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Dermatologists play a significant and multifaceted role in caring for sexual and gender minority (SGM) patients, an expansive population that includes individuals who identify as lesbian, gay, bisexual, asexual, queer, transgender, and gender nonconforming and those with differences in sex development. Multiple social determinants, including stigma and discrimination in health care and a lack of knowledgeable clinicians, have created health inequities for SGM individuals, leading the National Institutes of Health in 2016 to designate SGM individuals as a health-disparity population.1,2 Sexual and gender minority patients also face dermatology-specific disparities, ranging from increased rates of skin cancer among sexual minority men to higher rates of human papillomavirus infection among sexual minority women.3 To provide excellent care for SGM individuals, dermatologists must be able to deliver culturally competent care to SGM individuals with routine dermatologic conditions and address their population-specific health needs. These health needs include, but are not limited to, the screening for and prevention of certain sexually transmitted infections among high-risk SGM individuals, the management of cutaneous effects of gender-affirming hormone therapy, and the use of minimally invasive, gender-affirming procedures.3,4 In this issue of JAMA Dermatology, Jia and colleagues5 address a key component of improving clinical care and mitigating health disparities for SGM individuals—dermatology graduate medical education.
To our knowledge, this is the first published study of SGM-specific curricula in dermatology residency training. This is an important area of inquiry because, although the Association of American Medical Colleges issued recommendations for the inclusion of SGM health–related content in undergraduate medical education in 2014,6 implementation of these recommendations has been variable. In 2011, a survey found that students received a median of 5 hours of SGM health–related content in medical school curricula7; as of 2018, medical students continued to report that they received inadequate education in SGM health.8 A review of the American Academy of Dermatology (AAD) Basic Dermatology Curriculum, an online curriculum used by medical students, found minimal SGM health–related content.9 Thus, residents entering dermatology graduate medical education training may have had little exposure to SGM health–related topics. If we expect future dermatologists to provide culturally and clinically competent care to SGM individuals, we must consider graduate medical education training a critical period to prepare dermatologists to address SGM health.
Based on responses from 90 of 123 (73% response rate) surveyed graduate medical education dermatology residency programs, Jia and colleagues5 found that 46% of programs currently had zero curricular hours dedicated to SGM content, and another 37% reported only 1 to 2 hours of SGM content. When included in the residency curriculum, SGM-specific content most frequently addressed dermatologic concerns related to HIV/AIDS (73%), followed by pronoun use (26%) and SGM skin cancer risk (24%), and, less frequently, by cutaneous adverse effects of gender-affirming hormone therapy (18%). Only 12% of respondents reported that SGM-oriented history taking and physical examination were covered in their curriculum. When SGM health–related topics are covered in residency curricula, there is a lack of consistency in which topics are addressed. Many programs that reported coverage of SGM health–related topics may not be providing the breadth or depth of education needed to achieve clinical competency. In addition, when the only SGM-related education provided focuses on patients with HIV/AIDS, it risks further stigmatizing already marginalized populations.
The findings of Jia and colleagues5 call attention to the need for further research and/or expert consensus to define curricular objectives and competencies in SGM health for dermatology residents. There are no current Accreditation Council for Graduate Medical Education (ACGME) requirements related specifically to SGM health; however, SGM health–related topics can be incorporated into existing ACGME core competencies and Dermatology Milestones, which are dermatology-specific criteria used in resident assessment.10 Standardized curricula addressing SGM health have been shown to be successful in internal medicine residency training programs.11 This approach can be considered for dermatology residency training programs. In the meantime, there has been a notable increase in the number of research studies, review articles, and textbook chapters that can serve as resources for educators endeavoring to ensure their dermatology curricula cover key topics in SGM health.3,4
Despite the fact that almost half of all programs currently include minimal SGM-specific content, this study found that 80% of program directors thought that it was very important or somewhat important for trainees to receive training in SGM care and 51% were considering adding SGM-related content in the next 5 years.5 This finding highlights a considerable gap between desired and current education, and the need for dedicated resources to close this gap. In assessing barriers to curricular integration, Jia and colleagues5 found that insufficient time (69%) and lack of experienced faculty (62%) were the most frequently cited perceived barriers.
This study highlights the ongoing need for education opportunities for current practicing dermatologists and academic dermatology faculty to address this lack of experienced teachers. Progress has been made in this area, including the issuance of the AAD Position Statement on Sexual and Gender Minority Health12 that recognizes the importance of curricula covering SGM health–related topics. Educational sessions at national and international dermatology meetings have covered SGM-specific content, including interactive standardized patient sessions at the AAD Annual Meeting focused on caring for transgender individuals. The AAD LGBTQ (lesbian, gay, bisexual, transgender, and queer)/SGM Expert Resource Group has provided a forum for knowledge sharing among dermatologists interested in SGM health, and a module focused on SGM health–related topics is in development for the AAD Basic Dermatology Curriculum (Klint Peebles, oral communication, January 8, 2020). In addition, workforce diversity development, including support for SGM-identified dermatology faculty and all dermatology faculty with clinical and research interests in SGM health, may help increase the number of experienced faculty that can champion change. The AAD has already taken a critical step toward this last goal by collecting sexual orientation and gender identity demographic data on the AAD Member Satisfaction Survey.
As with other areas of dermatology, didactic education alone will be insufficient to train residents to care for SGM individuals. To provide adequate training in SGM health, academic dermatology practices will also need to focus on providing excellent clinical care to SGM individuals. A necessary component of this care will be the routine collection of sexual orientation and gender identity demographic information.13 The collection of these data allows dermatologists and trainees to know the SGM identity of their patients and use it to inform and improve care for these individuals. It also enables research to better understand the epidemiology of dermatologic diseases in SGM individuals. In the future, it will allow for the development of evidence-based educational interventions by measuring their association with clinical outcomes among SGM individuals.
Other important best practices in care for SGM individuals include creating a welcoming physical space (eg, gender-neutral restrooms), providing cultural competency training for all clinic staff, and ensuring the consistent use of patients’ names and pronouns.4 Critically, racial/ethnic minority identity can compound health care disparities for SGM individuals. Successful didactic and clinical training in the care of SGM individuals in dermatology should incorporate and emphasize best practices for care of racial/ethnic minority patients. These practices include specific knowledge of skin of color, cultural humility, and competence in caring for racially and ethnically diverse patients, as well as an understanding of the framework of intersectionality, which describes how combined multiple factors (including race, sex, gender, and class) can be associated with unique forms of discrimination.14
Institutional environments that support the development of a diverse workforce inclusive of visible SGM-identified members of the health care team have the potential to positively affect not only health care workers and learners but also patient outcomes. Unfortunately, discrimination in the health care workplace continues to be common. One recent survey found that almost half of medical students (41.7%) reported anti-SGM jokes, rumors, and/or bullying by fellow students or other health care workers.15 As highlighted in a 2019 New England Journal of Medicine perspective piece,16 concerns about discrimination continue and are associated with SGM-identified trainees’ and students’ important decisions, such as specialty choice. Concurrent with increasing SGM health–related content in the curriculum, it is incumbent on medical training programs to assess their institutional climate for SGM-identified faculty, staff, trainees, and patients and take action to improve this climate when necessary.6 For individual dermatology departments and divisions, this presents an opportunity for collaboration with institutional diversity officers and programs and LGBTQ/SGM community organizations. For dermatology as a specialty, this will mean considering diversity and inclusion policies, programs, and recruitment practices that value and promote sexual and gender minority diversity in the dermatology workforce and are responsive to the needs of sexual and gender minority clinicians and learners.
The study by Jia and colleagues5 identifies both a lack of consistent and comprehensive SGM health education for dermatology residents and a desire by many program directors to increase education on SGM health–related topics. Training dermatology residents to provide appropriate care for SGM individuals will require attention to the following separate but interrelated domains: (1) didactic curricula, (2) exposure to clinical environments providing excellence in care for SGM individuals, and (3) exposure to institutional environments that are inclusive and welcoming of SGM individuals and health care professionals. Addressing the demonstrated gap between current and desired SGM health education for future dermatologists will be critical to addressing health disparities among SGM individuals, and this should be a priority for the field of dermatology as it continues to emerge as a visionary leader in SGM health.
Corresponding Author: Kara Sternhell-Blackwell, MD, Division of Dermatology, Washington University School of Medicine in St Louis, 969 N Mason Rd, Ste 220, St Louis, MO 63141 (firstname.lastname@example.org).
Published Online: March 18, 2020. doi:10.1001/jamadermatol.2020.0112
Conflict of Interest Disclosures: Drs Sternhell-Blackwell and Peebles reported being current co-chairs of the American Academy of Dermatology LGBTQ/SGM Expert Resource Group. Dr Mansh reported being the current secretary of the American Academy of Dermatology LGBTQ/SGM Expert Resource Group. Dr Peebles reported being the American Academy of Dermatology Delegate to the Young Physicians Section of the American Medical Association. No other disclosures were reported.
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Sternhell-Blackwell K, Mansh M, Peebles JK. Residency Education on Sexual and Gender Minority Health: Ensuring Culturally Competent Dermatologists and Excellent Patient Care. JAMA Dermatol. Published online March 18, 2020. doi:10.1001/jamadermatol.2020.0112
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