An update, years delayed
On weekends, the Yale School of Medicine campus feels more like a ghost town than a medical school. The corridors of the Sterling Hall of Medicine are silent. The kids that usually play on the daycare’s playground are all at home. The food trucks that line Cedar Street, save maybe one or two, are nowhere in sight.
But a few weekends ago — as the remaining food trucks sold their wares to an exhausted resident coming off a shift at the hospital, or to a graduate student taking a break from slaving away on an experiment — John Encandela and Michael Solotke ’13 MED ’20 SOM ’21 stood in front of a crowd of LGBTQ students and health care professionals from across the country. The School of Medicine’s first-ever conference on queer leadership in medicine had entered its second day, and the duo was set to present a workshop on how trainees could help implement effective LGBTQ health curricula at their own respective institutions.
In the span of four years, the School of Medicine has overhauled its LGBTQ curriculum. Prior to 2015, the medical school offered just a few sessions related to the topic. Now, Associate Dean for Curriculum Michael Schwartz says that Yale is “clearly amongst [the] top group of medical schools in country beginning to thoughtfully address these issues in curriculum.” By the time they graduate, Yale’s medical students will have interacted with LGBTQ-specific health issues 24 different times across their four-year education.
Still, the Yale School of Medicine only began to implement these changes at the school four years ago, and many medical schools today only spend mere hours of a four-year curriculum learning about LGBTQ health and how to treat patients who identify as a sexual or gender minority.
In a nation that has made large strides over the past decades in how it addresses LGBTQ issues — why has medicine lagged so far behind?
A SHOCK TO THE SYSTEM
After wrapping up a job grant writing for UC Davis, Nix Zelin MED ’18 arrived at the School of Medicine in 2014. Zelin, who identifies as queer and pansexual, knew she wanted to specialize in LGBTQ health as a doctor. With its attractive research programs and seemingly up-and-coming support for LGBTQ issues, she chose Yale over other medical schools offering her full-ride scholarships. She felt good about her decision.
But when her first year started, Zelin discovered that she was the only person in her class openly out to students, faculty members and members of the administration. Though she had other LGBTQ classmates, they were not comfortable with superiors knowing their identities.
Worsening the situation, Zelin said she felt that the School of Medicine provided minimal social support for its LGBTQ students and offered few resources for them to find mentors or take part in community activities.
“I had a rosier picture coming in than what I found as a first-year student,” she said. “It was pretty rough the first couple months, and I didn’t want anyone else to have that experience.”
Back at UC Davis, Zelin had been surrounded by allies and other LGBTQ-identifying individuals who shared her passion for LGBTQ health. But at the medical school, she lacked this support.
“I felt alone,” she remembered.
As a student looking to specialize in LGBTQ health, Zelin took note when the medical school’s curriculum glossed over gender and sexual minority health issues. Among the few offerings was a panel discussion about being queer.
“One of the first questions was, ‘What’s it like to be gay?’ and three out of the four or so people sitting on it were white, cisgender gay-identified men in their 20s,” Zelin said. “One of them said, ‘It doesn’t really affect me.’”
She found the session unproductive; students walked away with a limited understanding of what being LGBTQ means for a variety of people with different identities and backgrounds.
Feeling increasingly isolated as the grind of medical school ticked up, Zelin grew frustrated. She gave herself two choices: either stay frustrated, or take action.
So she got to work.
FIRST, DO NO HARM
The year after Zelin arrived at the medical school, she teamed up with other researchers to survey how competent medical students felt treating LGBTQ patients. That study, published in 2018 on Medical Education Online, found that 76.7 percent of 658 surveyed medical students felt “not competent or somewhat not competent” treating gender minority patients. It also showed that more than half of medical students from northeast medical schools felt that the curriculum did not to adequately cover topics relevant to sexual and gender minority health.
Studies like Zelin’s — in addition to interviews with six medical students, residents and professors — demonstrate that medical schools often miss the mark when it comes to educating their students on LGBTQ health.
A 2018 Gallop Poll estimates that 11 million people in the U.S. identify as LGBTQ. Three professors interviewed by the News said that the LGBTQ population has a heightened risk for certain medical conditions. Some are more well known, such as HIV or mental health issues, but others like asthma or cancers are not. If health care providers are unable to address sexuality and gender in a way that makes patients feel comfortable sharing their identities, the 11 million people who identify as LGBTQ could receive inappropriate care or lose out on preventative screenings.
“Part of the etiology of those disparities is inadequate training of health care professionals,” Solotke said. “It would be impossible to address those disparities without also ensuring that the next generation of physicians are appropriately trained.”
While some residency programs help curb this — specialties such as psychiatry or endocrinology train students on certain LBGTQ topics such as hormone therapy — generations of doctors have entered the workforce with limited formal training on treating LGBTQ patients.
Benjamin Mazer, a third-year pathology resident at Yale New Haven Hospital, said he never felt uncomfortable being out as gay while training to become a doctor — his upstate New York medical school had a progressive social environment. Still, his school only taught LGBTQ health for a couple days out of its four-year curriculum.
“The assumption is that everyone’s intentions are good and they’re trying to provide the best care,” he said. “But people come from all parts of the country, all sorts of social environments and different levels of comfort interacting with LGBTQ patients.”
Mazer said that he has had conversations with colleagues whose medical schools offered students even less LGBTQ health education than his school’s few-day stint.
And the research agrees: one study from the Stanford University School of Medicine found that of 132 medical schools, nine reported zero hours of LGBTQ curriculum during the first two years of medical education. Forty-four schools reported zero hours during the latter two years — when students are trained in clinical skills. The median time spent on LGBTQ health issues at the 132 medical schools was found to be just five hours.
“Some people just don’t even get an idea of how to discuss these topics in a respectful way,” Mazer said.
Carl Streed, a psychiatrist who now works with national medical associations to improve LGBTQ curricula, said that his alma mater, Johns Hopkins University School of Medicine, hardly taught LGBTQ health. Though he graduated in 2013, it was only addressed during a lecture on HIV/AIDS and during a “pathological” discussion of trans-identifying patients.
Streed said that while most medical schools want to offer their students the best education possible, roadblocks often stand in the way. Some schools just do not have the resources to update their curriculum. Some are apathetic. A few refuse to change.
But each year, hundreds of doctors graduate from these schools — regardless of whether or not they are adequately trained in LGBTQ health.
“If we don’t introduce people to the topics on sexual and gender minority health, these providers are going to continue to do poorly by their patients,” Streed said.
STIGMA THRIVES WHERE KNOWLEDGE DOES NOT
Go back a couple decades and the state of LGBTQ medical training was much worse than today: Several School of Medicine professors told the News that before HIV — the virus that causes AIDS — came onto the medical scene during the 1980s, LGBTQ health was hardly, if ever, discussed during training.
After the first patient in the U.S. develop AIDS, pandemonium reverberated throughout the medical community as doctors and researchers scrambled to understand the virus raging throughout the nation. The New York Times reported in April 1984 that “within the week, two officials have declared that the guilty virus has at last been found. Less reassuringly, each named a different candidate.” A year later, the Times reported the infection as “incurable” and “believed to be always fatal.”
A resident trainee at the time, School of Medicine infectious disease specialist Rick Altice watched the AIDS epidemic unravel around him. Due to a lack of knowledge, the virus developed a stigma. Altice remembered a high-ranking physician telling him that Yale does not take care of “those kinds of patients.”
School of Medicine clinical professor Sidney Phillips remembered hospital staff leaving meals outside the rooms of patients with AIDS, fearing that they would contract the virus if they entered. If an infected patient needed an X-ray, he said staff would schedule their appointments late into the night to avoid interactions with other patients. Meanwhile, doctors avoided direct contact with those infected.
“At a time when someone needed human contact the most, people were going in gloved and gowned,” Phillips said.
A SEA CHANGE
Halfway through her first year, Zelin met with Schwartz to address the lack of LGBTQ health curricula at the medical school. Her hook? Yale could be a leader. A model for other medical schools.
Zelin pitched a new LGBTQ health curriculum. She explained what medicine knows regarding LGBTQ health issues, how it affects patients and why the School of Medicine needed to talk more about it.
To Zelin’s surprise, Schwartz agreed.
Schwartz told the News that the former LGBTQ curriculum was “piecemeal” — it was not effectively woven throughout the four-year curriculum, leaving students with an unclear takeaway. But now, he says that Yale “is clearly amongst the top group of medical schools in country beginning to thoughtfully address these issues in the curriculum.”
Given the green light to address gaps in the curriculum, Zelin partnered with Encandela to design a novel LGBTQ-inclusive curriculum. Zelin said that the medical school faculty and administration were “amazing” in terms of instituting the changes.
“Our education leaders assessed the curriculum for content related to LGBTQI health disparities, patient care and scientific knowledge,” School of Medicine Dean Robert Alpern told the News in an email. “From this needs analysis, we created a unified longitudinal thread of content throughout all four years of the medical school curriculum, tied to educating our students on the care and treatment of LGBTQI individuals and addressing the health disparities they experienced.”
Some of the new offerings include lectures titled “Healthcare for our LGBTQ patients,” “The Role of the Physician in Caring for LGBTQ Patients” and “Abnormal Puberty.”
To Encandela, the curriculum still needs more work to adequately train medical students in LGBTQ health. Though the new updates are a starting point, he said that building the curriculum is an ongoing, collaborative effort.
“You shouldn’t have to make your whole career about LGBTQI+ health in order to get some training, some education,” Zelin said. “It shouldn’t be some specialized thing that only the queer kids are into.”
KEEPING THE TIDE ROLLING
When Phillips, the psychiatrist who practiced in New Haven during the AIDS epidemic, was asked whether students feel comfortable being out at the School of Medicine, he compared its environment to that of the College.
“In some ways, it’s easier to be LGBTQ than it is to be in certain fraternities or Republican,” he joked.
Ten other LBGTQ faculty members and students interviewed all voiced the same sentiment: They, personally, have not felt uncomfortable being open about their identities at the medical school.
School of Medicine professor Marcella Nunez-Smith put it simply: “I don’t care, and I never have.”
Over the course of her time at the School of Medicine, Zelin played an instrumental role in instituting changes to foster inclusivity in the medical school’s LGBTQ community. She changed the name of the student group Gay-Straight Medical Alliance to the more inclusive OutPatient. She organized new events and social gatherings for LGBTQ students. She helped found — then chaired — the Dean’s Advisory Council on LGBTQI+ Affairs that meets regularly with the administration to discuss new initiatives.
After the council was established, Zelin remembered receiving feedback following a community meet-and-greet — “We got anonymous comments from community members saying things like ‘I’ve been here 30 years and I’ve never met another gay faculty member,’ and then there would be someone from their same department saying the same thing.”
Zelin’s efforts helped establish an institutional scaffolding for bridging the silos present in its LGBTQ community.
For her, “that is what I’m most proud of.”