Diversity in Medicine

What you really don’t want to do, if you want to improve diversity, equity, and inclusion (DEI) at your academic institution, is to recruit diverse people to your program and then have them come and feel not included, said Vivian Asare, MD. “That can work against your efforts,” she stated in an oral presentation at the annual meeting of the American College of Chest Physicians (CHEST). Dr. Asare is assistant professor and vice chief of DEI for Yale Pulmonary, Critical Care, and Sleep Medicine, and associate medical director of Yale Centers for Sleep Medicine, New Haven, Conn.

In offering a path to successful DEI, Dr. Asare said: “The first step is to build a team and discuss your mission. Invite everyone to participate and include your leadership because they’re the ones who set the stage, ensure sustainability, and can be a liaison with faculty.” Then a DEI leader should be elected, she added.

The next and very important step is to survey the current institutional climate. “You need to tap into how people feel about DEI in your program.” That entails speaking directly with the stakeholders (faculty, staff, trainees) and identifying their specific concerns and what they think is lacking. Retreats, serious group discussions, and self-reflecting (asking “what initiatives would be good for us?”), and meeting one-on-one with individuals for a truly personalized approach are among potentially productive strategies for identifying the priorities and DEI-related topics specific to a particular academic sleep program.

Dr. Asare offered up a sample DEI survey (Am J Obstet Gynecol. 2020 Nov;223[5]:715.e1-715.e7), that made direct statements inviting the respondent to check off one of the following responses: Yes, No, Somewhat, Do not know, and Not applicable. Among sample statements:

• Our department is actively committed to issues of diversity, equity, and inclusion.
• Faculty searches in the department regularly attract a diverse pool of highly qualified candidates and/or attract a pool that represents the availability of MDs in this field.
• Our outreach and recruitment processes employ targeted practices for attracting diverse populations.

Dr. Asare said that a survey can be a simple approach for garnering information that can be useful for prioritizing DEI topics of concern and igniting interest in them. Engagement requires regular DEI committee meetings with minutes or a newsletter and with updates and topics brought to faculty meetings.
 

Key DEI areas of focus

Dr. Asare listed several key DEI areas: Recruitment/retention, mentorship, scholarship, and inclusion and community engagement. Under scholarship, for example, she cited topics for potential inclusion in a DEI curriculum: Unconscious bias and anti-racism training, racism, discrimination and microaggression education (bystander/deescalation training), cultural competency and awareness, workplace civility, and health disparities. “We all know that implicit bias in providers is a reality, unfortunately,” Dr. Asare said. Being aware of these implicit biases is a start, but instruction on how to actively overcome them has to be provided. Tools may include perspective-taking, exploring common identity, and self-reflection.

To create an inclusive environment for all faculty, trainees, and staff may involve establishing a “welcome committee” for new faculty, perhaps with designating a “peer buddy,” creating social events and other opportunities for all opinions and ideas to be heard and valued. Particularly for underserved and disadvantaged patient populations, patient advocacy and community service need to be fostered through support groups and provision of resources.

Summarizing, Dr. Asare reiterated several key elements for a successful DEI program: Build a team and discuss the mission, survey the current climate allowing open communication and dialogue, plan and engage, organize, and form areas of DEI focus. Find out where you are and where you want to be with respect to DEI, she concluded.

Dr. Asare declared that she had no conflicts of interest.

What you really don’t want to do, if you want to improve diversity, equity, and inclusion (DEI) at your academic institution, is to recruit diverse people to your program and then have them come and feel not included, said Vivian Asare, MD. “That can work against your efforts,” she stated in an oral presentation at the annual meeting of the American College of Chest Physicians (CHEST). Dr. Asare is assistant professor and vice chief of DEI for Yale Pulmonary, Critical Care, and Sleep Medicine, and associate medical director of Yale Centers for Sleep Medicine, New Haven, Conn.

In offering a path to successful DEI, Dr. Asare said: “The first step is to build a team and discuss your mission. Invite everyone to participate and include your leadership because they’re the ones who set the stage, ensure sustainability, and can be a liaison with faculty.” Then a DEI leader should be elected, she added.

The next and very important step is to survey the current institutional climate. “You need to tap into how people feel about DEI in your program.” That entails speaking directly with the stakeholders (faculty, staff, trainees) and identifying their specific concerns and what they think is lacking. Retreats, serious group discussions, and self-reflecting (asking “what initiatives would be good for us?”), and meeting one-on-one with individuals for a truly personalized approach are among potentially productive strategies for identifying the priorities and DEI-related topics specific to a particular academic sleep program.

Dr. Asare offered up a sample DEI survey (Am J Obstet Gynecol. 2020 Nov;223[5]:715.e1-715.e7), that made direct statements inviting the respondent to check off one of the following responses: Yes, No, Somewhat, Do not know, and Not applicable. Among sample statements:

• Our department is actively committed to issues of diversity, equity, and inclusion.
• Faculty searches in the department regularly attract a diverse pool of highly qualified candidates and/or attract a pool that represents the availability of MDs in this field.
• Our outreach and recruitment processes employ targeted practices for attracting diverse populations.

Dr. Asare said that a survey can be a simple approach for garnering information that can be useful for prioritizing DEI topics of concern and igniting interest in them. Engagement requires regular DEI committee meetings with minutes or a newsletter and with updates and topics brought to faculty meetings.
 

Key DEI areas of focus

Dr. Asare listed several key DEI areas: Recruitment/retention, mentorship, scholarship, and inclusion and community engagement. Under scholarship, for example, she cited topics for potential inclusion in a DEI curriculum: Unconscious bias and anti-racism training, racism, discrimination and microaggression education (bystander/deescalation training), cultural competency and awareness, workplace civility, and health disparities. “We all know that implicit bias in providers is a reality, unfortunately,” Dr. Asare said. Being aware of these implicit biases is a start, but instruction on how to actively overcome them has to be provided. Tools may include perspective-taking, exploring common identity, and self-reflection.

To create an inclusive environment for all faculty, trainees, and staff may involve establishing a “welcome committee” for new faculty, perhaps with designating a “peer buddy,” creating social events and other opportunities for all opinions and ideas to be heard and valued. Particularly for underserved and disadvantaged patient populations, patient advocacy and community service need to be fostered through support groups and provision of resources.

Summarizing, Dr. Asare reiterated several key elements for a successful DEI program: Build a team and discuss the mission, survey the current climate allowing open communication and dialogue, plan and engage, organize, and form areas of DEI focus. Find out where you are and where you want to be with respect to DEI, she concluded.

Dr. Asare declared that she had no conflicts of interest.

What you really don’t want to do, if you want to improve diversity, equity, and inclusion (DEI) at your academic institution, is to recruit diverse people to your program and then have them come and feel not included, said Vivian Asare, MD. “That can work against your efforts,” she stated in an oral presentation at the annual meeting of the American College of Chest Physicians (CHEST). Dr. Asare is assistant professor and vice chief of DEI for Yale Pulmonary, Critical Care, and Sleep Medicine, and associate medical director of Yale Centers for Sleep Medicine, New Haven, Conn.

In offering a path to successful DEI, Dr. Asare said: “The first step is to build a team and discuss your mission. Invite everyone to participate and include your leadership because they’re the ones who set the stage, ensure sustainability, and can be a liaison with faculty.” Then a DEI leader should be elected, she added.

The next and very important step is to survey the current institutional climate. “You need to tap into how people feel about DEI in your program.” That entails speaking directly with the stakeholders (faculty, staff, trainees) and identifying their specific concerns and what they think is lacking. Retreats, serious group discussions, and self-reflecting (asking “what initiatives would be good for us?”), and meeting one-on-one with individuals for a truly personalized approach are among potentially productive strategies for identifying the priorities and DEI-related topics specific to a particular academic sleep program.

Dr. Asare offered up a sample DEI survey (Am J Obstet Gynecol. 2020 Nov;223[5]:715.e1-715.e7), that made direct statements inviting the respondent to check off one of the following responses: Yes, No, Somewhat, Do not know, and Not applicable. Among sample statements:

• Our department is actively committed to issues of diversity, equity, and inclusion.
• Faculty searches in the department regularly attract a diverse pool of highly qualified candidates and/or attract a pool that represents the availability of MDs in this field.
• Our outreach and recruitment processes employ targeted practices for attracting diverse populations.

Dr. Asare said that a survey can be a simple approach for garnering information that can be useful for prioritizing DEI topics of concern and igniting interest in them. Engagement requires regular DEI committee meetings with minutes or a newsletter and with updates and topics brought to faculty meetings.
 

Key DEI areas of focus

Dr. Asare listed several key DEI areas: Recruitment/retention, mentorship, scholarship, and inclusion and community engagement. Under scholarship, for example, she cited topics for potential inclusion in a DEI curriculum: Unconscious bias and anti-racism training, racism, discrimination and microaggression education (bystander/deescalation training), cultural competency and awareness, workplace civility, and health disparities. “We all know that implicit bias in providers is a reality, unfortunately,” Dr. Asare said. Being aware of these implicit biases is a start, but instruction on how to actively overcome them has to be provided. Tools may include perspective-taking, exploring common identity, and self-reflection.

To create an inclusive environment for all faculty, trainees, and staff may involve establishing a “welcome committee” for new faculty, perhaps with designating a “peer buddy,” creating social events and other opportunities for all opinions and ideas to be heard and valued. Particularly for underserved and disadvantaged patient populations, patient advocacy and community service need to be fostered through support groups and provision of resources.

Summarizing, Dr. Asare reiterated several key elements for a successful DEI program: Build a team and discuss the mission, survey the current climate allowing open communication and dialogue, plan and engage, organize, and form areas of DEI focus. Find out where you are and where you want to be with respect to DEI, she concluded.

Dr. Asare declared that she had no conflicts of interest.

Most adolescents with gender dysphoria who took puberty-blocking drugs for at least 3 months and then progressed to cross-sex hormone treatment were still taking hormones as they entered adulthood, new research of patients at a pioneering Dutch clinic shows.

The study negates past findings that large numbers of youth regret transitioning, say Maria Anna Theodora Catharina van der Loos, MD, and colleagues from the Centre of Expertise on Gender Dysphoria, Amsterdam, in their article published online in The Lancet Child & Adolescent Health. They believe the difference between their findings and those of other studies lies in proper diagnostic evaluation.

“The study aims to demonstrate, with a methodology that is more than adequate, that transgender people who begin their transition in childhood-adolescence do not give up,” Adrián Carrasco Munera, MD, a specialist in family and community medicine and member of the LGTBIQ+ Health Group of the Madrid Society of Family and Community Medicine told the UK Science Media Centre.

The cohort included 720 youth: 220 (31%) were assigned male at birth (AMAB) and 500 (69%) were assigned female at birth (AFAB). At the start of puberty-blocking treatment with a gonadotrophin-releasing hormone agonist, the median age of patients was 14.1 years for AMAB and 16.0 years for AFAB.

Of that cohort, 704 (98%) continued hormone therapy to the end of data collection (Dec. 31, 2018), at which point the median age of patients was 20 years for AMAB and 19 years for AFAB.

Careful consideration of patient needs

All the patients received care at the “Dutch Clinic,” which more than 20 years ago pioneered the approach of giving puberty-blocking drugs to children looking to transition, followed by cross-sex hormones. The study includes the “complete adolescent population” at the facility who met the inclusion criteria.

A similar U.S. study published earlier this year found that 74.4% of individuals who had started gender-affirming hormones before age 18 were still on them 4 years after starting medical treatment.

“However, it is unclear how many of these adolescents [in the U.S. study] used puberty-suppressing treatment before gender-affirming hormone treatment and to what extent they underwent diagnostic evaluation before initiation of medical treatment,” say Dr. van der Loos and colleagues.

She told this news organization that her clinic provides “a thorough diagnostic and mental health assessment” and discussion of fertility preservation prior to any youth being prescribed puberty blockers or cross-sex hormones.

About 40% of adolescents assessed by the gender clinic in Amsterdam go on to receive hormonal treatment.

“The gender identity unit of the Amsterdam UMC is a world leader in all aspects of transgender medicine and is governed by protocolized actions. This is reflected in the quality of the data and methodology of the study, and therefore of its conclusions,” endocrinologist Gilberto Pérez López, MD, Gregorio Marañón General University Hospital, Madrid, told the UK Science Media Centre.

“These findings can and should help and guide the current public and legal debate on the initiation of medical treatment in transgender minors.”

However, he cautioned the study is limited by the fact that the data come from a registry and they looked at only prescriptions issued and not compliance.

Another interesting thing to note in the research is that almost 70% of patients were born girls and they presented at the gender clinics later in adolescence than the natal boys.

“We don’t have a sound reason for this,” Dr. van der Loos noted.

Study limitations

She also acknowledges that the short follow-up data in some individuals make it difficult to draw conclusions about regret, to some extent.

The average use of cross-sex hormones in their study was 3.5 years for males transitioning to females and 2.3 years for females transitioning to males, so on average, this wouldn’t be long enough to see regret, she acknowledged.

Prior research shows that if youth decide to detransition to their natal sex, this can take, on average, 5 years from the start of medical therapy among born females and 7 years among born males.

However, some born males in the study had been taking hormones for 20 years and some natal females for 15 years, said Dr. van der Loos.

Another limitation is that the research only followed individuals until the end of 2018 while some government data estimate that the number of teens identifying as transgender has nearly doubled over the past 5 years.

The authors, Dr. Munera, and Dr. Lopez have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Most adolescents with gender dysphoria who took puberty-blocking drugs for at least 3 months and then progressed to cross-sex hormone treatment were still taking hormones as they entered adulthood, new research of patients at a pioneering Dutch clinic shows.

The study negates past findings that large numbers of youth regret transitioning, say Maria Anna Theodora Catharina van der Loos, MD, and colleagues from the Centre of Expertise on Gender Dysphoria, Amsterdam, in their article published online in The Lancet Child & Adolescent Health. They believe the difference between their findings and those of other studies lies in proper diagnostic evaluation.

“The study aims to demonstrate, with a methodology that is more than adequate, that transgender people who begin their transition in childhood-adolescence do not give up,” Adrián Carrasco Munera, MD, a specialist in family and community medicine and member of the LGTBIQ+ Health Group of the Madrid Society of Family and Community Medicine told the UK Science Media Centre.

The cohort included 720 youth: 220 (31%) were assigned male at birth (AMAB) and 500 (69%) were assigned female at birth (AFAB). At the start of puberty-blocking treatment with a gonadotrophin-releasing hormone agonist, the median age of patients was 14.1 years for AMAB and 16.0 years for AFAB.

Of that cohort, 704 (98%) continued hormone therapy to the end of data collection (Dec. 31, 2018), at which point the median age of patients was 20 years for AMAB and 19 years for AFAB.

Careful consideration of patient needs

All the patients received care at the “Dutch Clinic,” which more than 20 years ago pioneered the approach of giving puberty-blocking drugs to children looking to transition, followed by cross-sex hormones. The study includes the “complete adolescent population” at the facility who met the inclusion criteria.

A similar U.S. study published earlier this year found that 74.4% of individuals who had started gender-affirming hormones before age 18 were still on them 4 years after starting medical treatment.

“However, it is unclear how many of these adolescents [in the U.S. study] used puberty-suppressing treatment before gender-affirming hormone treatment and to what extent they underwent diagnostic evaluation before initiation of medical treatment,” say Dr. van der Loos and colleagues.

She told this news organization that her clinic provides “a thorough diagnostic and mental health assessment” and discussion of fertility preservation prior to any youth being prescribed puberty blockers or cross-sex hormones.

About 40% of adolescents assessed by the gender clinic in Amsterdam go on to receive hormonal treatment.

“The gender identity unit of the Amsterdam UMC is a world leader in all aspects of transgender medicine and is governed by protocolized actions. This is reflected in the quality of the data and methodology of the study, and therefore of its conclusions,” endocrinologist Gilberto Pérez López, MD, Gregorio Marañón General University Hospital, Madrid, told the UK Science Media Centre.

“These findings can and should help and guide the current public and legal debate on the initiation of medical treatment in transgender minors.”

However, he cautioned the study is limited by the fact that the data come from a registry and they looked at only prescriptions issued and not compliance.

Another interesting thing to note in the research is that almost 70% of patients were born girls and they presented at the gender clinics later in adolescence than the natal boys.

“We don’t have a sound reason for this,” Dr. van der Loos noted.

Study limitations

She also acknowledges that the short follow-up data in some individuals make it difficult to draw conclusions about regret, to some extent.

The average use of cross-sex hormones in their study was 3.5 years for males transitioning to females and 2.3 years for females transitioning to males, so on average, this wouldn’t be long enough to see regret, she acknowledged.

Prior research shows that if youth decide to detransition to their natal sex, this can take, on average, 5 years from the start of medical therapy among born females and 7 years among born males.

However, some born males in the study had been taking hormones for 20 years and some natal females for 15 years, said Dr. van der Loos.

Another limitation is that the research only followed individuals until the end of 2018 while some government data estimate that the number of teens identifying as transgender has nearly doubled over the past 5 years.

The authors, Dr. Munera, and Dr. Lopez have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Most adolescents with gender dysphoria who took puberty-blocking drugs for at least 3 months and then progressed to cross-sex hormone treatment were still taking hormones as they entered adulthood, new research of patients at a pioneering Dutch clinic shows.

The study negates past findings that large numbers of youth regret transitioning, say Maria Anna Theodora Catharina van der Loos, MD, and colleagues from the Centre of Expertise on Gender Dysphoria, Amsterdam, in their article published online in The Lancet Child & Adolescent Health. They believe the difference between their findings and those of other studies lies in proper diagnostic evaluation.

“The study aims to demonstrate, with a methodology that is more than adequate, that transgender people who begin their transition in childhood-adolescence do not give up,” Adrián Carrasco Munera, MD, a specialist in family and community medicine and member of the LGTBIQ+ Health Group of the Madrid Society of Family and Community Medicine told the UK Science Media Centre.

The cohort included 720 youth: 220 (31%) were assigned male at birth (AMAB) and 500 (69%) were assigned female at birth (AFAB). At the start of puberty-blocking treatment with a gonadotrophin-releasing hormone agonist, the median age of patients was 14.1 years for AMAB and 16.0 years for AFAB.

Of that cohort, 704 (98%) continued hormone therapy to the end of data collection (Dec. 31, 2018), at which point the median age of patients was 20 years for AMAB and 19 years for AFAB.

Careful consideration of patient needs

All the patients received care at the “Dutch Clinic,” which more than 20 years ago pioneered the approach of giving puberty-blocking drugs to children looking to transition, followed by cross-sex hormones. The study includes the “complete adolescent population” at the facility who met the inclusion criteria.

A similar U.S. study published earlier this year found that 74.4% of individuals who had started gender-affirming hormones before age 18 were still on them 4 years after starting medical treatment.

“However, it is unclear how many of these adolescents [in the U.S. study] used puberty-suppressing treatment before gender-affirming hormone treatment and to what extent they underwent diagnostic evaluation before initiation of medical treatment,” say Dr. van der Loos and colleagues.

She told this news organization that her clinic provides “a thorough diagnostic and mental health assessment” and discussion of fertility preservation prior to any youth being prescribed puberty blockers or cross-sex hormones.

About 40% of adolescents assessed by the gender clinic in Amsterdam go on to receive hormonal treatment.

“The gender identity unit of the Amsterdam UMC is a world leader in all aspects of transgender medicine and is governed by protocolized actions. This is reflected in the quality of the data and methodology of the study, and therefore of its conclusions,” endocrinologist Gilberto Pérez López, MD, Gregorio Marañón General University Hospital, Madrid, told the UK Science Media Centre.

“These findings can and should help and guide the current public and legal debate on the initiation of medical treatment in transgender minors.”

However, he cautioned the study is limited by the fact that the data come from a registry and they looked at only prescriptions issued and not compliance.

Another interesting thing to note in the research is that almost 70% of patients were born girls and they presented at the gender clinics later in adolescence than the natal boys.

“We don’t have a sound reason for this,” Dr. van der Loos noted.

Study limitations

She also acknowledges that the short follow-up data in some individuals make it difficult to draw conclusions about regret, to some extent.

The average use of cross-sex hormones in their study was 3.5 years for males transitioning to females and 2.3 years for females transitioning to males, so on average, this wouldn’t be long enough to see regret, she acknowledged.

Prior research shows that if youth decide to detransition to their natal sex, this can take, on average, 5 years from the start of medical therapy among born females and 7 years among born males.

However, some born males in the study had been taking hormones for 20 years and some natal females for 15 years, said Dr. van der Loos.

Another limitation is that the research only followed individuals until the end of 2018 while some government data estimate that the number of teens identifying as transgender has nearly doubled over the past 5 years.

The authors, Dr. Munera, and Dr. Lopez have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

DRESSLERVILLE, NEV. – Smoke began billowing into the skies of northwestern Nevada in September, clouding the mountains, dimming the sun – and quashing residents’ hopes that they would be spared from wildfires and the awful air quality the blazes produce.

The lung-irritating particles were blowing in from burning forests in California and settling in Douglas County, Nevada, home to nearly 50,000 people, prompting warnings that air quality had reached hazardous levels.

Those levels meant the air was very unhealthy, bad enough to raise alarms about people’s immediate health care needs and questions about whether worsening pollution could result in long-term health issues. People could increasingly face such risks as climate change makes wildfires, drought, dust storms, and floods more frequent across the United States and the world.

Some people simply feel powerless.

“There’s not much we could do about it,” said Serrell Smokey, chairman of the Washoe Tribe of Nevada and California. The tribe’s land straddles the border between California and Nevada near Lake Tahoe and extends into Douglas County, about 60 miles south of Reno.

Tribe members and other area residents are among millions of people nationwide who this year will experience poor air quality because of wildfires. In September, as smoke settled over Nevada, fire-related air quality alerts were dispatched in six other states: California, Idaho, Montana, Oregon, Washington, and Wyoming.

Yet, by one measure, people who live in Douglas County are better off than those in some other hard-hit areas. Douglas County residents must drive 30 minutes, on average, for medical care from lung specialists called pulmonologists. In other parts of the West and Upper Midwest, however, patients must drive an hour or more, according to data analyzed by GoodRx, a website that tracks prescription drug prices and conducts research.

Specifically, the research found that about 5.5 million Americans live in the 488 counties where drive times to pulmonologists are an hour or more. Much of Nevada and large parts of Montana fall into those gaps between specialists – places that have recently grappled with wildfires that fill the air with smoke and ash, which can cause lung problems or exacerbate existing ones.

Allergies, asthma, and similar issues are often handled by primary care physicians, but patients are sent to pulmonologists when problems escalate – think severe asthma; chronic obstructive pulmonary disease, or COPD; or emphysema.

Data from the Association of American Medical Colleges shows the number of pulmonary disease specialists in the United States dropped nearly 11% from 2014 to 2019. The group, which is based in Washington, D.C., and represents the academic medicine community, noted that the decline might not be as high as it appears because some physicians are opting to practice pulmonary critical care rather than just pulmonology. Many of those types of pulmonologists work in hospital intensive care units.

About 15,000 pulmonologists are practicing in the United States, according to the GoodRx report. Yet vast swaths of the country have few or none.

“New Mexico has one pulmonologist for the entire southeastern part of state, not counting Las Cruces, which is closer to El Paso,” said Victor Test, MD, a pulmonologist at Texas Tech Physicians.

Dr. Test, one of 13 pulmonologists in the Lubbock, Tex., region, said that his patients from within Texas sometimes drive 4 hours for an appointment and that other people travel from “New Mexico, Oklahoma, even far western Kansas.”

Increases in wildfires and their intensity will likely expand the need for pulmonologists.

“Climate change is going to affect lung disease,” said Nicholas Kenyon, MD, a professor of pulmonary, critical care, and sleep medicine at the University of California, Davis, where he and several other researchers are tracking the effects of wildfires. At his Sacramento practice, Dr. Kenyon said, he sees patients from far northern parts of California, including Eureka, a 5-hour drive from the state capital.

The short-term effects of breathing smoke are pretty well known. People show up in emergency rooms with asthma attacks, exacerbation of COPD, bronchitis, and even pneumonia, Dr. Kenyon said. Some have chest pain or other cardiac concerns.

“But we have very little understanding of what happens over the longer term,” he said. “If people get 2 or 3 weeks of wildfire exposure for 2 or 3 years, does that lead to worsening of asthma or COPD? We just don’t know.”

Fires release multiple pollutants, including carbon dioxide, carbon monoxide, and chemicals like benzene. All fires send particles into the air. Health researchers and air quality experts are most concerned about tiny pieces referred to as particulate matter 2.5. Far smaller than a human hair, the particles can lodge deep in the lungs and have been linked to heart and lung conditions.

Increases in those tiny particles are associated with a greater risk of death from all causes, excluding accidents, homicides, and other nonaccidental causes, for up to 4 days after a population is exposed, according to a 2020 New England Journal of Medicine overview.

The concentration of fine particulate matter is one of five gauges used to calculate the Air Quality Index, a numerical and color-coded index used to let the public know about local air pollution levels. Green denotes good air quality and is given if the total index is 50 or less. When the measurement exceeds 100, the air quality gets an orange label and may be bad for certain groups. Levels over 200 get a red label and are considered unhealthy for everyone.

Government agencies track those levels, as do people who use apps or websites to determine whether it’s safe to go outside.

When the AQI rises above 150, Farah Madhani-Lovely, MD, a pulmonologist, said, Renown Regional Medical Center in Reno shuts its outpatient pulmonary rehabilitation clinic because it doesn’t want to encourage patients to drive in. Some patients from Douglas County opt for care near home, about an hour away. “We don’t want these patients exposed outside because just 1 minute of exposure to the smoke can trigger an exacerbation of their chronic disease,” Dr. Madhani-Lovely said.

Mr. Smokey said connecting with pulmonologists can be difficult for Washoe Tribe members, particularly those who live on the California side of the reservation. “We cannot find providers for them,” he said. “We end up referring them out and sending them hundreds of miles out of their way just to get care that we should be able to provide here.”

Recruiting specialists to rural areas or smaller cities has long been difficult. For one thing, a specialist might be the only one for miles around, “so there’s a tremendous burden in terms of coverage and days off,” Dr. Test said.

Another concern is that physicians tend to train in larger cities and often want to practice in similar places. Even recruiting pulmonary physicians to Lubbock, a city of 260,000 in West Texas, is a challenge, Dr. Test said.

“I love Lubbock,” he said. “But I tell people who have never been here, I say, ‘It’s really flat.’ They don’t understand flat until they get here.”

In Nevada, on days when the air quality is bad, Washoe tribal members try to protect themselves with makeshift air purifiers created from fans, duct tape, and air filters, Mr. Smokey said.

Longer term, Mr. Smokey and other tribal leaders are pushing the Indian Health Service to establish a specialty care hospital in northern Nevada. The closest specialty care hospital for Washoe tribal members is more than 700 miles away, in Phoenix.

It’s difficult because “there’s a need we should be taking care of,” Mr. Smokey said. “But we have to fight for it. And sometimes that fight takes years, years, and years to accomplish.”
 

A version of this article first appeared on Medscape.com.

DRESSLERVILLE, NEV. – Smoke began billowing into the skies of northwestern Nevada in September, clouding the mountains, dimming the sun – and quashing residents’ hopes that they would be spared from wildfires and the awful air quality the blazes produce.

The lung-irritating particles were blowing in from burning forests in California and settling in Douglas County, Nevada, home to nearly 50,000 people, prompting warnings that air quality had reached hazardous levels.

Those levels meant the air was very unhealthy, bad enough to raise alarms about people’s immediate health care needs and questions about whether worsening pollution could result in long-term health issues. People could increasingly face such risks as climate change makes wildfires, drought, dust storms, and floods more frequent across the United States and the world.

Some people simply feel powerless.

“There’s not much we could do about it,” said Serrell Smokey, chairman of the Washoe Tribe of Nevada and California. The tribe’s land straddles the border between California and Nevada near Lake Tahoe and extends into Douglas County, about 60 miles south of Reno.

Tribe members and other area residents are among millions of people nationwide who this year will experience poor air quality because of wildfires. In September, as smoke settled over Nevada, fire-related air quality alerts were dispatched in six other states: California, Idaho, Montana, Oregon, Washington, and Wyoming.

Yet, by one measure, people who live in Douglas County are better off than those in some other hard-hit areas. Douglas County residents must drive 30 minutes, on average, for medical care from lung specialists called pulmonologists. In other parts of the West and Upper Midwest, however, patients must drive an hour or more, according to data analyzed by GoodRx, a website that tracks prescription drug prices and conducts research.

Specifically, the research found that about 5.5 million Americans live in the 488 counties where drive times to pulmonologists are an hour or more. Much of Nevada and large parts of Montana fall into those gaps between specialists – places that have recently grappled with wildfires that fill the air with smoke and ash, which can cause lung problems or exacerbate existing ones.

Allergies, asthma, and similar issues are often handled by primary care physicians, but patients are sent to pulmonologists when problems escalate – think severe asthma; chronic obstructive pulmonary disease, or COPD; or emphysema.

Data from the Association of American Medical Colleges shows the number of pulmonary disease specialists in the United States dropped nearly 11% from 2014 to 2019. The group, which is based in Washington, D.C., and represents the academic medicine community, noted that the decline might not be as high as it appears because some physicians are opting to practice pulmonary critical care rather than just pulmonology. Many of those types of pulmonologists work in hospital intensive care units.

About 15,000 pulmonologists are practicing in the United States, according to the GoodRx report. Yet vast swaths of the country have few or none.

“New Mexico has one pulmonologist for the entire southeastern part of state, not counting Las Cruces, which is closer to El Paso,” said Victor Test, MD, a pulmonologist at Texas Tech Physicians.

Dr. Test, one of 13 pulmonologists in the Lubbock, Tex., region, said that his patients from within Texas sometimes drive 4 hours for an appointment and that other people travel from “New Mexico, Oklahoma, even far western Kansas.”

Increases in wildfires and their intensity will likely expand the need for pulmonologists.

“Climate change is going to affect lung disease,” said Nicholas Kenyon, MD, a professor of pulmonary, critical care, and sleep medicine at the University of California, Davis, where he and several other researchers are tracking the effects of wildfires. At his Sacramento practice, Dr. Kenyon said, he sees patients from far northern parts of California, including Eureka, a 5-hour drive from the state capital.

The short-term effects of breathing smoke are pretty well known. People show up in emergency rooms with asthma attacks, exacerbation of COPD, bronchitis, and even pneumonia, Dr. Kenyon said. Some have chest pain or other cardiac concerns.

“But we have very little understanding of what happens over the longer term,” he said. “If people get 2 or 3 weeks of wildfire exposure for 2 or 3 years, does that lead to worsening of asthma or COPD? We just don’t know.”

Fires release multiple pollutants, including carbon dioxide, carbon monoxide, and chemicals like benzene. All fires send particles into the air. Health researchers and air quality experts are most concerned about tiny pieces referred to as particulate matter 2.5. Far smaller than a human hair, the particles can lodge deep in the lungs and have been linked to heart and lung conditions.

Increases in those tiny particles are associated with a greater risk of death from all causes, excluding accidents, homicides, and other nonaccidental causes, for up to 4 days after a population is exposed, according to a 2020 New England Journal of Medicine overview.

The concentration of fine particulate matter is one of five gauges used to calculate the Air Quality Index, a numerical and color-coded index used to let the public know about local air pollution levels. Green denotes good air quality and is given if the total index is 50 or less. When the measurement exceeds 100, the air quality gets an orange label and may be bad for certain groups. Levels over 200 get a red label and are considered unhealthy for everyone.

Government agencies track those levels, as do people who use apps or websites to determine whether it’s safe to go outside.

When the AQI rises above 150, Farah Madhani-Lovely, MD, a pulmonologist, said, Renown Regional Medical Center in Reno shuts its outpatient pulmonary rehabilitation clinic because it doesn’t want to encourage patients to drive in. Some patients from Douglas County opt for care near home, about an hour away. “We don’t want these patients exposed outside because just 1 minute of exposure to the smoke can trigger an exacerbation of their chronic disease,” Dr. Madhani-Lovely said.

Mr. Smokey said connecting with pulmonologists can be difficult for Washoe Tribe members, particularly those who live on the California side of the reservation. “We cannot find providers for them,” he said. “We end up referring them out and sending them hundreds of miles out of their way just to get care that we should be able to provide here.”

Recruiting specialists to rural areas or smaller cities has long been difficult. For one thing, a specialist might be the only one for miles around, “so there’s a tremendous burden in terms of coverage and days off,” Dr. Test said.

Another concern is that physicians tend to train in larger cities and often want to practice in similar places. Even recruiting pulmonary physicians to Lubbock, a city of 260,000 in West Texas, is a challenge, Dr. Test said.

“I love Lubbock,” he said. “But I tell people who have never been here, I say, ‘It’s really flat.’ They don’t understand flat until they get here.”

In Nevada, on days when the air quality is bad, Washoe tribal members try to protect themselves with makeshift air purifiers created from fans, duct tape, and air filters, Mr. Smokey said.

Longer term, Mr. Smokey and other tribal leaders are pushing the Indian Health Service to establish a specialty care hospital in northern Nevada. The closest specialty care hospital for Washoe tribal members is more than 700 miles away, in Phoenix.

It’s difficult because “there’s a need we should be taking care of,” Mr. Smokey said. “But we have to fight for it. And sometimes that fight takes years, years, and years to accomplish.”
 

A version of this article first appeared on Medscape.com.

DRESSLERVILLE, NEV. – Smoke began billowing into the skies of northwestern Nevada in September, clouding the mountains, dimming the sun – and quashing residents’ hopes that they would be spared from wildfires and the awful air quality the blazes produce.

The lung-irritating particles were blowing in from burning forests in California and settling in Douglas County, Nevada, home to nearly 50,000 people, prompting warnings that air quality had reached hazardous levels.

Those levels meant the air was very unhealthy, bad enough to raise alarms about people’s immediate health care needs and questions about whether worsening pollution could result in long-term health issues. People could increasingly face such risks as climate change makes wildfires, drought, dust storms, and floods more frequent across the United States and the world.

Some people simply feel powerless.

“There’s not much we could do about it,” said Serrell Smokey, chairman of the Washoe Tribe of Nevada and California. The tribe’s land straddles the border between California and Nevada near Lake Tahoe and extends into Douglas County, about 60 miles south of Reno.

Tribe members and other area residents are among millions of people nationwide who this year will experience poor air quality because of wildfires. In September, as smoke settled over Nevada, fire-related air quality alerts were dispatched in six other states: California, Idaho, Montana, Oregon, Washington, and Wyoming.

Yet, by one measure, people who live in Douglas County are better off than those in some other hard-hit areas. Douglas County residents must drive 30 minutes, on average, for medical care from lung specialists called pulmonologists. In other parts of the West and Upper Midwest, however, patients must drive an hour or more, according to data analyzed by GoodRx, a website that tracks prescription drug prices and conducts research.

Specifically, the research found that about 5.5 million Americans live in the 488 counties where drive times to pulmonologists are an hour or more. Much of Nevada and large parts of Montana fall into those gaps between specialists – places that have recently grappled with wildfires that fill the air with smoke and ash, which can cause lung problems or exacerbate existing ones.

Allergies, asthma, and similar issues are often handled by primary care physicians, but patients are sent to pulmonologists when problems escalate – think severe asthma; chronic obstructive pulmonary disease, or COPD; or emphysema.

Data from the Association of American Medical Colleges shows the number of pulmonary disease specialists in the United States dropped nearly 11% from 2014 to 2019. The group, which is based in Washington, D.C., and represents the academic medicine community, noted that the decline might not be as high as it appears because some physicians are opting to practice pulmonary critical care rather than just pulmonology. Many of those types of pulmonologists work in hospital intensive care units.

About 15,000 pulmonologists are practicing in the United States, according to the GoodRx report. Yet vast swaths of the country have few or none.

“New Mexico has one pulmonologist for the entire southeastern part of state, not counting Las Cruces, which is closer to El Paso,” said Victor Test, MD, a pulmonologist at Texas Tech Physicians.

Dr. Test, one of 13 pulmonologists in the Lubbock, Tex., region, said that his patients from within Texas sometimes drive 4 hours for an appointment and that other people travel from “New Mexico, Oklahoma, even far western Kansas.”

Increases in wildfires and their intensity will likely expand the need for pulmonologists.

“Climate change is going to affect lung disease,” said Nicholas Kenyon, MD, a professor of pulmonary, critical care, and sleep medicine at the University of California, Davis, where he and several other researchers are tracking the effects of wildfires. At his Sacramento practice, Dr. Kenyon said, he sees patients from far northern parts of California, including Eureka, a 5-hour drive from the state capital.

The short-term effects of breathing smoke are pretty well known. People show up in emergency rooms with asthma attacks, exacerbation of COPD, bronchitis, and even pneumonia, Dr. Kenyon said. Some have chest pain or other cardiac concerns.

“But we have very little understanding of what happens over the longer term,” he said. “If people get 2 or 3 weeks of wildfire exposure for 2 or 3 years, does that lead to worsening of asthma or COPD? We just don’t know.”

Fires release multiple pollutants, including carbon dioxide, carbon monoxide, and chemicals like benzene. All fires send particles into the air. Health researchers and air quality experts are most concerned about tiny pieces referred to as particulate matter 2.5. Far smaller than a human hair, the particles can lodge deep in the lungs and have been linked to heart and lung conditions.

Increases in those tiny particles are associated with a greater risk of death from all causes, excluding accidents, homicides, and other nonaccidental causes, for up to 4 days after a population is exposed, according to a 2020 New England Journal of Medicine overview.

The concentration of fine particulate matter is one of five gauges used to calculate the Air Quality Index, a numerical and color-coded index used to let the public know about local air pollution levels. Green denotes good air quality and is given if the total index is 50 or less. When the measurement exceeds 100, the air quality gets an orange label and may be bad for certain groups. Levels over 200 get a red label and are considered unhealthy for everyone.

Government agencies track those levels, as do people who use apps or websites to determine whether it’s safe to go outside.

When the AQI rises above 150, Farah Madhani-Lovely, MD, a pulmonologist, said, Renown Regional Medical Center in Reno shuts its outpatient pulmonary rehabilitation clinic because it doesn’t want to encourage patients to drive in. Some patients from Douglas County opt for care near home, about an hour away. “We don’t want these patients exposed outside because just 1 minute of exposure to the smoke can trigger an exacerbation of their chronic disease,” Dr. Madhani-Lovely said.

Mr. Smokey said connecting with pulmonologists can be difficult for Washoe Tribe members, particularly those who live on the California side of the reservation. “We cannot find providers for them,” he said. “We end up referring them out and sending them hundreds of miles out of their way just to get care that we should be able to provide here.”

Recruiting specialists to rural areas or smaller cities has long been difficult. For one thing, a specialist might be the only one for miles around, “so there’s a tremendous burden in terms of coverage and days off,” Dr. Test said.

Another concern is that physicians tend to train in larger cities and often want to practice in similar places. Even recruiting pulmonary physicians to Lubbock, a city of 260,000 in West Texas, is a challenge, Dr. Test said.

“I love Lubbock,” he said. “But I tell people who have never been here, I say, ‘It’s really flat.’ They don’t understand flat until they get here.”

In Nevada, on days when the air quality is bad, Washoe tribal members try to protect themselves with makeshift air purifiers created from fans, duct tape, and air filters, Mr. Smokey said.

Longer term, Mr. Smokey and other tribal leaders are pushing the Indian Health Service to establish a specialty care hospital in northern Nevada. The closest specialty care hospital for Washoe tribal members is more than 700 miles away, in Phoenix.

It’s difficult because “there’s a need we should be taking care of,” Mr. Smokey said. “But we have to fight for it. And sometimes that fight takes years, years, and years to accomplish.”
 

A version of this article first appeared on Medscape.com.

While rainbow-colored flags may wave proudly from hotel balconies and sports arenas, LGBTQ+ patients might still feel some discrimination in the medical space, according to a Center for American Progress survey.

“Despite health care being considered a basic human right by the World Health Organization, it’s common for LGBTQ+ folks to face difficulties not only when trying to access care but also within the walls of the doctor’s office or hospital,” says Samantha Estevez, MD, a reproductive endocrinology and infertility fellow in New York.

In Medscape’s Physicians’ Views on LGBTQ+ Rights Issues Report 2022: Strong Emotions, Contrary Opinions, physicians were asked whether they see disparities in the care LGBTQ+ patients receive in comparison with the care that non-LGBTQ+ patients receive. About 35% of physicians said LGBTQ+ patients receive a different level of care; 52% of respondents younger than 45 said so.

It’s an issue unlikely to be resolved without the medical community’s awareness. With insights from four LGBTQ+ clinicians, here are several steps physicians can take to close the disparity gap.
 

Update intake forms

Many patient medical forms are populated with checkboxes. These forms may make it easier for patients to share their medical information and for practices to collect data. But unfortunately, they don’t allow for patients to fill in contextual information.

“It’s extremely important for health care professionals to understand the people they are serving,” says Nicholas Grant, PhD, ABPP, president of GLMA: Health Professionals Advancing LGBTQ+ Equality. Dr. Grant is a board-certified clinical psychologist in Hawaii. “The more accurate we are with our information gathering and paperwork, the more accurate we will be at serving our LGBTQ+ communities.”

Dr. Grant recommends asking open-ended questions, such as the following:

• What is your gender identity?
• What was your assigned sex at birth?
• What pronouns do you prefer?
• What gender(s) are your sexual partners?

However, Frances Grimstad, MD, a Boston-based ob/gyn and GLMA board member, adds this advice: Before revising intake forms, consider their purpose.

“As an ob/gyn, information about a patient’s sexual orientation and their sexual activity is beneficial for my care,” says Dr. Grimstad. “But that information may not be relevant for a physical therapy clinic where most patients are coming in with knee injuries. So, you shouldn’t just place items on your intake forms by default. Instead, clinicians should consider what is relevant to the encounter you’re having and how you are going to use the information.”
 

Change signage

Take stock of posters and brochures in the office and signs outside restrooms. If they communicate traditional gender roles, then it may be time for a change.

“It’s important to ensure representation of all types of people and families in your office,” says Chase Anderson, MD, an assistant professor of child and adolescent psychiatry in San Francisco.

Hang posters with images of diverse families. Display brochures that address LGBTQ+ health concerns when warranted. And for restrooms, replace traditional binary images with gender-neutral ones. You can also add signage about each bathroom’s purpose, suggests Dr. Grimstad.

“Let’s not just de-gender bathrooms,” she says. “Let’s hang signs that tell if the bathroom has multiple stalls, urinals, or handicap access. Let signage focus on the functions of each bathroom, not gender.”
 

Ask for feedback

Feedback forms give LBGTQ+ patients a platform to share concerns. For example, consider an email with a linked document that all patients can fill out anonymously. Ask questions such as the following:

• Did you feel affirmed during your appointment? If so, how? If not, how can we improve?
• Did we use the proper pronouns?
• Did signage make you feel like you were in a safe space? What didn’t make you feel safe?

Set up a system with team members to process feedback and implement changes.

Also, if you have a large-scale practice, consider forming an LGBTQ+ community advisory board. “They can offer feedback about your practice’s clinical structure,” Dr. Grimstad tells Medscape.
 

Hire diverse employees

Building a diverse and inclusive workforce is critical to serving the LBGTQ+ community. Team members should reflect your patient population.

“Diversity isn’t a monolith,” says Dr. Grimstad. “It isn’t just racial diversity, or sexual or gender diversity. Even in a town which appears homogeneous in one area of diversity, such as a majority White town, it’s important to remember all the other facets of diversity that exist, such as gender, sexual orientation, cultural diversity.”

A diverse team may offer a surprising boost to your practice. According to a study published in the Journal of the National Medical Association, patient outcomes improve when a more diverse team provides care. In fact, diverse teams fare better in innovation, communication, risk assessment, and financial performance.

Dr. Anderson also recommends allowing team members “to be themselves.” For example, let employees wear their hair in whatever way they prefer or display their tattoos.

“This signals to patients that if staff members can be themselves here, patients can be themselves here, too,” says Dr. Anderson.
 

Provide training

Medical staff may sometimes feel uncomfortable serving LBGTQ+ patients because of their own biases, attitudes, or lack of knowledge about the community. Regular training can ease their discomfort.

“Make sure all health professionals are trained and educated on the needs of LGBTQ+ patients,” says Dr. Grant. “Understanding their health needs is the provider’s responsibility.”

For basic information, Dr. Anderson recommends visiting The Trevor Project, an organization that serves LGBTQ+ youth. “They’re really good at keeping up with changing verbiage and trends,” says Dr. Anderson.

To strengthen community connections, Dr. Grimstad recommends using trainers from your local area if possible. Do a Google search to find an LGBTQ+ center nearby or in the closest major city. Invite them to staff meetings or ask them to organize a workshop.

By implementing these strategies, you can start building a bridge between your practice and the LGBTQ+ community and provide better care for them as patients.

“Whether it’s knowing about PrEP ... or ensuring staff members are trained in caring for patients with any general or sexual identity, we as doctors and medical professionals must continue to move forward and serve our LGBTQ+ patients in big and small ways,” says Dr. Estevez.

For in-depth training, check the following organizations:

National LGBTQIA+ Health Education Center at the Fenway Institute provides educational programs and resources to health care organizations.

GLMA has a top 10 health issues webpage that doctors can use to educate themselves and staff members on the LGBTQ+ community’s most urgent health needs.

Alliance for Full Acceptance offers LGBTQ cultural competency training, including a 1-hour awareness class and a 3-hour inclusivity workshop for clinicians.

The Substance Abuse and Mental Health Services Administration has compiled a list of training curricula for behavioral health counselors and primary care providers.

UCSF’s Lesbian, Gay, Bisexual, and Transgender Resource Center has a list of training and educational materials for medical professionals.

Equality California Institute offers both in-person and virtual training covering basic terminology, data on LGBTQ+ health issues, and how to create an inclusive environment.

A version of this article first appeared on Medscape.com.

While rainbow-colored flags may wave proudly from hotel balconies and sports arenas, LGBTQ+ patients might still feel some discrimination in the medical space, according to a Center for American Progress survey.

“Despite health care being considered a basic human right by the World Health Organization, it’s common for LGBTQ+ folks to face difficulties not only when trying to access care but also within the walls of the doctor’s office or hospital,” says Samantha Estevez, MD, a reproductive endocrinology and infertility fellow in New York.

In Medscape’s Physicians’ Views on LGBTQ+ Rights Issues Report 2022: Strong Emotions, Contrary Opinions, physicians were asked whether they see disparities in the care LGBTQ+ patients receive in comparison with the care that non-LGBTQ+ patients receive. About 35% of physicians said LGBTQ+ patients receive a different level of care; 52% of respondents younger than 45 said so.

It’s an issue unlikely to be resolved without the medical community’s awareness. With insights from four LGBTQ+ clinicians, here are several steps physicians can take to close the disparity gap.
 

Update intake forms

Many patient medical forms are populated with checkboxes. These forms may make it easier for patients to share their medical information and for practices to collect data. But unfortunately, they don’t allow for patients to fill in contextual information.

“It’s extremely important for health care professionals to understand the people they are serving,” says Nicholas Grant, PhD, ABPP, president of GLMA: Health Professionals Advancing LGBTQ+ Equality. Dr. Grant is a board-certified clinical psychologist in Hawaii. “The more accurate we are with our information gathering and paperwork, the more accurate we will be at serving our LGBTQ+ communities.”

Dr. Grant recommends asking open-ended questions, such as the following:

• What is your gender identity?
• What was your assigned sex at birth?
• What pronouns do you prefer?
• What gender(s) are your sexual partners?

However, Frances Grimstad, MD, a Boston-based ob/gyn and GLMA board member, adds this advice: Before revising intake forms, consider their purpose.

“As an ob/gyn, information about a patient’s sexual orientation and their sexual activity is beneficial for my care,” says Dr. Grimstad. “But that information may not be relevant for a physical therapy clinic where most patients are coming in with knee injuries. So, you shouldn’t just place items on your intake forms by default. Instead, clinicians should consider what is relevant to the encounter you’re having and how you are going to use the information.”
 

Change signage

Take stock of posters and brochures in the office and signs outside restrooms. If they communicate traditional gender roles, then it may be time for a change.

“It’s important to ensure representation of all types of people and families in your office,” says Chase Anderson, MD, an assistant professor of child and adolescent psychiatry in San Francisco.

Hang posters with images of diverse families. Display brochures that address LGBTQ+ health concerns when warranted. And for restrooms, replace traditional binary images with gender-neutral ones. You can also add signage about each bathroom’s purpose, suggests Dr. Grimstad.

“Let’s not just de-gender bathrooms,” she says. “Let’s hang signs that tell if the bathroom has multiple stalls, urinals, or handicap access. Let signage focus on the functions of each bathroom, not gender.”
 

Ask for feedback

Feedback forms give LBGTQ+ patients a platform to share concerns. For example, consider an email with a linked document that all patients can fill out anonymously. Ask questions such as the following:

• Did you feel affirmed during your appointment? If so, how? If not, how can we improve?
• Did we use the proper pronouns?
• Did signage make you feel like you were in a safe space? What didn’t make you feel safe?

Set up a system with team members to process feedback and implement changes.

Also, if you have a large-scale practice, consider forming an LGBTQ+ community advisory board. “They can offer feedback about your practice’s clinical structure,” Dr. Grimstad tells Medscape.
 

Hire diverse employees

Building a diverse and inclusive workforce is critical to serving the LBGTQ+ community. Team members should reflect your patient population.

“Diversity isn’t a monolith,” says Dr. Grimstad. “It isn’t just racial diversity, or sexual or gender diversity. Even in a town which appears homogeneous in one area of diversity, such as a majority White town, it’s important to remember all the other facets of diversity that exist, such as gender, sexual orientation, cultural diversity.”

A diverse team may offer a surprising boost to your practice. According to a study published in the Journal of the National Medical Association, patient outcomes improve when a more diverse team provides care. In fact, diverse teams fare better in innovation, communication, risk assessment, and financial performance.

Dr. Anderson also recommends allowing team members “to be themselves.” For example, let employees wear their hair in whatever way they prefer or display their tattoos.

“This signals to patients that if staff members can be themselves here, patients can be themselves here, too,” says Dr. Anderson.
 

Provide training

Medical staff may sometimes feel uncomfortable serving LBGTQ+ patients because of their own biases, attitudes, or lack of knowledge about the community. Regular training can ease their discomfort.

“Make sure all health professionals are trained and educated on the needs of LGBTQ+ patients,” says Dr. Grant. “Understanding their health needs is the provider’s responsibility.”

For basic information, Dr. Anderson recommends visiting The Trevor Project, an organization that serves LGBTQ+ youth. “They’re really good at keeping up with changing verbiage and trends,” says Dr. Anderson.

To strengthen community connections, Dr. Grimstad recommends using trainers from your local area if possible. Do a Google search to find an LGBTQ+ center nearby or in the closest major city. Invite them to staff meetings or ask them to organize a workshop.

By implementing these strategies, you can start building a bridge between your practice and the LGBTQ+ community and provide better care for them as patients.

“Whether it’s knowing about PrEP ... or ensuring staff members are trained in caring for patients with any general or sexual identity, we as doctors and medical professionals must continue to move forward and serve our LGBTQ+ patients in big and small ways,” says Dr. Estevez.

For in-depth training, check the following organizations:

National LGBTQIA+ Health Education Center at the Fenway Institute provides educational programs and resources to health care organizations.

GLMA has a top 10 health issues webpage that doctors can use to educate themselves and staff members on the LGBTQ+ community’s most urgent health needs.

Alliance for Full Acceptance offers LGBTQ cultural competency training, including a 1-hour awareness class and a 3-hour inclusivity workshop for clinicians.

The Substance Abuse and Mental Health Services Administration has compiled a list of training curricula for behavioral health counselors and primary care providers.

UCSF’s Lesbian, Gay, Bisexual, and Transgender Resource Center has a list of training and educational materials for medical professionals.

Equality California Institute offers both in-person and virtual training covering basic terminology, data on LGBTQ+ health issues, and how to create an inclusive environment.

A version of this article first appeared on Medscape.com.

While rainbow-colored flags may wave proudly from hotel balconies and sports arenas, LGBTQ+ patients might still feel some discrimination in the medical space, according to a Center for American Progress survey.

“Despite health care being considered a basic human right by the World Health Organization, it’s common for LGBTQ+ folks to face difficulties not only when trying to access care but also within the walls of the doctor’s office or hospital,” says Samantha Estevez, MD, a reproductive endocrinology and infertility fellow in New York.

In Medscape’s Physicians’ Views on LGBTQ+ Rights Issues Report 2022: Strong Emotions, Contrary Opinions, physicians were asked whether they see disparities in the care LGBTQ+ patients receive in comparison with the care that non-LGBTQ+ patients receive. About 35% of physicians said LGBTQ+ patients receive a different level of care; 52% of respondents younger than 45 said so.

It’s an issue unlikely to be resolved without the medical community’s awareness. With insights from four LGBTQ+ clinicians, here are several steps physicians can take to close the disparity gap.
 

Update intake forms

Many patient medical forms are populated with checkboxes. These forms may make it easier for patients to share their medical information and for practices to collect data. But unfortunately, they don’t allow for patients to fill in contextual information.

“It’s extremely important for health care professionals to understand the people they are serving,” says Nicholas Grant, PhD, ABPP, president of GLMA: Health Professionals Advancing LGBTQ+ Equality. Dr. Grant is a board-certified clinical psychologist in Hawaii. “The more accurate we are with our information gathering and paperwork, the more accurate we will be at serving our LGBTQ+ communities.”

Dr. Grant recommends asking open-ended questions, such as the following:

• What is your gender identity?
• What was your assigned sex at birth?
• What pronouns do you prefer?
• What gender(s) are your sexual partners?

However, Frances Grimstad, MD, a Boston-based ob/gyn and GLMA board member, adds this advice: Before revising intake forms, consider their purpose.

“As an ob/gyn, information about a patient’s sexual orientation and their sexual activity is beneficial for my care,” says Dr. Grimstad. “But that information may not be relevant for a physical therapy clinic where most patients are coming in with knee injuries. So, you shouldn’t just place items on your intake forms by default. Instead, clinicians should consider what is relevant to the encounter you’re having and how you are going to use the information.”
 

Change signage

Take stock of posters and brochures in the office and signs outside restrooms. If they communicate traditional gender roles, then it may be time for a change.

“It’s important to ensure representation of all types of people and families in your office,” says Chase Anderson, MD, an assistant professor of child and adolescent psychiatry in San Francisco.

Hang posters with images of diverse families. Display brochures that address LGBTQ+ health concerns when warranted. And for restrooms, replace traditional binary images with gender-neutral ones. You can also add signage about each bathroom’s purpose, suggests Dr. Grimstad.

“Let’s not just de-gender bathrooms,” she says. “Let’s hang signs that tell if the bathroom has multiple stalls, urinals, or handicap access. Let signage focus on the functions of each bathroom, not gender.”
 

Ask for feedback

Feedback forms give LBGTQ+ patients a platform to share concerns. For example, consider an email with a linked document that all patients can fill out anonymously. Ask questions such as the following:

• Did you feel affirmed during your appointment? If so, how? If not, how can we improve?
• Did we use the proper pronouns?
• Did signage make you feel like you were in a safe space? What didn’t make you feel safe?

Set up a system with team members to process feedback and implement changes.

Also, if you have a large-scale practice, consider forming an LGBTQ+ community advisory board. “They can offer feedback about your practice’s clinical structure,” Dr. Grimstad tells Medscape.
 

Hire diverse employees

Building a diverse and inclusive workforce is critical to serving the LBGTQ+ community. Team members should reflect your patient population.

“Diversity isn’t a monolith,” says Dr. Grimstad. “It isn’t just racial diversity, or sexual or gender diversity. Even in a town which appears homogeneous in one area of diversity, such as a majority White town, it’s important to remember all the other facets of diversity that exist, such as gender, sexual orientation, cultural diversity.”

A diverse team may offer a surprising boost to your practice. According to a study published in the Journal of the National Medical Association, patient outcomes improve when a more diverse team provides care. In fact, diverse teams fare better in innovation, communication, risk assessment, and financial performance.

Dr. Anderson also recommends allowing team members “to be themselves.” For example, let employees wear their hair in whatever way they prefer or display their tattoos.

“This signals to patients that if staff members can be themselves here, patients can be themselves here, too,” says Dr. Anderson.
 

Provide training

Medical staff may sometimes feel uncomfortable serving LBGTQ+ patients because of their own biases, attitudes, or lack of knowledge about the community. Regular training can ease their discomfort.

“Make sure all health professionals are trained and educated on the needs of LGBTQ+ patients,” says Dr. Grant. “Understanding their health needs is the provider’s responsibility.”

For basic information, Dr. Anderson recommends visiting The Trevor Project, an organization that serves LGBTQ+ youth. “They’re really good at keeping up with changing verbiage and trends,” says Dr. Anderson.

To strengthen community connections, Dr. Grimstad recommends using trainers from your local area if possible. Do a Google search to find an LGBTQ+ center nearby or in the closest major city. Invite them to staff meetings or ask them to organize a workshop.

By implementing these strategies, you can start building a bridge between your practice and the LGBTQ+ community and provide better care for them as patients.

“Whether it’s knowing about PrEP ... or ensuring staff members are trained in caring for patients with any general or sexual identity, we as doctors and medical professionals must continue to move forward and serve our LGBTQ+ patients in big and small ways,” says Dr. Estevez.

For in-depth training, check the following organizations:

National LGBTQIA+ Health Education Center at the Fenway Institute provides educational programs and resources to health care organizations.

GLMA has a top 10 health issues webpage that doctors can use to educate themselves and staff members on the LGBTQ+ community’s most urgent health needs.

Alliance for Full Acceptance offers LGBTQ cultural competency training, including a 1-hour awareness class and a 3-hour inclusivity workshop for clinicians.

The Substance Abuse and Mental Health Services Administration has compiled a list of training curricula for behavioral health counselors and primary care providers.

UCSF’s Lesbian, Gay, Bisexual, and Transgender Resource Center has a list of training and educational materials for medical professionals.

Equality California Institute offers both in-person and virtual training covering basic terminology, data on LGBTQ+ health issues, and how to create an inclusive environment.

A version of this article first appeared on Medscape.com.

Increasing mentorship opportunities for gastroenterology and hepatology residents and medical students from populations underrepresented in medicine is essential to increase diversity in the specialty and improve health disparities among patients, according to a special report published simultaneously in Gastroenterology and three other journals.

“This study helps to establish priorities for diversity, equity and inclusion in our field and informs future interventions to improve workforce diversity and eliminate health care disparities among the patients we serve,” Folasade P. May, MD, PhD, MPhil, the study’s corresponding author and an associate professor of medicine at the University of California, Los Angeles, said in a prepared statement.

The report, the result of a partnership between researchers at UCLA and the Intersociety Group on Diversity, reveals the findings of a survey aimed at assessing current perspectives on individuals underrepresented in medicine and health equity within gastroenterology and hepatology. The collaboration involved five gastroenterology professional societies: the American Association for the Study of Liver Disease; American College of Gastroenterology; American Gastroenterological Association; American Society of Gastrointestinal Endoscopy; and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

”The current racial and ethnic composition of the GI and hepatology workforce does not reflect the population of patients served or the current matriculants in medicine,” Harman K. Rahal, MD, of UCLA and Cedars-Sinai Medical Center, Los Angeles, and James H. Tabibian, MD, PhD, of UCLA and Olive View–UCLA Medical Center, and colleagues wrote. “As there are several conditions in GI and hepatology with disparities in incidence, treatment, and outcomes, representation of UIM [underrepresented in medicine] individuals is critical to address health disparities.”

The term “underrepresented in medicine” is defined by the Association of American Medical Colleges as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” The authors explained that these groups “have traditionally included Latino (i.e., Latino/a/x), Black (or African American), Native American (namely, American Indian, Alaska Native, and Native Hawaiian), Pacific Islander, and mainland Puerto Rican individuals.”

The five gastroenterology and hepatology societies partnered with investigators at UCLA to develop a 33-question electronic survey “to determine perspectives of current racial, ethnic, and gender diversity within GI and hepatology; to assess current views on interventions needed to increase racial, ethnic, and gender diversity in the field; and to collect data on the experiences of UIM individuals and women in our field,” according to the report’s authors. The survey was then distributed to members of those societies, with 1,219 respondents.

The report found that inadequate representation of people from those underrepresented groups in the education and training pipeline was the most frequently reported barrier to improving racial and ethnic diversity in the field (35.4%), followed by insufficient racial and ethnic minority group representation in professional leadership (27.9%) and insufficient racial and ethnic minority group representation among practicing GI and hepatology professionals in the workplace (26.6%). Only 9% of fellows in GI and hepatology are from groups underrepresented in medicine, according to data from the Accreditation Council for Graduate Medical Education. Furthermore, one study has shown that the proportion of UIM in academic faculty has never exceeded 10% at each academic rank; there has even been a decline recently among junior academic faculty positions. That study also found that only 9% of academic gastroenterologists in the United states identify as underrepresented in medicine, with little change over the last decade.

Potential contributors to this low level of representation, the authors wrote, include “lack of racial and ethnic diversity in the medical training pipeline, nondiverse leadership, bias, racial discrimination, and the notion that UIM physicians may be less likely to promote themselves or be promoted.”

Another potential contributor, however, may be complacency within the field about the need to improve diversity and taking actions to do so.

Increasing mentorship opportunities for gastroenterology and hepatology residents and medical students from populations underrepresented in medicine is essential to increase diversity in the specialty and improve health disparities among patients, according to a special report published simultaneously in Gastroenterology and three other journals.

“This study helps to establish priorities for diversity, equity and inclusion in our field and informs future interventions to improve workforce diversity and eliminate health care disparities among the patients we serve,” Folasade P. May, MD, PhD, MPhil, the study’s corresponding author and an associate professor of medicine at the University of California, Los Angeles, said in a prepared statement.

The report, the result of a partnership between researchers at UCLA and the Intersociety Group on Diversity, reveals the findings of a survey aimed at assessing current perspectives on individuals underrepresented in medicine and health equity within gastroenterology and hepatology. The collaboration involved five gastroenterology professional societies: the American Association for the Study of Liver Disease; American College of Gastroenterology; American Gastroenterological Association; American Society of Gastrointestinal Endoscopy; and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

”The current racial and ethnic composition of the GI and hepatology workforce does not reflect the population of patients served or the current matriculants in medicine,” Harman K. Rahal, MD, of UCLA and Cedars-Sinai Medical Center, Los Angeles, and James H. Tabibian, MD, PhD, of UCLA and Olive View–UCLA Medical Center, and colleagues wrote. “As there are several conditions in GI and hepatology with disparities in incidence, treatment, and outcomes, representation of UIM [underrepresented in medicine] individuals is critical to address health disparities.”

The term “underrepresented in medicine” is defined by the Association of American Medical Colleges as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” The authors explained that these groups “have traditionally included Latino (i.e., Latino/a/x), Black (or African American), Native American (namely, American Indian, Alaska Native, and Native Hawaiian), Pacific Islander, and mainland Puerto Rican individuals.”

The five gastroenterology and hepatology societies partnered with investigators at UCLA to develop a 33-question electronic survey “to determine perspectives of current racial, ethnic, and gender diversity within GI and hepatology; to assess current views on interventions needed to increase racial, ethnic, and gender diversity in the field; and to collect data on the experiences of UIM individuals and women in our field,” according to the report’s authors. The survey was then distributed to members of those societies, with 1,219 respondents.

The report found that inadequate representation of people from those underrepresented groups in the education and training pipeline was the most frequently reported barrier to improving racial and ethnic diversity in the field (35.4%), followed by insufficient racial and ethnic minority group representation in professional leadership (27.9%) and insufficient racial and ethnic minority group representation among practicing GI and hepatology professionals in the workplace (26.6%). Only 9% of fellows in GI and hepatology are from groups underrepresented in medicine, according to data from the Accreditation Council for Graduate Medical Education. Furthermore, one study has shown that the proportion of UIM in academic faculty has never exceeded 10% at each academic rank; there has even been a decline recently among junior academic faculty positions. That study also found that only 9% of academic gastroenterologists in the United states identify as underrepresented in medicine, with little change over the last decade.

Potential contributors to this low level of representation, the authors wrote, include “lack of racial and ethnic diversity in the medical training pipeline, nondiverse leadership, bias, racial discrimination, and the notion that UIM physicians may be less likely to promote themselves or be promoted.”

Another potential contributor, however, may be complacency within the field about the need to improve diversity and taking actions to do so.

Increasing mentorship opportunities for gastroenterology and hepatology residents and medical students from populations underrepresented in medicine is essential to increase diversity in the specialty and improve health disparities among patients, according to a special report published simultaneously in Gastroenterology and three other journals.

“This study helps to establish priorities for diversity, equity and inclusion in our field and informs future interventions to improve workforce diversity and eliminate health care disparities among the patients we serve,” Folasade P. May, MD, PhD, MPhil, the study’s corresponding author and an associate professor of medicine at the University of California, Los Angeles, said in a prepared statement.

The report, the result of a partnership between researchers at UCLA and the Intersociety Group on Diversity, reveals the findings of a survey aimed at assessing current perspectives on individuals underrepresented in medicine and health equity within gastroenterology and hepatology. The collaboration involved five gastroenterology professional societies: the American Association for the Study of Liver Disease; American College of Gastroenterology; American Gastroenterological Association; American Society of Gastrointestinal Endoscopy; and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

”The current racial and ethnic composition of the GI and hepatology workforce does not reflect the population of patients served or the current matriculants in medicine,” Harman K. Rahal, MD, of UCLA and Cedars-Sinai Medical Center, Los Angeles, and James H. Tabibian, MD, PhD, of UCLA and Olive View–UCLA Medical Center, and colleagues wrote. “As there are several conditions in GI and hepatology with disparities in incidence, treatment, and outcomes, representation of UIM [underrepresented in medicine] individuals is critical to address health disparities.”

The term “underrepresented in medicine” is defined by the Association of American Medical Colleges as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” The authors explained that these groups “have traditionally included Latino (i.e., Latino/a/x), Black (or African American), Native American (namely, American Indian, Alaska Native, and Native Hawaiian), Pacific Islander, and mainland Puerto Rican individuals.”

The five gastroenterology and hepatology societies partnered with investigators at UCLA to develop a 33-question electronic survey “to determine perspectives of current racial, ethnic, and gender diversity within GI and hepatology; to assess current views on interventions needed to increase racial, ethnic, and gender diversity in the field; and to collect data on the experiences of UIM individuals and women in our field,” according to the report’s authors. The survey was then distributed to members of those societies, with 1,219 respondents.

The report found that inadequate representation of people from those underrepresented groups in the education and training pipeline was the most frequently reported barrier to improving racial and ethnic diversity in the field (35.4%), followed by insufficient racial and ethnic minority group representation in professional leadership (27.9%) and insufficient racial and ethnic minority group representation among practicing GI and hepatology professionals in the workplace (26.6%). Only 9% of fellows in GI and hepatology are from groups underrepresented in medicine, according to data from the Accreditation Council for Graduate Medical Education. Furthermore, one study has shown that the proportion of UIM in academic faculty has never exceeded 10% at each academic rank; there has even been a decline recently among junior academic faculty positions. That study also found that only 9% of academic gastroenterologists in the United states identify as underrepresented in medicine, with little change over the last decade.

Potential contributors to this low level of representation, the authors wrote, include “lack of racial and ethnic diversity in the medical training pipeline, nondiverse leadership, bias, racial discrimination, and the notion that UIM physicians may be less likely to promote themselves or be promoted.”

Another potential contributor, however, may be complacency within the field about the need to improve diversity and taking actions to do so.

Pregnant or postpartum women with disabilities are at relatively high risk of experiencing violence, often from the people closest to them, new research suggests.

The researchers set out to measure risk of interpersonal violence, which the World Health Organization defines as “the intentional use of physical force or power against an individual by an intimate partner, family member, or other community member.”

Hilary K. Brown, PhD, with the department of health & society, University of Toronto, led the study published online in Obstetrics and Gynecology.

Large, population-based dataset

The population study included people 15-49 years old with births in Ontario from 2004 to 2019. They included 147,414 people with physical disabilities; 47,459 people with intellectual disabilities; 2,557 with developmental disabilities; and 9,598 with multiple disabilities.

The control group was 1,594,441 million people without disabilities.

The outcome measured was “any emergency department visit, hospital admission, or death related to physical, sexual, or psychological violence between fertilization and 365 days post partum.”

Researchers found that the adjusted relative risk of interpersonal violence for those with disabilities, compared with those with no disabilities was 1.40 (95% confidence interval, 1.31-1.50) in those with physical disabilities; 2.39 (95% CI, 1.98-2.88) in those with intellectual or developmental disabilities; and 1.96 (95% CI, 1.66-2.30) in those with multiple disabilities.
 

History of violence means higher risk

Those with a history of interpersonal violence and a disability were at particularly high risk for perinatal violence.

The authors note that pregnancy is a high-risk period for interpersonal violence for all women, particularly by an intimate partner.

“More than 30% of intimate partner violence begins during pregnancy, and preexisting violence tends to escalate perinatally,” they write.

The authors cite previous research that found women with disabilities experience higher rates of abuse overall and by an intimate partner – two to four times rates reported by those without disabilities.
 

Opportunities for provider intervention

Since the period surrounding pregnancy is a time of increased contact with medical providers and resources, there may be opportunities for identifying abuse and providing interventions.

Those might include better screening, access to violence-related information and services, and education of health care professionals to support people with disabilities. For example, “Tools used for violence screening perinatally do not include items about forms of violence that are unique to individuals with disabilities, such as refusal to assist with activities of daily living.”

The authors add: “[G]iven that the strongest risk factor for interpersonal violence in the perinatal period, particularly in those with disabilities, was a prepregnancy history of interpersonal violence, our findings suggest that more could be done before pregnancy to offer screening and support at the index encounter.”
 

Violence can lead to adverse outcomes

Implications are important as the violence can result in barriers to care and adverse perinatal outcomes.

Jeanne L. Alhusen, PhD, CRNP, RN, University of Virginia Medical Center professor of nursing and associate dean for research, was not part of this research but wrote a paper earlier this year on the subject and had similar conclusions.

She said before this study by Brown et al., “our understanding of the risk of violence by disability type throughout the perinatal period, on a population-based level, was quite limited.”

With the size of this dataset, she said, this paper provides critical information for health care providers. It extends physicians’ ability to examine risk of violence by disability type as well as these patients’ risk of experiencing different types of violence.

She pointed out that the Pregnancy Risk Assessment Monitoring System (PRAMS) recently incorporated a disability supplement that allows better understanding of pregnancy risks in people with disabilities.

“It will be critical that U.S. states continue to incorporate the disability questions into their PRAMS administration [because] without that information, persons with disabilities will continue to experience unconscionable inequities,” she said.
 

Barriers to equitable care

Dr. Alhusen added that people with disabilities experience significant barriers in accessing equitable care – both at the provider and the system level.

She said it is critical that we recognize and address the sexual and reproductive health needs of all persons with disability. “This includes screening every person for violence and [ensuring] the tools we utilize are accessible and include items specific to disability-related abuse. In our qualitative studies, we have heard from pregnant persons that they were never screened or that they were screened with their abusive partner sitting next to them.”
 

Screening questions to ask

The American College of Obstetricians and Gynecologists provides examples of screening questions that are specific to people with disabilities such as asking if a partner has ever prevented the individual from using an assistive device (for example, a wheelchair, cane, or respirator) or refused to help with an important personal need, such as taking medication or getting out of bed.

“For many reasons, people with disabilities are less likely to disclose violence, and health care professionals are less likely to ask them about it,” said coauthor of the current study, Yona Lunsky, PhD, clinician-scientist, Centre for Addiction and Mental Health, Toronto, in a statement. Based on the findings, she said, she hopes clinicians will see the need to develop disability-informed screening tools to capture abuse and identify the appropriate resources for this population before, during, and after pregnancy.

Coauthor Dr. Natasha Saunders receives an honorarium from the BMJ Group (Archives of Diseases in Childhood). Coauthor Dr. Simone N. Vigod receives royalties from UpToDate for authorship of materials related to depression and pregnancy. The other authors did not report any potential conflicts of interest. Dr. Alhusen reported no relevant financial relationships.

Pregnant or postpartum women with disabilities are at relatively high risk of experiencing violence, often from the people closest to them, new research suggests.

The researchers set out to measure risk of interpersonal violence, which the World Health Organization defines as “the intentional use of physical force or power against an individual by an intimate partner, family member, or other community member.”

Hilary K. Brown, PhD, with the department of health & society, University of Toronto, led the study published online in Obstetrics and Gynecology.

Large, population-based dataset

The population study included people 15-49 years old with births in Ontario from 2004 to 2019. They included 147,414 people with physical disabilities; 47,459 people with intellectual disabilities; 2,557 with developmental disabilities; and 9,598 with multiple disabilities.

The control group was 1,594,441 million people without disabilities.

The outcome measured was “any emergency department visit, hospital admission, or death related to physical, sexual, or psychological violence between fertilization and 365 days post partum.”

Researchers found that the adjusted relative risk of interpersonal violence for those with disabilities, compared with those with no disabilities was 1.40 (95% confidence interval, 1.31-1.50) in those with physical disabilities; 2.39 (95% CI, 1.98-2.88) in those with intellectual or developmental disabilities; and 1.96 (95% CI, 1.66-2.30) in those with multiple disabilities.
 

History of violence means higher risk

Those with a history of interpersonal violence and a disability were at particularly high risk for perinatal violence.

The authors note that pregnancy is a high-risk period for interpersonal violence for all women, particularly by an intimate partner.

“More than 30% of intimate partner violence begins during pregnancy, and preexisting violence tends to escalate perinatally,” they write.

The authors cite previous research that found women with disabilities experience higher rates of abuse overall and by an intimate partner – two to four times rates reported by those without disabilities.
 

Opportunities for provider intervention

Since the period surrounding pregnancy is a time of increased contact with medical providers and resources, there may be opportunities for identifying abuse and providing interventions.

Those might include better screening, access to violence-related information and services, and education of health care professionals to support people with disabilities. For example, “Tools used for violence screening perinatally do not include items about forms of violence that are unique to individuals with disabilities, such as refusal to assist with activities of daily living.”

The authors add: “[G]iven that the strongest risk factor for interpersonal violence in the perinatal period, particularly in those with disabilities, was a prepregnancy history of interpersonal violence, our findings suggest that more could be done before pregnancy to offer screening and support at the index encounter.”
 

Violence can lead to adverse outcomes

Implications are important as the violence can result in barriers to care and adverse perinatal outcomes.

Jeanne L. Alhusen, PhD, CRNP, RN, University of Virginia Medical Center professor of nursing and associate dean for research, was not part of this research but wrote a paper earlier this year on the subject and had similar conclusions.

She said before this study by Brown et al., “our understanding of the risk of violence by disability type throughout the perinatal period, on a population-based level, was quite limited.”

With the size of this dataset, she said, this paper provides critical information for health care providers. It extends physicians’ ability to examine risk of violence by disability type as well as these patients’ risk of experiencing different types of violence.

She pointed out that the Pregnancy Risk Assessment Monitoring System (PRAMS) recently incorporated a disability supplement that allows better understanding of pregnancy risks in people with disabilities.

“It will be critical that U.S. states continue to incorporate the disability questions into their PRAMS administration [because] without that information, persons with disabilities will continue to experience unconscionable inequities,” she said.
 

Barriers to equitable care

Dr. Alhusen added that people with disabilities experience significant barriers in accessing equitable care – both at the provider and the system level.

She said it is critical that we recognize and address the sexual and reproductive health needs of all persons with disability. “This includes screening every person for violence and [ensuring] the tools we utilize are accessible and include items specific to disability-related abuse. In our qualitative studies, we have heard from pregnant persons that they were never screened or that they were screened with their abusive partner sitting next to them.”
 

Screening questions to ask

The American College of Obstetricians and Gynecologists provides examples of screening questions that are specific to people with disabilities such as asking if a partner has ever prevented the individual from using an assistive device (for example, a wheelchair, cane, or respirator) or refused to help with an important personal need, such as taking medication or getting out of bed.

“For many reasons, people with disabilities are less likely to disclose violence, and health care professionals are less likely to ask them about it,” said coauthor of the current study, Yona Lunsky, PhD, clinician-scientist, Centre for Addiction and Mental Health, Toronto, in a statement. Based on the findings, she said, she hopes clinicians will see the need to develop disability-informed screening tools to capture abuse and identify the appropriate resources for this population before, during, and after pregnancy.

Coauthor Dr. Natasha Saunders receives an honorarium from the BMJ Group (Archives of Diseases in Childhood). Coauthor Dr. Simone N. Vigod receives royalties from UpToDate for authorship of materials related to depression and pregnancy. The other authors did not report any potential conflicts of interest. Dr. Alhusen reported no relevant financial relationships.

Pregnant or postpartum women with disabilities are at relatively high risk of experiencing violence, often from the people closest to them, new research suggests.

The researchers set out to measure risk of interpersonal violence, which the World Health Organization defines as “the intentional use of physical force or power against an individual by an intimate partner, family member, or other community member.”

Hilary K. Brown, PhD, with the department of health & society, University of Toronto, led the study published online in Obstetrics and Gynecology.

Large, population-based dataset

The population study included people 15-49 years old with births in Ontario from 2004 to 2019. They included 147,414 people with physical disabilities; 47,459 people with intellectual disabilities; 2,557 with developmental disabilities; and 9,598 with multiple disabilities.

The control group was 1,594,441 million people without disabilities.

The outcome measured was “any emergency department visit, hospital admission, or death related to physical, sexual, or psychological violence between fertilization and 365 days post partum.”

Researchers found that the adjusted relative risk of interpersonal violence for those with disabilities, compared with those with no disabilities was 1.40 (95% confidence interval, 1.31-1.50) in those with physical disabilities; 2.39 (95% CI, 1.98-2.88) in those with intellectual or developmental disabilities; and 1.96 (95% CI, 1.66-2.30) in those with multiple disabilities.
 

History of violence means higher risk

Those with a history of interpersonal violence and a disability were at particularly high risk for perinatal violence.

The authors note that pregnancy is a high-risk period for interpersonal violence for all women, particularly by an intimate partner.

“More than 30% of intimate partner violence begins during pregnancy, and preexisting violence tends to escalate perinatally,” they write.

The authors cite previous research that found women with disabilities experience higher rates of abuse overall and by an intimate partner – two to four times rates reported by those without disabilities.
 

Opportunities for provider intervention

Since the period surrounding pregnancy is a time of increased contact with medical providers and resources, there may be opportunities for identifying abuse and providing interventions.

Those might include better screening, access to violence-related information and services, and education of health care professionals to support people with disabilities. For example, “Tools used for violence screening perinatally do not include items about forms of violence that are unique to individuals with disabilities, such as refusal to assist with activities of daily living.”

The authors add: “[G]iven that the strongest risk factor for interpersonal violence in the perinatal period, particularly in those with disabilities, was a prepregnancy history of interpersonal violence, our findings suggest that more could be done before pregnancy to offer screening and support at the index encounter.”
 

Violence can lead to adverse outcomes

Implications are important as the violence can result in barriers to care and adverse perinatal outcomes.

Jeanne L. Alhusen, PhD, CRNP, RN, University of Virginia Medical Center professor of nursing and associate dean for research, was not part of this research but wrote a paper earlier this year on the subject and had similar conclusions.

She said before this study by Brown et al., “our understanding of the risk of violence by disability type throughout the perinatal period, on a population-based level, was quite limited.”

With the size of this dataset, she said, this paper provides critical information for health care providers. It extends physicians’ ability to examine risk of violence by disability type as well as these patients’ risk of experiencing different types of violence.

She pointed out that the Pregnancy Risk Assessment Monitoring System (PRAMS) recently incorporated a disability supplement that allows better understanding of pregnancy risks in people with disabilities.

“It will be critical that U.S. states continue to incorporate the disability questions into their PRAMS administration [because] without that information, persons with disabilities will continue to experience unconscionable inequities,” she said.
 

Barriers to equitable care

Dr. Alhusen added that people with disabilities experience significant barriers in accessing equitable care – both at the provider and the system level.

She said it is critical that we recognize and address the sexual and reproductive health needs of all persons with disability. “This includes screening every person for violence and [ensuring] the tools we utilize are accessible and include items specific to disability-related abuse. In our qualitative studies, we have heard from pregnant persons that they were never screened or that they were screened with their abusive partner sitting next to them.”
 

Screening questions to ask

The American College of Obstetricians and Gynecologists provides examples of screening questions that are specific to people with disabilities such as asking if a partner has ever prevented the individual from using an assistive device (for example, a wheelchair, cane, or respirator) or refused to help with an important personal need, such as taking medication or getting out of bed.

“For many reasons, people with disabilities are less likely to disclose violence, and health care professionals are less likely to ask them about it,” said coauthor of the current study, Yona Lunsky, PhD, clinician-scientist, Centre for Addiction and Mental Health, Toronto, in a statement. Based on the findings, she said, she hopes clinicians will see the need to develop disability-informed screening tools to capture abuse and identify the appropriate resources for this population before, during, and after pregnancy.

Coauthor Dr. Natasha Saunders receives an honorarium from the BMJ Group (Archives of Diseases in Childhood). Coauthor Dr. Simone N. Vigod receives royalties from UpToDate for authorship of materials related to depression and pregnancy. The other authors did not report any potential conflicts of interest. Dr. Alhusen reported no relevant financial relationships.

THE COMPARISON

A Areas of alopecia with erythema and scale in a young Black boy with tinea capitis. He also had an enlarged posterior cervical lymph node (arrow) from this fungal infection.

B White patches of scale from tinea capitis in a young Black boy with no obvious hair loss; however, a potassium hydroxide preparation from the scale was positive for fungus.

C A subtle area of tinea capitis on the scalp of a Latina girl showed comma hairs.

Tinea capitis is a common dermatophyte infection of the scalp in school-aged children. The infection is spread by close contact with infected people or with their personal items, including combs, brushes, pillowcases, and hats, as well as animals. It is uncommon in adults.

Epidemiology

Tinea capitis is the most common fungal infection among school-aged children worldwide.¹ In a US-based study of more than 10,000 school-aged children, the prevalence of tinea capitis ranged from 0% to 19.4%, with Black children having the highest rates of infection at 12.9%.² However, people of all races and ages may develop tinea capitis.³

Tinea capitis most commonly is caused by Trichophyton tonsurans and Microsporum canis. Dermatophyte scalp infections caused by T tonsurans produce fungal spores that may occur within the hair shaft (endothrix) or with fungal elements external to the hair shaft (exothrix) caused by M canis. M canis usually fluoresces an apple green color on Wood lamp examination because of the location of the spores.

Key clinical features

Tinea capitis has a variety of clinical presentations:

• broken hairs that appear as black dots on the scalp
• diffuse scale mimicking seborrheic dermatitis
• well-demarcated annular plaques
• exudate and tenderness caused by inflammation
• scalp pruritus
• occipital scalp lymphadenopathy.

Worth noting

Tinea capitis impacts all patient groups, not just Black patients. In the United States, Black and Hispanic children are most commonly affected.⁴ Due to a tendency to have dry hair and hair breakage, those with more tightly coiled, textured hair may routinely apply oil and/or grease to the scalp. However, the application of heavy emollients, oils, and grease to camouflage scale contributes to false-negative fungal cultures of the scalp if applied within 1 week of the fungal culture, which may delay diagnosis. If tinea capitis is suspected, occipital lymphadenopathy on physical examination should prompt treatment for tinea capitis, even without a fungal culture.⁵

Health disparity highlight

A risk factor for tinea capitis is crowded living environments. Some families may live in crowded environments due to economic and housing disparities. This close contact increases the risk for conditions such as tinea capitis.⁶ Treatment delays may occur due to some cultural practices of applying oils and grease to the hair and scalp, camouflaging the clinical signs of tinea capitis.

THE COMPARISON

A Areas of alopecia with erythema and scale in a young Black boy with tinea capitis. He also had an enlarged posterior cervical lymph node (arrow) from this fungal infection.

B White patches of scale from tinea capitis in a young Black boy with no obvious hair loss; however, a potassium hydroxide preparation from the scale was positive for fungus.

C A subtle area of tinea capitis on the scalp of a Latina girl showed comma hairs.

Tinea capitis is a common dermatophyte infection of the scalp in school-aged children. The infection is spread by close contact with infected people or with their personal items, including combs, brushes, pillowcases, and hats, as well as animals. It is uncommon in adults.

Epidemiology

Tinea capitis is the most common fungal infection among school-aged children worldwide.¹ In a US-based study of more than 10,000 school-aged children, the prevalence of tinea capitis ranged from 0% to 19.4%, with Black children having the highest rates of infection at 12.9%.² However, people of all races and ages may develop tinea capitis.³

Tinea capitis most commonly is caused by Trichophyton tonsurans and Microsporum canis. Dermatophyte scalp infections caused by T tonsurans produce fungal spores that may occur within the hair shaft (endothrix) or with fungal elements external to the hair shaft (exothrix) caused by M canis. M canis usually fluoresces an apple green color on Wood lamp examination because of the location of the spores.

Key clinical features

Tinea capitis has a variety of clinical presentations:

• broken hairs that appear as black dots on the scalp
• diffuse scale mimicking seborrheic dermatitis
• well-demarcated annular plaques
• exudate and tenderness caused by inflammation
• scalp pruritus
• occipital scalp lymphadenopathy.

Worth noting

Tinea capitis impacts all patient groups, not just Black patients. In the United States, Black and Hispanic children are most commonly affected.⁴ Due to a tendency to have dry hair and hair breakage, those with more tightly coiled, textured hair may routinely apply oil and/or grease to the scalp. However, the application of heavy emollients, oils, and grease to camouflage scale contributes to false-negative fungal cultures of the scalp if applied within 1 week of the fungal culture, which may delay diagnosis. If tinea capitis is suspected, occipital lymphadenopathy on physical examination should prompt treatment for tinea capitis, even without a fungal culture.⁵

Health disparity highlight

A risk factor for tinea capitis is crowded living environments. Some families may live in crowded environments due to economic and housing disparities. This close contact increases the risk for conditions such as tinea capitis.⁶ Treatment delays may occur due to some cultural practices of applying oils and grease to the hair and scalp, camouflaging the clinical signs of tinea capitis.

THE COMPARISON

A Areas of alopecia with erythema and scale in a young Black boy with tinea capitis. He also had an enlarged posterior cervical lymph node (arrow) from this fungal infection.

B White patches of scale from tinea capitis in a young Black boy with no obvious hair loss; however, a potassium hydroxide preparation from the scale was positive for fungus.

C A subtle area of tinea capitis on the scalp of a Latina girl showed comma hairs.

Tinea capitis is a common dermatophyte infection of the scalp in school-aged children. The infection is spread by close contact with infected people or with their personal items, including combs, brushes, pillowcases, and hats, as well as animals. It is uncommon in adults.

Epidemiology

Tinea capitis is the most common fungal infection among school-aged children worldwide.¹ In a US-based study of more than 10,000 school-aged children, the prevalence of tinea capitis ranged from 0% to 19.4%, with Black children having the highest rates of infection at 12.9%.² However, people of all races and ages may develop tinea capitis.³

Tinea capitis most commonly is caused by Trichophyton tonsurans and Microsporum canis. Dermatophyte scalp infections caused by T tonsurans produce fungal spores that may occur within the hair shaft (endothrix) or with fungal elements external to the hair shaft (exothrix) caused by M canis. M canis usually fluoresces an apple green color on Wood lamp examination because of the location of the spores.

Key clinical features

Tinea capitis has a variety of clinical presentations:

• broken hairs that appear as black dots on the scalp
• diffuse scale mimicking seborrheic dermatitis
• well-demarcated annular plaques
• exudate and tenderness caused by inflammation
• scalp pruritus
• occipital scalp lymphadenopathy.

Worth noting

Tinea capitis impacts all patient groups, not just Black patients. In the United States, Black and Hispanic children are most commonly affected.⁴ Due to a tendency to have dry hair and hair breakage, those with more tightly coiled, textured hair may routinely apply oil and/or grease to the scalp. However, the application of heavy emollients, oils, and grease to camouflage scale contributes to false-negative fungal cultures of the scalp if applied within 1 week of the fungal culture, which may delay diagnosis. If tinea capitis is suspected, occipital lymphadenopathy on physical examination should prompt treatment for tinea capitis, even without a fungal culture.⁵

Health disparity highlight

A risk factor for tinea capitis is crowded living environments. Some families may live in crowded environments due to economic and housing disparities. This close contact increases the risk for conditions such as tinea capitis.⁶ Treatment delays may occur due to some cultural practices of applying oils and grease to the hair and scalp, camouflaging the clinical signs of tinea capitis.

THE COMPARISON

A Areas of alopecia with erythema and scale in a young Black boy with tinea capitis. He also had an enlarged posterior cervical lymph node (arrow) from this fungal infection.

B White patches of scale from tinea capitis in a young Black boy with no obvious hair loss; however, a potassium hydroxide preparation from the scale was positive for fungus.

C A subtle area of tinea capitis on the scalp of a Latina girl showed comma hairs.

Photographs courtesy of Richard P. Usatine, MD.

Tinea capitis is a common dermatophyte infection of the scalp in school-aged children. The infection is spread by close contact with infected people or with their personal items, including combs, brushes, pillowcases, and hats, as well as animals. It is uncommon in adults.

Epidemiology

Tinea capitis is the most common fungal infection among school-aged children worldwide.¹ In a US-based study of more than 10,000 school-aged children, the prevalence of tinea capitis ranged from 0% to 19.4%, with Black children having the highest rates of infection at 12.9%.² However, people of all races and ages may develop tinea capitis.³

Tinea capitis most commonly is caused by Trichophyton tonsurans and Microsporum canis. Dermatophyte scalp infections caused by T tonsurans produce fungal spores that may occur within the hair shaft (endothrix) or with fungal elements external to the hair shaft (exothrix) such as M canis. Microsporum canis usually fluoresces an apple green color on Wood lamp examination because of the location of the spores.

Key clinical features

Tinea capitis has a variety of clinical presentations: • broken hairs that appear as black dots on the scalp • diffuse scale mimicking seborrheic dermatitis • well-demarcated annular plaques • exudate and tenderness caused by inflammation • scalp pruritus • occipital scalp lymphadenopathy. Worth noting Tinea capitis impacts all patient groups, not just Black patients. In the United States, Black and Hispanic children are most commonly affected.4 Due to a tendency to have dry hair and hair breakage, those with more tightly coiled, textured hair may routinely apply oil and/or grease to the scalp; however, the application of heavy emollients, oils, and grease to camouflage scale contributes to falsenegative fungal cultures of the scalp if applied within 1 week of the fungal culture, which may delay diagnosis. If tinea capitis is suspected, occipital lymphadenopathy on physical examination should prompt treatment for tinea capitis, even without a fungal culture.5 Health disparity highlight A risk factor for tinea capitis is crowded living environments. Some families may live in crowded environments due to economic and housing disparities. This close contact increases the risk for conditions such as tinea capitis.6 Treatment delays may occur due to some cultural practices of applying oils and grease to the hair and scalp, camouflaging the clinical signs of tinea capitis.

THE COMPARISON

A Areas of alopecia with erythema and scale in a young Black boy with tinea capitis. He also had an enlarged posterior cervical lymph node (arrow) from this fungal infection.

B White patches of scale from tinea capitis in a young Black boy with no obvious hair loss; however, a potassium hydroxide preparation from the scale was positive for fungus.

C A subtle area of tinea capitis on the scalp of a Latina girl showed comma hairs.

Photographs courtesy of Richard P. Usatine, MD.

Tinea capitis is a common dermatophyte infection of the scalp in school-aged children. The infection is spread by close contact with infected people or with their personal items, including combs, brushes, pillowcases, and hats, as well as animals. It is uncommon in adults.

Epidemiology

Tinea capitis is the most common fungal infection among school-aged children worldwide.¹ In a US-based study of more than 10,000 school-aged children, the prevalence of tinea capitis ranged from 0% to 19.4%, with Black children having the highest rates of infection at 12.9%.² However, people of all races and ages may develop tinea capitis.³

Tinea capitis most commonly is caused by Trichophyton tonsurans and Microsporum canis. Dermatophyte scalp infections caused by T tonsurans produce fungal spores that may occur within the hair shaft (endothrix) or with fungal elements external to the hair shaft (exothrix) such as M canis. Microsporum canis usually fluoresces an apple green color on Wood lamp examination because of the location of the spores.

Key clinical features

Tinea capitis has a variety of clinical presentations: • broken hairs that appear as black dots on the scalp • diffuse scale mimicking seborrheic dermatitis • well-demarcated annular plaques • exudate and tenderness caused by inflammation • scalp pruritus • occipital scalp lymphadenopathy. Worth noting Tinea capitis impacts all patient groups, not just Black patients. In the United States, Black and Hispanic children are most commonly affected.4 Due to a tendency to have dry hair and hair breakage, those with more tightly coiled, textured hair may routinely apply oil and/or grease to the scalp; however, the application of heavy emollients, oils, and grease to camouflage scale contributes to falsenegative fungal cultures of the scalp if applied within 1 week of the fungal culture, which may delay diagnosis. If tinea capitis is suspected, occipital lymphadenopathy on physical examination should prompt treatment for tinea capitis, even without a fungal culture.5 Health disparity highlight A risk factor for tinea capitis is crowded living environments. Some families may live in crowded environments due to economic and housing disparities. This close contact increases the risk for conditions such as tinea capitis.6 Treatment delays may occur due to some cultural practices of applying oils and grease to the hair and scalp, camouflaging the clinical signs of tinea capitis.

THE COMPARISON

A Areas of alopecia with erythema and scale in a young Black boy with tinea capitis. He also had an enlarged posterior cervical lymph node (arrow) from this fungal infection.

B White patches of scale from tinea capitis in a young Black boy with no obvious hair loss; however, a potassium hydroxide preparation from the scale was positive for fungus.

C A subtle area of tinea capitis on the scalp of a Latina girl showed comma hairs.

Photographs courtesy of Richard P. Usatine, MD.

Tinea capitis is a common dermatophyte infection of the scalp in school-aged children. The infection is spread by close contact with infected people or with their personal items, including combs, brushes, pillowcases, and hats, as well as animals. It is uncommon in adults.

Epidemiology

Tinea capitis is the most common fungal infection among school-aged children worldwide.¹ In a US-based study of more than 10,000 school-aged children, the prevalence of tinea capitis ranged from 0% to 19.4%, with Black children having the highest rates of infection at 12.9%.² However, people of all races and ages may develop tinea capitis.³

Tinea capitis most commonly is caused by Trichophyton tonsurans and Microsporum canis. Dermatophyte scalp infections caused by T tonsurans produce fungal spores that may occur within the hair shaft (endothrix) or with fungal elements external to the hair shaft (exothrix) such as M canis. Microsporum canis usually fluoresces an apple green color on Wood lamp examination because of the location of the spores.

Key clinical features

Tinea capitis has a variety of clinical presentations: • broken hairs that appear as black dots on the scalp • diffuse scale mimicking seborrheic dermatitis • well-demarcated annular plaques • exudate and tenderness caused by inflammation • scalp pruritus • occipital scalp lymphadenopathy. Worth noting Tinea capitis impacts all patient groups, not just Black patients. In the United States, Black and Hispanic children are most commonly affected.4 Due to a tendency to have dry hair and hair breakage, those with more tightly coiled, textured hair may routinely apply oil and/or grease to the scalp; however, the application of heavy emollients, oils, and grease to camouflage scale contributes to falsenegative fungal cultures of the scalp if applied within 1 week of the fungal culture, which may delay diagnosis. If tinea capitis is suspected, occipital lymphadenopathy on physical examination should prompt treatment for tinea capitis, even without a fungal culture.5 Health disparity highlight A risk factor for tinea capitis is crowded living environments. Some families may live in crowded environments due to economic and housing disparities. This close contact increases the risk for conditions such as tinea capitis.6 Treatment delays may occur due to some cultural practices of applying oils and grease to the hair and scalp, camouflaging the clinical signs of tinea capitis.

Hair loss is a primary reason why women with skin of color seek dermatologic care.^1-3 In addition to physical disfigurement, patients with hair loss are more likely to report feelings of depression, anxiety, and low self-esteem compared to the general population.⁴ There is a critical gap in advocacy efforts and educational information intended for women with skin of color. The American Academy of Dermatology (AAD) has 6 main public health programs (https://www.aad.org/public/public-health) and 8 stated advocacy priorities (https://www.aad.org/member/advocacy/priorities) but none of them focus on outreach to minority communities.

Historically, hair in patients with skin of color also has been a systemic tangible target for race-based discrimination. The Create a Respectful and Open World for Natural Hair (CROWN) Act was passed to protect against discrimination based on race-based hairstyles in schools and workplaces.⁵ Health care providers play an important role in advocating for their patients, but studies have shown that barriers to effective advocacy include a lack of knowledge, resources, or time.^6-8 Virtual advocacy events improve participants’ understanding and interest in community engagement and advocacy.^6,7 With the mission to engage, educate, and empower women with skin of color and the dermatologists who treat them, the Virginia Dermatology Society hosted the virtual CROWNing Event on Hair Loss in Women of Color in July 2021. We believe that this event, as well as this column, can serve as a template to improve advocacy and educational efforts for additional topics and diseases that affect marginalized or underserved populations. Survey data were collected and analyzed to establish a baseline of awareness and understanding of hair loss in women with skin of color and to evaluate the impact of a virtual event on participants’ empowerment and familiarity with resources for this population.

Methods

The Virginia Dermatology Society organized a virtual event focused on hair loss and practical political advocacy for women with skin of color. As members of the Virginia Dermatology Society and as part of the planning and execution of this event, the authors engaged relevant stakeholder organizations and collaborated with faculty at a local historically Black university to create a targeted, culturally sensitive communication strategy known as the Framework for Advocacy and Community Engagement (FACE) model (Figure). The agenda included presentations by 2 patients of color living with a hair loss disorder, a dermatologist with experience in advocacy, a Virginia state legislator, and a dermatologic hair loss expert, followed by a final question-and-answer session.

We created pre- and postevent Likert scale surveys assessing participant attitudes, knowledge, and awareness surrounding hair loss that were distributed electronically to all 399 registrants before and after the event, respectively. The responses were analyzed using a Mann-Whitney U test.

Results

All 399 registrants completed the pre-event survey; 115 (28.8%) and 189 (47.4%) identified as patients and health care professionals, respectively (Table 1). Overall, 137 (34.3%) respondents disagreed or strongly disagreed with the statement, “I am familiar with the various and specific resources for hair loss in women of color.” Treatments and resources emerged as prevalent themes when respondents were asked about information or support they wished they had on hair loss. Respondents reported self-esteem/self-worth, treatment efficacy, and lack of knowledge/understanding as the most challenging aspects for women with skin of color experiencing hair loss.

Based on preliminary pre-event survey data, we created a resource toolkit (https://bit.ly/vadermhairlosstoolkit) for distribution to both patients and physicians. The toolkit included articles about evaluating, diagnosing, and treating different types of hair loss that would be beneficial for dermatologists, as well as informational articles, online resources, and videos that would be helpful to patients.

Of the 399 registrants, 165 (41.4%) attended the live virtual event. The postevent survey was completed by 70 (42.4%) participants and showed that familiarity with resources and treatments (z=−3.34, P=.0008) and feelings of empowerment (z=−3.55, P=.0004) significantly increased from before the event (Table 2). Participants indicated that the event exceeded (84.3%) or met (15.7%) their expectations.

Hair Loss Is Prevalent in Skin of Color Patients—Alopecia is the fourth most common reason women with skin of color seek care from a dermatologist, accounting for 8.3% of all visits in a study of 1412 patient visits; however, it was not among the leading 10 diagnoses made during visits for White patients.³ Traction alopecia, discoid lupus erythematosus, and central centrifugal cicatricial alopecia occur more commonly in Black women,⁹ many of whom do not feel their dermatologists understand hair in this population.^10,11 Lack of skin of color education in medical school and dermatology residency programs has been reported and must be improved to eliminate the knowledge gaps, acquire cultural competence, and improve all aspects of care for patients with skin of color.^11-14 Our survey results similarly demonstrated that only 66% of board-certified dermatologists reported being familiar with the various and specific resources and treatments for hair loss in women of color. Improved understanding of hair in patients of color is a first step in diagnosing and treating hair loss.¹⁵ Expertise of dermatologists in skin of color improves the dermatology experience of patients of color.¹¹

Hair loss is more than a cosmetic issue, and it is essential that it is regarded as such. Patients with hair loss have an increased prevalence of depression and anxiety compared to the general population and report lower self-esteem, heightened self-consciousness, and loss of confidence.^4,9 Historically, the lives of patients of color have been drastically affected by society’s perceptions of their skin color and hairstyle.¹⁶

Hair-Based Discrimination in the Workplace—To compound the problem, hair also is a common target of race-based discrimination behind the illusion of “professionalism.” Hair-based discrimination keeps people of color out of professional workplaces; for instance, women of color are more likely to be sent home due to hair appearance than White women.⁵ The CROWN Act, created in 2019, extends statutory protection to hair texture and protective hairstyles such as braids, locs, twists, and knots in the workplace and public schools to protect against discrimination due to race-based hairstyles. The CROWN Act provides an opportunity for dermatologists to support legislation that protects patients of color and the fundamental human right to nondiscrimination. As societal pressure for damaging hair practices such as hot combing or chemical relaxants decreases, patient outcomes will improve.⁵

How to Support the CROWN Act—There are various meaningful ways for dermatologists to support the CROWN act, including but not limited to signing petitions, sending letters of support to elected representatives, joining the CROWN Coalition, raising awareness and educating the public through social media, vocalizing against hair discrimination in our own workplaces and communities, and asking patients about their experiences with hair discrimination.5 In addition to advocacy, other antiracist actions suggested to improve health equity include creating curricula on racial inequity and increasing diversity in dermatology.¹⁶

There are many advocacy and public health campaigns promoted on the AAD website; however, despite the AAD’s formation of the Access to Dermatologic Care Task Force (ATDCTF) with the goal to raise awareness among dermatologists of health disparities affecting marginalized and underserved populations and to develop policies that increase access to care for these groups, there are still critical gaps in advocacy and information.¹³ This gap in both advocacy and understanding of hair loss conditions in women of color is one reason the CROWNing Event in July 2021 was held, and we believe this event along with this column can serve as a template for addressing additional topics and diseases that affect marginalized or underserved populations.

Dermatologists can play a vital role in advocating for skin and hair needs in all patient populations from the personal or clinical encounter level to population-level policy legislation.^5,8 As experts in skin and hair, dermatologists are best prepared to assume leadership in addressing racial health inequities, educating the public, and improving awareness.^5,16 Dermatologists must be able to diagnose and manage skin conditions in people of color.¹² However, health advocacy should extend beyond changes to health behavior or health interventions and instead address the root causes of systemic issues that drive disparate health outcomes.⁶ Every dermatologist has a contribution to make; it is time for us to acknowledge that patients’ ailments neither begin nor end at the clinic door.^8,16 As dermatologists, we must speak out against the racial inequities and discriminatory policies affecting the lives of patients of color.¹⁶

Although the CROWNing event should be considered successful, reflection in hindsight has allowed us to find ways to improve the impact of future events, including incorporating more lay members of the respective community in the planning process, allocating more time during the event programming for questions, and streamlining the distribution of pre-event and postevent surveys to better gauge knowledge retention among participants and gain crucial feedback for future event planning.

How to Use the FACE Model—We believe that the FACE model (Figure) can help providers engage lay members of the community with additional topics and diseases that affect marginalized and underserved populations. We recommend that future organizers engage stakeholders early during the design, planning, and implementation phases to ensure that the community’s most pressing needs are addressed. Dermatologists possess the knowledge and influence to serve as powerful advocates and champions for health equity. As physicians on the front lines of dermatologic health, we are uniquely positioned to engage and partner with patients through educational and advocacy events such as ours. Similarly, informed and empowered patients can advocate for policies and be proponents for greater research funding.⁵ We call on the AAD and other dermatologic organizations to expand community outreach and advocacy efforts to include underserved and underrepresented populations.

Acknowledgments—The authors would like to thank and acknowledge the faculty at Hampton University (Hampton, Virginia)—specifically Ms. B. DáVida Plummer, MA—for assistance with communication strategies, including organizing the radio and television announcements and proofreading the public service announcements. We also would like to thank other CROWNing Event Planning Committee members, including Natalia Mendoza, MD (Newport News, Virginia); Farhaad Riyaz, MD (Gainesville, Virginia); Deborah Elder, MD (Charlottesville, Virginia); and David Rowe, MD (Charlottesville, Virginia), as well as Sandra Ring, MS, CCLS, CNP (Chicago, Illinois), from the AAD and the various speakers at the event, including the 2 patients; Victoria Barbosa, MD, MPH, MBA (Chicago, Illinois); Avery LaChance, MD, MPH (Boston, Massachusetts); and Senator Lionell Spruill Sr (Chesapeake, Virginia). We acknowledge Marieke K. Jones, PhD, at the Claude Moore Health Sciences Library at the University of Virginia (Charlottesville, Virginia), for her statistical expertise.

Hair loss is a primary reason why women with skin of color seek dermatologic care.^1-3 In addition to physical disfigurement, patients with hair loss are more likely to report feelings of depression, anxiety, and low self-esteem compared to the general population.⁴ There is a critical gap in advocacy efforts and educational information intended for women with skin of color. The American Academy of Dermatology (AAD) has 6 main public health programs (https://www.aad.org/public/public-health) and 8 stated advocacy priorities (https://www.aad.org/member/advocacy/priorities) but none of them focus on outreach to minority communities.

Historically, hair in patients with skin of color also has been a systemic tangible target for race-based discrimination. The Create a Respectful and Open World for Natural Hair (CROWN) Act was passed to protect against discrimination based on race-based hairstyles in schools and workplaces.⁵ Health care providers play an important role in advocating for their patients, but studies have shown that barriers to effective advocacy include a lack of knowledge, resources, or time.^6-8 Virtual advocacy events improve participants’ understanding and interest in community engagement and advocacy.^6,7 With the mission to engage, educate, and empower women with skin of color and the dermatologists who treat them, the Virginia Dermatology Society hosted the virtual CROWNing Event on Hair Loss in Women of Color in July 2021. We believe that this event, as well as this column, can serve as a template to improve advocacy and educational efforts for additional topics and diseases that affect marginalized or underserved populations. Survey data were collected and analyzed to establish a baseline of awareness and understanding of hair loss in women with skin of color and to evaluate the impact of a virtual event on participants’ empowerment and familiarity with resources for this population.

Methods

The Virginia Dermatology Society organized a virtual event focused on hair loss and practical political advocacy for women with skin of color. As members of the Virginia Dermatology Society and as part of the planning and execution of this event, the authors engaged relevant stakeholder organizations and collaborated with faculty at a local historically Black university to create a targeted, culturally sensitive communication strategy known as the Framework for Advocacy and Community Engagement (FACE) model (Figure). The agenda included presentations by 2 patients of color living with a hair loss disorder, a dermatologist with experience in advocacy, a Virginia state legislator, and a dermatologic hair loss expert, followed by a final question-and-answer session.

We created pre- and postevent Likert scale surveys assessing participant attitudes, knowledge, and awareness surrounding hair loss that were distributed electronically to all 399 registrants before and after the event, respectively. The responses were analyzed using a Mann-Whitney U test.

Results

All 399 registrants completed the pre-event survey; 115 (28.8%) and 189 (47.4%) identified as patients and health care professionals, respectively (Table 1). Overall, 137 (34.3%) respondents disagreed or strongly disagreed with the statement, “I am familiar with the various and specific resources for hair loss in women of color.” Treatments and resources emerged as prevalent themes when respondents were asked about information or support they wished they had on hair loss. Respondents reported self-esteem/self-worth, treatment efficacy, and lack of knowledge/understanding as the most challenging aspects for women with skin of color experiencing hair loss.

Based on preliminary pre-event survey data, we created a resource toolkit (https://bit.ly/vadermhairlosstoolkit) for distribution to both patients and physicians. The toolkit included articles about evaluating, diagnosing, and treating different types of hair loss that would be beneficial for dermatologists, as well as informational articles, online resources, and videos that would be helpful to patients.

Of the 399 registrants, 165 (41.4%) attended the live virtual event. The postevent survey was completed by 70 (42.4%) participants and showed that familiarity with resources and treatments (z=−3.34, P=.0008) and feelings of empowerment (z=−3.55, P=.0004) significantly increased from before the event (Table 2). Participants indicated that the event exceeded (84.3%) or met (15.7%) their expectations.

Hair Loss Is Prevalent in Skin of Color Patients—Alopecia is the fourth most common reason women with skin of color seek care from a dermatologist, accounting for 8.3% of all visits in a study of 1412 patient visits; however, it was not among the leading 10 diagnoses made during visits for White patients.³ Traction alopecia, discoid lupus erythematosus, and central centrifugal cicatricial alopecia occur more commonly in Black women,⁹ many of whom do not feel their dermatologists understand hair in this population.^10,11 Lack of skin of color education in medical school and dermatology residency programs has been reported and must be improved to eliminate the knowledge gaps, acquire cultural competence, and improve all aspects of care for patients with skin of color.^11-14 Our survey results similarly demonstrated that only 66% of board-certified dermatologists reported being familiar with the various and specific resources and treatments for hair loss in women of color. Improved understanding of hair in patients of color is a first step in diagnosing and treating hair loss.¹⁵ Expertise of dermatologists in skin of color improves the dermatology experience of patients of color.¹¹

Hair loss is more than a cosmetic issue, and it is essential that it is regarded as such. Patients with hair loss have an increased prevalence of depression and anxiety compared to the general population and report lower self-esteem, heightened self-consciousness, and loss of confidence.^4,9 Historically, the lives of patients of color have been drastically affected by society’s perceptions of their skin color and hairstyle.¹⁶

Hair-Based Discrimination in the Workplace—To compound the problem, hair also is a common target of race-based discrimination behind the illusion of “professionalism.” Hair-based discrimination keeps people of color out of professional workplaces; for instance, women of color are more likely to be sent home due to hair appearance than White women.⁵ The CROWN Act, created in 2019, extends statutory protection to hair texture and protective hairstyles such as braids, locs, twists, and knots in the workplace and public schools to protect against discrimination due to race-based hairstyles. The CROWN Act provides an opportunity for dermatologists to support legislation that protects patients of color and the fundamental human right to nondiscrimination. As societal pressure for damaging hair practices such as hot combing or chemical relaxants decreases, patient outcomes will improve.⁵

How to Support the CROWN Act—There are various meaningful ways for dermatologists to support the CROWN act, including but not limited to signing petitions, sending letters of support to elected representatives, joining the CROWN Coalition, raising awareness and educating the public through social media, vocalizing against hair discrimination in our own workplaces and communities, and asking patients about their experiences with hair discrimination.5 In addition to advocacy, other antiracist actions suggested to improve health equity include creating curricula on racial inequity and increasing diversity in dermatology.¹⁶

There are many advocacy and public health campaigns promoted on the AAD website; however, despite the AAD’s formation of the Access to Dermatologic Care Task Force (ATDCTF) with the goal to raise awareness among dermatologists of health disparities affecting marginalized and underserved populations and to develop policies that increase access to care for these groups, there are still critical gaps in advocacy and information.¹³ This gap in both advocacy and understanding of hair loss conditions in women of color is one reason the CROWNing Event in July 2021 was held, and we believe this event along with this column can serve as a template for addressing additional topics and diseases that affect marginalized or underserved populations.

Dermatologists can play a vital role in advocating for skin and hair needs in all patient populations from the personal or clinical encounter level to population-level policy legislation.^5,8 As experts in skin and hair, dermatologists are best prepared to assume leadership in addressing racial health inequities, educating the public, and improving awareness.^5,16 Dermatologists must be able to diagnose and manage skin conditions in people of color.¹² However, health advocacy should extend beyond changes to health behavior or health interventions and instead address the root causes of systemic issues that drive disparate health outcomes.⁶ Every dermatologist has a contribution to make; it is time for us to acknowledge that patients’ ailments neither begin nor end at the clinic door.^8,16 As dermatologists, we must speak out against the racial inequities and discriminatory policies affecting the lives of patients of color.¹⁶

Although the CROWNing event should be considered successful, reflection in hindsight has allowed us to find ways to improve the impact of future events, including incorporating more lay members of the respective community in the planning process, allocating more time during the event programming for questions, and streamlining the distribution of pre-event and postevent surveys to better gauge knowledge retention among participants and gain crucial feedback for future event planning.

How to Use the FACE Model—We believe that the FACE model (Figure) can help providers engage lay members of the community with additional topics and diseases that affect marginalized and underserved populations. We recommend that future organizers engage stakeholders early during the design, planning, and implementation phases to ensure that the community’s most pressing needs are addressed. Dermatologists possess the knowledge and influence to serve as powerful advocates and champions for health equity. As physicians on the front lines of dermatologic health, we are uniquely positioned to engage and partner with patients through educational and advocacy events such as ours. Similarly, informed and empowered patients can advocate for policies and be proponents for greater research funding.⁵ We call on the AAD and other dermatologic organizations to expand community outreach and advocacy efforts to include underserved and underrepresented populations.

Acknowledgments—The authors would like to thank and acknowledge the faculty at Hampton University (Hampton, Virginia)—specifically Ms. B. DáVida Plummer, MA—for assistance with communication strategies, including organizing the radio and television announcements and proofreading the public service announcements. We also would like to thank other CROWNing Event Planning Committee members, including Natalia Mendoza, MD (Newport News, Virginia); Farhaad Riyaz, MD (Gainesville, Virginia); Deborah Elder, MD (Charlottesville, Virginia); and David Rowe, MD (Charlottesville, Virginia), as well as Sandra Ring, MS, CCLS, CNP (Chicago, Illinois), from the AAD and the various speakers at the event, including the 2 patients; Victoria Barbosa, MD, MPH, MBA (Chicago, Illinois); Avery LaChance, MD, MPH (Boston, Massachusetts); and Senator Lionell Spruill Sr (Chesapeake, Virginia). We acknowledge Marieke K. Jones, PhD, at the Claude Moore Health Sciences Library at the University of Virginia (Charlottesville, Virginia), for her statistical expertise.

Hair loss is a primary reason why women with skin of color seek dermatologic care.^1-3 In addition to physical disfigurement, patients with hair loss are more likely to report feelings of depression, anxiety, and low self-esteem compared to the general population.⁴ There is a critical gap in advocacy efforts and educational information intended for women with skin of color. The American Academy of Dermatology (AAD) has 6 main public health programs (https://www.aad.org/public/public-health) and 8 stated advocacy priorities (https://www.aad.org/member/advocacy/priorities) but none of them focus on outreach to minority communities.

Historically, hair in patients with skin of color also has been a systemic tangible target for race-based discrimination. The Create a Respectful and Open World for Natural Hair (CROWN) Act was passed to protect against discrimination based on race-based hairstyles in schools and workplaces.⁵ Health care providers play an important role in advocating for their patients, but studies have shown that barriers to effective advocacy include a lack of knowledge, resources, or time.^6-8 Virtual advocacy events improve participants’ understanding and interest in community engagement and advocacy.^6,7 With the mission to engage, educate, and empower women with skin of color and the dermatologists who treat them, the Virginia Dermatology Society hosted the virtual CROWNing Event on Hair Loss in Women of Color in July 2021. We believe that this event, as well as this column, can serve as a template to improve advocacy and educational efforts for additional topics and diseases that affect marginalized or underserved populations. Survey data were collected and analyzed to establish a baseline of awareness and understanding of hair loss in women with skin of color and to evaluate the impact of a virtual event on participants’ empowerment and familiarity with resources for this population.

Methods

The Virginia Dermatology Society organized a virtual event focused on hair loss and practical political advocacy for women with skin of color. As members of the Virginia Dermatology Society and as part of the planning and execution of this event, the authors engaged relevant stakeholder organizations and collaborated with faculty at a local historically Black university to create a targeted, culturally sensitive communication strategy known as the Framework for Advocacy and Community Engagement (FACE) model (Figure). The agenda included presentations by 2 patients of color living with a hair loss disorder, a dermatologist with experience in advocacy, a Virginia state legislator, and a dermatologic hair loss expert, followed by a final question-and-answer session.

We created pre- and postevent Likert scale surveys assessing participant attitudes, knowledge, and awareness surrounding hair loss that were distributed electronically to all 399 registrants before and after the event, respectively. The responses were analyzed using a Mann-Whitney U test.

Results

All 399 registrants completed the pre-event survey; 115 (28.8%) and 189 (47.4%) identified as patients and health care professionals, respectively (Table 1). Overall, 137 (34.3%) respondents disagreed or strongly disagreed with the statement, “I am familiar with the various and specific resources for hair loss in women of color.” Treatments and resources emerged as prevalent themes when respondents were asked about information or support they wished they had on hair loss. Respondents reported self-esteem/self-worth, treatment efficacy, and lack of knowledge/understanding as the most challenging aspects for women with skin of color experiencing hair loss.

Based on preliminary pre-event survey data, we created a resource toolkit (https://bit.ly/vadermhairlosstoolkit) for distribution to both patients and physicians. The toolkit included articles about evaluating, diagnosing, and treating different types of hair loss that would be beneficial for dermatologists, as well as informational articles, online resources, and videos that would be helpful to patients.

Of the 399 registrants, 165 (41.4%) attended the live virtual event. The postevent survey was completed by 70 (42.4%) participants and showed that familiarity with resources and treatments (z=−3.34, P=.0008) and feelings of empowerment (z=−3.55, P=.0004) significantly increased from before the event (Table 2). Participants indicated that the event exceeded (84.3%) or met (15.7%) their expectations.

Hair Loss Is Prevalent in Skin of Color Patients—Alopecia is the fourth most common reason women with skin of color seek care from a dermatologist, accounting for 8.3% of all visits in a study of 1412 patient visits; however, it was not among the leading 10 diagnoses made during visits for White patients.³ Traction alopecia, discoid lupus erythematosus, and central centrifugal cicatricial alopecia occur more commonly in Black women,⁹ many of whom do not feel their dermatologists understand hair in this population.^10,11 Lack of skin of color education in medical school and dermatology residency programs has been reported and must be improved to eliminate the knowledge gaps, acquire cultural competence, and improve all aspects of care for patients with skin of color.^11-14 Our survey results similarly demonstrated that only 66% of board-certified dermatologists reported being familiar with the various and specific resources and treatments for hair loss in women of color. Improved understanding of hair in patients of color is a first step in diagnosing and treating hair loss.¹⁵ Expertise of dermatologists in skin of color improves the dermatology experience of patients of color.¹¹

Hair loss is more than a cosmetic issue, and it is essential that it is regarded as such. Patients with hair loss have an increased prevalence of depression and anxiety compared to the general population and report lower self-esteem, heightened self-consciousness, and loss of confidence.^4,9 Historically, the lives of patients of color have been drastically affected by society’s perceptions of their skin color and hairstyle.¹⁶

Hair-Based Discrimination in the Workplace—To compound the problem, hair also is a common target of race-based discrimination behind the illusion of “professionalism.” Hair-based discrimination keeps people of color out of professional workplaces; for instance, women of color are more likely to be sent home due to hair appearance than White women.⁵ The CROWN Act, created in 2019, extends statutory protection to hair texture and protective hairstyles such as braids, locs, twists, and knots in the workplace and public schools to protect against discrimination due to race-based hairstyles. The CROWN Act provides an opportunity for dermatologists to support legislation that protects patients of color and the fundamental human right to nondiscrimination. As societal pressure for damaging hair practices such as hot combing or chemical relaxants decreases, patient outcomes will improve.⁵

How to Support the CROWN Act—There are various meaningful ways for dermatologists to support the CROWN act, including but not limited to signing petitions, sending letters of support to elected representatives, joining the CROWN Coalition, raising awareness and educating the public through social media, vocalizing against hair discrimination in our own workplaces and communities, and asking patients about their experiences with hair discrimination.5 In addition to advocacy, other antiracist actions suggested to improve health equity include creating curricula on racial inequity and increasing diversity in dermatology.¹⁶

There are many advocacy and public health campaigns promoted on the AAD website; however, despite the AAD’s formation of the Access to Dermatologic Care Task Force (ATDCTF) with the goal to raise awareness among dermatologists of health disparities affecting marginalized and underserved populations and to develop policies that increase access to care for these groups, there are still critical gaps in advocacy and information.¹³ This gap in both advocacy and understanding of hair loss conditions in women of color is one reason the CROWNing Event in July 2021 was held, and we believe this event along with this column can serve as a template for addressing additional topics and diseases that affect marginalized or underserved populations.

Dermatologists can play a vital role in advocating for skin and hair needs in all patient populations from the personal or clinical encounter level to population-level policy legislation.^5,8 As experts in skin and hair, dermatologists are best prepared to assume leadership in addressing racial health inequities, educating the public, and improving awareness.^5,16 Dermatologists must be able to diagnose and manage skin conditions in people of color.¹² However, health advocacy should extend beyond changes to health behavior or health interventions and instead address the root causes of systemic issues that drive disparate health outcomes.⁶ Every dermatologist has a contribution to make; it is time for us to acknowledge that patients’ ailments neither begin nor end at the clinic door.^8,16 As dermatologists, we must speak out against the racial inequities and discriminatory policies affecting the lives of patients of color.¹⁶

Although the CROWNing event should be considered successful, reflection in hindsight has allowed us to find ways to improve the impact of future events, including incorporating more lay members of the respective community in the planning process, allocating more time during the event programming for questions, and streamlining the distribution of pre-event and postevent surveys to better gauge knowledge retention among participants and gain crucial feedback for future event planning.

How to Use the FACE Model—We believe that the FACE model (Figure) can help providers engage lay members of the community with additional topics and diseases that affect marginalized and underserved populations. We recommend that future organizers engage stakeholders early during the design, planning, and implementation phases to ensure that the community’s most pressing needs are addressed. Dermatologists possess the knowledge and influence to serve as powerful advocates and champions for health equity. As physicians on the front lines of dermatologic health, we are uniquely positioned to engage and partner with patients through educational and advocacy events such as ours. Similarly, informed and empowered patients can advocate for policies and be proponents for greater research funding.⁵ We call on the AAD and other dermatologic organizations to expand community outreach and advocacy efforts to include underserved and underrepresented populations.

Acknowledgments—The authors would like to thank and acknowledge the faculty at Hampton University (Hampton, Virginia)—specifically Ms. B. DáVida Plummer, MA—for assistance with communication strategies, including organizing the radio and television announcements and proofreading the public service announcements. We also would like to thank other CROWNing Event Planning Committee members, including Natalia Mendoza, MD (Newport News, Virginia); Farhaad Riyaz, MD (Gainesville, Virginia); Deborah Elder, MD (Charlottesville, Virginia); and David Rowe, MD (Charlottesville, Virginia), as well as Sandra Ring, MS, CCLS, CNP (Chicago, Illinois), from the AAD and the various speakers at the event, including the 2 patients; Victoria Barbosa, MD, MPH, MBA (Chicago, Illinois); Avery LaChance, MD, MPH (Boston, Massachusetts); and Senator Lionell Spruill Sr (Chesapeake, Virginia). We acknowledge Marieke K. Jones, PhD, at the Claude Moore Health Sciences Library at the University of Virginia (Charlottesville, Virginia), for her statistical expertise.

Approximately 4.5% of adults within the United States identify as members of the lesbian, gay, bisexual, transgender (LGBT) community.¹ This is an umbrella term inclusive of all individuals identifying as nonheterosexual or noncisgender. Although the LGBT community has increasingly become more recognized and accepted by society over time, health care disparities persist and have been well documented in the literature.^2-4 Dermatologists have the potential to greatly impact LGBT health, as many health concerns in this population are cutaneous, such as sun-protection behaviors, side effects of gender-affirming hormone therapy and gender-affirming procedures, and cutaneous manifestations of sexually transmitted infections.^5-7

An education gap has been demonstrated in both medical students and resident physicians regarding LGBT health and cultural competency. In a large-scale, multi-institutional survey study published in 2015, approximately two-thirds of medical students rated their schools’ LGBT curriculum as fair, poor, or very poor.⁸ Additional studies have echoed these results and have demonstrated not only the need but the desire for additional training on LGBT issues in medical school.^9-11 The Association of American Medical Colleges has begun implementing curricular and institutional changes to fulfill this need.^12,13

The LGBT education gap has been shown to extend into residency training. Multiple studies performed within a variety of medical specialties have demonstrated that resident physicians receive insufficient training in LGBT health issues, lack comfort in caring for LGBT patients, and would benefit from dedicated curricula on these topics.^14-18 Currently, the 2022 Accreditation Council for Graduate Medical Education (ACGME) guidelines related to LGBT health are minimal and nonspecific.¹⁹

Ensuring that dermatology trainees are well equipped to manage these issues while providing culturally competent care to LGBT patients is paramount. However, research suggests that dedicated training on these topics likely is insufficient. A survey study of dermatology residency program directors (N=90) revealed that although 81% (72/89) viewed training in LGBT health as either very important or somewhat important, 46% (41/90) of programs did not dedicate any time to this content and 37% (33/90) only dedicated 1 to 2 hours per year.²⁰

To further explore this potential education gap, we surveyed dermatology residents directly to better understand LGBT education within residency training, resident preparedness to care for LGBT patients, and outness/discrimination of LGBT-identifying residents. We believe this study should drive future research on the development and implementation of LGBT-specific curricula in dermatology training programs.

Methods

A cross-sectional survey study of dermatology residents in the United States was conducted. The study was deemed exempt from review by The Ohio State University (Columbus, Ohio) institutional review board. Survey responses were collected from October 7, 2020, to November 13, 2020. Qualtrics software was used to create the 20-question survey, which included a combination of categorical, dichotomous, and optional free-text questions related to patient demographics, LGBT training experiences, perceived areas of curriculum improvement, comfort level managing LGBT health issues, and personal experiences. Some questions were adapted from prior surveys.^15,21 Validated survey tools used included the 2020 US Census to collect information regarding race and ethnicity, the Mohr and Fassinger Outness Inventory to measure outness regarding sexual orientation, and select questions from the 2020 Association of American Medical Colleges Medical School Graduation Questionnaire regarding discrimination.^22-24

The survey was distributed to current allopathic and osteopathic dermatology residents by a variety of methods, including emails to program director and program coordinator listserves. The survey also was posted in the American Academy of Dermatology Expert Resource Group on LGBTQ Health October 2020 newsletter, as well as dermatology social media groups, including a messaging forum limited to dermatology residents, a Facebook group open to dermatologists and dermatology residents, and the Facebook group of the Gay and Lesbian Dermatology Association. Current dermatology residents, including those in combined dermatology and internal medicine programs, were included. Individuals who had been accepted to dermatology training programs but had not yet started were excluded. A follow-up email was sent to the program director listserve approximately 3 weeks after the initial distribution.

Statistical Analysis—The data were analyzed in Qualtrics and Microsoft Excel using descriptive statistics. Stata software (Stata 15.1, StataCorp) was used to perform a Kruskal-Wallis equality-of-populations rank test to compare the means of education level and feelings of preparedness.

Results

Demographics of Respondents—A total of 126 responses were recorded, 12 of which were blank and were removed from the database. A total of 114 dermatology residents’ responses were collected in Qualtrics and analyzed; 91 completed the entire survey (an 80% completion rate). Based on the 2020-2021 ACGME data listing, there were 1612 dermatology residents in the United States, which is an estimated response rate of 7% (114/1612).²⁵ The eTable outlines the demographics of the survey respondents. Most were cisgender females (60%), followed by cisgender males (35%); the remainder preferred not to answer. Regarding sexual orientation, 77% identified as straight or heterosexual; 17% as gay, lesbian, or homosexual; 1% as queer; and 1% as bisexual. The training programs were in 26 states, the majority of which were in the Midwest (34%) and in urban settings (69%). A wide range of postgraduate levels and residency sizes were represented in the survey.

LGBT Education—Fifty-one percent of respondents reported that their programs offer 1 hour or less of LGBT-related curricula per year; 34% reported no time dedicated to this topic. A small portion of residents (5%) reported 10 or more hours of LGBT education per year. Residents also were asked the average number of hours of LGBT education they thought they should receive. The discrepancy between these measures can be visualized in Figure 1. The median hours of education received was 1 hour (IQR, 0–4 hours), whereas the median hours of education desired was 4 hours (IQR, 2–5 hours). The most common and most helpful methods of education reported were clinical experiences with faculty or patients and live lectures.

Overall, 45% of survey respondents felt that LGBT topics were covered poorly or not at all in dermatology residency, whereas 26% thought the coverage was good or excellent. The topics that residents were most likely to report receiving good or excellent coverage were dermatologic manifestations of HIV/AIDS (70%) and sexually transmitted diseases in LGBT patients (48%). The topics that were most likely to be reported as not taught or poorly taught included dermatologic concerns associated with puberty blockers (71%), body image (58%), dermatologic concerns associated with gender-affirming surgery (55%), skin cancer risk (53%), taking an LGBT-oriented history and physical examination (52%), and effects of gender-affirming hormone therapy on the skin (50%). A detailed breakdown of coverage level by topic can be found in Figure 2.

Preparedness to Care for LGBT Patients—Only 68% of survey respondents agreed or strongly agreed that they feel comfortable treating LGBT patients. Furthermore, 49% of dermatology residents reported that they feel not at all prepared or insufficiently prepared to provide care to LGBT individuals (Figure 2), and 60% believed that LGBT training needed to be improved at their residency programs.

There was a significant association between reported level of education and feelings of preparedness. A high ranking of provided education was associated with higher levels of feeling prepared to care for LGBT patients (Kruskal-Wallis rank test, P<.001).

Discrimination/Outness—Approximately one-fourth (24%; 4/17) of nonheterosexual dermatology residents reported that they had been subjected to offensive remarks about their sexual orientation in the workplace. One respondent commented that they were less “out” at their residency program due to fear of discrimination. Nearly one-third of the overall group of dermatology residents surveyed (29%; 27/92) reported that they had witnessed inappropriate or discriminatory comments about LGBT persons made by employees or staff at their programs. Most residents surveyed (96%; 88/92) agreed or strongly agreed that they feel comfortable working alongside LGBT physicians.

There were 18 nonheterosexual dermatologyresidents who completed the Mohr and Fassinger Outness Inventory.²³ In general, respondents reported that they were more “out” with friends and family than work peers and were least “out” with work supervisors and strangers.

Comment

Dermatology Residents Desire More Time on LGBT Health—This cross-sectional survey study explored dermatology residents’ educational experiences with LGBT health during residency training. Similar studies have been performed in other specialties, including a study from 2019 surveying emergency medicine residents that demonstrated residents find caring for LGBT patients more challenging.¹⁵ Another 2019 study surveying psychiatry residents found that 42.4% (N=99) reported no coverage of LGBT topics.¹⁸ Our study is unique in that it surveyed dermatology residents directly regarding this topic. Although most dermatology program directors view LGBT dermatologic health as an important topic, a prior study revealed that many programs are lacking dedicated LGBT educational experiences. The most common barriers reported were insufficient time in the didactic schedule and lack of experienced faculty.²⁰

Our study revealed that dermatology residents overall tend to agree with residents from other specialties and dermatology program directors. Most of the dermatology residents surveyed reported desiring more time per year spent on LGBT health education than they receive, and 60% expressed that LGBT educational experiences need to be improved at their residency programs. Education on and subsequent comfort level with LGBT health issues varied by subtopic, with most residents feeling comfortable dealing with dermatologic manifestations of HIV/AIDS and other sexually transmitted diseases and less comfortable with topics such as puberty blockers, gender-affirming surgery and hormone therapy, body image, and skin cancer risk.

Overall, LGBT health training is viewed as important and in need of improvement by both program directors and residents, yet implementation lags at many programs. A small proportion of the represented programs are excelling in this area—just over 5% of respondents reported receiving 10 or more hours of LGBT-relevant education per year, and approximately 26% of residents felt that LGBT coverage was good or excellent at their programs. Our study showed a clear relationship between feelings of preparedness and education level. The lack of LGBT education at some dermatology residency programs translated into a large portion of dermatology residents feeling ill equipped to care for LGBT patients after graduation—nearly 50% of those surveyed reported feeling insufficiently prepared to care for the LGBT community.

Discrimination in Residency Programs—Dermatology residency programs also are not free from sexual orientation–related and gender identity–related workplace discrimination. Although 96% of dermatology residents reported that they feel comfortable working alongside LGBT physicians, 24% of nonheterosexual respondents stated they had been subjected to offensive remarks about their sexual orientation, and 29% of the overall group of dermatology residents had witnessed discriminatory comments to LGBT individuals at their programs. In addition, some nonheterosexual dermatology residents reported being less “out” with their workplace supervisors and strangers, such as patients, than with their family and friends, and 50% of this group reported that their sexual identity was not openly discussed with their workplace supervisors. It has been demonstrated that individuals are more likely to “come out” in perceived LGBT-friendly workplace environments and that being “out” positively impacts psychological health because of the effects of perceived social support and self-coherence.^26,27

Study Strengths and Limitations—Strengths of this study include the modest sample size of dermatology residents that participated, high completion rate, and the anonymity of the survey. Limitations include the risk of sampling bias by posting the survey on LGBT-specific groups. The survey also took place in the fall, so the results may not accurately reflect programs that cover this material later in the academic year. Lastly, not all survey questions were validated.

Implementing Change in Residency Programs—Although the results of this study exposed the need for increasing LGBT education in dermatology residency, they do not provide guidelines for the best strategy to begin implementing change. A study from 2020 provides some guidance for incorporating LGBT health training into dermatology residency programs through a combination of curricular modifications and climate optimization.²⁸ Additional future research should focus on the best methods for preparing dermatology residents to care for this population. In this study, residents reported that the most effective teaching methods were real encounters with LGBT patients or faculty educated on LGBT health as well as live lectures from experts. There also appeared to be a correlation between hours spent on LGBT health, including various subtopics, and residents’ perceived preparedness in these areas. Potential actionable items include clarifying the ACGME guidelines on LGBT health topics; increasing the sexual and gender diversity of the faculty, staff, residents, and patients; and dedicating additional didactic and clinical time to LGBT topics and experiences.

Conclusion

This survey study of dermatology residents regarding LGBT learning experiences in residency training provided evidence that dermatology residents as a whole are not adequately taught LGBT health topics and therefore feel unprepared to take care of this patient population. Additionally, most residents desire improvement of LGBT health education and training. Further studies focusing on the best methods for implementing LGBT-specific curricula are needed.

Approximately 4.5% of adults within the United States identify as members of the lesbian, gay, bisexual, transgender (LGBT) community.¹ This is an umbrella term inclusive of all individuals identifying as nonheterosexual or noncisgender. Although the LGBT community has increasingly become more recognized and accepted by society over time, health care disparities persist and have been well documented in the literature.^2-4 Dermatologists have the potential to greatly impact LGBT health, as many health concerns in this population are cutaneous, such as sun-protection behaviors, side effects of gender-affirming hormone therapy and gender-affirming procedures, and cutaneous manifestations of sexually transmitted infections.^5-7

An education gap has been demonstrated in both medical students and resident physicians regarding LGBT health and cultural competency. In a large-scale, multi-institutional survey study published in 2015, approximately two-thirds of medical students rated their schools’ LGBT curriculum as fair, poor, or very poor.⁸ Additional studies have echoed these results and have demonstrated not only the need but the desire for additional training on LGBT issues in medical school.^9-11 The Association of American Medical Colleges has begun implementing curricular and institutional changes to fulfill this need.^12,13

The LGBT education gap has been shown to extend into residency training. Multiple studies performed within a variety of medical specialties have demonstrated that resident physicians receive insufficient training in LGBT health issues, lack comfort in caring for LGBT patients, and would benefit from dedicated curricula on these topics.^14-18 Currently, the 2022 Accreditation Council for Graduate Medical Education (ACGME) guidelines related to LGBT health are minimal and nonspecific.¹⁹

Ensuring that dermatology trainees are well equipped to manage these issues while providing culturally competent care to LGBT patients is paramount. However, research suggests that dedicated training on these topics likely is insufficient. A survey study of dermatology residency program directors (N=90) revealed that although 81% (72/89) viewed training in LGBT health as either very important or somewhat important, 46% (41/90) of programs did not dedicate any time to this content and 37% (33/90) only dedicated 1 to 2 hours per year.²⁰

To further explore this potential education gap, we surveyed dermatology residents directly to better understand LGBT education within residency training, resident preparedness to care for LGBT patients, and outness/discrimination of LGBT-identifying residents. We believe this study should drive future research on the development and implementation of LGBT-specific curricula in dermatology training programs.

Methods

A cross-sectional survey study of dermatology residents in the United States was conducted. The study was deemed exempt from review by The Ohio State University (Columbus, Ohio) institutional review board. Survey responses were collected from October 7, 2020, to November 13, 2020. Qualtrics software was used to create the 20-question survey, which included a combination of categorical, dichotomous, and optional free-text questions related to patient demographics, LGBT training experiences, perceived areas of curriculum improvement, comfort level managing LGBT health issues, and personal experiences. Some questions were adapted from prior surveys.^15,21 Validated survey tools used included the 2020 US Census to collect information regarding race and ethnicity, the Mohr and Fassinger Outness Inventory to measure outness regarding sexual orientation, and select questions from the 2020 Association of American Medical Colleges Medical School Graduation Questionnaire regarding discrimination.^22-24

The survey was distributed to current allopathic and osteopathic dermatology residents by a variety of methods, including emails to program director and program coordinator listserves. The survey also was posted in the American Academy of Dermatology Expert Resource Group on LGBTQ Health October 2020 newsletter, as well as dermatology social media groups, including a messaging forum limited to dermatology residents, a Facebook group open to dermatologists and dermatology residents, and the Facebook group of the Gay and Lesbian Dermatology Association. Current dermatology residents, including those in combined dermatology and internal medicine programs, were included. Individuals who had been accepted to dermatology training programs but had not yet started were excluded. A follow-up email was sent to the program director listserve approximately 3 weeks after the initial distribution.

Statistical Analysis—The data were analyzed in Qualtrics and Microsoft Excel using descriptive statistics. Stata software (Stata 15.1, StataCorp) was used to perform a Kruskal-Wallis equality-of-populations rank test to compare the means of education level and feelings of preparedness.

Results

Demographics of Respondents—A total of 126 responses were recorded, 12 of which were blank and were removed from the database. A total of 114 dermatology residents’ responses were collected in Qualtrics and analyzed; 91 completed the entire survey (an 80% completion rate). Based on the 2020-2021 ACGME data listing, there were 1612 dermatology residents in the United States, which is an estimated response rate of 7% (114/1612).²⁵ The eTable outlines the demographics of the survey respondents. Most were cisgender females (60%), followed by cisgender males (35%); the remainder preferred not to answer. Regarding sexual orientation, 77% identified as straight or heterosexual; 17% as gay, lesbian, or homosexual; 1% as queer; and 1% as bisexual. The training programs were in 26 states, the majority of which were in the Midwest (34%) and in urban settings (69%). A wide range of postgraduate levels and residency sizes were represented in the survey.

LGBT Education—Fifty-one percent of respondents reported that their programs offer 1 hour or less of LGBT-related curricula per year; 34% reported no time dedicated to this topic. A small portion of residents (5%) reported 10 or more hours of LGBT education per year. Residents also were asked the average number of hours of LGBT education they thought they should receive. The discrepancy between these measures can be visualized in Figure 1. The median hours of education received was 1 hour (IQR, 0–4 hours), whereas the median hours of education desired was 4 hours (IQR, 2–5 hours). The most common and most helpful methods of education reported were clinical experiences with faculty or patients and live lectures.

Overall, 45% of survey respondents felt that LGBT topics were covered poorly or not at all in dermatology residency, whereas 26% thought the coverage was good or excellent. The topics that residents were most likely to report receiving good or excellent coverage were dermatologic manifestations of HIV/AIDS (70%) and sexually transmitted diseases in LGBT patients (48%). The topics that were most likely to be reported as not taught or poorly taught included dermatologic concerns associated with puberty blockers (71%), body image (58%), dermatologic concerns associated with gender-affirming surgery (55%), skin cancer risk (53%), taking an LGBT-oriented history and physical examination (52%), and effects of gender-affirming hormone therapy on the skin (50%). A detailed breakdown of coverage level by topic can be found in Figure 2.

Preparedness to Care for LGBT Patients—Only 68% of survey respondents agreed or strongly agreed that they feel comfortable treating LGBT patients. Furthermore, 49% of dermatology residents reported that they feel not at all prepared or insufficiently prepared to provide care to LGBT individuals (Figure 2), and 60% believed that LGBT training needed to be improved at their residency programs.

There was a significant association between reported level of education and feelings of preparedness. A high ranking of provided education was associated with higher levels of feeling prepared to care for LGBT patients (Kruskal-Wallis rank test, P<.001).

Discrimination/Outness—Approximately one-fourth (24%; 4/17) of nonheterosexual dermatology residents reported that they had been subjected to offensive remarks about their sexual orientation in the workplace. One respondent commented that they were less “out” at their residency program due to fear of discrimination. Nearly one-third of the overall group of dermatology residents surveyed (29%; 27/92) reported that they had witnessed inappropriate or discriminatory comments about LGBT persons made by employees or staff at their programs. Most residents surveyed (96%; 88/92) agreed or strongly agreed that they feel comfortable working alongside LGBT physicians.

There were 18 nonheterosexual dermatologyresidents who completed the Mohr and Fassinger Outness Inventory.²³ In general, respondents reported that they were more “out” with friends and family than work peers and were least “out” with work supervisors and strangers.

Comment

Dermatology Residents Desire More Time on LGBT Health—This cross-sectional survey study explored dermatology residents’ educational experiences with LGBT health during residency training. Similar studies have been performed in other specialties, including a study from 2019 surveying emergency medicine residents that demonstrated residents find caring for LGBT patients more challenging.¹⁵ Another 2019 study surveying psychiatry residents found that 42.4% (N=99) reported no coverage of LGBT topics.¹⁸ Our study is unique in that it surveyed dermatology residents directly regarding this topic. Although most dermatology program directors view LGBT dermatologic health as an important topic, a prior study revealed that many programs are lacking dedicated LGBT educational experiences. The most common barriers reported were insufficient time in the didactic schedule and lack of experienced faculty.²⁰

Our study revealed that dermatology residents overall tend to agree with residents from other specialties and dermatology program directors. Most of the dermatology residents surveyed reported desiring more time per year spent on LGBT health education than they receive, and 60% expressed that LGBT educational experiences need to be improved at their residency programs. Education on and subsequent comfort level with LGBT health issues varied by subtopic, with most residents feeling comfortable dealing with dermatologic manifestations of HIV/AIDS and other sexually transmitted diseases and less comfortable with topics such as puberty blockers, gender-affirming surgery and hormone therapy, body image, and skin cancer risk.

Overall, LGBT health training is viewed as important and in need of improvement by both program directors and residents, yet implementation lags at many programs. A small proportion of the represented programs are excelling in this area—just over 5% of respondents reported receiving 10 or more hours of LGBT-relevant education per year, and approximately 26% of residents felt that LGBT coverage was good or excellent at their programs. Our study showed a clear relationship between feelings of preparedness and education level. The lack of LGBT education at some dermatology residency programs translated into a large portion of dermatology residents feeling ill equipped to care for LGBT patients after graduation—nearly 50% of those surveyed reported feeling insufficiently prepared to care for the LGBT community.

Discrimination in Residency Programs—Dermatology residency programs also are not free from sexual orientation–related and gender identity–related workplace discrimination. Although 96% of dermatology residents reported that they feel comfortable working alongside LGBT physicians, 24% of nonheterosexual respondents stated they had been subjected to offensive remarks about their sexual orientation, and 29% of the overall group of dermatology residents had witnessed discriminatory comments to LGBT individuals at their programs. In addition, some nonheterosexual dermatology residents reported being less “out” with their workplace supervisors and strangers, such as patients, than with their family and friends, and 50% of this group reported that their sexual identity was not openly discussed with their workplace supervisors. It has been demonstrated that individuals are more likely to “come out” in perceived LGBT-friendly workplace environments and that being “out” positively impacts psychological health because of the effects of perceived social support and self-coherence.^26,27

Study Strengths and Limitations—Strengths of this study include the modest sample size of dermatology residents that participated, high completion rate, and the anonymity of the survey. Limitations include the risk of sampling bias by posting the survey on LGBT-specific groups. The survey also took place in the fall, so the results may not accurately reflect programs that cover this material later in the academic year. Lastly, not all survey questions were validated.

Implementing Change in Residency Programs—Although the results of this study exposed the need for increasing LGBT education in dermatology residency, they do not provide guidelines for the best strategy to begin implementing change. A study from 2020 provides some guidance for incorporating LGBT health training into dermatology residency programs through a combination of curricular modifications and climate optimization.²⁸ Additional future research should focus on the best methods for preparing dermatology residents to care for this population. In this study, residents reported that the most effective teaching methods were real encounters with LGBT patients or faculty educated on LGBT health as well as live lectures from experts. There also appeared to be a correlation between hours spent on LGBT health, including various subtopics, and residents’ perceived preparedness in these areas. Potential actionable items include clarifying the ACGME guidelines on LGBT health topics; increasing the sexual and gender diversity of the faculty, staff, residents, and patients; and dedicating additional didactic and clinical time to LGBT topics and experiences.

Conclusion

This survey study of dermatology residents regarding LGBT learning experiences in residency training provided evidence that dermatology residents as a whole are not adequately taught LGBT health topics and therefore feel unprepared to take care of this patient population. Additionally, most residents desire improvement of LGBT health education and training. Further studies focusing on the best methods for implementing LGBT-specific curricula are needed.

Approximately 4.5% of adults within the United States identify as members of the lesbian, gay, bisexual, transgender (LGBT) community.¹ This is an umbrella term inclusive of all individuals identifying as nonheterosexual or noncisgender. Although the LGBT community has increasingly become more recognized and accepted by society over time, health care disparities persist and have been well documented in the literature.^2-4 Dermatologists have the potential to greatly impact LGBT health, as many health concerns in this population are cutaneous, such as sun-protection behaviors, side effects of gender-affirming hormone therapy and gender-affirming procedures, and cutaneous manifestations of sexually transmitted infections.^5-7

An education gap has been demonstrated in both medical students and resident physicians regarding LGBT health and cultural competency. In a large-scale, multi-institutional survey study published in 2015, approximately two-thirds of medical students rated their schools’ LGBT curriculum as fair, poor, or very poor.⁸ Additional studies have echoed these results and have demonstrated not only the need but the desire for additional training on LGBT issues in medical school.^9-11 The Association of American Medical Colleges has begun implementing curricular and institutional changes to fulfill this need.^12,13

The LGBT education gap has been shown to extend into residency training. Multiple studies performed within a variety of medical specialties have demonstrated that resident physicians receive insufficient training in LGBT health issues, lack comfort in caring for LGBT patients, and would benefit from dedicated curricula on these topics.^14-18 Currently, the 2022 Accreditation Council for Graduate Medical Education (ACGME) guidelines related to LGBT health are minimal and nonspecific.¹⁹

Ensuring that dermatology trainees are well equipped to manage these issues while providing culturally competent care to LGBT patients is paramount. However, research suggests that dedicated training on these topics likely is insufficient. A survey study of dermatology residency program directors (N=90) revealed that although 81% (72/89) viewed training in LGBT health as either very important or somewhat important, 46% (41/90) of programs did not dedicate any time to this content and 37% (33/90) only dedicated 1 to 2 hours per year.²⁰

To further explore this potential education gap, we surveyed dermatology residents directly to better understand LGBT education within residency training, resident preparedness to care for LGBT patients, and outness/discrimination of LGBT-identifying residents. We believe this study should drive future research on the development and implementation of LGBT-specific curricula in dermatology training programs.

Methods

A cross-sectional survey study of dermatology residents in the United States was conducted. The study was deemed exempt from review by The Ohio State University (Columbus, Ohio) institutional review board. Survey responses were collected from October 7, 2020, to November 13, 2020. Qualtrics software was used to create the 20-question survey, which included a combination of categorical, dichotomous, and optional free-text questions related to patient demographics, LGBT training experiences, perceived areas of curriculum improvement, comfort level managing LGBT health issues, and personal experiences. Some questions were adapted from prior surveys.^15,21 Validated survey tools used included the 2020 US Census to collect information regarding race and ethnicity, the Mohr and Fassinger Outness Inventory to measure outness regarding sexual orientation, and select questions from the 2020 Association of American Medical Colleges Medical School Graduation Questionnaire regarding discrimination.^22-24

The survey was distributed to current allopathic and osteopathic dermatology residents by a variety of methods, including emails to program director and program coordinator listserves. The survey also was posted in the American Academy of Dermatology Expert Resource Group on LGBTQ Health October 2020 newsletter, as well as dermatology social media groups, including a messaging forum limited to dermatology residents, a Facebook group open to dermatologists and dermatology residents, and the Facebook group of the Gay and Lesbian Dermatology Association. Current dermatology residents, including those in combined dermatology and internal medicine programs, were included. Individuals who had been accepted to dermatology training programs but had not yet started were excluded. A follow-up email was sent to the program director listserve approximately 3 weeks after the initial distribution.

Statistical Analysis—The data were analyzed in Qualtrics and Microsoft Excel using descriptive statistics. Stata software (Stata 15.1, StataCorp) was used to perform a Kruskal-Wallis equality-of-populations rank test to compare the means of education level and feelings of preparedness.

Results

Demographics of Respondents—A total of 126 responses were recorded, 12 of which were blank and were removed from the database. A total of 114 dermatology residents’ responses were collected in Qualtrics and analyzed; 91 completed the entire survey (an 80% completion rate). Based on the 2020-2021 ACGME data listing, there were 1612 dermatology residents in the United States, which is an estimated response rate of 7% (114/1612).²⁵ The eTable outlines the demographics of the survey respondents. Most were cisgender females (60%), followed by cisgender males (35%); the remainder preferred not to answer. Regarding sexual orientation, 77% identified as straight or heterosexual; 17% as gay, lesbian, or homosexual; 1% as queer; and 1% as bisexual. The training programs were in 26 states, the majority of which were in the Midwest (34%) and in urban settings (69%). A wide range of postgraduate levels and residency sizes were represented in the survey.

LGBT Education—Fifty-one percent of respondents reported that their programs offer 1 hour or less of LGBT-related curricula per year; 34% reported no time dedicated to this topic. A small portion of residents (5%) reported 10 or more hours of LGBT education per year. Residents also were asked the average number of hours of LGBT education they thought they should receive. The discrepancy between these measures can be visualized in Figure 1. The median hours of education received was 1 hour (IQR, 0–4 hours), whereas the median hours of education desired was 4 hours (IQR, 2–5 hours). The most common and most helpful methods of education reported were clinical experiences with faculty or patients and live lectures.

Overall, 45% of survey respondents felt that LGBT topics were covered poorly or not at all in dermatology residency, whereas 26% thought the coverage was good or excellent. The topics that residents were most likely to report receiving good or excellent coverage were dermatologic manifestations of HIV/AIDS (70%) and sexually transmitted diseases in LGBT patients (48%). The topics that were most likely to be reported as not taught or poorly taught included dermatologic concerns associated with puberty blockers (71%), body image (58%), dermatologic concerns associated with gender-affirming surgery (55%), skin cancer risk (53%), taking an LGBT-oriented history and physical examination (52%), and effects of gender-affirming hormone therapy on the skin (50%). A detailed breakdown of coverage level by topic can be found in Figure 2.

Preparedness to Care for LGBT Patients—Only 68% of survey respondents agreed or strongly agreed that they feel comfortable treating LGBT patients. Furthermore, 49% of dermatology residents reported that they feel not at all prepared or insufficiently prepared to provide care to LGBT individuals (Figure 2), and 60% believed that LGBT training needed to be improved at their residency programs.

There was a significant association between reported level of education and feelings of preparedness. A high ranking of provided education was associated with higher levels of feeling prepared to care for LGBT patients (Kruskal-Wallis rank test, P<.001).

Discrimination/Outness—Approximately one-fourth (24%; 4/17) of nonheterosexual dermatology residents reported that they had been subjected to offensive remarks about their sexual orientation in the workplace. One respondent commented that they were less “out” at their residency program due to fear of discrimination. Nearly one-third of the overall group of dermatology residents surveyed (29%; 27/92) reported that they had witnessed inappropriate or discriminatory comments about LGBT persons made by employees or staff at their programs. Most residents surveyed (96%; 88/92) agreed or strongly agreed that they feel comfortable working alongside LGBT physicians.

There were 18 nonheterosexual dermatologyresidents who completed the Mohr and Fassinger Outness Inventory.²³ In general, respondents reported that they were more “out” with friends and family than work peers and were least “out” with work supervisors and strangers.

Comment

Dermatology Residents Desire More Time on LGBT Health—This cross-sectional survey study explored dermatology residents’ educational experiences with LGBT health during residency training. Similar studies have been performed in other specialties, including a study from 2019 surveying emergency medicine residents that demonstrated residents find caring for LGBT patients more challenging.¹⁵ Another 2019 study surveying psychiatry residents found that 42.4% (N=99) reported no coverage of LGBT topics.¹⁸ Our study is unique in that it surveyed dermatology residents directly regarding this topic. Although most dermatology program directors view LGBT dermatologic health as an important topic, a prior study revealed that many programs are lacking dedicated LGBT educational experiences. The most common barriers reported were insufficient time in the didactic schedule and lack of experienced faculty.²⁰

Our study revealed that dermatology residents overall tend to agree with residents from other specialties and dermatology program directors. Most of the dermatology residents surveyed reported desiring more time per year spent on LGBT health education than they receive, and 60% expressed that LGBT educational experiences need to be improved at their residency programs. Education on and subsequent comfort level with LGBT health issues varied by subtopic, with most residents feeling comfortable dealing with dermatologic manifestations of HIV/AIDS and other sexually transmitted diseases and less comfortable with topics such as puberty blockers, gender-affirming surgery and hormone therapy, body image, and skin cancer risk.

Overall, LGBT health training is viewed as important and in need of improvement by both program directors and residents, yet implementation lags at many programs. A small proportion of the represented programs are excelling in this area—just over 5% of respondents reported receiving 10 or more hours of LGBT-relevant education per year, and approximately 26% of residents felt that LGBT coverage was good or excellent at their programs. Our study showed a clear relationship between feelings of preparedness and education level. The lack of LGBT education at some dermatology residency programs translated into a large portion of dermatology residents feeling ill equipped to care for LGBT patients after graduation—nearly 50% of those surveyed reported feeling insufficiently prepared to care for the LGBT community.

Discrimination in Residency Programs—Dermatology residency programs also are not free from sexual orientation–related and gender identity–related workplace discrimination. Although 96% of dermatology residents reported that they feel comfortable working alongside LGBT physicians, 24% of nonheterosexual respondents stated they had been subjected to offensive remarks about their sexual orientation, and 29% of the overall group of dermatology residents had witnessed discriminatory comments to LGBT individuals at their programs. In addition, some nonheterosexual dermatology residents reported being less “out” with their workplace supervisors and strangers, such as patients, than with their family and friends, and 50% of this group reported that their sexual identity was not openly discussed with their workplace supervisors. It has been demonstrated that individuals are more likely to “come out” in perceived LGBT-friendly workplace environments and that being “out” positively impacts psychological health because of the effects of perceived social support and self-coherence.^26,27

Study Strengths and Limitations—Strengths of this study include the modest sample size of dermatology residents that participated, high completion rate, and the anonymity of the survey. Limitations include the risk of sampling bias by posting the survey on LGBT-specific groups. The survey also took place in the fall, so the results may not accurately reflect programs that cover this material later in the academic year. Lastly, not all survey questions were validated.

Implementing Change in Residency Programs—Although the results of this study exposed the need for increasing LGBT education in dermatology residency, they do not provide guidelines for the best strategy to begin implementing change. A study from 2020 provides some guidance for incorporating LGBT health training into dermatology residency programs through a combination of curricular modifications and climate optimization.²⁸ Additional future research should focus on the best methods for preparing dermatology residents to care for this population. In this study, residents reported that the most effective teaching methods were real encounters with LGBT patients or faculty educated on LGBT health as well as live lectures from experts. There also appeared to be a correlation between hours spent on LGBT health, including various subtopics, and residents’ perceived preparedness in these areas. Potential actionable items include clarifying the ACGME guidelines on LGBT health topics; increasing the sexual and gender diversity of the faculty, staff, residents, and patients; and dedicating additional didactic and clinical time to LGBT topics and experiences.

Conclusion

This survey study of dermatology residents regarding LGBT learning experiences in residency training provided evidence that dermatology residents as a whole are not adequately taught LGBT health topics and therefore feel unprepared to take care of this patient population. Additionally, most residents desire improvement of LGBT health education and training. Further studies focusing on the best methods for implementing LGBT-specific curricula are needed.