Implementing LGBTQ Curriculum in Physician Assistant Programs

Short Powerpoint Presentation

Implementing LGBTQ Curriculum Capstone Paper

Model Policy and Curriculum Outline

Model Policy: Promotion of LGBT Health Care Competency

PURPOSE: To improving students’ understanding of the health care needs of lesbian, gay, bisexual, transgender (LGBT) patients and promote greater cultural competence to improve communication and trust between patients and health care providers.

POLICY STATEMENTS:  This program will incorporate education on topics pertinent to the specific health needs of LGBT patients into existing physician assistant curriculum. LGBT health will be addressed throughout the curriculum, including didactic lectures on professional ethics, physical assessment, clinical medicine, pharmacotherapeutics, counseling and preventive medicine, and health policy. Clinical preceptors with special experience in providing care to LGBT patients will be identified.

LGBT patients often face social stigmatization and discrimination when they seek health care services, which may lead these patients to avoid or delay accessing the health care system. For LGBT patients who do access care, they often encounter providers who lack of knowledge about LGBT-specific health issues and who demonstrate discomfort when discussing LGBT sexual health. Patient distrust of the health care system and provider unfamiliarity with the needs of the LGBT patients can lead to a clinical failure to correctly identify and treat health issues, poor patient compliance with recommendations and follow-up, and poor health outcomes overall. By providing opportunities to learn about the needs of LGBT patients, all students will be better prepared to care for LGBT patients upon completion of this program.

DEFINITIONS:

This list of definitions addresses terms that occur in this document. This is not intended to be an inclusive list of terms pertaining to gender identity, sexual orientation, or gender expression.  (National LGBT Health Education Center 2016)

Sexual Orientation: How a person characterizes their emotional and sexual attraction to others.

Lesbian: A sexual orientation that describes a woman who is emotionally and sexually attracted to other women.

Gay: A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender. It can be used regardless of gender identity but is more commonly used to describe men who are sexually attracted to men.

Bisexual: A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender and to people of other genders.

Gender Identity: A person’s internal sense of being a man/male, woman/female, both, neither, or another gender.

Transgender: Describes a person whose gender identity does not correspond with their assigned sex at birth. Also used as an umbrella term to include gender identities outside of male and female. Sometimes abbreviated as trans.

Cisgender: A person whose gender identity corresponds with their assigned sex at birth (i.e., a person who is not transgender).

Gender Non-conforming: Describes a gender expression that differs from a given society’s norms for males and females.

Gender Dysphoria: Distress experienced by some individuals whose gender identity does not correspond with their assigned sex at birth. Manifests itself as clinically significant distress or impairment in social, occupational, or other important areas of functioning. The 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes gender dysphoria as a psychiatric diagnosis.

Transition: For transgender people, this refers to the process of coming to recognize, accept, and express one’s gender identity. Most often, this refers to the period when a person makes social and legal changes, such as changing their clothing, name, and sex designation. It may also refer to the use of medical and surgical interventions to conform their physical gender presentation with their gender identity. Sometimes referred to as gender affirmation process.

Cross-sex hormone therapy: refers to the use of androgen blockers and estrogen to assist transgender patients in physically aligning their body with their self-identified gender.

Gender affirming surgery: refers to a number of different surgical procedures that may be performed to assist transgender patients in physically aligning their body with their self-identified gender.

PROCEDURE

Didactic Curriculum: Education on topics of importance to the health of LGBT patients will be incorporated throughout the current curricula. Unless necessary, discussion of LGBT health will be included with broader discussion on the subject (e.g. sexually transmitted infection testing and cancer. Some topics may be presented as distinct lectures on LGBT heath (e.g. cross-sex hormone therapy) but where possible screening). Topics that will be covered will include but not be limited to:

  1. Professional ethics: cultural awareness, personal bias
  2. Physical assessment:
    1. Obtaining a culturally sensitive, non-judgmental history
    2. Performing clinical exams for transgender patients
  3. Behavioral/community heath: barriers to health care experienced by LGBT patients, community resources to support patients
  4. Clinical medicine:
    1. Internal medicine: prostate cancers screening, tobacco related disease
    2. Sexual and reproductive health: sexually transmitted infections, safer sex, reproduction, gynecological cancer and breast cancer screening
    3. Pediatrics: gender dysphoria in childhood, transgender and gender non-conforming youth, use of puberty blockers
    4. Infectious disease: prevention of HIV and use of pre- and post-exposure prophylaxis
    5. Endocrine: cross-sex hormone therapy
    6. Mental health: gender dysphoria, trauma, depression, and anxiety
    7. Surgery: gender affirming surgery
    8. Pharmacotherapeutics: cross-sex hormone therapy and puberty blockers, antiretroviral therapy
    9. Counseling for preventive medicine: interpersonal communication, cancer screening, tobacco use, safer sex
  5. Health policy: hospital and office practices that influence patient/provider relationships and LGBT community health

Clinical Rotations

  1. Identify preceptors with expertise in care of LGBT patients:
    1. Preceptors who focus on primary care for LGBT patients
    2. Preceptors with experience in cross-sex hormone therapy
    3. Obstetrics and gynecology preceptors who provide care to LGBT patients
    4. Preceptors who participate in gender affirming surgery
    5. Identify clinical sites such as hospitals and practices that promote culturally competent care for LGBT patients through facility policies and staff training

Professional Ethics

  1. Cultural awareness / diversity: 
    1. Students will be able to define the following terms:
      1. Sexual Orientation
      2. Heterosexual
      3. Lesbian
      4. Gay
      5. Bisexual
      6. Gender Identity
      7. Transgender
      8. Cisgender
      9. Gender non-conforming
      10. Queer
      11. Natal sex
      12. Sex assigned at birth
      13. Gender dysphoria
  2. Students will be able to discuss the between sexual orientation and sexual behavior.
  3. Students will be able to list barriers in healthcare delivery that may adversely affect LGBT patient health.
  4. Students will examine their own personal biases and how they might impact patient care.

Physical Assessment

  1. Barriers to Patient/Provider relationship
    1. Students will be able to describe how past trauma can influence a patient’s trust of their clinician and willingness to provide needed history or consent to a physical exam/diagnostic testing.
    2. Students will be able to demonstrate interpersonal techniques to put a patient at ease and foster trust, communication and participation in care.
  2. Demographics, Social and Sexual History
    1. Describe the importance of identifying the name and pronouns a patient uses
    2. Describe he importance of obtaining history that is pertinent to the reason for the visit
      1. Not obtaining relevant history may lead to missed or misdiagnosis
      2. Asking questions that are not pertinent to the reason for the visit can lead to mistrust
    3. Demonstrate obtaining a non-judgmental sexual history including behavior history (partner history, types of sexual activity)
  3. Surgical history
    1. Discuss what surgical procedures a patient might have as part of gender reassignment surgery as well as why some patients may choose not to have these procedures
  4. Physical Exams
    1. Pelvic and breast exams on transgender men
      1. Explain the need to assess retained breast tissue even after reduction
      2. Explain the need to perform pelvic exams on transgender men who retain their cervix, uterus and/or ovaries.
    2. Pelvic and breast exams on transgender women
      1. Explain the need to perform breast cancer screening on transgender women
      2. Explain the need to examine the vaginal vault in patients who have had gender-affirming surgery.
    3. Anal pap smears
      1. List the indications to perform anal pap smears
    4. Demonstrate how to obtain an anal pap smear

Behavioral Aspects of Medicine/Community Health

  1. Discuss barriers commonly faced by LGBT patients
    1. Social/community
    2. Discrimination (community, family, school, employers, church, social services
    3. Domestic/Intimate partner violence
    4. Homelessness, poverty, food insecurity
    5. Substance abuse
    6. Sex work
    7. Federal and State government issues
    8. Employment discrimination
    9. Housing discrimination
    10. Federal and State ID laws
    11. Health care institutional barriers
    12. Provider bias
    13. Institutional discrimination
    14. EMR/intake forms
    15. Visitor/health care proxy policies
    16. Lack of insurance coverage
    17. Uninsured
    18.  Unemployed
    19. Lack of access to partner/spouse employer sponsored plan
    20. Insured, but insurance doesn’t provide coverage
  2. Gender reassignment
    1. Hormone therapy / puberty blockers
    2. Testing or procedures that do not align with assigned sex at birth or with sex as indicated on insurance/health records
  3. Community resources
    1. Identify community resources such as providers specializing in LGBT healthcare or who provide LGBT-friendly services, HIV/STD testing and treatment programs, mental health services and providers, Pride and other community support organizations
    2. Identify online resources for both patients and providers

Model LGBT Health Curriculum

Clinical Medicine

  1. INTERNAL MEDICINE
    1. Genitourinary
      1. Describe the increased risk of urinary tract infections in transgender and gender nonconforming individuals who may lack access to safe restrooms
      2. Prostate cancer: Discuss prostate screening in transgender men who are on hormone therapy or who have had vaginoplasty
    2. Pulmonary
      1. Discuss the increased incidence of tobacco dependence in lesbian and bisexual women and the risk for tobacco-related lung disease
    3. SEXUAL AND REPRODUCTIVE HEALTH
      1. Sexually Transmitted Infection (STI)
        1. Understand STI evaluation and treatment
        2. Chlamydia
        3. Gonorrhea
        4. Syphilis
        5. Herpes Simplex I and II
        6. Hepatitis B and C
        7. Human Papilloma Virus (HPV)
          1. Genital warts
          2. Cervical and anal cancer risk
      2. Safer Sex
        1. Discuss STI risk reduction relevant to the sexual activity of the patient
        2. Demonstrate the ability to discuss the use of barrier methods
        3. Demonstrate the ability to identify patients who are appropriate for Pre-exposure prophylaxis (PrEP) to reduce the risk of HIV infection
        4. Demonstrate the provision of counseling for PrEP initiation
        5. Discuss appropriate follow-up for patients using PrEP
        6. Discuss the use of vaccination to prevent HPV and state the recommended vaccination schedule
      3. Pregnancy Prevention
        1. Discuss pregnancy prevention for lesbian and bisexual ciswomen, and transgender men who retain the ability to get pregnant and have receptive vaginal sex with cisgender men
        2. Discuss birth control options
      4. Assisted reproduction
        1. Discuss the barriers faced by LGBT patients seeking pregnancy
          1. Discrimination from providers
          2. Denial of coverage from insurance companies that may occur when gender identified on insurance forms or medical records does not align with the services/procedures to be provided
      5. Binding and padding, tucking and packing
        1. Describe breast binding and penis and testicular tucking
        2. Define padding and packing
        3. Discuss the benefits of breast binding/tucking and padding/packing
        4. Discuss the risks associated with breast binding
        5. Discuss the risks associated with tucking
      6. Cervical cancer, uterine disorders and other gynecological cancers
        1. Discuss the need for cervical cancer screening in
          1. Lesbian and bisexual women
          2. transgender men who retain a cervix
            1. Understand effect of testosterone therapy on cervical cytology
        2. Discuss uterine and ovarian disorders in transgender men who have not had hysterectomies or oophorectomies.
      7. Breast cancer
        1. Identify factors that may contribute to the increased risk of breast cancer and the lower rate of breast cancer screening in lesbian and bisexual women
          1. List breast cancer screening recommendations for lesbian and bisexual women based on risk
          2. Discuss breast cancer risk and screening recommendations for transgender women and men
    4. PEDIATRICS
      1. Transgender, gender nonconformity and gender dysphoria
        1. Define gender non-conformity, gender dysphoria and transgender identity.
        2. Describe the symptoms of gender dysphoria in childhood
        3. Discuss the use of puberty blockers to delay the development of secondary sex characteristics in gender non-conforming and transgender youth
    5. INFECTIOUS DISEASE
      1.  HIV
        1. Discuss incidence and prevalence of HIV
        2. Discuss behaviors that are associated with increased risk of HIV transmission
        3. Demonstrate the provision of counseling addressing HIV testing and risk reduction
        4. Be able to identify patient who are appropriate for PrEP and post-exposure prophylaxis PEP
        5. Demonstrate knowledge of current CDC guidelines for post-exposure prophylaxis
    6. ENDOCRINE
        1. Medical Transition
        2. Define terms related to transitioning in the care of transgendered patients
          1. social transition
          2. medical transition
          3. surgical transition
        3. Discuss barriers faced by patients wishing to transition
          1. discrimination from healthcare providers
          2. expense/insurance coverage
          3. legal obstacles
          4. discrimination from family, community, and coworkers
        4. Discuss the benefits of transition for patients with gender dysphoria
        5. Discuss the informed consent model for provision of care related to medical transition
        6. Discuss the use of puberty blockers in adolescents and teens.
        7. Discuss medical and mental health conditions that may be exacerbated by use of cross-sex hormone therapy
        8. Discuss the need for psychosocial support during transition
        9. Demonstrate knowledge of protocols for initiation and monitoring cross-sex hormone therapy
        10. Describe possible adverse effects of cross-sex hormone therapy
    7. MENTAL HEALTH
      1. Define gender dysphoria
      2. Discuss mental health issues encountered by LGBT patients including depression, anxiety, substance abuse and suicide
      3. Define trauma and discuss the experience of trauma in LGBT patients
        1. Discrimination
        2. Sexual abuse
        3. Domestic violence/intimate partner violence
        4. Child abuse
        5. Physical assault
    8. SURGERY
      1. Discuss the range of surgical interventions that may be used as part of gender affirming surgery
        1. Male-to-female
        2. Female-to-male

PHARMACOTHERAPEUTICS

    1. Cross Sex-Hormone therapy
    2. GnRH analogs as puberty blockers
    3. Estrogens and Testosterone
    4. Androgen blockers
    5. Antiretroviral medication for HIV prevention and treatment
  •  

COUNSELING FOR PREVENTIVE MEDICINE

  1. Interpersonal communication
    1. Demonstrate the ability to obtain appropriate and meaningful social and sexual histories
  2. Cancer risk
      1. Demonstrate knowledge of cancer screening guidelines
      2. Discuss why some LGBT patient may be at increased risk for cancers being diagnosed at later stages
  3. Tobacco use
    1. Demonstrate knowledge of smoking cessation strategies, community resources, and medication aids for smoking cessation
  4. Safer sex and STI counseling
    1. Demonstrate knowledge of safer sex techniques to minimize risk of STIs, HIV and unintended pregnancy
  1.  

HEALTH POLICY

  1. Office practices that support LGBT patients
    1. Understand how the practice/hospital environment can send signals to LGBT patients that may either foster trust and communication or undermine the patient/provider relationship
      1. Representation in office materials
      2. Bathrooms
      3. Use of gender markers and preferred names by health care staff
      4. Inclusive intake paperwork/data collection for electronic records

Published by Meg Sharp

A physician assistant currently working in hospital medicine on Long Island, NY, Meghan's interests and professional goals include working on health and public policy from the perspective of a clinician and bioethicist. Meghan has worked in health care since 1991 as a respiratory therapist and physician assistant. Her clinical experiences include general surgery, allergy and asthma, pulmonary, sleep medicine, reproductive health, acute and subacute rehabilitation, primary care and internal medicine.

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