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Are Our Future Doctors Receiving Enough Training to Care for LGBT People?

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After relocating halfway across the country to New York City, finding an LGBT-friendly and culturally competent doctor was not high on my priority list. However, my priorities changed when I required medical services in November. I quickly realized I would have to find a new primary care physician who is both knowledgeable in LGBT health care, and who will treat me with understanding and respect.

My experience is not unique, as many others in the LGBT community face similar challenges. In a 2005 survey 22 percent of lesbian, gay, and bisexual patients reported having experienced some form of discrimination in a health care setting. So why are so many health care providers ill-equipped to handle the health care needs of LGBT people? As a medical school candidate with my sights set on starting medical school in fall 2012, I am cross-comparing prospective M.D. programs and actively examining components of medical school curricula.

A medical school's curriculum must meet rigorous standards established by the Liaison Committee on Medical Education (LCME) to receive accreditation. Nonetheless, recent studies and testimony on behalf of medical school administrations indicate that there are significant gaps in curricular content. More specifically, the quality and breadth of LGBT health-related content is lacking and remarkably uneven across medical schools.

One of the most comprehensive studies examining the incorporation of LGBT content in medical education was recently published in the Journal of the American Medical Association. The report indicated that the median time dedicated to teaching LGBT-related content was five hours (during the entire four years of medical education) in the 132 U.S. and Canadian medical schools that were surveyed. Additionally, nine schools reported zero hours taught during the preclinical years, and 44 schools reported zero hours of clinical training.

In terms of overall assessment of quality, the results are equally discouraging. A majority of medical school administrators revealed that their coverage of LGBT-related content was fair or worse. Thirty-two deans responded that their school's coverage of LGBT health care was "good" or "very good," while 58 reported that it was "fair," and 34 indicated that it was "poor" or "very poor."

The results are especially problematic given the fact that LGBT people have historically faced barriers in accessing competent medical care in addition to having specific health care needs.

Research findings reported by the American Psychological Association indicate that LGBT individuals may be at an increased risk for negative health behaviors and outcomes and experience a number of health disparities compared with their heterosexual peers. For example, gay men and lesbians report higher rates of smoking. Cardiac and cancer risk factors are also more prevalent among lesbians compared with heterosexual women. A large-scale study published in 2000 found that breast cancer rates and several associated risk factors are higher among lesbians and bisexual women.

Furthermore, men who have sex with men (MSM) continue to face disproportionate rates of HIV and are the only demographic in which new infections are rising in the U.S. According to the Centers for Disease Control and Prevention (CDC), MSM represent 2 percent of the general population yet accounted for 61 percent of all new infections in 2009. Clearly, the health care needs of LGBT individuals, which are largely complicated by stigma, homophobia, and other structural factors, underscore the necessity for comprehensive LGBT-related content in medical school curricula.

Medical students' ability to effectively care for LGBT patients has also been measured. Survey results from an online study in 2006 indicated that third- and fourth-year medical students with greater clinical exposure to LGBT patients reported performing more frequent sexual history assessment with their patients. This is a critical component of comprehensive health assessment and management and provides patients an opportunity to indicate their sexual experiences. Furthermore, the students had more positive attitude scores and achieved higher knowledge scores compared to their peers with less clinical exposure to LGBT patients.

At the end of the day, some may question why medical school administrators should care about LGBT health services. The reality is that although many doctors primarily treat patients at the individual level, they also have the social responsibility to act as community-level providers. They have an obligation to deliver unbiased, culturally competent health care, and they also have a role to play in reducing health-related disparities at the population level.

Part of the solution to the problem is rooted in education. With the identified gap in medical school curricula, momentum has been building toward reform.

The Association of American Medical Colleges (AAMC), the Institute of Medicine (IOM) of the National Academy of Sciences, and the U.S. Department of Health and Human Services (HHS) have released their own respective reports on strategies to improve the health and well-being of LGBT communities. In 2007 the AAMC recommended that "medical school curricula ensure that students master the knowledge, skills, and attitudes necessary to provide excellent, comprehensive care for [LGBT] patients." Thereafter, in 2011, the IOM and HHS reports formally acknowledged how the lack of culturally competent provider training and knowledge are structural barriers to care for many LGBT patients. The IOM explicitly stated that "few physicians are knowledgeable about or sensitive to LGBT health risks or needs." Moreover, the IOM recognized that "medical schools teach very little about sexuality in general and little or nothing about the unique aspects of lesbian, gay, and bisexual health, and it is rare for students to receive any training in transgender health."

Although these recent policy recommendations are a promising step forward, the fact remains that many LGBT patients continue to face numerous challenges in accessing health care. Moreover, inadequate coverage of LGBT health-related content in medical school curricula may not meet the LCME's cultural competency requirements as stated in the ED-21 mandate of their accreditation standards. In order to remain in compliance, internal reviews of LGBT curricular content are needed in order to address the reported deficiencies.

Furthermore, the LCME and the American Osteopathic Association (AOA) should initiate a comprehensive review of LGBT health-related content in medical school curricula and expand curricular requirements as part of their accreditation standards in order to ensure that LGBT health care is sufficiently represented in medical school education. Many patients, including me, will benefit from this reform in medical education, and future doctors will receive the necessary training to more effectively care for LGBT patients.