Gendered Expectations: Strategies for Navigating Structural Challenges in Support of Transgender and Nonbinary Trainees in Academic Medicine

Abstract

Members of the lesbian, gay, bisexual, transgender, and queer community experience marginalization, bias, and discrimination, including in the world of academic medicine. People who are transgender and nonbinary (TGNB) experience further marginalization compared with individuals who are lesbian, gay, bisexual, and queer. According to a recent survey, more than half of medical students who are TGNB chose not to disclose their gender identities during training due to fears of discrimination, feeling a lack of support, and concerns about future career options. Academic medicine has historically pathologized TGNB individuals, perpetuating discrimination structurally and reinforcing discriminatory behaviors of peers and faculty. In this Perspective, the authors provide a comprehensive overview of the challenges that administrators and educators face in creating a learning environment that is inclusive of TGNB trainees. They outline opportunities for change and provide strategies to address administrative and educational challenges, including those related to institutional climate, policies, data collection, physical spaces, health care, curriculum, mentoring, and the evaluation of TGNB trainees. Finally, the authors issue a call to action for medical educators and administrators to create environments in which trainees who are TGNB can fulfill their educational mission: to learn the practice of medicine.

Since 2014, the Association of American Medical Colleges (AAMC) has asked matriculating medical students whether they identify as a gender different than their sex assigned at birth. The most recent data analysis indicates that 0.7% of the students matriculating into MD-granting medical schools in the United States and Canada in 2018 self-identified as transgender and nonbinary (TGNB).¹ This figure is similar to the current prevalence of transgender individuals in the United States, which is 0.4%, or approximately 1 million adults.² Importantly, recent research—including the finding that 1.8% of adolescents (in grades 9–12) identify as transgender³—indicates this estimate may be low.

Studies of physicians who are lesbian, gay, bisexual, transgender, and queer (LGBTQ) provide a sense of how the climate of medicine affects sexual and gender minorities. LGBTQ physicians report witnessing discriminatory care, hearing derogatory comments about LGBTQ people, being harassed by colleagues, and being socially ostracized.⁴ As of 2014, 36% of medical students, residents, and medical center employees who are lesbian, gay, bisexual, or transgender did not disclose their sexual orientation or gender identity for fear of discrimination and harassment.⁵

Individuals who are TGNB experience further marginalization compared with people who are lesbian, gay, bisexual, and queer. While gender identity and sexual orientation are 2 separate constructs (see Table 1), many studies about the experiences of sexual minorities such as lesbian, gay, bisexual, and queer individuals also include, in a cursory fashion, gender minorities or TGNB individuals. These umbrella studies often capture few, if any, TGNB individuals and are not tailored to gender identity–related experiences. In one study that did disaggregate the experiences of gender minority medical students, 60% (n = 35) reported that they do not disclose their identities at school due to fears of discrimination, feeling a lack of support, and concerns about future career options.⁶ Another recent study reported similar results—that only 50% of TGNB medical students and 40% of TGNB physicians disclosed their identities to their institution.⁷ The factors that go into the decision to disclose—or not—and in what context are complex, and recent studies indicate that navigating cisnormative medical culture influences how comfortable TGNB trainees are with disclosing their identities.^7,8

Table 1: Terminology Related to Gender

While academic medicine is rapidly establishing LGBTQ health initiatives and medical school diversity affairs offices are acknowledging the distinct needs of the LGBTQ population, those of us involved in medical education often find ourselves without a foundation of evidence to address the unique and vital needs of LGBTQ trainees. While the AAMC Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development has developed much-needed materials for improving LGBTQ health content and integrating this into undergraduate medical curriculum,⁹ there exists a significant dearth of resources for those working with LGBTQ trainees—and even fewer for supporting TGNB medical students and residents.

We, the authors, collectively represent various stakeholders in developing a collaborative approach to support, specifically, TGNB trainees in an academic medical center. Our team includes student and diversity affairs administrators, TGNB individuals, and LGBTQ subject matter experts. Recent studies relay how interpersonal interactions, institutional climate, curriculum, policy, and access to affirming spaces affect TGNB trainees.^7,8 Thus, in this Perspective, we (1) highlight the differing needs of TGNB medical students and physicians, (2) explore the challenges medical education administrators and educators face, and (3) provide recommendations for improving the learning and working environment and creating a more inclusive culture in academic medical centers. While we cannot possibly address every issue that may arise, we hope our Perspective will provide a starting point for institutional leaders, administrators, educators and others who want to develop a more supportive learning environment for TGNB trainees.

Important Considerations When Supporting TGNB Trainees

TGNB individuals must self-identify as such before anyone can apply the terms “transgender” or “nonbinary” to them. Gender expression and gender identity are separate constructs, though interrelated, and they may change throughout one’s lifetime (see Table 1). As noted above, TGNB trainees may choose not to disclose their identity out of fear and/or concern for retribution; thus, modeling and using inclusive language at all times is vital. Faculty members or others in the academic medicine community may be addressing someone who is TGNB but has not disclosed this identity.

TGNB trainees may hold multiple other marginalized identities that compound in unique ways.¹⁰ While student and diversity affairs professionals are becoming more sophisticated in addressing multiple intersectional identities beyond race, there remains a need to address deep-seated misogyny, ableism, homophobia, and transphobia across geographical, cultural, and racial contexts. Every school’s leaders will need to consider their school’s structure and expertise in championing interventions, and they may need to seek further expertise when they uncover gaps in knowledge.

Finally, medical educators must keep in mind that TGNB trainees who socially and/or legally transition during medical school or residency may have different needs than those who socially and/or legally transitioned before matriculating. For example, TGNB trainees who have legally changed their names before medical school may not need accommodations related to their name, badge, and/or sign-off within an electronic medical record, whereas a trainee who begins the transition while in a trainee role may need more assistance from student affairs professionals, human resources, and/or the registrar.

Administrative Challenges and Recommendations

Advocating for TGNB trainees requires collaboration among multiple offices within an academic medical center and with members of the TGNB community themselves. As noted, the needs of TGNB trainees are complex and cross a number of domains, including providing physical, psychosocial, and academic support. Developing a comprehensive approach to supporting TGNB trainees requires key collaborations that include, but are not limited to, TGNB individuals; LGBTQ subject matter experts; the Title IX coordinator; and stakeholders from the offices of student affairs, diversity affairs, medical education, admissions, human resources, and the registrar.

While collaboration is essential, personnel from the offices of student affairs and diversity affairs are the natural leaders for coordinating efforts to support TGNB trainees. Student affairs and diversity affairs educators have explicit guidance from 2 national organizations: the Student Affairs Administrators in Higher Education (NASPA) and the College Student Educators International (ACPA). These bodies create, assess, and advocate practices, policies, and initiatives that not only promote social justice and inclusion but also reflect the needs of all students. Their guidance explicitly calls for student affairs educators “to dismantle systems of oppression, privilege, and power on campus” and to “foster and promote an institutional culture that supports the free and open expression of ideas, identities, and beliefs, and where individuals have the capacity to negotiate different standpoints.”¹¹

Institutional culture

Challenges.

Medicine and academic medical institutions have historically been inaccessible to socially marginalized trainees. Since these institutions were not designed by, or with consideration for, such individuals, the systems and infrastructures perpetuate oppressive learning environments.^7,8 The inclusion of TGNB trainees in medicine is, in and of itself, radical, and today’s highly polarized political climate intensifies the need for institutional accountability.

Although efforts by administrators to generate an inclusive culture and climate within academic medicine are essential, they are futile without a full understanding of the LGBTQ population. Even when academic medical centers are explicitly “LGBTQ friendly,” in-group dynamics are pervasive and often LGBTQ spaces are dominated by white cisgender gay men.¹² Crenshaw describes the phenomenon that the least oppressed member of any underrepresented group is often allowed to speak for the group overall, leaving little space or expression for other identities in the group.^10,13 Given this dynamic, institutions that claim LGBTQ-inclusive policies and procedures may fall short in protecting TGNB trainees, faculty, and staff.

Recommendations.

Student affairs and diversity affairs administrators are charged with creating a climate within academic medicine where trainees and faculty can thrive, bringing their full, authentic selves to school and the workplace. It is incumbent upon administrators to advocate for the most marginalized trainees, including transgender women and nonbinary people of color who are likely to face multifaceted discrimination and bias in the course of their professional careers. Offices of diversity affairs may consider explicitly adding the support of LGBTQ trainees to their mission.

While student affairs and diversity affairs staff are trained as educators and advocates available to serve students, they may also provide resources for faculty development and staff training. Developing effective collaboration between administrators and educators, specifically through the training and evaluation of staff and faculty, is vital for supporting a holistic approach to improving the institutional climate of academic medical centers.

To increase accountability, institutional leaders can engage in the ongoing assessment of policies, procedures, and culture and provide transparent communication to trainees, faculty, and staff about opportunities for growth, changes, barriers, and next steps.

Policies

Challenges.

At the moment, no federal antidiscrimination policy protects TGNB individuals. Due to the lack of federal protections, many health care facilities have antidiscrimination policies that do not explicitly name gender expression and gender identity as protected classes, despite recommendations from the Joint Commission.¹⁴

Even when TGNB-inclusive policies are in place, they remain ineffective without a robust implementation process, including training and accountability measures.⁸ For example, if a policy protects an individual’s name, gender marker, and pronoun changes, but does not have a process in place to actually accommodate these changes in day-to-day practices (email, badge, sign-off, faculty web page, internal articles, etc.), then the policy does not ultimately fulfill its purpose.

Recommendations.

To ensure that trainees’ rights are not infringed upon, institutional leaders, administrators, and faculty must be aware of federal, state, and local laws applicable to gender identity and/or expression. If no local protective policies apply to TGNB trainees, then updating the institution’s policies and procedures to support TGNB trainees is imperative.¹⁵ In addition, all student policies should be reviewed to consider how they apply to TGNB trainees.¹⁴ Additional policies that may need to be revised include, but are not limited to, mistreatment policies, Title IX policies, and reporting structures. Institutions may consider developing a policy that explicitly affirms TGNB students and their right to transition-related needs.¹⁶

Once the appropriate institutional policies are in place, implementation is the next challenge. Within academic medical centers, policies and their implementation (or lack thereof) can perpetuate oppressive environments for TGNB trainees.^7,8 For example, while it is important to eliminate gendered dress code expectations, it is also vital to train department leaders to ensure that they are not applying separate gendered dress codes to their trainees. This consideration is especially critical for students on clinical rotations since implicit bias related to dress and gender expression may influence the assessment of TGNB students.¹⁷

Finally, institutions can and should support legislative efforts to create and/or expand city, state, and federal antidiscrimination policies for TGNB individuals.

Data collection

Challenges.

First and foremost, providing support to TGNB trainees is difficult for any institution or its leaders if the leaders and administrators do not know who their TGNB trainees are. While most programs agree that collecting gender identity data is important given the unique struggles of TGNB individuals, the questions many institutions are grappling with are how and when to collect these data.^18,19 The American Medical College Application Service (AMCAS) currently collects data on gender identity and pronouns in use, but no national recommendations inform how gender identity may inform admissions decisions. Further, institutions may or may not export such data into their educational records. The Electronic Residency Application Service (ERAS) currently does not collect gender identity data or pronouns in use, and neither do the majority of employers. Additionally, to our knowledge, no best practices guidelines are available for trainees or others who undergo changes of gender identity and/or pronouns during their academic medical career.

Recommendations.

The academic medicine community may look to guidance from undergraduate (i.e., baccalaureate) education to inform policies and practices for collecting and storing data on students’ gender identity, as well as for procuring informed consent for sharing students’ gender identity information with others.²⁰ We recommend, in addition to collecting gender identity data, asking for trainees’ preferred pronouns (e.g., he/him/his, she/her/hers, they/them/theirs). Notably, pronouns may change over time and in different situations, particularly in letters (including the Medical Student Performance Evaluation [MSPE]) and assessments that may be seen by future program directors and admissions committee members. Developing a protocol to ensure correct pronoun usage in such letters is a safety issue for TGNB trainees; thus, it is vital to ensure autonomy around disclosure decisions during application processes and to communicate the importance of following the protocol to mentors and faculty members.^19,20

Health and wellness

Challenges.

TGNB individuals face significant minority stress as they move through the world and may, therefore, need additional support maintaining their health and well-being. In a recent study, 78% of TGNB medical students and physicians heard derogatory comments about TGNB patients.⁷ Encountering such discrimination and bias may leave trainees feeling less safe in seeking health care within their own institutions. Even if they do seek care, TGNB trainees may struggle to access fundamental primary care services since health insurance benefits do not always include transition-related care.²¹

Recommendations.

Student programming around health and wellness must respect all trainees, including those who are TGNB. A trainee’s gender identity and expression provide critical context for potential needs. To provide comprehensive health care to TGNB individuals, insurance plans should include transition care such as hormone therapy, anatomy-specific care regardless of legal sex marker, and any other medically indicated procedures relevant to TGNB people. More information about what constitutes trans-inclusive medical coverage is available on the website of the Human Rights Campaign.²²

Gendered spaces, housing, and facilities

Challenges.

Many academic medical centers still segregate housing, restrooms, and locker rooms, which can be distressing for TGNB trainees,^8,23 especially nonbinary students who must choose a designation that does not fit their identity.

Recommendations.

Developing inclusive, all-gender (all genders are welcome), or gender-neutral (not gendered) housing options can affirm TGNB trainees’ identities and provide more housing options for all trainees. Construction of new trainee facilities should include gender-neutral or all-gender restrooms and/or locker rooms.⁸ For institutions where gendered spaces may be policed by cisgender individuals, developing and disseminating inclusive locker room policies that protect individuals who are TGNB may be useful for training trainees and staff.

Educational Challenges and Recommendations

Many undergraduate and graduate medical curricula contain LGBTQ health content following the AAMC’s guidance in 2014.⁹ Despite this increase in LGBTQ health content, TGNB medical students perceive the TGNB-specific content as inadequate and ineffective.^7,8 Undergraduate medical students often expect an inclusive medical culture, but upon matriculating or entering clinical rotations, encounter discrimination. Additionally, the hidden curriculum, manifested in clinical culture, mentoring, and evaluation, likely harms TGNB trainees on both individual and structural levels.

Classroom learning

Challenges.

When TGNB identity is referenced in the curriculum, it is often in ways that are pathologizing, such as with a diagnosis of “gender dysphoria” as listed in the Diagnostic and Statistical Manual of Mental Disorders 5, rather than as a social identity.²⁴ Historically, the literature has relied on the variable of “sex” as a proxy for both genetics and gender identity; little has changed, despite the awareness of a more complex reality. Further, the variables used to collect data related to “sex” or “gender” often ignore social factors related to identity, which may have more influence on individuals’ health than genetics.²⁵

Recommendations.

Those of us who teach must think critically about how and why we teach content the way that we do. When presenting content to trainees, we need to be clear and specific about when we intend to discuss “sex” and when we intend to discuss “gender.”

Faculty development related to TGNB health, specifically around sex and gender, can correct misuse of these terms and mitigate incorrect assumptions. Preparing educators to teach the complex realities of the interplay among chromosomes, hormones, sex organs, and social identities enables trainees to deliver high-value care to increasingly diverse patient populations, including TGNB people.

Clinical teaching

Challenges.

The way in which care teams treat and discuss TGNB patients matters and affects TGNB students, staff, and physicians.⁷ Since medicine is taught in an apprenticeship model, any clinical staff and faculty who apply and teach inappropriate and outdated medical practices are perpetuating health disparities and serving as poor models. Faculty and staff members without training in LGBTQ health may model inappropriate interactions with TGNB patients that disproportionately affect TGNB trainees who are present.^4,7,8

Recommendations.

By providing students, staff, and faculty with comprehensive LGBTQ health training, health care leaders can support the development of a health workforce that is prepared to both teach and model inclusive care and interaction. Additionally, leaders may provide clinical educators with mentoring and other support to appropriately engage TGNB trainees and to model best practices in TGNB medical care to interprofessional care teams. Importantly, best practices include modeling appropriate recovery after inevitable errors around these topics.

Mentorship

Challenges.

Data on the number of TGNB physicians in the current workforce are limited; however, the lack of identified TGNB faculty members leaves TGNB trainees with few identity-concordant mentors.⁷ Faculty and staff who hold marginalized identities are often underrepresented among leaders and hold less power to advocate for trainees. Faculty members who do not know how to approach a trainee with an identity different from theirs may disengage entirely.

Recommendations.

To support faculty members, especially those who do not have gender identity concordance with TGNB trainees, institutional leaders should provide training and faculty development on engaging with trainees who have different identities and life experiences than themselves. Coaching may help clinical instructors support TGNB trainees during particularly challenging moments on rotations that may trigger insecurity and imposter syndrome. Recruiting and retaining diverse faculty members, including TGNB individuals, enables critical representation for a TGNB trainee. LGBTQ mentorship programs may offer in-group safety to TGNB trainees; even still, having an identity-concordant faculty mentor may be critical to retaining TGNB trainees.⁷

Faculty and staff who hold fewer marginalized identities can use their voices to amplify those of more marginalized colleagues, working as allies to transform their latent power into tangible change.

Performance evaluation

Challenges.

Medicine is a conservative profession with long-held norms of behavior. Discomfort in working with TGNB trainees, internalized transphobia, other implicit biases, and perceptions of TGNB trainees as nonconforming can contribute to biased assessments.¹⁷ The cumulative results of biased assessments are likely to cascade and compound, potentially damaging students’ summative assessments and their MSPE.²⁶

Recommendations.

Vigilant screening of trainee feedback may mitigate bias based on gender identity and/or gender expression. Processes and protocols for both collecting and analyzing trainee outcomes in relation to gender identity should be developed in collaboration with the Title IX coordinator and personnel from the offices of student affairs, diversity affairs, medical education, admissions, and the registrar. Regular analysis will identify trends and biases in trainee experiences and outcomes that can, in turn, be addressed.

Call to Action

Our responsibility as medical educators is to support students and residents individually and collectively and to be knowledgeable about their needs and experiences. TGNB trainees are among the most vulnerable as their identities are often overlooked, even among LGBTQ populations. They are susceptible to bias and have less power to advocate for themselves within academic medical centers. Thus, the responsibility falls to leaders of health professions education to create educational environments that are safe and conducive to learning for all trainees. Only in this way can TGNB students fulfill their educational mission: to learn the practice of medicine. By working together in collaboration, we have the power to transform the medical education environment to ensure that all trainees, including those who are TGNB, thrive.

Acknowledgments:

The authors wish to thank the many people who are transgender and nonbinary, including medical students and physicians, who shared their experiences and/or otherwise informed the writing of this Perspective.