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Debate: Why should gender-affirming health care be included in health science curricula?

"4 out of 5 parents support teaching gender and sexuality diversity in Australian schools "

Published: 14 February 2020

Elma de Vries, Harsha Kathard & Alex Müller

BMC Medical Education volume 20, Article number: 51 (2020) Cite this article
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Abstract

Background

Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse people have experienced significant marginalization and discrimination in health care settings. Health professionals are generally not adequately prepared by current curricula to provide appropriate healthcare to trans and gender diverse people. This strongly implies that health care students would benefit from curricula which facilitate learning about gender-affirming health care.

Main body

Trans and gender diverse people have been pathologized by the medical profession, through classifications of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). Although this is changing in the new ICD-11, tension remains between depathologization discourses and access to gender-affirming health care.

Trans and gender diverse people experience significant health disparities and an increased burden of disease, specifically in the areas of mental health, Human Immunodeficiency Virus, violence and victimisation. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professional ignorance.

This paper will outline gaps in health science curricula that have been described in different contexts, and specific educational interventions that have attempted to improve awareness, knowledge and skills related to gender-affirming health care. The education of primary care providers is critical, as in much of the world, specialist services for gender-affirming health care are not widely available. The ethics of the gatekeeping model, where service providers decide who can access care, will be discussed and contrasted with the informed-consent model that ?upholds autonomy by empowering patients to make their own health care decisions.

Conclusion

There is an ethical imperative for health professionals to reduce health care disparities of trans and gender diverse people and practice within the health care values of social justice and cultural humility. As health science educators, we have an ethical duty to include gender-affirming health in health science curricula in order to prevent harm to the trans and gender diverse patients that our students will provide care for in the future.

Peer Review reports
https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-1963-6/peer-review

Background

Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse (TGD) people have experienced significant marginalization and discrimination in health care settings, as will be described further below. Health professionals are generally not adequately prepared by current curricula to provide healthcare to TGD people and have described feeling “completely out-at-sea” [1]. This strongly implies that healthcare students would benefit from curricula which facilitate learning about gender-affirming health care.

The literature search for this debate started with a key word search of databases including Scopus, Medline, Pubmed and Web of Science during the time period 2017–2018. Search terms included ‘trans’, ‘transgender’, ‘medical education’, ‘health science education’, ‘gender-affirming’, ‘curriculum’ and combinations thereof. A search of article reference lists identified further relevant articles as did personal communication with colleagues. This data informed the main topics for this debate.

Transgender is a term that refers to persons whose gender identity is different to that normatively expected on the basis of assigned sex. Gender diverse is a term to describe “people who do not conform to society’s or culture’s expectations for men and women” [2]. Nonbinary is a term used for a person who identifies as neither male nor female [3] and gender nonconforming for a person whose gender identity is different to that normatively expected on the basis of assigned sex, “but may be more complex, fluid, multifaceted, or otherwise less clearly defined than a transgender person” [3]. Genderqueer is another term used by some with this range of identities [3]. For this article, trans and gender diverse (TGD) will be used as an umbrella term to include transgender, gender nonconforming, genderqueer and gender diverse people. Cisgender is a term for someone whose gender identity is the same as that normatively expected on the basis of their assigned sex. Gender-affirming health care ?has been described by Radix, Reisner and Deutch [4] as “health care that holistically attends to transgender people’s physical, mental, and social health needs and well-being while respectfully affirming their gender identity”. This is more than just transition-related care and refers to an affirming experience in all health care encounters. Gender-affirming care models utilise an approach of depathologisation of human gender diversity (transgender as “identity”), rather than a pathological perspective (transgender as “disorder”) [4].

Until recently, little gender-affirming research existed, and, in the literature, TGD people have often been included in the broader grouping LGBT. This acronym combines sexual minority people (lesbian, gay, and bisexual people), and gender minority people (TGD people). These sexual and gender minority groups have in common that they often experience social exclusion, stigma, discrimination, violence, as well as ignorance from health professionals [5]. These experiences are rooted in societal heteronormativity and cisnormativity that generally marginalises non-heteronormative sexual (LGB) and gender (TGD) identities. Heteronormativity is “the assumption that everyone is heterosexual, and that heterosexuality is superior to all other sexualities” [6]. Cisnormativity is “the assumption all people are cisgender, that those assigned male at birth always grow up to be men and those assigned female at birth always grow up to be women” [7]. This strong normative facilitates transphobia, which is emotional disgust, fear, hostility, violence, anger or discomfort felt or expressed towards people who do not conform to the gender expectations of society [8]. Thus, transphobia has been described as a symptom of hetero-cis-normativity [9]. Müller comments that “though there is a common source of oppression [hetero-cis-normativity], it has to be acknowledged that this oppression acts on different identities (sexual orientation or gender) in different ways” [10].

Compared to cisgender people, TGD people experience significant health disparities and an increased burden of disease [11]. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professionals’ ignorance [12]. It is thus critical to educate health professionals to deliver equitable care for TGD populations, but most health sciences education institutions do not yet provide sufficient education [13].
Brief history of pathologisation, Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD)

People with diverse gender identities and expressions have been part of society for millennia. With increasing medical interest in providing transition-related care in the 1950’s, the TGD person became a “patient” and with the “medical gaze”, diverse gender identities have often been viewed as pathology [14]. The history of pathologisation is important to understand in relation to gender-affirming health care, as there is a tension between pathologisation and access to health care [15].

Continued - https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-1963-6

It's a lengthy look at efforts to make life easier for some 2% of children. Innocent children who
are bullied and otherwise treated badly by too many of their peers. And by unskilled adults too.