Hi everyone, my name is Clint Peebles and I'm a board certified dermatologist in Washington DC and suburban Maryland and I'm honored to be a part of the American Academy of Dermatology's Medicine Without Barriers program. If this particular presentation is your first exposure to content focused on sexual and gender diversity in this series, welcome. If you've already viewed the other modules and levels related to this content in this series, then welcome back. Either way, I'm happy that you're here and today in the context of sexual and gender diversity, we'll be addressing the final step of departmental inclusion and creation of structural and longitudinal change across a variety of concepts. I have no relationships with industry and also I want to acknowledge my privilege as someone of Caucasian background and perceived male gender expression. I do not speak for the entirety of this gender and sexual diverse community and as always I hope for the empowerment of all voices to drive meaningful change and conversation throughout these topics. And I also want to acknowledge the forced labor upon individuals of African descent and the colonization and forced removal inflicted upon indigenous peoples in our history and to celebrate the contributions of these groups to our nation and the importance of advancing health equity amid the call to consistently advocate for all those who are marginalized. And I hope you'll find ways to join in these efforts in whatever way you see appropriate. And so just to briefly review our progress throughout these levels in this series in case you may not have followed it sequentially. So in the first level, we talked about basic concepts, foundations, and terminology of sexual and gender diverse health more broadly and in dermatology. We talked about concepts of intersectionality, power, and privilege and how that relates to healthcare delivery. The consequences of discrimination as well as some background on the national and global sociopolitical landscape. And level two, we expanded on these concepts and made them a bit more translational and talked about general principles of effective allyship, advocacy, and building a welcoming environment. And in this module, we're going to talk a bit more specifically about differences we can make in the specialty of dermatology at the department and in the specialty level, arranging concepts from data collection and workforce diversity to general education. And with that, the first thing's always first, we need to talk about education. And if you think that this is the first exposure you've had to many of these topics, particularly from a formal educational standpoint, I'm not surprised and don't feel alone. So the problem is that we know that there's no official requirement for sexual and gender diverse education and medical school or residency curricula. The AAMC encourages medical schools to include this content, but does not mandate it in any sort of significant way. ACGME does not have specific educational requirements for these issues and residency programs. And there's no mandate so far for surgical specialties to include transgender health exposure in terms of clinical skills and case log requirements and the like. And there was a study of about 150 U.S. and Canadian medical schools showing that LGBTQ-specific content was taught for a median of only five hours. And in fact, a third of those programs reported no hours whatsoever. So again, there is a lack of standardized sexual health competencies and curricula, and there's an especially poor range of longitudinal training throughout the educational continuum. Some studies have even shown that number of hours dedicated to sexual health content, notwithstanding the rest of sexual and gender diverse health education and medical school curricula are decreasing. And we also know from a variety of studies about some trainee attitudes and perceptions, including a lack of comfort taking care of LGBTQ patients, not comfortable taking sexual histories comprehensively, especially in these populations, and a lack of knowledge and familiarity about transgender care and other health guidelines. So in terms of looking specifically at undergraduate medical education, the AAMC actually did issue about a decade ago at this point, really great recommendations for the inclusion of sexual and gender diverse health related content in undergraduate medical education. In this wonderful document called Implementing Curricular and Institutional Climate Change for Individuals Who Are LGBT, Gender Nonconforming, or Born with Differences in Sex Development. Unfortunately, though, as wonderful as this document was, and as comprehensive as it was, the implementation has been highly variable. There have been very few programs who have taken up these guidelines and formally integrated them into their curricular structure. And even as of 2018, students continue to report that they receive inadequate education in sexual and gender diverse health, and that theme continues to emerge across a variety of studies. But there's been numerous studies exploring the impact of these LGBTQ specific health interventions and curricular innovations across various specialties and settings, really showing that having an inclusive and comprehensive curriculum can be highly impactful. Historically, though, unfortunately, not many of these have really evaluated the impact of that training specifically in dermatology. But more broadly, these interventions really do demonstrate that knowledge increases and confidence increases and general comfort increases in terms of care for sexual and gender diverse patients when there are these various types of curricular interventions and inclusions in the existing curricula. And even though many of these types of curricula are increasing, and we're seeing a bit more of them, very few, if any, really are looking critically at higher level outcomes of knowledge retention and clinical skills acquisition. And in fact, even among those programs who were looking to incorporate the AAMC guidelines from that Implementing Institutional Change guideline, very few of them actually had longitudinal focuses. And so not only do we need that longitudinal focus instead of just a, let's say, one hour module or a lecture focused on this content kind of peppered throughout the curriculum, but we also need to focus on intersectional factors as well. So again, acknowledging that sexual and gender diverse populations are not monolithic. There is a range of variable ethnic and racial identities within that group, as well as differences based on ability, et cetera. And we also know that there's many barriers to inclusion, specifically of transgender health content, including limited curricular time, lack of expertise among faculty, issues with institutional support, and certainly in our current socio-political climate, there are states that have moved to effectively ban some of this education as well. And also, we've seen that there is a general lack of disaggregation of transgender health content from that broader LGBTQ umbrella. So we'll even see instances where some programs will insert a sexual health content, for example, looking at things like sexually transmitted illnesses, et cetera, and they basically kind of pitch that as essentially satisfying broad sexual and gender diverse health content, which really isn't the case. But again, as I mentioned, the bulk of these educational efforts primarily address or look at one-time attitude and awareness-based interventions, but with a lack of longitudinally oriented and clinical skills acquisition paradigms. But that being said, we have seen the number of publications and research efforts and curricular innovation efforts increase in this realm over the last several years. So I think that we're getting into an era of improvement, but still not quite where we need to be. So what about when we're looking specifically at dermatology residency programs? Well, this was a great study out of Stanford a few years ago that basically surveyed 123 dermatology residency programs around the year of 2018 through the APD, and there was about a 73% response rate. And what they found was that almost half of these programs had zero content hours dedicated to sexual and gender diversity in the curriculum. Another 37% had only one or maybe a few hours. There was a lot of focus on potentially conflating topics like STIs and HIV-AIDS that can actually unduly stigmatize both marginalized populations when the content is not appropriately presented. Only 3% of programs formally covered dermatologic concerns related to gender affirming procedures. So definitely a lot of work to do there. But importantly, there are some guidelines in dermatology residency program initiatives, and in particular, when we look at the Dermatology Milestones Project. So this was a joint initiative of the ACGME and the American Board of Dermatology led by the Dermatology Milestones Working Group. And it's used to measure resident competence during training, and it's a developmental framework from less to more advanced for each of the six ACGME core competencies that are listed at the bottom of the slide. And the Milestones Group basically what was really great in showing where some of this content can be organically integrated into some of these milestone metrics. For example, under systems-based practice and system navigation for patient-centered care, there is an example of assisting to design protocols for clinic check-in of transgender patients in terms of the milestone of participation in changing and adapting the practice for provision of the needs for specific populations. So there are ways to include these populations and these disparities in existing milestone frameworks and core competency frameworks as well. And I encourage everyone to take a close look at that. And also, basically, to really drive home the concept as well that these interventions are actually quite meaningful. And this was a study that really showed the impact very clearly. So the graphs on the left of this chart, A and B, reflect the number of curricular hours dedicated to this content. And those on the right reflect the number of sexual and gender-diverse patients that trainees are exposed to, particularly in medical school. And as both of those increase, the comfort and competency in caring for those populations increases as well. So in general, there's a positive association between patient exposure and curricular hours in terms of comfort providing that care. And we did see in this study that lesbian, gay, bisexual trainees reported greater comfort than their heterosexual peers in caring for LGBT patients. So it really does show that exposure to diverse students as well as patients can be helpful as well. Interestingly and notably, there was no association between the comfort and caring for these populations and the respondents' gender, home state, training year, or extracurricular LGBT health training. Further emphasizing some of the importance of these focused curricular hours and also more arguably equally importantly, the exposure directly to these patients in the clinical setting. And we've written about this as well in terms of how to really achieve culturally humble dermatologists in residency training and how to build on the knowledge that we're able to instill into trainees during residency. And we really saw these core three interrelated domains, of course, one being didactic curricula, but the other, as I just mentioned, exposure to clinical environments providing that care for sexual and gender diverse people. And then also exposure to broader institutional environments that are inclusive and welcoming. So institutional climate policies that are welcoming, safe spaces, collaborative engagement among specialties and departments. And we can also extend that to local regional laws and things like that as well in terms of really providing that consistent and comprehensive educational framework and background across all of those domains. And this is really to show too that there is a spectrum and how we can support our sexual and gender diverse students and to give voice to these issues in the curriculum all the way from a basic level of awareness, kind of at a rudimentary level, just simply avoiding discriminatory language and having a basic acknowledgement of gender and sexual diversity in the curriculum all the way up to more of a transformative approach where we see not just a very basic acknowledgement or very loose discussion of these issues, but critical engagement with inclusive language, role models and allies in the teaching environment, and then critical approaches to learning and social engagement and even advocacy. And as I pointed out in a prior module, it's really important that we recognize the continuum of these concepts and the spectrum of impact they can have, ranging all the way from exploitation of marginalized populations when there's a broad lack of awareness to mere accommodation when there is a general consideration and a loose recognition. And then finally, to inclusion and transformation when inequities are not only recognized, but fundamentally understood and mitigated with marginalized populations actually feeling a sense of belonging and core integration into the group. And this model here really recognizes that a programmatic or policy approach to gender and health can be highly transformative, i.e. addressing the causes of gender inequity, but it actually may fail to achieve equity for non-cisgender populations, as can be seen in many existing programs. Alternatively, a program or a policy can be inclusive, yet it can promote practices that are merely sensitive, but not truly transformative. So to truly achieve gender equity, it is vital for gender transformative approaches to really be explicit and intentional and including diverse gender identities and presentations and policies, practices, organizational culture and data, which we'll also talk about. And using this framework, people's experiences of gender-based inequities and health needs are explicitly recognized and integrated in services, program and policy strategies and solutions. And this change starts in part by encouraging healthcare services, programs and policies to redefine and expand their concept of gender and to explicitly outline strategies that cause gender inequities and to allocate resources for those strategies. And another issue that we see is that in terms of really integrating dermatology into the clinical care more directly for gender diverse populations is to really be a part of multidisciplinary care models. And this is unpublished preliminary data, really looking across a variety of multidisciplinary gender-affirming care programs at major centers and looking to see what specialties and disciplines are represented. So really looking at the whole spectrum of specialties and expertise that goes into gender-affirming care, ranging from the surgical subspecialties to endocrinology, primary care, voice, ENT, fertility, psychiatry, even looking at case management and social work. And we really have found that dermatology is among the least represented. So it's not routinely noted as a collaborating discipline and there can be a variety of reasons for that, but we definitely need to explore that in more detail in terms of being sure that we are collaborating with these multi-specialty gender care programs at our respective institutions and to really amplify the fact that dermatology has a major role to play in the care that we provide to transgender populations. And these are resources that you're free to explore in terms of some of the clinical content related to sexual and gender diverse dermatology, and there's a variety of these. There's even a new-ish module in the AAD's basic dermatology curriculum focusing on this content, but there's a variety of publications and other modules out there as well. This is one of my own curricular rubrics that really covers the full gamut and spectrum of a comprehensive approach to teaching this material, ranging from core concepts and terminology to principles of structural competency and cultural humility to clinical dermatology and gender-affirming dermatology and also incorporating socio-political considerations and advocacy and issues of health access and coverage. So this is something that you can feel free to incorporate as well. But one of the things that's also important to discuss is the importance of data collection, and data is really how we understand populations, how we drive research, how we guide resource allocation, and really inform policies to advance equity. And sexual orientation and gender identity and even intersex status and those data points are often not included in standardized surveys, clinical trials, other research studies, administrative systems, and even electronic medical records. And even when this data is included, it's usually only partial, for instance, focusing on sexual orientation alone and not gender identity. And gender identity can be assessed in a number of ways, which doesn't lend itself to great research potential. And of course, we lack longitudinal data as well. So when I'm talking about this data, what data points am I talking about? Well, really the core four would be sex assigned at birth, gender identity, organ inventory, and then also the pronouns an individual uses as well. There's been a lot written about how to measure gender identity and how to assess these data points and to ask these questions. My disclaimer right now is that there is a very broad consensus that assessing this data is important. There is a little bit less of a consensus in terms of how to assess these data and how to ask these questions. I'm going to walk you through a few examples of how to do this. At the top of this photo on the right, you can see what's known as the one-step method, where we simply ask, do you consider yourself transgender? Then of course, another example of that question is, does your gender identity match the gender you were assigned at birth? This really isn't favored because this really on its face automatically calls out transgender individuals and others them from their cisgender counterparts and really focuses on the transgender identity as opposed to basic demographic variables that are unique to everyone. The two-step method is an arguably much better method in order to assess this question. That two-step method consists of asking about sex assigned at birth and then separately asking about gender identity. Not explicitly asking whether someone identifies as transgender or not, but obviously gauging a gender expansive or gender diverse identity from the responses that come from answering questions about sex assigned at birth or gender identity. That empowers a normalization of gender diversity because everyone has a gender identity and everyone has a sex assigned at birth. But of course, not everyone considers themselves to be transgender. There are various ways that this can be integrated into our electronic medical records and other data collection devices, which would be an example of this as a smart form in my EMR, which goes over ways to input someone's sexual orientation, their legal name, legal information, their gender identity, sex assigned at birth, pronouns, and also any gender affirmation steps they've taken if that's applicable. There's also ways in which we can assess an organ inventory. What organs a patient has, what organs have been surgically enhanced or constructed, etc. A great example of this is, for instance, if I'm thinking about cervical cancer screening, let's say. Really, when we're thinking about who needs cervical cancer screening, that just simply boils down to anyone who has a cervix for the most part. What we don't really need to know in that particular context is information about sexual orientation and even gender identity. All we need to know is whether they have a cervix or not, regardless of their gender identity. If they do, they need screening. This is a way of getting to that valuable information among many other things as well. Sexual orientation and gender identity data has actually been encouraged for many years at this point. More than a decade ago, the Healthy People 2020 and other federal initiatives emphasized the need for this data and research. Many other entities joined shortly thereafter, the Joint Commission, HHS, Institute of Medicine, in terms of calling for this information and health records and basic surveys and research. The NIH has even dedicated an entire department to augmenting sexual and gender diverse health research. We've also seen more recently some efforts to come up with consensus standards in terms of how to ask these questions about sexual orientation and gender identity information. This is one example from the National Academies of Sciences, Engineering, and Medicine, that not only said very explicitly that the standard should be for NIH, among other entities, to be collecting data on gender and sexual orientation and report it by default, but also how institutions and entities may go about asking this information. You can see their example here. Now, I'm also going to share with you shortly my own personal approach for asking this information, and I hope you'll find that valuable, but it's just one example. But this is an example from the National Academies of Science, Engineering, and Medicine, which I don't favor this one as much, and I'll share with you why in a little bit. But it's also important to take a step back and even thinking more generally than sexual orientation and gender identity data, even thinking about the differences, the distinctions between sex and gender, and really understanding what variables we're collecting and how we're reporting them. For instance, there's been numerous calls of one great paper in JAMA several years ago, encouraging to report sex variables and reporting biologic factors, and to use gender variables when reporting gender identity or psychosocial or cultural factors, and to explicitly outline how each of those is determined and the methodology, and to really be clear about what we're collecting and why. This is some snippets from that paper basically showing how sex and gender both can be reported and disaggregated from each other. Just to point out that there are numerous calls to collect this data and to emphasize the notion that sex and gender are distinct concepts, and this is really important when we're thinking about clinical trials and really bridging some of these disparities and gaps in terms of how we conceptualize sex and gender. But my personal approach to this two-step question approach for assessing gender identity. Of course, I do adhere to the two-step method, asking about sex assigned at birth and gender identity. But my preferences in terms of the options for each are a little bit different in a hybrid of what we've just seen. You can see here that this actually accomplishes several things. One thing that I like about this is that it does not conflate sex and gender. You see sex terms like female and male related to sex assigned at birth, and gender terms like woman and man that are under gender identity. This also doesn't other or alienate gender diverse people by normalizing all possible responses. It doesn't explicitly ask if someone is transgender or not. It's simply asking about sex assigned at birth and gender identity which applies to everyone. The other thing is that it does allow for free response as well as an opt-out or prefer not to answer which is also important. You can adapt this as you see fit. For example, if you happen to have a significant indigenous or Native American patient population, you could consider listing two-spirit or another appropriate term depending on the culture that you work with. For example, the Mahu in Native Hawaiian culture, just as an example of that. But there are numerous ways of basically listing and organizing and framing these questions, and this is just my own personal approach for doing this. Looking at these data collection efforts specific to dermatology, are we doing a good job or not? Really, unfortunately, we could do a lot better. This was a paper that we published in the JAD last year, that looked across 10 years of a representative number of articles across four major dermatology journals in two distinct time periods to capture the bridge over inflection points calling for an increase in this data collection. What we found was that there was no significant increase in sexual orientation or gender identity data reporting. We have a lot more work to do and we've seen similar articles published in terms of the mental health and psychiatry literature, as well as cancer clinical trials. Let's also look at dermatology workforce and diversity. We know that the more diverse our workforce, the better we're going to be able to meet patients where they are and care for everyone in a holistic way. In terms of the dermatology workforce, we do have limited data, but much more is emerging. There's a lot of work around this. Sexual orientation and gender identity data hasn't been historically collected by organized dermatology. But for the first time, the Academy's Member Satisfaction Survey introduced questions about this in 2020. These are examples of those questions that you may have seen if you took that survey or if you were exposed to it, as well as the options that were available, keeping in mind that these questions aren't necessarily congruent with my preferred approach with how to ask. But this is another example of some questions that were asked in that survey. Really, the take-home point for what we found is that LGBTQ or sexual and gender diverse dermatologists are underrepresented in that survey compared to that of the general population. But interestingly, when we actually separate this out, disaggregate it to females and males, we actually find that males identifying as LGBT are actually overrepresented in dermatology, at least according to these results compared to the general population. But female LGBT identifying dermatologists are vastly underrepresented. We also found that the LGBT respondents were younger and more likely to be in academics. Now, how does that mirror medical students, sexual and gender diversity when we're thinking about the pipeline? This is looking at the AAMC graduation questionnaire from 2016-2019, looking at almost 60,000 respondents. This only looked at sexual orientation. There wasn't any explicit information on gender identity with this. But it basically found similar themes, that there's an underrepresentation of female identifying LGB individuals going into dermatology. But in terms of males, it seemed to be a slightly overrepresented compared to the general population. Also, this is to point out as well, that we are seeing a gradual uptick in the numbers of medical students identifying as LGBTQ over the years, for example, from 2017-2021, both in terms of diverse gender identity as well as diverse sexual orientations. Even some of the more recent 2022 data shows that this number continues to increase and even more at this point. The AAMC has also introduced a more inclusive range of options for sexual orientation, even as you see here, with a lot more options represented. We are seeing an increase in the number of LGBTQ identifying medical students congruent with what we see in general population trends with younger generations. It's important that we bolster that pipeline in dermatology as well. But again, looking at intersectionality, we also know that sexual and racial minority medical students have poor experiences in the medical school learning environment compared to their heterosexual and white peers. This actually seems to be exacerbated in lesbian, gay, bisexual students of color irrespective of representation. Again, these intersectional variables are incredibly important. Also, it's interesting here, is that when we look at male students, medical students identifying as sexual minority, and we look at the specialties that they are planning to go into, we find that dermatology is actually very well represented among these male graduating medical students who identify as sexual minority individuals. As you see here, dermatology well represented almost at the top of the list. But when we look at female students identifying as sexual minority graduating from medical school, what specialty they're looking to go in, we actually see somewhat disturbingly that dermatology is at the very bottom of the list. The reasons for that, we don't really know, of course, and there's more work to be done. We can certainly speculate, but it's very important that we look specifically at how we can increase the number of sexual minority women who want to go into dermatology as well. And whether that's more of an issue with role models or exposure or whatever the case may be, it's definitely important to look at that. And as we think in our programs in terms of LGBTQ health equity and even recruitment in terms of making our programs more welcoming and inclusive, there's several steps that can be taken. And I especially appreciated this paper that really leveraged some of this conversation in the setting of the virtual residency interview environment that we saw during COVID, for example. And there's some best practices that they were able to identify in particular, given the limitations of the virtual environment with identifying whether or not a program is inclusive and welcoming or not. So in other words, some factors would be enabling self-identification. So giving students the opportunity to identify themselves as LGBTQ in a way that avoids stigma and is optional and is basically welcomed, but not required. And allows for networking with other like-minded peers, whether that be current residents or faculty, advertising local sexual and gender diverse organizations or health training resources. And of course, providing training to faculty and anyone else involved with highlighting the program to prospective residents. This is very important too. And so thinking about all of these factors in terms of how we signal inclusion and acceptance in this setting, is this as easy as putting your pronouns next to your name in Zoom? Is it wearing pins like I am in terms of signaling that kind of support and making explicit your non-discrimination policies and diversity, equity, inclusion, belonging statements and the like. And so just to think about inclusive language in that setting as well. So these are some guidelines for general language considerations when we're signaling inclusion. And of course, we ultimately do want to echo the language of the person or people across from us. But before we actually know what language they prefer, it's important to not make assumptions and to be as inclusive as possible. And one example that I really like to use is let's imagine that you have a prospective resident or a current resident, let's say, who identifies as non-binary or otherwise gender diverse. And let's say that they actually don't use pronouns at all. Or let's say that they use Neo pronouns, for example, as we talked about in another module level. Well, is your entire department capable of confidently and non-assumingly and easily conversing with that particular person in a way that validates those pronouns or the lack thereof? Remember that for people who are used to using binary pronouns and using them in a way that is fairly cis-normative, it can be very challenging to incorporate Neo pronouns into your language and conversation. And it can be even more difficult to address and converse with individuals and to talk about individuals who do not use pronouns at all. So certainly important that everyone in the department and everyone in the program is appropriately trained and aware of the importance of that, especially as we start seeing more visibility of gender-expansive, gender-diverse and non-binary individuals. And I wanna close by basically talking about what about gender-diverse physicians in general? So this was a qualitative survey and an interview-based study looking at the experiences of a small number, but just about a couple dozen trans and gender-expansive physicians. And prominent themes of those interviews included emotional distress in the work environment as a result of transphobia, concerns about the dominance of a rigid binary gender paradigm and structural and institutional factors associated with psychological and physical safety and feelings of isolation as a gender-expansive physician. And clear steps of affirmation were identified that could mitigate those emotional stressors, including signs of safety, active allyship, intentional, explicit, active allyship and mentorship, of course, by other trans and gender-diverse physicians when available. So we do know that this is a population that needs active allies and needs more support. And there's a lot of potential issues in terms of meeting these individuals and their unique needs in the workplace and allowing for them to do their work in the most comfortable, reassuring, welcoming and validating and affirming environments possible. So with all of that being said, I just want to thank you for your attention, not only in this module, but in the others and the other levels if you happen to view those. I am happy, more than happy, to provide much more detail on everything that we've discussed. Please feel free to email me, contact me, reach out. If you have any questions, any concerns, or just want any more resources, I'm always happy to talk to other departments specifically, talk about any specific content that you would like. This was a rapid fire and fairly broad introduction to many of these topics, but I hope that it was helpful and inspires further thought. Also, if anyone is interested in getting a pin, similar to what I'm wearing to show your support for these populations and for these topics, please reach out and let me know. I'm happy to get one to you. And with that, again, I thank you for your attention and be well.

sexual and gender diversity

dermatology

inclusive approaches

LGBTQ-specific health interventions

data collection

sexual minority women

mentorship