Identifying transgender health-related content in health sciences curricula

Dr Alexandra Muller School of Public Health and Family Medicine University of Cape Town

Teaching transgender health ¡ We are calling for better transgender health

care, yet our health care providers are not educated

¡  Education opportunities: in health professions education (medical/ nursing school) and continuous professional development courses

¡  SA health professions curricula do not include transgender health

¡  Little is known internationally about pedagogical approaches

Teaching sexual and gender identity ¡  Health professions students do not learn about

sexual and gender diversity

¡  Positivist approach, biology dominates

¡  Hardly any space for social constructivist theories of gender

¡ No space to challenge their own attitudes/ prejudices towards transgender/ non-heteronormative people

The need ¡  Stevens (2012): transgender people experience

discrimination and transphobia at the hands of health care providers

¡  International evidence of health care providers’ normative and judgmental attitudes

¡  In 2012, the Curriculum Revision Task Team of the University of Cape Town’s medical school asked for evidence for the lack of LGBTI content in the curriculum

Methodology ¡  Online survey administered to all academics

lecturing in UCT health sciences

¡  Content: 10 questions, hosted on Surveymonkey

¡  Distribution: invitations to participate through faculty listservs, departmental listservs, direct contact

¡  Run for 14 days, reminders emailed out on day 8 and 11

¡  Data analysis in Surveymonkey and Excel

¡  Approved by UCT’s Human Research Ethics Committee (537/2012)

Survey content ¡ Questions adapted from Obedin-Maliver (2012)

¡  Lecturer info ¡  Department ¡  Position ¡  Course

¡  Teaching info about gender identity and sexuality ¡  Topic ¡  Semester/ course ¡  Format ¡  Assessment

Results ¡  Participants: 127 academics clicked on website,

93 provided information

respondents agreed to participate by reading and accept-ing an online informed consent form.

ResultsA total of 127 UCT academic staff, from 31 different divi-sions and research units, responded to the call for partici-pation and visited the survey information site. Of these,116 consented to participate in the survey. Of the 116 re-spondents who consented, 93 proceeded to the survey andprovided information. A wide range of teaching unitsresponded to the survey, including preclinical (e.g. HumanBiology, Public Health), clinical (e.g. Paediatrics, Surgery)and allied health sciences (Table 3). Only 10 respondentstaught LGBT health-related topics as outlined in Table 2.Forty-one respondents requested a report of the outcomesafter completing the survey.

Teaching contentThere was no course dedicated exclusively to teachingLGBT health. However, certain issues of LGBT healthcontent were taught within various existing courses withinthe MBChB curriculum, ranging from Human Biology to

Psychiatry (Table 2). No LGBT health related teaching wasconducted within the allied health sciences. Materials re-lated to LGBT safer sex, mental health, substance use,chronic disease risks, and adolescent health were nottaught at all. One lecture on HIV in men who have sexwith men also addressed heteronormativity and homopho-bia. Health system concerns about LGBT health, notablyaccess to health care (n = 4), as well as disorders of sex de-velopment (n = 3), transitioning (n = 6) and gender re-assignment surgery (n = 4) were well covered. No courseor lecture addressed medical students’ own knowledge, at-titudes, prejudices and beliefs about sexual minorities.LGBT health topics were mostly taught in lecture formats(Table 4).

AssessmentThe assessment methods for LGBT health content var-ied across disciplines and lecturers. Often these assess-ment questions were incorporated into exams at the endof one teaching block, and not directly linked to theLGBT health teaching unit. Three respondents (33%)stated that they did not assess students at all. Amongthe remaining seven respondents, four used multiplechoice questions and four open questions. ObjectiveStructured Clinical Examinations (OSCE), useful tools toassess bedside manners and student-patient communica-tion, were hardly used: only one respondent incorpo-rated LGBT aspects into an OSCE. The two respondentswho taught an elective module required their studentsto produce a report for assessment.

DiscussionThe results of this curriculum mapping show that therewas no structured approach to teaching LGBT health re-lated content in the MBChB curriculum at the University

Table 2 LGBT health topics, number and division of respondents teachingTopic n Division

Definition and theories of sexual orientation 4 HUB*, Psychiatry, paediatrics, Medicine

Homophobia, heterosexism 1 Medicine

Barriers to access to health care for LGBT people 4 PHC, Medicine, psychiatry, family medicine

Alcohol, tobacco, or other drug use for LGBT people 0 -

Safer sex for LGBT people 0 -

HIV in LGBT people 2 CLS †, Medicine

Sexually transmitted infections (not HIV) in LGBT people 2 CLS, Medicine

Chronic disease risk for LGBT populations 0 -

Disorders of sex development (DSD)/Intersex 3 HUB, Paediatrics

Transitioning (e.g. male-to-female, female-to-male) 6 HUB, PHC ‡, Family medicine, paediatrics, psychiatry

Sex reassignment surgery (SRS)/Gender affirming treatment 4 HUB, Paediatrics, Psychiatry

LGBT adolescent health 0 -

Mental health in LGBT people 0 -

*HUB: Human Biology; †CLS: Clinical Laboratory Sciences; ‡ PHC: Primary Health Care Directorate.

Table 3 Respondents to the surveyCurriculum Total

respondentsRespondents teachingLGBT health

MBChB preclinical 29 5

MBChB clinical 32 5

Nursing & midwifery 5 -

Occupational therapy 12 -

Communication sciencesand disorders

4 -

Physiotherapy 7 -

Audiology 4 -

Müller BMC Medical Education 2013, 13:174 Page 4 of 7http://www.biomedcentral.com/1472-6920/13/174

Topics covered

respondents agreed to participate by reading and accept-ing an online informed consent form.

ResultsA total of 127 UCT academic staff, from 31 different divi-sions and research units, responded to the call for partici-pation and visited the survey information site. Of these,116 consented to participate in the survey. Of the 116 re-spondents who consented, 93 proceeded to the survey andprovided information. A wide range of teaching unitsresponded to the survey, including preclinical (e.g. HumanBiology, Public Health), clinical (e.g. Paediatrics, Surgery)and allied health sciences (Table 3). Only 10 respondentstaught LGBT health-related topics as outlined in Table 2.Forty-one respondents requested a report of the outcomesafter completing the survey.

Teaching contentThere was no course dedicated exclusively to teachingLGBT health. However, certain issues of LGBT healthcontent were taught within various existing courses withinthe MBChB curriculum, ranging from Human Biology to

Psychiatry (Table 2). No LGBT health related teaching wasconducted within the allied health sciences. Materials re-lated to LGBT safer sex, mental health, substance use,chronic disease risks, and adolescent health were nottaught at all. One lecture on HIV in men who have sexwith men also addressed heteronormativity and homopho-bia. Health system concerns about LGBT health, notablyaccess to health care (n = 4), as well as disorders of sex de-velopment (n = 3), transitioning (n = 6) and gender re-assignment surgery (n = 4) were well covered. No courseor lecture addressed medical students’ own knowledge, at-titudes, prejudices and beliefs about sexual minorities.LGBT health topics were mostly taught in lecture formats(Table 4).

AssessmentThe assessment methods for LGBT health content var-ied across disciplines and lecturers. Often these assess-ment questions were incorporated into exams at the endof one teaching block, and not directly linked to theLGBT health teaching unit. Three respondents (33%)stated that they did not assess students at all. Amongthe remaining seven respondents, four used multiplechoice questions and four open questions. ObjectiveStructured Clinical Examinations (OSCE), useful tools toassess bedside manners and student-patient communica-tion, were hardly used: only one respondent incorpo-rated LGBT aspects into an OSCE. The two respondentswho taught an elective module required their studentsto produce a report for assessment.

DiscussionThe results of this curriculum mapping show that therewas no structured approach to teaching LGBT health re-lated content in the MBChB curriculum at the University

Table 2 LGBT health topics, number and division of respondents teachingTopic n Division

Definition and theories of sexual orientation 4 HUB*, Psychiatry, paediatrics, Medicine

Homophobia, heterosexism 1 Medicine

Barriers to access to health care for LGBT people 4 PHC, Medicine, psychiatry, family medicine

Alcohol, tobacco, or other drug use for LGBT people 0 -

Safer sex for LGBT people 0 -

HIV in LGBT people 2 CLS †, Medicine

Sexually transmitted infections (not HIV) in LGBT people 2 CLS, Medicine

Chronic disease risk for LGBT populations 0 -

Disorders of sex development (DSD)/Intersex 3 HUB, Paediatrics

Transitioning (e.g. male-to-female, female-to-male) 6 HUB, PHC ‡, Family medicine, paediatrics, psychiatry

Sex reassignment surgery (SRS)/Gender affirming treatment 4 HUB, Paediatrics, Psychiatry

LGBT adolescent health 0 -

Mental health in LGBT people 0 -

*HUB: Human Biology; †CLS: Clinical Laboratory Sciences; ‡ PHC: Primary Health Care Directorate.

Table 3 Respondents to the surveyCurriculum Total

respondentsRespondents teachingLGBT health

MBChB preclinical 29 5

MBChB clinical 32 5

Nursing & midwifery 5 -

Occupational therapy 12 -

Communication sciencesand disorders

4 -

Physiotherapy 7 -

Audiology 4 -

Müller BMC Medical Education 2013, 13:174 Page 4 of 7http://www.biomedcentral.com/1472-6920/13/174

No lecturer addressed or challenged students’ attitudes towards non-heteronormative people

Curriculum cohesion ¡ Content scattered across the curriculum

¡  1st year: Human Biology and “development of sex disorders” (intersex)

¡ Clinical years: gender-affirming treatment, transitioning – Psychiatry, paediatrics and family medicine

Format and assessment ¡ Mostly lectures, one optional special study module

¡ No practical teaching session, eg patient-provider interaction

¡ One third of lecturers did not assess content

¡ Other content assessed in multiple choice questions (SSM: report)

¡ No assessment of practical skills (eg. OSCE)

Discussion ¡ Good online survey participation by academics ¡  Online surveys a cost-efficient tool to map curriculum

inclusion of transgender health topics

¡  Easy to administer

¡  Easy to analyse

¡  Provides ‘hard-data’ evidence for gaps in health professions education

Curriculum content ¡  The ‘biology’ of transgender health relatively well

represented in curriculum ¡  GSH Transgender Health Clinic part of academic

teaching hospital

¡  Dedicated individuals in psychiatry and endocrinology

¡ Other transgender health concerns under-represented ¡  No mention of transgender identities beyond trans

‘biology’ topics

¡  No ‘mainstreaming’ of transgender health concerns

Lack of student skills ¡ No acknowledgement of social context of

transgender people’s lives ¡  No opportunity for students to learn about social

determinants of health

¡  No acknowledgement of the role of transphobia, homophobia, social exclusion and violence in trans people’s lives

¡ No opportunity for students to challenge their own attitudes and beliefs ¡  Direct patient skills not included

¡  No opportunity to challenge students’ potentially transphobic views

What SHOULD we teach about transgender health? ¡  Beyond the ‘biology’: social contexts, social

determinants, social realities

¡  Include transgender identities in the relevant disciplines (eg. Infectious disease, mental health,…)

¡  Trans-specific health concerns (health promotion, gender-affirming treatment)

¡  Professional attitudes and obligations ¡  Non-judgmental and

¡  Non-discriminatory services

Conclusion ¡ Online surveys are an easy tool to provide

evidence of curricular gaps

¡  Health profession students lack education about the social realities of transgender people’s lives

¡  The emphasis needs to be on professionalism

¡ National surveys needed in order to develop national educational guidelines for the health professions

Thank you for your interest! ¡ Contact: alexandra.muller@uct.ac.za

¡  Feedback/ questions/ (constructive) criticism welcome!