Letters to the Editor
To the Editor:
I commend Donald and colleagues’ proposed pedagogy for students and providers to improve treatment for patients who are lesbian, gay, bisexual, transgender; gender nonconforming; and/or born with disorders of sex development.1 Specifically, I appreciate their emphasis on “structural interventions” in addressing health outcomes for these patients. These interventions recognize the influence of upstream factors such as discrimination, internalized conflict, and social bias.
Those of us who live in North Carolina—a state with five medical schools and several physician assistant and nursing programs—see such structural determinants of health manifested in the Public Facilities Privacy & Security Act, otherwise known as House Bill 2 (HB2).2 The bill restricts the use of bathrooms and other sex-segregated facilities on the basis of sex assigned at birth. While HB2 has received significant press in mainstream media, a simple PubMed search of various permutations of the bill’s name yields only two results as of September 9, 2017. This lack of scholarship speaks to a missed opportunity in the medical community to publicly recognize a structural determinant of health for patients identifying as transgender; it also suggests that educators must rethink how to treat these systemic issues.
As more states deliberate similar “bathroom bills,” leaders of medical institutions must decide whether to be politically engaged or absent.3 Simply educating providers on structural competency is no longer good enough. Institutions can directly improve the health of patients by advocating against such laws, pointing to the deleterious effects they have on the mental well-being and social health of patients who identify as transgender. I would expect, therefore, that Donald and colleagues likely agree that lobbying against such laws is a sort of “structural intervention.” If lobbying is indeed an intervention, then a component of improved pedagogy may include policy education—through which students are provided the background and resources to effect change through legislation.
Given that medicine seeks to improve health, medical educators should strongly consider including structural interventions in curricula, as these interventions affect health outcomes. Medical students and providers would be better served in learning not just how systemic issues shape patient health but also the skills and tools to address those issues through advocacy and action.
Danish Zaidi, MTS, MBE
Second-year medical student, Wake Forest School of Medicine, Winston-Salem, North Carolina; firstname.lastname@example.org; ORCID: http://orcid.org/0000-0003-4629-5599.
1. Donald CA, DasGupta S, Metzl JM, Eckstrand KL. Queer frontiers in medicine: A structural competency approach. Acad Med. 2017;92:345–350.