Over recent years, the experiences of individuals with diverse sexual orientations, gender identities, and sex developments have received increasing attention. This attention has led to activism, initiative, and change across all realms of society, including health care, to better accommodate and serve these communities. However, health equity is not yet a reality for many people who are lesbian, gay, bisexual, transgender (LGBT); gender nonconforming (GNC); and/or born with differences in sex development (DSD). Significant causes of morbidity—and subsequent mortality—remain disproportionally prevalent among the aforementioned populations.1 These health disparities are not inherent to individuals with diverse sexual orientations, gender identities, and sex developments but stem from structural factors including federal and statewide nondiscrimination policies, interpersonal factors such as family and social discrimination, and individual barriers such as internalized homophobia/transphobia. These factors, combined with the challenge of accessing affirming, responsible health care, can lead to a delay in necessary and routine care.2
Significant research has focused on the detrimental effect that interpersonal and individual factors have on the health of individuals who are LGBT, GNC, and/or born with DSD1; however, a parallel, emerging body of research highlights the importance of considering structural factors when conceptualizing health of the aforementioned populations. For example, comparing all-cause mortality between lesbian, gay, and bisexual individuals in communities with high versus low antigay prejudice, the individuals living in high-prejudice communities had a shorter life expectancy by 12 years.3 Similarly, high levels of structural stigma are further associated with greater lifetime suicide attempts among transgender adults.4 These upstream social and structural factors must be considered when conceptualizing health care for the aforementioned communities.
To improve access to care and health outcomes, it is critical that medical education for current and future providers include training to appropriately address sexual orientation, gender identity, and sex development with all patients. The Association of American Medical Colleges (AAMC) recently qualified a competency-based medical education framework to facilitate training and assessment of individual provider competence in providing responsible care for the aforementioned populations5; however, if general upstream factors underlie health inequities among these communities, training providers to address these structural factors is similarly necessary to alleviate health disparities.6 Whether to use a population-specific or structural competency approach to curriculum remains unclear.
In this article, we propose that these frameworks can work symbiotically, where the theoretical framework of structural competency—the consideration of forces that influence health outcomes at the level above individual interaction—can serve as an approach to teaching the AAMC’s professional competencies to improve health care for people who are or may be LGBT, GNC, and/or born with DSD.6–8 While both frameworks endeavor to increase medical provider competency, they differ in scope; the AAMC’s recommendations qualify an existing competency-based framework9 to ensure that individual providers ensure appropriate care to patients who are LGBT, GNC, and/or born with DSD, whereas structural competency emphasizes forces beyond individual and interpersonal interactions as critical for achieving and maintaining health. Combined, these two frameworks address health across individual, interpersonal, and structural factors of health.
Here, these frameworks are compared to demonstrate how the two schemes symbiotically enhance medical education on identity-specific health topics by addressing individual, interpersonal, and structural factors contributing to the health of the aforementioned populations. As there is an emerging need for addressing structural determinants of health, we then use a narrative approach to demonstrate teaching population-specific structural determinants of health for individuals who are LGBT, GNC, or born with DSD within the AAMC framework.
AAMC LGBT/GNC/DSD Competency Qualifiers
As of 2010, the median reported time dedicated to teaching LGBT-related content in the entire curriculum among medical schools across the United States and Canada was five hours; one-third of the schools reported zero hours.10 Two-thirds of these schools’ students rated their schools’ LGBT-related curriculum as “fair,” “poor,” or “very poor.”11 Further, very few studies have addressed medical students’ ability to deliver appropriate care to individuals identifying as LGBT, GNC, or DSD affected. To date, the most promising international medical education effort seeking to address these gaps in knowledge, skills, and attitudes is the chapter “Professional Competency Objectives to Improve Health Care for People Who Are or May Be LGBT, Gender Nonconforming, and/or Born with DSD” published by the AAMC Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development in the AAMC’s medical education guide on providing care to the aforementioned communities.6 These competencies qualify those from the Physician Competency Reference Set, the standard set of competencies used in medical education, to provide a framework for teaching and assessing competence for providing care to individuals with diverse sexual orientations, gender identities, and sex developments,5 and thus ensure that current and future health care providers are able to deliver appropriate care inclusive of these topics. Importantly, these qualifiers address the competence of individual providers and their interpersonal interactions with patients, with colleagues, and within the larger health care system. In-depth explanation of these competencies, and associated recommendations for curricular integration and assessment, can be found in the AAMC’s original publication.6
There is an overwhelming curricular need in medical training to address how patients who are LGBT, GNC, and/or born with DSD can be seen in their human complexity, to understand their health as a product of biopsychosocial development, intersecting identities, societal and personal ideologies, and structural/geographic resources and barriers. As such, these recommendations represent a new frontier in medical education that attempts to redefine health to be inclusive of sexual orientation, gender identity, gender expression, and sex development—four intrinsic components of personhood. The interarticulation of these components with other aspects of identity and culture across the life span creates the spectrum of diversity among people who are or may be LGBT, GNC, and/or born with DSD, and thus contribute to each individual’s unique health needs.
Metzl and Hansen8 define structural competency as
the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or disease also present the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health.
Within this theoretical framework exist five core skills: (1) recognition that structures shape clinical interactions, (2) development of an extraclinical language of structure, (3) rearticulation of “cultural” formations in structural terms, (4) ability to observe and imagine structural interventions, and (5) cultivation of structural humility.8
Structural competency builds upon and complements an already heavily relied-upon concept in medical education: cultural competency. Cultural competency implies the trained ability to identify and address cultural manifestations of illness and health.12 Under a cultural competency model, clinical professionals learn approaches to communication, diagnosis, and treatment that take into account culturally specific sources of stigma within the clinical encounter. Yet cultural competency alone does not provide individuals the skills, values, or perspective necessary to adequately consider the health needs of various communities and identities. Not only is it impossible to memorize all aspects of “culturally specific” information that could be important for an individual patient’s care, but operating solely under a culturally competent framework reinforces reductive understandings of identity markers without consideration of context.13
It is necessary to integrate training that includes the health needs of diverse communities into the provision of medicine. Integral to this training is a broader consideration of the impact that stigma and bias have on treatment decisions14 and the self-reflective ability of providers to manage their roles in perpetuating ideas and systems that facilitate or preclude patients’ ability to thrive.15 Culture and access to resources are mediated and often limited by social, economic, legal, and political structures that marginalized individuals rarely have agency in constructing or controlling. Structural competency operates under the understanding that stigma and health disparity are not simply the product of interpersonal encounters but also are the result of structural inequity.16 For example, as previously mentioned, structural determinants of health impacting individuals who are LGBT are associated with morbidity and mortality.1 Thus, oft-invisible structural-level determinants, biases, inequities, and blind spots shape definitions of health and illness before the clinical providers or patients enter examination rooms.8 If clinicians are to impact stigma-related health inequalities, clinical training must redirect its attention from an exclusive focus on “cultural elements” of the clinical encounter to also include the organization of institutions and policies, as well as of geography and access to essential resources.17,18
The structure of medical education and the provision of health care must continue interrogating their own culpability in invisibly reinforcing social injustices and must develop effective strategies for mitigating those injustices. Structural competency affords health care professionals the opportunity to develop new policies, practices, and political agendas that address broader structural factors impacting health in a dynamic and meaningful fashion. As medicine continues to actively address disparities within the health of and treatment provided to individuals and communities who are LGBT, GNC, and/or born with DSD, there must be specific focus on the unique structural factors contributing to the health of the aforementioned communities and how these same institutions can begin dismantling outside paradigms that perpetuate structural determinants of health among these persons and communities. Structural competency has been most extensively applied to considerations of race and racial health disparities in medical education13; however, the model’s relevance to sexual orientation, gender identity, and sex development has not been fully analyzed.
Comparing AAMC and Structural Competency Approaches
We assessed compatibility between the AAMC6 and structural competence8 approaches by comparing how the components of each converge. Given the scope of the AAMC’s aforementioned recommendations, elements of structural competency were naturally encapsulated in the AAMC’s proposed learning competencies. Table 1 demonstrates where these two models overlap.
Teaching Structural Competence Based on Sexual Orientation, Gender Identity, and Sex Development
Table 1 provides a visual representation of how the AAMC’s6 and Metzl and Hansen’s8 approaches can be applied synchronously, allowing for the teaching and assessment of structural competence as it relates to sexual orientation, gender identity, and sex development in alignment within an existing medical education framework. In this section, we explore a previously published narrative patient case to illustrate how the two approaches can be applied in a hypothetical practice situation.
First, we will rearticulate into structural terms a narrative-based patient case study published by Potter19 in the AAMC implementation guide, thereby unifying individual, interpersonal, and structural approaches to provide a multilevel understanding to individualized patient care. This reframing also adds further depth and structural context to Forcier and Potter’s20 AAMC competency-specific assessment of the same vignette.
In the case by Potter, a 65-year-old female-to-male transgender man, Mikal Brown, presents alone at a gynecology oncology clinic for treatment planning after being diagnosed with a pelvic mass consistent with stage IIIB cervical cancer. The mass was found during an ER visit prompted by intermittent bloody discharge on his underwear and recent-onset pelvic pain. By the time Mikal enters the oncology clinic’s exam room to be attended to by the physician, he is frustrated and scared, as he has encountered two instances of misnaming during clinic intake and has been additionally told, “This is a gynecology clinic; we only see women here” by medical support staff. In the exam room, Mikal tells the physician that he is not sure he wants to stay for the remainder of his appointment and is having second thoughts about pursuing evaluation and treatment because “What difference will it make, anyway?”19
The first step in developing structural competency is to consider the forces that shaped the clinical interaction and resultant gaps in care. Mikal’s initial statement wherein he voices thoughts of not pursuing treatment for cervical cancer—a fatal decision—may have been influenced by discrimination throughout the clinic including misnaming, misgendering, and denial of access to care by support staff due to normative and gendered understandings of gynecological health. What could have led to the reactions of Mikal and clinic staff?
Mikal’s medical record provides additional insight: Mikal lives alone, as his romantic partner left him when he came out as transgender 20 years ago; he works at a relatively low-paying job as an information technician; he has experienced traumatic life events; and he has not sought primary care services in years. The record elaborates, noting that pelvic exams reawaken for Mikal the trauma of an adolescent sexual assault, and that “he is [loath] to reveal genitalia discordant with his gender identity.”19 Because Mikal is an older individual who transitioned later in life, it is unclear who remains in his family and support system, and how transphobia has affected those relationships. Or, if he is engaged in community support, how might community misinformation about whether transmen need Pap tests have changed Mikal’s thoughts on receiving care? Chronic experiences of victimization and rejection, including those in the clinic, certainly challenge the ability of individuals who have experienced trauma to revisit similar, triggering contexts. Lack of legal protections based on gender identity could also have impacted Mikal’s prospects for employment and economic opportunity (or ability to take time off work), access to affordable health insurance, and/or ability to undergo transition without exorbitant financial burden. Isolation, expectation of rejection, and lack of social and financial support may further influence Mikal’s ability and willingness to continue seeking necessary medical care. Finally, Mikal may be receiving care at a clinic that does not require its front desk or clinical staff to receive training in providing safe and affirmative care such that the discrimination Mikal faced could have been entirely avoided. Indeed, Mikal’s health history and current clinical interactions have been influenced by economic, physical, and sociopolitical forces.
Identification of extraclinical structure makes explicit that Mikal’s experience extends beyond the clinic. Mikal’s disposition and health status are not a cultural phenomenon inherent to “transgender men” but are in fact facilitated by stigma, trauma, and transphobia; strict understandings of gender and health; inadequate provider training; and sociopolitical and economic systems facilitating ongoing discrimination and decreased access to care. Referring to the work of Crenshaw,21 Collins,22 and Levine-Rasky23 in intersectionality, we can additionally acknowledge that minority stress24 may affect Mikal not only through his transgender status but also as a person of color.25 As a masculine-appearing person of color, Mikal may also face daily stereotype threat.26 Again, considering the clinical context, might the likelihood of rejection from front desk staff also be due to the staff’s own implicit fears27 about black men?28 Identifying factors facilitating Mikal’s ability to thrive and the rearticulation of these factors into structural terms can enhance the ability of health care providers to better support Mikal.
As health status becomes understood as a product of these many factors, imagining structural interventions becomes necessary to ultimately improve health and access to care. For Mikal, this would require a paradigm shift inside and outside of health care. For example, this shift could occur within institutions providing gynecological care, where gynecology is not narrowly referent (symbolically or explicitly) to feminine gender but is instead inclusive and cognizant of all people necessitating gynecological health examination and treatment. This ideological shift can manifest in the changing of built environments like the clinic waiting room, where reading materials and health promotion pamphlets can attempt to inclusively reflect all patient populations accessing care. For example, Pap tests and mammography screening pamphlets, in addition to other patient education materials, can reflect various genders, family structures, romantic partnerships, and racial makeups. Electronic health records may make explicit affirming information such as a person’s preferred name (versus legal name) and gender pronoun. Education on the structural considerations regarding individuals identifying as LGBT, GNC, and/or born with DSD, and ways to better support these individuals, must be provided to all employees of the medical system across the training continuum.
Finally, structural interventions require health care institutions and providers to be cognizant of, or create, structural resources that address the many sociopolitical, economic, and geographic barriers and traumas that many sexual and gender minorities face. The clinic Mikal is accessing could begin offering a cancer support group for transgender individuals to better serve people of diverse gender identities. Similarly, given the prevalence of trauma, trauma-informed care should be provided at all sites where patients are seen29,30 (e.g., the PurPLE Clinic, a trauma-informed primary care clinic).31 Structural support could also come from specific transgender patient advocacy programs (e.g., the Trans Buddy program)32 wherein a patient advocate assists patients through in-person and resource support. Finally, health care and support could be tailored based on Mikal’s age and life experience (e.g., Elderly LGBT Interprofessional Care Collaborative).33
Throughout these efforts, structural humility—the awareness that structural competence alone is an incomplete solution—must be employed. It is with this humility that we can value and affirm Mikal’s knowledge and humbly seek to understand what has motivated him to seek care, maintain his job, and remain in a long-term relationship. Identification of Mikal’s resilience simultaneously clarifies opportunities for health care to further support his ability to thrive in new—or “queered”—ways. Indeed, it is with this humility that we recommend this proposed synergy of competency frameworks to enhance individual, interpersonal, and structural aspects supporting responsible and appropriate care for patients who are LGBT, GNC, and/or born with DSD.
Competing competency frameworks aimed at addressing the health of underserved communities can ultimately prohibit the inclusion of such material in health professions curricula. In an effort to advance continued education and training in providing quality health care for people who are LGBT, GNC, and/or born with DSD, using the AAMC and structural competency frameworks synergistically can facilitate opportunities for improving health care across individual, interpersonal, and structural levels. Although future work is necessary to develop assessment strategies for students and providers across the training continuum, myriad examples exist nationwide that model implementation of these approaches to appropriate and responsible provision of care to these communities. Through the lenses and models outlined in this paper, new and opened-up—or “queered”—modalities for attending to vulnerable patients who are LGBT, GNC, and/or born with DSD are offered as informants that guide improved medical training on these topics.
Acknowledgments: The authors wish to thank Edgar Rivera-Colon; Vanderbilt Medical Center’s Program for Lesbian Gay Bisexual, Transgender and Intersex Health; the Trans Buddy Program; the Elder LGBT Interprofessional Collaborative Care Program at Columbia University Medical Center; and Columbia University’s Narrative Medicine Program for their encouragement and support for the writing of this article.
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