, Boston Medical Center, Boston, MA, USA John  A.  Davis, PhD, MD University of California, San Francisco, San Francisco, CA, USA Kristine  Diaz, PsyD  Defense Health Agency-National Capital, Bethesda, MD, USA Jason  D.  Domogauer, MD, PhD Rutgers New Jersey Medical School, Newark, NJ, USA Florence Doo, MD  Mount Sinai West, New York, NY, USA Kristen  Eckstrand, MD, PhD Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA Michele  J.  Eliason, PhD San Francisco State University, San Francisco, CA, USA Christopher Estes, MD  University of Miami, Miami, FL, USA Lydia A. Fein, MD, MPH  University of Miami Miller School of Medicine, Miami, FL, USA

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Vanessa  Ferrel, MD, MPH  Montefiore Medical Center, The Bronx, NY, USA Eric Fifield, MD  University of Toronto, Toronto, ON, Canada Ivy H. Gardner, MD  Oregon Health & Science University, Portland, OR, USA Jennifer L. Glick, PhD, MPH  Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Philipp Hannan, MD  University of Arizona, Tucson, AZ, USA Michael Haymer, MSW  David Geffen School of Medicine, Los Angeles, CA, USA Ronni Hayon, MD  University of Wisconsin School of Medicine and Public Health, Madison, WI, USA Michael  C.  Honigberg, MD, MPP Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Elan L. Horesh, MD, MPH  Mount Sinai Hospital, New York, NY, USA Laura  Irastorza, MD Arnold Palmer Children’s Hospital, Orlando, FL, USA Aron Janssen, MD  New York University, New York, NY, USA Laura Jennings, MHS, PA-C  University of Pennsylvania Health System, Philadelphia, PA, USA Kevin Johnson, MD  Yale University, New Haven, CT, USA Bobby Kelly, MD, MPH  Geisel School of Medicine at Dartmouth, Hanover, NH, USA Julie Kinzel, MEd, PA-C  Drexel University Physician Assistant Program, Philadelphia, PA, USA Brandyn  D.  Lau, MPH, CPH Johns Hopkins School of Medicine, Baltimore, MD, USA Katherine Lawrence, MD, MPH  New York University School of Medicine, New York, NY, USA Rita S. Lee, MD  University of Colorado School of Medicine, Aurora, CO, USA James  R.  Lehman, MD, MPH Department of Psychiatry, University of Wisconsin–Madison, Madison, WI, USA Kara  Malone, MD The Ohio State University College of Medicine, Columbus, OH, USA Ashley Rae Martinez, MD  University of California, San Diego, La Jolla, CA, USA

Contributors

Contributors

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W. Christopher Mathews, MD, MSPH  Department of Medicine, University of California San Diego, La Jolla, CA, USA Brent  C.  Monseur, MD, ScM Thomas Jefferson University Hospital, Philadelphia, PA, USA Brian  A.  Nuyen, MD  Stanford University School of Medicine, Stanford, CA, USA Robert  Obara, MB BCh BAO, MIPH Health Plus Medical Centre, Winnipeg, MB, USA Poornima  Oruganti, MD, MPH Loyola University Medical Center, Maywood, IL, USA Shilpen Patel, MD  University of Washington Department of Global Health, Redwood City, CA, USA Andrew Petroll, MS, MD  Medical College of Wisconsin, Wauwatosa, WI, USA Marina Petsalis, BS  University of Texas Health Science Center at Houston, Houston, TX, USA Elizabeth  M.  Petty, MD UW School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA John R. Power, MD  Vanderbilt University Medical Center, Nashville, TN, USA Joyce Rosenfeld, MD  Harrington Memorial Hospital, Southbridge, MA, USA Christopher J. Salgado, MD  University of Miami, Miami, FL, USA Elizabeth  A.  Samuels, MD, MPH, MHS Alpert Medical School, Brown University, Providence, RI, USA Ryan Smith, MD  Yale New Haven Hospital, New Haven, CT, USA Carl  G.  Streed Jr., MD, MPH Boston University School of Medicine, Center for Transgender Medicine & Surgery, Boston Medical Center, Boston, MA, USA Erryn  E.  Tappy, MD, MPH George Washington University Hospital, Washington, DC, USA Christopher Terndrup, MD  Oregon Health & Science University, Portland, OR, USA Meena Thatikunta, MD  University of Louisville, Louisville, KY, USA Marcus Tye, PhD  College of Staten Island, City University of New York (CUNY), Staten Island, NY, USA A.  Ning  Zhou, MD NewYork-Presbyterian, Columbia and Cornell, New York, NY, USA

Introduction

Education is the most powerful weapon, which you can use to change the world. –Nelson Mandela

Over 100 years ago, Abraham Flexner released his 1910 report calling for necessary change in the foundations of medical education. Higher professional entry standards and rigorous, evidence-based curricula formed the core of the Flexner report, resulting in an academic system taking pride in research, evidence, analytic reasoning, and the overwhelming dissemination of this content to physicians in training. The resultant structure and process education, where students trained for a fixed time in a fixed curriculum, became the standard for medical education for nearly a century. Flexner’s structure and process approach standardized medical education; however, it became clear that a fixed time curriculum led to variable outcomes. At the turn of the twenty-first century, accountability, responsibility, and quality of care for patients became equally recognized as core tenets of education. Indeed, it is not the structure and process of the education that needs to be fixed; rather it is the outcome of what defines a physician. This outcome should drive training, and it is this paradigm shift that leads us to competency-based medical education (CBME). The Association of American Medical Colleges (AAMC) broadly defines CBME as an educational framework utilizing curricula and assessments that support the achievement of competence in clinical practice. Competence is “measurable or observable behaviors that combine knowledge, skills, and attitudes related to specific professional activities.” Competencies are arranged across eight competency domains, each of which describes a particular theme in medicine. Competencies for graduating medical students are defined by Dr. Robert Englander’s 2013 Reference List of General Physician Competencies. Finally, different competencies work in concert to describe Entrustable Professional Activities (EPAs), the essential professional tasks or responsibilities in which a trainee should demonstrate competence before being allowed to practice unsupervised. Figure I.1 demonstrates these key pieces of CBME. Importantly, this framework has already been adopted by the AAMC Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development to describe the key features of competence in caring for individuals who are lesbian, gay, bisexual, and transgender (LGBT), gender nonconforming, and/or born with a difference of sex development (DSD).

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Introduction

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Learning Objectives

Competency

Competency Domain

EPA

Knowledge Skill

Competency

Attitude

Competency Domain

Knowledge Skill

Competency

Attitude Knowledge Skill

Competency

Attitude

Competency Domain

Knowledge Skill

Competency

Attitude Knowledge Skill

Competency

Attitude

Competency Domain

Knowledge Skill

Competency

Attitude

Fig. I.1  Understanding competency-based medical education

The Equal Curriculum strives to advance the work of the AAMC by creating the content necessary to support the acquisition of competence in caring for people who identify as LGBT. (In this section, we are using LGBT rather than LGBTQ or sexual and gender minorities, because that is the term used in the AAMC competencies.) This textbook is designed to stimulate health educators’ and students’ interest and knowledge about issues that are relevant to the optimization of the health and well-being of LGBT individuals throughout their lifespan. Most importantly, it seeks to create an educational resource to address current unmet needs of learners across diverse health professional education and training programs. The textbook was developed with consideration of varying curriculum delivery formats  – from problem-based learning to required didactic courses  – that focus on LGBT health. We will highlight how this textbook may be integrated into the curriculum at your institution as well as strategies to evaluate the integration of LGBT health topics (Fig. I.2). First, we will provide a brief overview of the chapters in the textbook. Chapters 1, 2, 3, and 4 cover general content that is highly relevant to all health professionals working with individuals who are LGBT; Chaps. 5, 6, 7,

Entrustable Professional Activity

Introduction

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CURRICULAR INTEGRATION

CONTENT

The Equal Curriculum Textbook

LGBT Specific Learning Objectives

Other

Instructional Strategies

Case scenarios

Blended/Flipped classroom

Current literature Popular media Expert panels

LERANER OUTCOME

Knowledge Assessment Competency exams High stakes exam

Skill Assessment OSCE, standardized patient exercises

Team based learning Clinical case based or Problem based learning Clinical simulation

Practical and Professional Assessment Clinical evaluations Peer evaluations

Fig. I.2  Framework to address LGBT health issues in health professions education

8, 9, 10, 11, and 12 focus on specific patient populations and areas of clinical delivery; and Chaps. 13 and 14 focus on special topics. Content was developed to highlight key points in each chapter to aid in the comprehension of each topic. Cases provided throughout the textbook will allow learners to apply the content to clinical scenarios in order to analyze how the application of relevant knowledge may impact health outcomes. Questions at the end of each chapter, which are usually written in National Board of Medical Examiners (NBME) style, assist in the application of content material. The spirit of this textbook from its inception has been a learner-centered, collaborative approach to LGBT health education. While we acknowledge the limitations of time, necessary resources, and volume of material allotted for courses, we passionately advocate for the integration of LGBT health into all aspects of curricula. The Equal Curriculum serves as a guide to support curriculum development and integration. Without proper introduction, some LGBT topics may feel disingenuous (topic included just to meet an accreditation standard) or displaced in the context of the larger course. Knowledge-­based activities (tables, charts, figures, guest speaker) in a traditional didactic, lecture format should be given in short time frames (