America’s inadequate LGBTQ medical education

The uncomfortable numbers: how little LGBTQ health has been taught

The most widely cited wake-up call came from a national survey of U.S. and Canadian medical schools
published in JAMA. Deans reported a median of just 5 hours of LGBTQ-related content
across the entire undergraduate medical curriculumand roughly a third reported zero hours during
clinical years. Five hours. Across four years. That’s not a curriculum; that’s a long coffee break.

Yes, things have improved in some places. A more recent survey reported a higher median number of
hours dedicated to LGBTQI+ topics by 2022. But the same conclusion keeps popping up like a recurring
diagnosis: coverage varies widely, and the quality and breadth of instruction are inconsistent.
In other words, some schools are building serious competencyothers are still teaching “be nice” and calling it a day.

AAMC commentary has also described a pattern that looks good on paper but thin in practice:
many schools “include” LGBTQ+ themes, yet do so in a small number of learning activitiessometimes
just a single lecture or discussion. That’s better than nothing, but it’s not enough to build durable clinical skill.

Why inadequate LGBTQ medical education matters (beyond being awkward)

1) Patients experience disrespect and discriminationoften enough to change their behavior

A big part of “inadequate education” is not knowing what to ask, how to ask it, or what to do with the answer.
That uncertainty can leak out as assumptions, dismissiveness, or avoidance. National survey findings from KFF
show that LGBT adults report unfair or disrespectful treatment by providers at notably higher rates than non-LGBT adults,
and many report consequences like delaying care, switching clinicians, or feeling less comfortable asking questions.

2) Preventive care gets missed when identity is confused with anatomy (or risk)

Preventive care isn’t optionalyet it’s commonly where knowledge gaps show up. If a clinician assumes every patient
is straight, cisgender, and monogamous (a triple assumption that deserves its own ICD-10 code), they may not take an
accurate sexual history, may misjudge STI risks, or may miss screening needs.

Practical data work underscores the point: when clinics collect sexual orientation and gender identity (SOGI) information
in the EHR, they can identify disparities in services like cervical cancer screening and depression screening. That’s not an
abstract equity argumentit’s a quality improvement roadmap.

3) “Hidden curriculum” can reinforce stereotypes

Even when schools mention LGBTQ health, how they mention it matters. An ethics analysis in the AMA Journal of Ethics
warned about pitfalls such as stereotyping gay men as automatically high-risk for HIV regardless of behavior, or mislabeling
transgender identity as pathology. Poorly designed teaching can do more damage than silence because it hands students
misinformation with confidence.

4) Students report discomfort and low competenceespecially around transgender care and DSD

Surveys of learners have repeatedly found that students may feel generally “comfortable” but still feel not competent
to provide medical care for gender minority patients or for people born with differences of sex development (DSD).
Comfort without competence is just politeness with a stethoscope.

What’s missing in LGBTQ medical training (the “why does no one teach this?” list)

Many schools aren’t ignoring LGBTQ health on purpose. Often, it’s addressed in fragmentsone lecture in endocrinology,
a case vignette in psychiatry, maybe a discussion during OB/GYN. The result is a patchwork that students can’t reliably
use in clinic. Here are common blind spots that show up across programs:

Inclusive communication that’s actually usable in a 15-minute visit

It’s one thing to say “use inclusive language.” It’s another to practice it with real phrasing:
how to ask about partners without assuming gender, how to ask about sex without making it weird, and how to apologize
briefly if you mess up (because you will, and that’s fixable).

Sexual history-taking based on behavior, not identity

The clinical goal is not to “label” someoneit’s to understand health risks, safety, and needs. Many students are taught
a checkbox-style history that doesn’t translate into respectful, precise questions. AAMC teaching resources emphasize
concrete strategies for engaging patients and identifying SOGI respectfully, which is exactly the kind of practical skill students need.

Gender-affirming care basics (not an elective, not a rumor)

You don’t have to be a specialist to practice safe, evidence-based care. But students often graduate without a clear
framework for gender-affirming care: terminology, confidentiality, puberty-related considerations, hormone basics,
surgical histories, fertility counseling, and preventive screening aligned with anatomy and exposurenot assumptions.

Preventive screening tailored to anatomy and exposure

“Pap smears are for women” is a sentence that should be retired like a pager. Screening decisions depend on organs present,
sexual practices, age, and risk factors. In the real world, that means caring for transgender men who may need cervical screening,
transgender women who may need prostate considerations, and nonbinary patients who may have avoided care for years.

Mental health, minority stress, and suicide risktaught with clinical nuance

LGBTQ patients, especially youth and those facing discrimination, can be at higher risk of anxiety, depression, and suicidality.
But “screen more” is not a plan. Students need training on trauma-informed interviewing, safe environment signals,
and referral pathways that don’t accidentally send people into hostile systems.

Reproductive and family-building care beyond heterosexual default

Fertility, contraception, pregnancy, parenting, and sexual function are relevant to LGBTQ patients across life stages.
Too often, education treats these topics as if only one family structure exists. Real clinical competency includes discussing
reproductive goals without assumptions and documenting family structures accurately.

Intersex/DSD education that’s ethical, not sensational

Some curricula skip DSD entirely. Others cover it only as an endocrine puzzle. Learners need ethical, patient-centered
frameworks, including shared decision-making, respectful language, and long-term outcomes.

Why medical schools struggle to fix it (even when they want to)

The curriculum is crowdedand LGBTQ health gets treated like a “special topic”

If LGBTQ health is taught as a standalone lecture, it competes with every other “important-but-not-on-the-exam” topic.
A more durable approach is integration: teach it inside endocrinology, OB/GYN, psychiatry, primary care, pediatrics,
geriatrics, oncologywhere it naturally belongs.

Faculty expertise is uneven

Multiple national surveys have found that schools often identify the same bottleneck: not enough faculty feel prepared
to teach LGBTQ content. Without faculty development, schools either avoid the material or rely on one overworked
“LGBTQ champion” who cannot carry the whole institution on their back.

Clinical years are the hardest to standardize

A student might get an incredible preceptor who models inclusive careor a rotation where LGBTQ patients are never
discussed unless someone makes a joke (yes, that still happens). The “hidden curriculum” can undo what the formal
curriculum tries to build.

Assessment drives learning, and assessment often ignores LGBTQ competency

Students learn what they’re tested on. If LGBTQ clinical skills aren’t evaluatedthrough OSCEs, standardized patients,
chart review, or competency milestonesmany learners will treat it as optional, even if they personally care about doing better.

What works: a practical blueprint to build LGBTQ clinical competency

The fix is not “add one more lecture.” It’s to move LGBTQ health from “special topic” to “standard of care,” using the same
educational logic schools already apply to diabetes, hypertension, and depression: repeated exposure, skills practice,
feedback, and assessment.

1) Use competency frameworks (and stop reinventing the wheel)

National organizations have published competency-based guidance for integrating LGBTQ and gender-nonconforming health
into medical education, including domains that map to clinical skills, professionalism, and systems-based practice.
Competencies are helpful because they convert “be inclusive” into observable behaviors (what students should be able to do).

2) Integrate content across the curriculum (spiral learning beats one-and-done)

• Preclinical: inclusive interviewing, terminology, anatomy-based screening logic, case-based discussion
• Clinical: rotation-specific teaching points (OB/GYN, pediatrics, psychiatry, family medicine, internal medicine)
• Capstone: OSCE stations with standardized patients and charting exercises using SOGI fields

3) Practice with standardized patients and real scripts

Students need rehearsals, not just readings. AAMC and other educator resources include clinical vignettes and
structured teaching strategies for gender and sexual history-taking. That kind of “say this, then do this” training is
what turns good intentions into reliable clinical performance.

4) Build faculty comfort the same way you build student comfort

Faculty development can include short workshops, teaching toolkits, and co-teaching models where content experts partner
with course directors. External, evidence-based training resources (including national education centers offering toolkits and CME)
can reduce the burden on any single institution.

5) Teach SOGI data collection and quality improvement as mainstream medicine

Collecting sexual orientation and gender identity data in the EHR can help clinics detect disparities in preventive screenings
and other services. Training students to document and use SOGI data appropriately is not “political”it’s the clinical
equivalent of knowing allergies and medications: essential context for safe care.

6) Improve the learning environment (because students learn culture, not just content)

Institutional climate matters. If LGBTQ students feel unsafe, if patients are treated like teaching props, or if discriminatory
comments go unchecked, the educational mission fails. Health systems and accreditation-focused organizations have long
emphasized patient-centered communication, cultural competence, and non-discrimination as core to quality care.

7) Measure outcomes (otherwise the “improvement” is imaginary)

Ask: Can students take an inclusive sexual history? Can they recommend appropriate screening? Can they document SOGI respectfully?
Can they identify bias and respond professionally? If the answers aren’t tested, schools can’t tell whether training is working.

Examples of momentum (proof it’s doable)

Several schools have published practical approaches to reform, including systematic curriculum review methods that compare
existing teaching against established competency lists and then implement targeted fixes. Others have piloted integration projects
and created replicable modules. The common thread is not perfectionit’s iteration, measurement, and institutional support.

Bottom line: the problem isn’t “lack of kindness”it’s lack of training

Most clinicians want to do right by their patients. But wanting is not the same as knowing. When LGBTQ health education is
minimal, inconsistent, or stereotyped, the system produces graduates who are forced to learn on patients in real timeand
patients can feel that improvisation.

The good news is that solutions are known: competency frameworks, integrated teaching, standardized patient practice,
faculty development, SOGI-informed quality improvement, and accountability through assessment. In other words:
teach it like it mattersbecause it does.

Experiences from classrooms and clinics (extra 500+ words)

The most revealing stories about inadequate LGBTQ medical education tend to sound boring at firstbecause they happen
in ordinary clinics on ordinary days. That’s the point. The gap is not limited to rare subspecialty scenarios. It shows up in
basic primary care, routine OB/GYN visits, and the “simple” intake questions that set the tone for everything that follows.

Experience 1: The intake form that starts a chain reaction

A third-year student sits in a family medicine clinic, watching the intake process. The form asks: “Male or Female.”
No space for pronouns. No place for sexual orientation. No “name used.” The studentwell-meaning and clinically diligent
walks into the room and says, “Hi, Ms. ___,” reading the chart. The patient quietly corrects them: “Actually, I go by Alex,
and I use they/them.” The student freezes for half a second, not because they’re rude, but because no one ever trained them
on what to do when the chart is wrong. They apologize, switch to “they,” and continue… but the rest of the visit feels tense.

Later, the preceptor says, “Don’t worry about all thatjust focus on the medical stuff.” The student learns a powerful,
unspoken lesson: identity is “extra,” and time spent getting it right is time stolen from “real medicine.” That’s hidden curriculum
in its natural habitat. Nobody is trying to be harmful, but the training environment quietly teaches that accuracy about a person’s
life is optional. And accuracy is the foundation of diagnosis.

Experience 2: “We didn’t cover that” meets “we need that today”

In an OB/GYN rotation, a student meets a transgender man who needs cervical cancer screening. The student knows the
technical steps of a Pap test, but not the communication steps: how to explain the exam in a way that reduces dysphoria,
how to ask consent using language that respects the patient’s body, how to check comfort, how to offer options like a support
person, breaks, or a different position. Nobody taught that in the pelvic exam workshop; the standardized patient scenarios
used gendered scripts and assumptions.

The student tries anyway. They speak carefully, ask permission, and keep the patient informed. The visit goes finebut the
student leaves with the uneasy feeling of having learned by improvisation. That’s a problem because improvisation doesn’t scale.
Next week, another student might do the same visit and accidentally say something like, “This will be easier for women,” or
“Are you sure you’re in the right clinic?” One sentence can undo trust that took years to build.

Experience 3: The “LGBTQ lecture” that doesn’t survive contact with reality

Many students can recall the day their school covered LGBTQ healthbecause it was a single day. It often arrives as a guest
lecture packed with terms, flags, and a sprint through disparities: higher depression rates, higher smoking rates, HIV burden,
barriers to care. Students take notes, nod, and feel enlightened. Then the next month, on internal medicine, they present a case:
“Forty-year-old male, homosexual…” and the attending stops them: “Don’t say that. Also, why does it matter?” The student
realizes they were never taught how to document sexual orientation clinically, when it’s relevant, and how to avoid turning
identity into a diagnosis.

The lesson students need is not “mention LGBTQ less.” It’s “mention it correctly.” Because sometimes it matters a lotlike
when discussing fertility goals, sexual health screening, PrEP, intimate partner violence, cancer screening, or mental health.
Other times it matters mainly for rapport and respect, which still matters because patients tell the truth more often when they
feel safe. (Medical secret: accurate histories are a cheat code for better outcomes.)

These experiences are exactly why LGBTQ medical education needs to be built like other clinical competencies: repeated,
practiced, assessed, and reinforced in real clinical settingsnot dropped into the curriculum as a one-time cultural cameo.
When schools do that, learners stop feeling like they’re “walking on eggshells,” and patients stop feeling like they’re walking
into a clinic that wasn’t designed for them.

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