The Body Guidelines: A Metacognitive and Harm Reducing Approach to Gender and Sex in Preclinical Medical School Curriculum

Abstract

The incorporation of sex and gender variables in medical education can be made more intuitive and accurate with thoughtful intervention. The authors propose a flowchart to make medical education tools more precise and applicable to patients who would benefit from a nuanced approach to sex and gender. The Body Guidelines can empower educators to consider sex and gender in terms of the etiology and epidemiology of any given pathologic process or disease.

Keywords

Transgender intersex gender sex

Introduction

Medical school preclinical curricula seldom engage intentionally with gender and sex as distinct concepts. Patients in clinical vignettes are assumed to be cisgender and endosex (see Table 1). Pathophysiology often conflates gender and sex. Downstream, this sets false expectations for patients’ identities and predisposes to dangerous thought processes in the clinical environment. The current pedagogical approach to improving engagement with gender and sex in medical curricula is sequestered to Diversity, Equity, and Inclusion (DEI) offices, consigned to workshops, and relegated to guest speakers. Guidelines demand educators develop a new vocabulary and knowledge base without offering appropriate instruction.^1–3 Moreover, this framework frequently places the onus of implementation on students (predominantly LGBTQIA+ students).^4,5 This approach impairs the pace and quality of curriculum updates. Meanwhile, medical students continue to graduate into the ranks of doctors without a better understanding of how gender and sex affects their patients and how to interact with those who are not cisgender or endosex.¹ Characterization of gender and sex in medical education materials is not solely an issue of inclusion but of accuracy.

Table 1.

Operationalizing terms.

Term	Definition for this paper	Select examples
Sex	Sex assignment at birth. Sex-related variables* might include hormones, gonads, genitals, and chromosomes.	Male, female, and intersex
Gender	Identity and expression. Gender-related variables* might include behaviors, habits, roles, and clothing.	Man, woman, nonbinary, agender, and queer
Transgender	A person who identifies with any gender other than the one they were assigned at birth.	A woman who was assigned male at birth.
Cisgender	A person who identifies with the gender they were assigned at birth.	A woman who was assigned female at birth.
Intersex	An umbrella term for unique variations in reproductive or sex anatomy. Variations may appear in a person's chromosomes, genitals, or internal organs such as testes or ovaries. Some intersex traits are identified at birth, while others may not be discovered until puberty or later in life.⁶	A person with XXY chromosomes, a penis, breast buds, and testicular atrophy.
Endosex	A person whose sex characteristics are all within the parameters of one single binary sex.	A person with XX chromosomes, a vulva and vagina, and testosterone, estrogen, and progesterone levels within a reference range for others assigned female at birth.

*For the purpose of this paper, “sex-related variables” and “gender-related variables” will be shortened to “sex variables” and “gender variables” respectively.

We propose a metacognitive framework to incorporate gender and sex in the medical school curriculum accurately and efficiently. With an appropriate understanding, inclusion follows as a natural and intended consequence. Our approach is based on the following principles:

Change must be sustainable, time efficient, and relieve the burden from LGBTQIA+ students.

Gender and sex must be approached with the same exactitude and granularity that other topics are granted.

Our proposed framework is meant to redirect inefficient attempts at correcting how gender and sex are presented in medical school curricula. Our metacognitive design takes a “harm reduction” approach to reform. A harm reduction approach mitigates the gap between the ideal and the reality; a metacognitive design equips implementers with a flexible thought process that is transferable to most scenarios encountered in preclinical curricula. Taken together, this framework circumvents common pitfalls in curriculum reform and imparts an accurate understanding of sex and gender.

Terms

Table 1 summarizes key terms as understood by the authors.

The above terms are defined with the understanding that attempts at defining or categorizing sex and gender fall short of reality, but are an important means of communication. The above categories are not mutually exclusive, and sex and gender both have many internal variables. In other words, there are no innate and inalienable consistencies between all “males,” but rather a collaborative consensus on what constitutes “male.”⁷ While it is hard to forgo these categories altogether, it is important to recognize their subjectivity and limitations as classification systems.

Literature Review

Initiatives to incorporate transgender health and sex/gender determinants of health are often sequestered to guest speakers, standalone DEI lectures, and lectures focused on the theoretical.^8,9 Barriers to incorporating transgender medicine and differences of sex development in undergraduate medical school education include a lack of established knowledge and space in the curriculum for additional information.¹⁰ An impediment to effective reform includes “an understanding of sex and gender as uncomplicated” among medical educators.¹¹ Attempts to make medical school curricula more hospitable to transgender and/or intersex people are not uncommon, but guidelines informing systematic change are scant.^12,13 Those that do exist are largely anti-bias initiatives, which are unwieldy and ineffective when applied to specific scientific principles.¹⁴ These current approaches have applications to clinical vignette writing, but their benefits do not extend to preclinical coursework. The present proposal provides a framework that is feasible to implement, capitalizes on the existing skills of medical educators, and serves to complement learning objectives without congesting the curriculum.

Conceptual Framework

The authors developed a framework to engage with sex and gender as they pertain to the etiology of pathophysiology and the epidemiology of disease. We will first discuss the conceptual framework, and then explore implementation.

Etiology

When sex or gender is invoked but certain sex and gender variables are identifiable as the causal agents, the specific variables should be invoked instead of the demographic group. Etiologic variables are useful to understand the health needs of transgender, nonbinary, and intersex patients; approach sex and gender with greater accuracy; and deepen students’ understanding of processes and mechanisms.

To observe the impact of a certain disease process on a transgender or intersex person, an educator must understand the sex and gender variables that impact, or are impacted by, the progression of disease. There are limitations to a holistic understanding of pathophysiology in transgender, nonbinary, and intersex populations (discussed later). However, untangling sex (eg, male) from a sex variable (eg, prostate) expands binary sex schemas to include transgender, nonbinary and intersex patients—a critical step toward inclusive care.¹⁵ The same strategy applies when untangling gender from a gender variable. Being alert to specific information about which aspects of “manhood” (eg, diet, habits, orientation to wellness) impact the development of coronary artery disease will better equip students to counsel their future patients; particularly when patients outside the category of “man” possess relevant sex- and gender-related risk factors.¹⁶ Equipped with this nuance, medical students will be able to assign risk to patients based on that patient's constellation of gender or sex variables. This is very relevant to patients with a combination of “sex” and “gender” traits that sort more independently, for example, transgender and/or intersex patients.

In addition, focusing on etiological reasoning improves accuracy by identifying the implicated variable. For example, a researcher may incorrectly imply that all people with a Y chromosome are men and characterize them as such in their research design and conclusions. This assumption has the potential to conflate the impact of sex and gender on a certain etiology, as some men (namely, some intersex and most transgender men) are men despite not having a Y chromosome. Moreover, transgender and intersex men are liable to be assumed as endosex cisgender men and treated and counseled as men with Y chromosomes. Even if a patient is known to be intersex or transgender, if the physician counseling them on their risk factors is unsure about the sex or gender variables that are specifically implicated in any certain pathophysiology, they would be unable to counsel the patient appropriately. This etiological approach teaches students about the many ways sex and gender impact health while opening the door for longitudinal learning opportunities. Instructional practices that support intellectual specificity over haste drive curiosity.¹⁷

Epidemiology and Research Literacy

When etiologic variables are not distinguishable or one wishes to convey the populations burdened by disease, an epidemiologic approach is suggested. Information such as the inclusion criteria for a groundbreaking study is important to include in preclinical curricula, particularly when the specific etiology is unknown. As we will discuss, many medical education materials are built from a canon of research that uses male, female, man, and woman as categories.

For the vast majority of topics, there may be scant literature about transgender and/or intersex patients. There is no immediate need to find the one or two public health queries that tie, for example, ankylosing spondylitis to trans-masculinity. Ethical and well-designed transgender- and intersex-specific research is of the utmost importance. Including such studies in curriculum changes is welcome and will broaden students’ understanding of medical science. However, requiring educators to locate and interpret case studies for lesson materials is currently unrealistic at the preclinical level and may impair the pace of change.

It is valuable to identify gaps in medicine's fund of knowledge about transgender and/or intersex patients. Thus, it should be noted that there is no additional information about inclusion criteria and scant literature on transgender and/or intersex patients. This is an opportunity to discuss challenges with statistical analyses when data collection involves more than two binary genders. Awareness of how sex and gender are used in research will better equip students to interpret resources in their future practices and advocate for more inclusive research processes. While it is clinically useful to know broad patterns of illness distribution, it is equally important to recognize who is left out of censuses.

Implementation

The Body Guidelines are meant to be applied to preclinical curriculum materials, such as slide decks, readings, and lectures. Additionally, this tool can be consulted when considering word choice, educating patients, and writing patient notes. The thought process outlined by The Body Guidelines is applicable to many scenarios but should never upstage a patient's insight about themself.

Etiology

When gender or sex is part of the etiology, pathophysiology, or affected population of a disease process, we propose educators teach the relevant sex or gender variable(s) that pertain to the given scenario. In other words, salient trait(s) (an XY genotype, a vagina, testosterone level, patients who play contact sports, vaginally receptive sexual partners, anally receptive sexual partners, etc) are named instead of the demographic (males, females, men, women, transgender people, boys, and girls). It is important these substitutions are made critically, as replacing female with XX genotype or patients with vulvas or patients assigned female at birth without consideration for pathophysiologic applicability may lead to inaccuracies and is a misapplication of this tool. Specifically naming the component of sex and gender most salient to the given pathophysiology is paramount.

Epidemiology

If a population-level approach is required or there is no information about specific sex and gender variables, we propose educators first identify if sex and gender are relevant to the current discussion. If so, MedEd materials about the epidemiology of a certain illness should note the inclusion criteria of the studies that underlie those claims. When possible, it should be specified whether participants were all cisgender and endosex and if not, how intersex and transgender participants were categorized. (ie, when discussing osteoporosis, it is important to note whether a study categorized “women” based on self-identification, or exposure to particular levels of endogenous/exogenous estrogen). If the study does not provide this information, we encourage educators to note this in their materials (see Figure 1). If there is high-quality, readily available information about the illness process that is directly applicable to transgender and/or intersex patients, this should be included. Disclaimers in place of a critical lens into the literature should be avoided.

Figure 1.

The body guidelines flowchart.

Limitations

As a harm reduction measure, we recognize this metacognitive approach is open to critique from many perspectives. As discussed in the flowchart section, the main limitation of this approach is also its most salient attribute: compromise.

Time Investment

The sheer volume of medical education materials and the supporting research pose a barrier to updating the current pedagogy. As opposed to a “total overhaul approach,” we propose this tool be used as a resource during curricula production and routine updates to preclinical materials. Integrated at the nexus of improving existing materials for updated knowledge, the usage of the Body Guidelines should not pose a time burden to preclinical curriculum teams.

Priority Level

For medical educators and medical students alike, time is a limited resource, and clarity and efficiency are imperative to a smooth preclinical period. A concern may be posed that this method is not adequately tailored to the standardized exams to which students will be oriented. On the contrary, the present approach, correctly implemented, will facilitate a deeper understanding of pathophysiology and causation. Medical students are wholly capable of applying nuanced information from preclinical courses to clinical vignettes that are designed for licensing exams.

Limited Retroactive Applicability

Data informing the underlying etiology of conditions very seldom are collected with the transgender or intersex patient in mind. Caution must be taken when applying this etiological knowledge to transgender or intersex patients, as its applicability may be limited and unprecedented. Importantly, the implementation of this tool should be balanced with any available epidemiological studies on the patient population in question. As this method is oriented toward reducing harm, it is important to acknowledge that applying some degree of basic knowledge is preferable to operating in a black box.

Scope

The flowchart was designed to improve the specificity and accuracy of preclinical materials. Caution must be used when implementing this tool in the clinical setting or applying it to clinical vignette writing. Further investigations into how the aforementioned anti-bias checklists may best be balanced with the Body Guidelines to improve clinical vignette writing and patient-centered care bring to future directions of the project.

Harm Reduction

We refer to our approach as a form of “harm reduction.” Harm reduction in public health has been defined as “interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely.” Historically implemented for patients who use drugs, harm reduction facilitates other safe use practices (ie, access to clean needles, medically supervised consumption sites, etc) to avoid fatal incidents while engaging patients with healthcare.¹⁸ The concept is widely applied to other public health measures, including public health approaches to adolescent sexual health.^19,20

We propose a harm reduction approach to sex and gender in MedEd knowing that a true, complete shift in culture and knowledge is at odds with the urgent need to graduate doctors with an improved understanding of sex and gender. A more ideal approach would be critical of sex and gender as categories, instead of incorporating their usage by design. Until a robust body of medical literature engages critically with sex and gender, this approach remains impractical. We advocate for conducting medical research such that it applies to the widest swath of patients and a more rigorous collective medical understanding of sex and gender. Meanwhile, implementing timely changes to curriculum materials will better equip future physicians.⁸ The present approach is tailored to these parameters.

Fidelity

There are ways to misuse this flowchart. Misuse of this flowchart may not yield meaningful change and even could be a step backward. Ethical stewardship to this proposal is contingent on the understanding that sex cannot be broken down into disparate variables to determine an inalienable trait. For example, indiscriminately replacing certain words for others (eg, swapping all instances of “male” for “people with XY chromosomes”) would not be a useful application of this tool. Moreover, implementation would be unsuccessful should sex be framed as the objective, scientific, and measurable category and gender be framed as the subjective and purely social category.

Future Directions

It is prudent to determine how care and health outcomes of transgender and/or intersex patients improve as medical schools adopt this approach. In the scheme of curriculum development and the practice of medicine, two next steps for the Body Guidelines are evident.

The first step is upstream to teaching and clinical guidance: application to research. Ideally, clinical research cohesively includes variables of sex and gender and incorporates epidemiological data. Currently, reference ranges for cisgender and endosex subjects are applied as assumed parameters, rather than explicitly stated.²¹ This is not to say that research should or could be conducted on the basis of individual variables alone, but rather that data be analyzed and presented without the assumption that aspects of sex fall within the reference range for cisgender endosex subjects.²² Applying the Body Guidelines to research has compounding benefits. It begins to answer pressing questions from underappreciated populations. In addition, it standardizes an approach to etiologic considerations of sex while proactively laying the groundwork for pathophysiologic investigations. Considering variables of sex can illuminate instances where assumed groupings differ by single aspects. These instances of juxtaposition are uniquely positioned to be valuable controls, be it they are recompensed and studies are conducted ethically, thoughtfully, and respectfully.

The second step is applying the Body Guidelines to clinical-level and graduate medical education curricula. Application of this tool to tangible clinical scenarios may have unique challenges and warrants an intentional adaptation of implementation guidelines.

Conclusion

This tool is a cohesive framework for accurate teaching of sex and gender in preclinical medical education. Furthermore, this framework can improve students’ thinking about causality, mechanisms of pathological processes, and research methods. The present proposal will highlight gaps in sex and gender health literature, clarify the current reach of medical knowledge, and encourage new research. The metacognitive design leverages medical instructors’ expertise, can be implemented efficiently and guides instructors toward a better understanding of gender and sex. Our harm reduction approach relieves students from the onus of reform, applies general standards of accuracy and completeness to the realm of sex and gender, and encourages critical thinking among curriculum teams. We believe this proposal is the best way to make immediate, effective, and sustainable changes to didactic medical school curricula.

Footnotes

Acknowledgments

The authors would like to extend sincerest thanks to the Harvard SOGIE (Sexual Orientation and Gender Identity and Expression) Health Equity Research Collaborative, particularly, Drs. Yee-Ming Chan, Frances Grimstad, Sabra Katz-Wise, Brittany Charlton, and Elizabeth Boskey whose feedback on an early iteration of this proposal changed its course for the better. We would also like to thank the Larner College of Medicine (LCOM) Medical Curriculum Committee for hearing this proposal, and to Dr. Lee-Anna Burgess for broaching its implementation for the Nutrition, Metabolism, and Gastrointestinal Systems course at LCOM. Thank you to our editor and reviewers for their thoughtful feedback which shaped this proposal to be more rigorous, easier to implement, and more broadly accessible.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions

NP and HM co-developed the flowchart, conceptual framework, literature review, implementation guidelines and limitations. KR provided logistical guidance and editorial insight to the conceptual framework and manuscript structure. Drs. tk and GI provided insight into the conceptual framework, oversight for the scope, scientific accuracy, and perspective for implementation of the tool. All authors read and approved the final manuscript.

ORCID iD

Neeki Parsa

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