A curriculum content change increased medical students' knowledge and comfort with transgender medicine
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INTRODUCTION: Transgender individuals experience distress due to the persistent feeling that their gender identity is incongruent with their assigned sex. This distress is associated with depression, a high suicide rate, and increased mortality. The best solution for transgender patients is cross-sex hormone therapy, a treatment that changes the physical sex of the patient to be more congruent with their gender identity. This treatment has been proven to reduce depression and suicide rates, as well as increase overall quality of life. Unfortunately transgender patients face unacceptable barriers to accessing this treatment, due in most part to the lack of willing and knowledgeable transgender care providers. Many physicians share the misconceptions that gender identity is malleable, making transgender identity a psychiatric problem, and that cross-sex hormone therapy may not be effective and carries too great a risk. However, the literature supports the notion that gender identity is a rigid biological phenomenon and that cross-sex hormone therapy is safe and effective. Studies reporting failed attempts to assign female sex to XY patients with disorders of sexual development provide evidence that gender identity is not malleable. Other studies reporting elevated gender identity disorder rates in XX individuals with excess prenatal androgen suggest that gender identity is a biological phenomenon influenced by hormones during prenatal development. Neuroanatomical studies of transgender cadavers report that some sexually dimorphic areas of the transgender brain are more similar to the opposite sex than the natal sex, suggesting that gender identity is a rigid biological phenomenon originating in the structure of the brain. A review of the side effects and risks associated with cross-sex hormone therapy concluded that treatment is safe provided the physician is familiar with the recommended treatment and monitoring regimens. The lack of transgender care providers is perpetuated by the fact that transgender medicine is not a standard part of the medical school curriculum. Few physicians, therefore, have experience or training in transgender medicine, which is why, to combat this problem, this study has focused on the medical school education system. Previous studies have demonstrated that the addition of transgender medicine to the medical school curriculum increases student comfort and willingness to provide transgender care. Building upon these findings the present study aims to demonstrate that the addition of transgender medicine to the medical school curriculum is an effective means to increase knowledge and change attitudes towards transgender medicine. METHODS: A single lecture on gender identity and transgender medicine was added to the mandatory first-year biochemistry course and the mandatory second-year pathophysiology course at Boston University School of Medicine. An audience response survey was conducted immediately before and after the first- year lecture to assess the change in students opinions regarding of the etiology of gender identity. An elective online survey consisting of two exam style questions was also sent to the first-year students prior to exposure to the curricular content. The same questions were also added to the first-year biochemistry and second-year pathophysiology exams following exposure to the content. The exam-style questions were designed to assess student knowledge of the rigidity of gender identity and transgender medicine. Results: Following exposure to the curricular content there was an increase in the number of students who believe that the origin of gender identity is in the neuroanatomical structure of the brain (p<0.001). The relative number of correct responses to the exam-style questions significantly improved between the online survey and the first-year exam (p<0.001). On one of the exam questions there was no significant difference between the relative number of correct responses given first-year students the second-year students. On the other exam question the second-year students performed significantly worse (p<0.001). CONCLUSION: Here we demonstrate that the addition of transgender medicine to a medical school curriculum can increase students' knowledge and change their attitudes towards transgender medicine. Following the curricular content students were convinced that gender identity is a rigid biological phenomenon and that cross-sex hormone therapy is a medically justified treatment. These findings suggest that a simple curricular content change is an effective means of training knowledgeable physicians who are willing to provide transgender care.