Protecting Graduate Medical Education and Gender-Diverse Youth Open Access

In June 2022, the Dobbs v Jackson Women’s Health Organization decision changed the landscape of reproductive health care in the United States by removing the constitutional right to abortion. Since that time, 21 states have banned abortion or applied additional restrictions to the procedure than the standard set by Roe v Wade.¹  The impact of this decision is far reaching and includes real impact on trainees who are learning to provide safe, equitable, and high-quality reproductive care.²  After the ruling, the Accreditation Council for Graduate Medical Education (ACGME) issued a statement reaffirming the requirement for obstetrics and gynecology programs,³  regardless of where they are located, to provide “access to clinical experience in the provision of abortions,” and to “participate in the management of complications of abortions.” The ACGME added that programs in restricted states must “provide access to this clinical experience in a different jurisdiction where it is lawful.”³  As medical educators and advocates, we applaud the ACGME for advocating on behalf of trainees to learn these necessary clinical skills. This messaging reaffirms abortion care as medically appropriate care.

As the accrediting bodies for training programs and the certifying bodies for individual physicians, the ACGME, the American Board of Pediatrics (ABP), the American Board of Psychiatry and Neurology (ABPN), and the American Board of Family Medicine (ABFM) could have a similar and tremendous impact by mandating that training programs provide education in gender-affirming care.

Like abortion care, gender-affirming care in the United States is under political attack. To date, there are 22 states that restrict gender-affirming care. It is estimated that 35% of transgender youth now live in states where gender-affirming care is banned or restricted.⁴  Studies have shown that nonaffirming health care experiences have been associated with health care avoidance for transgender adolescents⁵  and that half of transgender and nonbinary adolescents have intentionally avoided disclosure of their gender identity to a clinician.⁶  The mental health burden for this population also far exceeds the general population, in part related to isolating experiences with the health care system.⁷  Furthermore, inability to access gender-affirming medical care has been linked to worse mental health outcomes for transgender youth.⁷  Conversely, access to gender-affirming care is associated with improved outcomes in these areas.⁸ 

Ensuring we have a workforce prepared to care for gender-diverse patients and provide affirming services means that physicians must receive training in these domains. Yet, of the 210 pediatric residency programs, 75 (36%) programs exist in states where legislation limiting gender-affirming care has passed.^4,9  For family medicine, 303 of 756 (40%) programs are in states with laws or policies restricting gender-affirming care to minors, and for psychology, 115 of 309 (37%).^4,9  How can we ensure trainees receive this essential training, regardless of location?

The importance of training for medical professionals in gender-affirming care and care for gender-diverse populations has been stated and underscored by a number of professional associations. The American Academy of Pediatrics (AAP) issued a statement in support of pediatric gender-affirming care.¹⁰  In this statement, the AAP listed, among other recommendations¹¹ :

1. that youth who identify as TGD [transgender and gender diverse] have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space;

2. that provider education, including medical school, residency, and continuing education, integrate core competencies on the emotional and physical health needs and best practices for the care of youth who identify as TGD and their families;

3. that pediatricians have a role in advocating for, educating, and developing liaison relationships with school districts and other community organizations to promote acceptance and inclusion of all children without fear of harassment, exclusion, or bullying because of gender expression.

The American Academy of Family Physicians (AAFP) similarly issued a policy statement, the “Care for the Transgender and Gender Nonbinary Patient,” which described how family medicine physicians should support pediatric-aged gender-diverse youth and added that “the AAFP supports education on gender diversity and gender-affirming care at all levels of medical education, including medical school, residency and continuing professional development.”¹²  Although the American Psychiatric Association published a statement supporting access to mental health supports and medical treatment for transgender and gender-diverse youth,¹³  they stopped short of delineating a specific role for psychiatrists and training. Although these statements are important, we contend that only when education is mandated by the various ACGME Review Committees and/or by the certifying boards (ABP, ABFM, ABPN), will it become imperative for programs to provide this training.

In June 2022, the ACGME Review Committee for Pediatrics revised the requirements for pediatrics training to include that pediatric residents must display “competence in respect and responsiveness to diverse patient populations, including but not limited to diversity in gender, age, culture, …” as a core milestone,¹⁴  falling short of listing gender-minority youth as a minoritized population. There also is no explicit mention of training requirements related to gender-diverse youth beyond the one required block of training in adolescent medicine,¹⁴  which does not explicitly call for exposure to the care of gender-diverse youth.

Furthermore, in the ABP content requirements for residency, under adolescent medicine, gender identity is mentioned once, but not explicitly gender-diverse youth or gender-affirming care.¹⁵  The ABPN does list “gender dysphoria” in the content outline, while the ABFM’s content outline is vague. Inclusion of this domain and clarification about what training level is expected upon graduation from certifying bodies would help ensure trainee competence in this area.

The ABP has put forward entrustable professional activities (EPAs) to assess the progression of general pediatric trainees. EPA 5 lists demonstrating “sensitivity and responsiveness to patient’s…gender, age, culture, disabilities, ethnicity, and sexual orientation” in providing a medical home without explicitly listing gender diversity. EPA 14 encompasses population health and health inequity, and here the EPAs call out the importance of eliminating gender-based health care discrimination.¹⁶ 

At a time when pediatric gender health centers around the United States are being forced to close their doors, it is imperative that the ACGME clearly states that graduate medical education in the area of gender-affirming care is required for pediatrics, family medicine, psychiatry, and other relevant disciplines and will follow medical evidence and guidelines.

In doing so, the ACGME, ABP, ABFM, and ABPN can do what the Association of American Medical Colleges (AAMC) has done for undergraduate medical education in the United States, with a clear statement: “The AAMC is committed to improving the health of all people everywhere, and we will continue to oppose any effort to restrict the health care community’s ability to provide necessary care to any patient in need.”¹⁷ 

Accrediting and certifying bodies have the power and responsibility to ensure trainees continue to receive evidence-based training, and this is critical for those who, upon graduation, will care for gender-diverse youth. We call on them to ensure that the current and future cohorts of trainees continue to have access to gender-affirming education and have the capacity and competence to provide children and adolescents with this care.

This statement should include specific language related to transgender health such as: The program is required to provide instruction and experience in gender-affirming care, including recognition of gender diversity and discussion of options for social and medical transition, and referral for specialized care as needed.

In doing so, training programs will be better positioned to provide this instruction to trainees, ensuring continued graduation of well-trained physicians who are able to provide high-quality care to all pediatric patients and will reaffirm gender care as medically appropriate care.