Increasing trans and gender diverse education for Australian medical students: An opportunity to improve access and mental health care

Strauss et al. (2020) describe the inadequate numbers of gender-inclusive psychiatrists and the long wait times experienced by trans and gender diverse (TGD) young people within Australia’s mental health system. They report TGD youth had mixed experiences with mental health services and suggest implementing systems-based reforms such as improving TGD-inclusive training for mental health professionals and establishing more specialised gender clinics (Strauss et al., 2020). However, it is important to recognise the fundamental role of medical education in developing TGD-inclusive practices across all health care settings, including mental health. Alarmingly, teaching in this area is currently scarce within Australian medical schools. Given an estimated 2.3% of Australian high school students identify as TGD, we believe medical curricula should better reflect the diversity of patients seen in the community (Strauss et al., 2020). This commentary explains the importance and ways in which TGD-inclusive education can be integrated in Australian medical curricula to improve the mental health of TGD individuals.

While Strauss et al. (2020) report that TGD youth in Australia have high uptake rates of mental health services, TGD patients of all ages also frequently access the services of general practitioners (GPs) and other medical specialists. An Australian survey of 928 TGD adults found that 84% (n = 779) of respondents sought help from a GP while 55% (n = 508) and 32% (n = 298) had seen an endocrinologist and surgeon, respectively (Bretherton et al., 2020). Nonetheless, participants in this survey reported difficulty in finding specialists who could help medically affirm their gender identity (Bretherton et al., 2020). More alarmingly, many TGD individuals in Australia have reported discrimination and a lack of cultural competency by doctors which contributes to the barriers in accessing care and poorer health-seeking behaviours (Sanchez et al., 2017). This highlights the necessity of integrating TGD-inclusive care in Australian medical curricula to prevent exacerbating these negative experiences.

Meaningful curricular integration for TGD-inclusive care must address two key issues. First, educational standards must be consistently applied across all Australian medical curricula. A survey of medical curriculum administrators from 15 Australian and New Zealand medical schools found only 43% (n = 7) included the teaching of ‘gender identity’ in their curriculum and only 33% (n = 5) covered content on TGD mental health (Sanchez et al., 2017). Assessment methods in these topics were also varied. Only 13% (n = 2) of medical schools reported using Objective Structured Clinical Examinations (OSCEs) to assess their teaching (Sanchez et al., 2017). Overcoming this barrier requires stakeholders (educators, community groups, health practitioners, medical students) to develop a national set of standards that can be applied across Australian medical schools and through accreditation boards (e.g. Australian Medical Council). Encouragingly, America’s postgraduate medical accreditation council has already mandated standardised competencies in TGD health and is moving towards logging cases for TGD-specific procedures (Dubin et al., 2018). We also recommend these initiatives be adapted to specialty training programmes (e.g. the RANZCP does not currently include TGD-inclusive practice in their syllabi and learning outcomes).

Second, TGD-inclusive practice needs to have a meaningful, longitudinal integration into existing curricula. While a growing body of evidence suggests that one-off educational interventions in TGD-inclusive practice may improve attitudes, knowledge and skills in medical students, the educational effects of short-term interventions are often lost to follow-up (Dubin et al., 2018). As a result, medical curricula should consider longitudinal integration to allow medical students further opportunities to cement their knowledge and clinical skills when working with TGD patients. This may include explaining the indications and side-effects of gender-affirming hormones for TGD patients, inviting TGD individuals to speak about their mental health and experiences with health care professionals and discussing the ethical implications of different models of TGD care (e.g. gender-affirming informed consent and ‘watchful waiting’). Furthermore, Nowaskie and Patel (2020) found greater lesbian, gay, bisexual and transgender (LGBT) patient contact and education hours significantly improved clinical preparedness and knowledge in LGBT health care. For medical students, repeated exposure to TGD-inclusive practice may reduce stigma and normalise interactions with TGD patients. While further research is required to capture the long-term outcomes of educational interventions on patients’ clinical outcomes, we recommend longitudinal integration as a core component of TGD-inclusive teaching.

Increasing TGD-inclusive education is a sustainable, future-focused approach that may help improve the mental health of TGD individuals. Establishing more specialised clinics are vital in reducing the long waiting times TGD individuals currently experience when accessing psychiatry services (Strauss et al., 2020). However, reforming the medical curriculum to integrate TGD-inclusive education requires little to no cost in comparison. While all mental health professionals do require ongoing professional development to understand the evolving developments in Australian TGD health provision (e.g. 2017 Re Kelvin), many TGD individuals also require access to multiple medical specialists. This invitation must therefore be extended to all medical students and doctors to increase the number of TGD-inclusive clinicians, reduce the amount of negative TGD patient experiences with doctors and improve overall access to care.