STANFORD, Calif. -- The average medical student spends just five hours in medical school learning about the health-care needs of the lesbian, gay, bisexual and transgendered community, despite evidence that these patients often face a unique set of health risks, according to a new study from the Stanford University School of Medicine that will be published Sept. 7 in the Journal of the American Medical Association.
Results of the study -- based on a survey sent to deans at medical schools across the United States and Canada -- showed that 33.3 percent of medical schools that responded spent zero hours on LGBT health-related content during the students' clinical training, which usually takes place during the third and fourth year of medical school. Questions about course content ranged from topics such as sexual identity, chronic disease risk within the LGBT community and sex-reassignment surgery.
But while the amount of time spent on training students was found to be extremely low, almost all medical students today -- 97 percent -- are being taught to ask patients if they "have sex with men, women or both" when obtaining a sexual history -- a positive step toward improved care, the researchers said.
"It's great that a lot of schools are starting to teach these topics," said senior author Mitchell Lunn, MD, an internal medicine resident at Brigham and Women's Hospital/Harvard Medical School who was a medical student at Stanford when the study began. "But the conversation needs to go deeper. We heard from the deans that a lot of these important LGBT health topics are completely off the radar screens of many medical schools."
The study was conducted by members of the Lesbian, Gay, Bisexual and Transgender Medical Education Research Group, which was founded at Stanford's School of Medicine in 2007. The study was undertaken to determine exactly what was being taught in medical schools. The researchers hope their findings will shape future efforts to improve curricula.
A high rate of response from the deans -- 85 percent -- indicates a growing interest in the topic, researchers said. The deans also self-reported that training in LGBT-related health care is only "fair" at their institutions, and that their schools need to improve by increasing the number of faculty well-trained in these issues along with implementing new curricula that covers the often poorly understood health concerns of the LGBT community.
"This is really about visibility and partnering with other organizations to get a better sense of how we can train a next generation of providers to be really sensitive and competent in meeting the needs of the LGBT community," said first author Juno Obedin-Maliver, MD, a Stanford graduate now doing an ob/gyn residency at the University of California-San Francisco. "These issues are something that every health-care provider will encounter."
The survey -- based on a review of the literature and interviews with LGBT health experts across the country -- highlighted 16 of the most pressing LGBT health-care topics. The survey asked about issues such as depression, barriers to accessing care, substance abuse and safer sex. Research has shown a number of health disparities exist, such as increased risk factors for breast cancer among lesbians, higher rates of depression and anxiety due to homophobic discrimination, and increased rates of hepatitis among gay men.
The survey also provided a glossary of terms including: "Intersex: A general term used for a variety of conditions in which a person is born with reproductive or sexual anatomy that does not fit the typical definitions of female or male." And: "Transitioning: The process through which a person modifies physical characteristics and/or manner of gender expression to be consistent with gender identity ... may include hormone therapy, sex-reassignment surgery and/or other components."
Of the 16 topics listed, less than 63 percent of the schools covered at least eight of them, the deans reported. Eleven schools of the 132 that completed the questionnaire (from a total of 176 schools) reported teaching all 16. Issues rarely taught included transitioning and body image -- issues relating to the transgender community. Low scores were also reported in teaching such issues as dealing with unhealthy relationships, substance abuse and chronic disease risks.
"If you don't know what transitioning is, that makes it difficult for you to even talk to your patients who may be struggling with their identity," Lunn said. "This happens with patients across the board, from pediatrics to the VA. There are transgender patients at the VA in their 60s or 70s who have never been asked about gender identity."
Lack of medical education on issues such as reproductive health and transitioning have led to serious health-care problems, the researchers said.
"Pap-smear screening is still underperformed among lesbians," Obedin-Maliver said. "I've taken care of lesbian patients who have abnormal pap smears or even advanced cervical cancer. Often, doctors don't know that lesbians are still at risk for receiving HPV (human papilloma virus) from another woman, which can eventually lead to cervical cancer.
"Because of a lack of understanding or abject discrimination or lack of access to care, certain patients won't have the same, routine health care that we want everybody to have."
Another health-care problem arises when doctors aren't aware that transgendered youth are more likely to use "street" hormones as part of their transitioning process rather than prescribed hormones received under supervised medical care.
"That exposes these patients to a number of blood-borne infections along with poor side effects from unclean materials and needles," said Obedin-Maliver.
Teaching future doctors not only how to get these conversations started with their patients but continuing them at a well-informed level is essential to providing the overall good patient care that all doctors should strive for, said co-author Gabriel Garcia, MD, associate dean of admissions and professor of medicine.
"It's important for physicians who want to provide good health care to understand their patients," Garcia said. "The only way to do that is to be able to ask the questions that get at issues of identity. That's why teaching medical students to do this with the LGBT community will help them in so many other ways as well. This is just good patient-centered care."
Other co-authors include current Stanford medical students Elizabeth Goldsmith, William White, Stephanie Brenman and Maggie Wells; former medical student Leslie Stewart, MD, an internal medicine resident at the University of Pennsylvania; Stanford University graduate Eric Tran, an MFA student at the University of North Carolina-Wilmington; and David Fetterman, PhD, former director of evaluation at the medical school, currently president and CEO of Fetterman & Associates.
This study was funded by the school's Office of the Dean and the Office for Diversity and Leadership. Additional support was provided by the Haas Center for Public Service at Stanford University, the Stanford University LGBT Community Resources Center and the Stanford Medical Scholars Fellowship Program.
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