Introduction

In the United States, there are significant disparities in health outcomes and access to health care among individuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ+), as compared to their heterosexual and cisgender peers. LGBTQ+ individuals experience disproportionately higher rates of cardiovascular disease, cancer, mental health disorders, and substance abuse.¹ Some of the most marked health disparities exist for transgender individuals, who are nine times more likely to attempt suicide, four more times more likely to be diagnosed with HIV, and twice as likely to have no health insurance, when compared to the general population. Further, transgender individuals report disproportionately negative experiences when seeking health care, including verbal harassment, refusal of treatment, and needing to teach the healthcare provider about transgender people to receive appropriate care.  Because they fear mistreatment, nearly 28% of transgender people avoid seeing a physician when they need medical care.^{1, 2} Health disparities among LGBTQ+ people worsen when you add the compounding effects of other intersectional identities, such as belonging to a racial minority.

One factor contributing to LGBTQ+ health disparities is a medical community that lacks a foundational understanding of the unique needs of this community due to insufficient education and training in medical school and residency programs. The median time that medical students spend learning about LGBTQ+ health is five hours, and one-third of medical schools provide no instruction at all.³ This lack of inclusive LGBTQ+ medical education leaves providers unprepared to provide affirming and inclusive care and propagates further the implicit and explicit biases towards LGBTQ+ identifying patients.⁴ To address gaps in knowledge and training among providers, the Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity and Sex Development released the guide, Implementing Curricular and Institutional Climate Changes to Improve Heath Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD, to influence curriculum development. Although some curricular reforms have been adopted, progress has been slow and LGBTQ+ health concerns have not been systematically integrated throughout undergraduate, graduate and continuing medical education.

While it is true that some topics covered in medical school will be encountered only by students pursuing subspecialties, all physicians will care for LGBTQ+ identifying patients throughout their careers. In a 2017 Gallup Poll, 4.5% of the U.S. population or 14.5 million people identified as LGBTQ+ and these estimates increase annually.⁵ Though most health conditions, diseases, and treatments are the same in both LGBTQ+ and cisgender, heterosexual patients, physicians must be prepared to address barriers to care in the institutional climate and create an inclusive environment that is able to address the unique needs of LGBTQ+ persons. The inclusion of LGBTQ+ content into the curriculum increases knowledge and develops positive attitudes in medical students about healthcare delivery to LGBTQ+ persons. Comprehensive medical education and training about LGBTQ+ health creates a profession that is better prepared to serve this community with empathy, comfort, and cultural competence. Medical schools and training programs should adopt the AAMC’s recommendations so that students and residents are well- prepared to provide high quality, patient-centered LGBTQ+ health care.

The Legal Landscape for LGBTQ+ Healthcare Discrimination

In 2020, the U.S. Supreme Court’s historic ruling in Bostock v. Clayton County established that discrimination against a person because they are gay or transgender constitutes unlawful sex discrimination. 140 S. Ct. 1731 (2020). In this landmark ruling, the Court made clear that its decision was a “straightforward application of legal terms with plain and settled meanings” and plainly stated that one “must scramble to justify” the rationale for carving LGBTQ+ individuals out of the protections based on sex. The far-reaching implications of that decision were anticipated: “What the Court has done today––interpreting discrimination because of ‘sex’ to encompass discrimination because of sexual orientation or gender identity––is virtually certain to have far-reaching consequences.” Id. at 1778 (Alito, J., dissenting). More than 100 federal statutes prohibit discrimination based on sex, including the prohibitions against discrimination in health care. It did not take long for federal courts across the country to begin applying the Bostock framework to protect the rights of LGBTQ+ Americans seeking equal access to health care.

Congress enacted the Affordable Care Act (“ACA”) in 2010. The ACA contains a non-discrimination provision, known as § 1557, which states in relevant part: “[A]n individual shall not…[on the basis of sex]…be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity...”. The U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights is responsible for enforcing Section 1557 and protecting the civil rights of individuals in accessing health care. After the Supreme Court ruling in Bostock, the DHHS issued a Notification of Interpretation and Enforcement stating that the agency would be interpreting and enforcing Section 1557’s prohibition on discrimination on the basis of sex to include: (1) discrimination on the basis of sexual orientation; and (2) discrimination on the basis of gender identity. Thus, Section 1557 of the ACA imposes an affirmative obligation not to discriminate against LGBTQ+ individuals in the provision of health care. Meeting this legal obligation requires medical providers to be trained to competently identify and address the needs of the LGBTQ+ patient population.

In conclusion, because of the recent changes to the legal landscape through binding case law and notices of interpretation and enforcement by the responsible government agencies, medical schools should ensure their students are equipped to uphold their legal obligations to provide non-discriminatory healthcare services to LGBTQ+ patients.

Moving Forward: From Silence to Action

Medical education and patient care that are not inclusive are, by default, exclusive, narrow, circumscribed, limited, and incomplete. Every medical school can take steps to create a LGBTQ+ inclusive curriculum by following these suggestions:

1. Assess the institutional climate and current curriculum.

• Evaluate mission statements and non-discrimination statements to ensure they are inclusive of LGBTQ+ populations.
• Conduct focus groups that include students, faculty, administrators, community stakeholders, and patients to determine how LGBTQ+ health education can be improved.
• Evaluate the diversity fostered throughout the admissions process

2. Create a LGBTQ+ Health Education Advisory Committee.

• Include faculty, students, community members, patients, and stakeholders.
• Build relationships with LGBTQ+ organizations on campus and the community. Open a dialogue to learn about suggestions that promote inclusive care and medical education.

3. Integrate LGBTQ+ health and care into the core competencies.

• List core LGBTQ+ learning objectives and recommendations for their integration into the curriculum. Use the AAMC’s Implementing Curricular and Institutional Climate Changes to Improve Heath Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD as a guide.
• Include LGBTQ+ patients in case presentations, simulations, and as standardized patients
• Learn about reliable LGBTQ+ resources

4. Evaluate progress.

• Measure changes in student and faculty knowledge, attitudes, and skills as discussions about LGBTQ+ patients become more frequent, deliberate, and explicit.
• Measure changes in medical students’ satisfaction with the curriculum and their perceived ability to provide inclusive care.

5. Disseminate work outcomes and innovations so other institutions can learn from your failures and successes.

As the United States continues the struggle to create a more fair and just society, we as clinicians and medical educators must examine our roles in cultivating future physicians who can help all patients access high quality health care in an affirming and inclusive environment. This is not only our ethical obligation but also a legal one. The stakes for our students and their patients are high and the time to act is now!