In 2010, a social media campaign called “It Gets Better” was launched to help support lesbian, gay, bisexual, and transgender youth around the world. The goal was to offer hope and encouragement and to empower youth to create and inspire the changes needed to make the world better for them and others. This was also the year I joined the faculty of Albert Einstein College of Medicine. Although I had lived in New York City for nearly five years, I had been to the Bronx only a handful of times and knew little about the borough’s deep cultural roots and wonderful diversity. I knew even less about Einstein, and was initially guarded about my personal life. Like many other LGBTQIA persons, I had had my own experiences that provided me with ample reasons to be guarded.
In time, the Bronx would become a home for my husband and me as I further developed my skills as a bioethicist and medical educator. My career path here at Einstein would also flourish with rewarding new opportunities, including my appointment to the role of chair of Einstein’s LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Questioning/Queer, Intersex, and Asexual/Ally) Health Curriculum Working Group last year. While there are evolving variations in the meaning of the acronym, LGBTQIA, Einstein’s working group intended to have a broadly inclusive version when it was initially established.
History and Health
Einstein’s founding mandate in 1955 combined the pursuit of scientific excellence with an overriding social mission to improve human health through engagement in local, national, and global communities. As at most institutions at the time, however, concern for the well-being of LGBTQIA persons was given little if any consideration at Einstein.
Fourteen years after the College of Medicine’s founding came the establishment of the gay liberation movement following the conflict at New York City’s historic Stonewall Inn—recognized as a national monument in 2016. The 50 years since Stonewall have seen countless lives lost to societal indifference, legal battles, stigma, and suffering. Yet there has also been a persistent dedication and commitment to enact civil rights legislation and protections for the community. And medicine has made strides and continues to work toward recognizing the profession’s own troubled past in the treatment of LGBTQIA patients and families.
Any discussion regarding the health needs of LGBTQIA persons must start with an understanding of the history of oppression and discrimination that these communities have faced and continue to face today. Research has shown that such harmful experiences lead to poorer overall health for patients from these communities compared to heterosexual and cisgender patients. Discrimination toward LGBTQIA persons has many sources, including discriminatory behavior from our own fellow health professionals, whether manifested in internalized or external homophobia, transphobia, gender bias, or the pervasive impact of implicit bias due to privilege and lack of awareness. These barriers to respectful, person-centered quality care contribute to the numerous health disparities experienced by LGBTQIA patients and communities. Such structural and social determinants of health affect members of the LGBTQIA communities in many varied ways due to the intersectional influences of race, ethnicity, culture, disability, and socioeconomic status. All of these factors make our efforts to develop and implement an LGBTQIA curriculum so important.
Advances at Einstein
Even here at Einstein, the fight for equality and respect for our patients, our colleagues, and our students has been a struggle. If not for countless LGBTQIA faculty members, students, staff members, and allies who have advocated tirelessly for equitable treatment and a more inclusive community, I would not have the privilege of writing this post. I’m extraordinarily grateful and indebted for their willingness to step forward and challenge the status quo. In that same spirit of inclusivity, the office of medical education approved the creation of a longitudinal LGBTQIA health curriculum in 2014 to ensure that all of our medical students would be helped to develop the requisite knowledge, clinical skills, and cultural competence to deliver high-quality, patient-centered care to LGBTQIA patients, families, and communities.
While our volunteer working group of faculty and students leading this initiative has made considerable progress since its formation five years ago, there remain many challenges and areas for further development. Achieving our goals requires extensive collaboration with institutional stakeholders to create a more welcoming learning environment for our LGBTQIA students, faculty, and staff associates. One result of this activity has been the increased visibility of LGBTQIA persons throughout the entire Einstein Montefiore community. This is vital because when our students and patients and members of our Bronx community see in us reflections of themselves, it helps affirm their own visibility and Einstein’s commitment to diversity and inclusion.
Curricular enhancement is welcomed by many, though it is not simple given the tremendous responsibility of addressing the needs of all underserved patients and communities. At many institutions, content related to sexual- and gender-minority health is viewed as a recommended, not a required, component. The Liaison Committee on Medical Education (LCME) fosters expectations for medical school curricula to address “gender and cultural biases” and to support the needs of “medically underserved populations,” but makes no specific reference to LGBTQIA patients and communities. Thus, there is minimal LGBTQIA health education offered to U.S. medical students. The median time devoted to such education is approximately five hours, and as many as a third of U.S. medical schools provide no LGBTQIA health content in their curricula. Approximately 50 percent of all transgender persons reported having to teach their healthcare providers about transgender care. Even more alarming is that nearly 8 percent of all lesbian, gay, or bisexual individuals and 25 percent of transgender or gender-nonbinary individuals reported being denied healthcare outright. Clearly, these educational deficits only perpetuate the health disparities harming LGBTQIA patients.
As the director of bioethics education and a former codirector of our Introduction to Clinical Medicine program, I know firsthand the difficulty of deliberating about which content should be included given the time limits we face. It never feels as though we have covered enough, but curricular overload is not beneficial to our students. Instead, we look toward more-effective teaching approaches. Among the goals of Einstein’s LGBTQIA working group is partnering with course and clerkship directors to incorporate LGBTQIA health throughout the curricula rather than displacing existing curricula and student assessments. We surpass some institutional counterparts in the LGBTQIA health sessions and workshops we have created or revised within both our preclerkship curriculum and the clerkship curriculum. And there are plans to add new courses and clerkships in the coming academic year. Einstein’s use of longitudinal theme curricula—introducing key topics throughout the students’ education—promotes optimal linking of LGBTQIA-specific content and clinical skills with relevant educational goals and objectives. Similar approaches are being adopted by other schools and are recognized by educational leaders in LGBTQIA health education as the most-effective means of providing opportunities for inclusion of marginalized patient populations and social-justice principles that better prepare our graduates as they advance in their clinical training.
As a member of the LGBTQIA community, I often reflect on the past and the changes that have taken place in recent years. Certainly, in the years since Stonewall, society and medicine have clearly progressed. As with other civil rights movements, we’ve seen moments of regression followed by hope and progress. In the medical field we also have much more work to do toward providing equitable, high-quality, person-centered healthcare to all patients. Continued progress in medical education will serve as a crucial reminder to the LGBTQIA community that yes—it does get better!