Table 2 Studies results and conclusions

Arora, 2019⁵⁰

5-points Likert scale or as ‘true’ or ‘false’ to categorical statements. Pre/ Post session

3rd year medical students, n = 79

‘Agreed or strongly agreed’ - Pre/Post, p value - A FEMALE patient reports identifying as MALE since adolescence and requests hormonal therapy’ − 11%/ 33%, p = 0.001 ‘A 13-year-old patient who has entered puberty reports identifying with a sex different to that assigned at birth and requests help with transition’ − 14%/ 35%, p = 0.001; ‘A 55-year-old MALE to FEMALE patient who has been treated with hormones but has not undergone sex reassignment surgery should be offered prostate cancer screening’ − 68%/ 88%, p = 0.007; ‘I believe that hormonal and/or surgical therapies are appropriate for most transgender patients and should be provided to those patients who request them’- 49%/ 75%, p = 0.004.

Following the intervention, significantly more students felt confident to facilitate transgender health care for adults, adolescents, and children; and more students agreed that medical and surgical treatment should be offered to transgender patients if desired.

10.5

Berenson, 2020⁵¹

Satisfaction levels with the module. Self-Perceived Confidence; 5-point Likert scale. Pre/ Post session

2nd year medical students; n = 123

Pre/Post mean (1 to 5): Describe the unique health issues and disparities experienced by TG 1.6/ 2.8, p < 0.001; Describe medical transitioning and hormonal therapies for TG 1.1/ 2.5, p < 0.001; Describe best practices for promoting culturally competent and affirming care for TG 1.5 to 2.9, p < 0.001.

This multimodal approach using didactic sessions, video-based small-group case discussions, and patient panels were correlated with a significant increase in confidence regarding care for the transgender community.

10

Bi, 2020⁵²

The 5-point Likert “1-not at all confident” to “5-completely confident”, self-assessed in knowledge of SGM patients’ barriers, intersectionality, and communication. Pre/ Post session

1st year medical students, n = 82

(#) Define the terms sex, gender, sexual orientation, gender identity, and expression 4.2(0.66)/ 4.5(0.55), p = 0.02; Define intersectionality 3.5(1.21)/4.4(0.61), p < 0.001; Define minority stress 3.5(0.98)/ 4.6(0.55), p < 0.001; Identify barriers to care for LGBTQ patients. 3.5 (0.91)/ 4.2 (0.60), p < 0.001. Ask LGBTQ patients about their identities. 2.9(1.09)/ 4.0(0.73), p < 0.001.

Our teaching module on intersectionality improved students’ knowledge of and confidence in caring for diverse patients.

10.5

Click, 2019⁵³

9-item multiple choice and true or false knowledge questions. Comfort and attitude answer choices were based on a 5-point Likert-type scale, (1 = strongly disagree, 5 = strongly agree). Pre/ Post session

1st /2nd -year medical students, n = 138

(#) I am comfortable interacting with transgender people 3.81(0.92)/ 4.14(0.70), p < 0.01; I am comfortable with my knowledge base in providing care to the transgender population 2.4(0.83)/ 3.70(0.63), p < 0.01; I prefer not to treat transgender or gender non-conforming patients in my future practice 1.86(0.93)/ 1.73(0.92), p < 0.01

This study shows a significant effect of participating in a student-led half-day educational intervention on many facets of medical students’ attitudes and knowledge about transgender patients.

11

Cooper, 2018⁵⁴

Ability to complete each of the lecture objectives, on a 10-point scale (1 = low, 10 = high). Pre/ Post session

3rd year medical students, n = 63

(#) Describe the unique health risks often encountered by LGBT and gender-diverse patients 5.8 (3.2)/ 8.1 (3.2), p < 0.01; Explain how stages of physical and identity development across the life span affect LGBT and gender-diverse patients 5.1 (4)/ 7.7 (3.2), p < 0.01; Describe factors that may underlie health care disparities experienced by LGBT and gender-diverse patients 5.0 (4)/ 7.9 (3.2), p < 0.01.

The didactic lecture was able to increase students’ knowledge of how social determinants impact the health of LGBT patients. The lecture can be incorporated into a longitudinal curriculum on LGBT health.

9.5

Dale, 2022⁵⁵

A 6question survey selfassessed knowledge and comfort with transgender issues; 5point Likert scale, where 1 was strongly disagree and 5 was strongly agree. Pre/ Post session.

1st to final year medical students; n = 22

(#) I am comfortable with my understanding about TG 3.67(1.03)/ 4.39(1.20), p < 0.05; I am familiar with the issues faced in medicine by TG 2.44(1.25)/ 3.56(1.25), p < 0.05; I need more teaching on gender and TG issues 4.22(1.35)/ 3.89(1.23), p > 0.05; I have enough knowledge to feel comfortable seeing TG as a patient for a nongender related issue 3.17(1.50)/ 4.00(1.24), p > 0.05; I have enough knowledge to feel comfortable seeing TG as a patient for a gender related issue 2.17(1.47)/ 3.22 1.26), p < 0.05

Our study showed that an education session can increase medical students’ understanding of, and comfort at interacting professionally with transgender patients.

11

Gavzy, 2019⁵⁶

Confidence in addressing each of the learning objectives. 1 to 4 points scale. Pre/ Post session

1st year medical students, n = 178

Evaluation of Self-Perceived Confidence in Define/compare terms 2.78/3.59, p < 0.001; Describe unique health issues/disparities 2.34/3.34, p < 0.001; Develop better practices 2.24/ 3.42, p < 0.001.

This workshop was effective in helping 1st-year medical students appreciate the spectrum of sexual diversity, health issues facing LGBT individuals, and better practices to promote affirming care.

10.5

Lee, 2020⁵⁷

GTS 7-point Likert scale (1 strongly agree to 7 strongly disagree). Pre/ 4 weeks after the session

2nd -year medical students, n = 49

(#) GTS 92.35(24.52)/ 85.69 (23.73); Higher scores reflect more positive attitudes.

Although there was no significant attitude change after the lecture, those who had previous LGBT related education showed significantly positive attitudes at pre/postintervention surveys than those without.

10

Lee, 2022⁵⁸

Survey assessing the impact of the teaching on the knowledge of and comfort in dealing with transgender health issues. Pre/ Post session

Final year medical students n = 57

Pre-lecture reported good understanding/ post-lecture - better understanding - what TG means − 80%/79%; Healthcare issues unique to TG − 10%/95%; Role of gynaecology in the care of TG patients – 18%/93%. Comfortable with history taking from a TG patient – 66%/Increased confidence − 91%.

Our results demonstrate that one-hour teaching session was effective at significantly improving students’ knowledge of and comfort with the healthcare needs of transgender people.

9.5

Levy, 2021⁵⁹

17-item attitude, knowledge, confidence regarding senior LGBT individuals’ health status and healthcare. 5-point Likert scale: ‘strongly disagree’ to ‘strongly agree’. Pre/ Post session

1st -year medical students, n = 38

(#) I am confident in my knowledge about… ‘the barriers to health faced by LGBTQ + individuals’ 3.21(1.02)/ 4.05(0.66),p < 0.001); ‘the unique health issues for LGBTQ + individuals’ 3.16(1.00)/ 4.05(0.77),p < 0.001; ‘good practices for promoting competent care for LGBT individuals’ 3.34(1.02)/ 4.21(0.74), p < 0.001); ‘inappropriate practices that prevent competent care for LGBT individuals’ 3.21(1.04)/ 4.16(0.72),p < 0.001.

Our study data demonstrate the effectiveness of the small group, case-based discussion approach involving members of the LGBT community as facilitators to enhance the cultural competency of the medical students

12

Mahabamunuge, 2021⁶⁵

Comfort discussing topics presented. 5-point rating scale as follows: “1 = very uncomfortable,” to “5 = very comfortable.” Pre/ Post session

All medical students 2018–20 (n = 152)

How comfortable are you talking to patients about issues related to sexuality? ‘Very confident’ - TG 29% [22, 36]/ 68%[59,77]; LGBT 49% [41, 57]/ 84%[77,91]; How comfortable are you discussing with patients? Medical Transition 22% [15, 28]/ 57% [48, 67].

Our findings demonstrate that student-initiated lecture series can improve medical student comfort discussing sensitive topics related to gender and sexual health.

8.5

Minturn, 2021⁶¹

4-point Likert scale on confidence and acquisition of knowledge related to LGBTQ health or true/false questions. Pre/ Post session

2nd year medical students, n = 42

(#) Sex anatomy and gender identity 2.41(1.1)/ 3.46(1.1), p < 0.01; Articulate health needs for LGB patients 2.22(1.2)/3.56(1.1),p 0 < 0.01; Articulate health needs for transgender patients 2.00(1.2)/3.50(1), p < 0.01; Culturally sensitive terminology 73%/ 90%, p = 0.036; Gender-affirming hormone therapy 51%/75%, p = 0.096; LGBT-related health risks 31%/ 43%, p = 0.999; Barriers to accessing care 40%(25-55%)/ 33%(18-47%), p = 0.999.

Our 10-hour LGBTQ health curriculum was effective at improving medical students’ self-confidence in working with LGBTQ patients but was less effective at increasing LGBTQ-related medical knowledge.

11

Najor, 2020⁶²

A 21-question online survey, on the comfort level with treating TG patients and personal beliefs and experiences. Pre/ 1 week after the session (and 1 year after)

1st year medical students, n = 86

Students who were comfortable pre/post session: caring for TG 76%/ 91%, p = 0.0073; Aware that TG have unique health risks and health 99%/ 89%, p = 0.0043; Correctly identify a definition of gender 57%/ 67%, p = 0.19; Recognize the disproportionate burden of illness and socially determined barriers to health in TG 91%/ 96%, p = 0.21; Recognize that LGBT + status independently predicts less access to health care 97%/ 97%, p = 0.82.

1-hour lecture can increase the proportion of medical students who demonstrate positive attitudes and correct knowledge on TG patient care for at least a year.

10.5

Norwood, 2022⁶³

5-items survey on the training on TG health and healthcare. 5point Likert scale, where 1 was strongly disagree and 5 was strongly agree. Two true/false questions. Pre/ Post session

2nd /3rd years medical students, n = 44

(#) Gender identity and using pronouns with gender-diverse patients − 2.92(0.84)/ 3.19(0.82), p = 0.048; Discussing sexual practices with gender-diverse patients − 2.78(0.76)/ 3.00(0.83), p = 0.103; 2.86 Define differences between sex and gender; gender expression and identity − 2.89 (0.75)/ 3.22 (0.83), p = 0.026; Identify and address communication patterns that adversely affect the care of gender-diverse patients − 2.69 (0.79)/ 3.17 (0.81), p < 0.001

Our data suggest that stand-alone educational interventions developed in collaboration with TG patient that include direct interaction improved soft skills and provide a needed forum for students to ask questions and dialogue.

11

Pathoulas, 2021⁶⁴

Surveys addressing self-perceived preparedness and comfort with learning objectives using a 5-point Likert scale. Pre/ Post session

2nd -year medical students, n = 263

(#) I am familiar with how to use a dosing guide in gender-affirming hormone care 1.0(0.14)/ 3.5 (0.16), p < 0.001; I am familiar with different medication options in gender-affirming hormone care 1.5 (0.17)/ 3.8 (0.11), p > 0.001; I feel confident that I could find resources to provide gender-affirming hormone care 2.5 (0.19)/ 4.1 (0.11), p < 0.001; I am familiar with the idea of gender-affirming hormone care in a primary care setting. 2.9 (0.21)/ 4.3 (0.09), p < 0.001.

1-hour interactive lecture on GAHT increases medical students’ perceived familiarity and comfort with gender-affirming care in the primary care setting.

10.5

Sanchez, 2022⁴⁴

CSUN - Attitudes Toward LGBTQ issues (20 questions). 5-point Likert scale (1 - strongly agree to 5 - strongly disagree). Pre/ 48 h after the lecture

1st -year medical students, n = 103

(#) Comfort with LGBTQI + Patient Interactions: Gay men 4.44(0.82)/ 4.35(0.96), p = 0.38; Lesbian women 4.34(0.88)/ 4.36(0.91), p = 0.84; Female-to-male TG 3.57(1.22)/ 3.73(1.15), p = 0.23; Male-to-female TG 3.56(1.18)/ 3.74(1.18),p = 0.17; One is born homosexual, straight, or bisexual 3.38 (1.13) / 3.49 (1.15), p = 0.32; Homosexual people cannot become heterosexual 3.66(1.04)/ 3.55(1.14), p = 0.24; One is born transgender 3.14(1.13)/3.39(1.07), p = 0.006; Gender and Sexuality − 3.32 (0.77)/ 3.43 (0.86), p = 0.05.

The findings support the incorporation of LGBTQI + instruction into medical curricula and suggest that educators may consider consulting pre-intervention data before teaching LGBTQI + health content.

10.5

Silverberg, 2021⁴⁵

Likert scale survey addressing improved confidence in solicitation of a social history and negotiation of pronouns with transgender patients. Pre/ Post session

2nd year medical students n = 126

92.2% of students agreed that they felt more confident using their patient’s identified pronouns, with 67.4% asserting strong agreement. 95.4% of students agreed that that they felt more confident soliciting sexual history. In total, 95.4% of students indicated improved confidence with the overall experience of taking a history from a TG patient.

Students felt more confident using their patient’s identified pronouns and improved global confidence.

10.5

Stumbar, 2018⁴⁶

Comfort with and beliefs about various aspects of sexual and reproductive health. Likert-type questions. A positive rank is any change on the scale that results in an increase in score. Pre/ Post session

1st /2nd -year medical students, n = 90

Ranked Students’ Responses- Positive/ Negative Mean Rank, p - I feel comfortable discussing a patient’s sexual history as it relates to issues of gender development and identity 25.0/ 21.4, p < 0.001; I feel comfortable treating people with a different sexual orientation than my own 14.6/12.6, p = 0.025; I feel comfortable treating people with a transgender identity 19.7/18.6, p < 0.001; LGBTQ + people face unique health concerns compared to heterosexual and cis-gender people 21.2/15.1, p = 0.129.

This instructional format provided an effective way to teach medical students about the social determinants of sexual and reproductive health. Students reported increased comfort and confidence related to the subject matter.

10.5

Taylor, 2018⁴⁷

Short questionnaire scale 1–4 (1 being the lowest level of competency and 4 being the highest). Pre/ Post session

2nd year medical students, from 2012-15, n = 350

How prepared students felt to consult with LGBT patient − 69% of the students rated themselves at a competency level of 1 or 2 before the workshop, and after the workshop went on to rate themselves as a competency level of 3 or 4.

The sessions are useful for students in terms of improving awareness of health inequalities and enabling consultation skills practice in an informal environment.

6.5

Thompson, 2019⁴⁸

A gender identity-adapted version of the SOPCS. 5-point Likert (1 = strongly agree, 5 = strongly disagree). Pre/ Post session

2nd year medical students, n = 129

(#) Total scale score 93.31(10.34)/ 103.31 (12.76), p < 0.001; Skills subscale − 18.87 (4.59)/ 27.38 (4.53), p < 0.001; Negative attitudes subscale − 14.54 (6.70)/ 15.38 (8.58), p > = 0.001; Knowledge subscale 28.98 (4.30)/ 31.31 (4.71), p < 0.001.

The curriculum improved students’ gender-affirming medical competency, knowledge, and skills. The development of a sustained, longitudinal curriculum is recommended in addition to the continuing education.

11

Wahlen, 2020⁴⁹

Questionnaire − 28 statements; Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). ATHQ, SEKHQ, LGBT assessment scale, GTS. Pre/ One month following the course.

4th -year medical students; n = 117

(#) Attitudes 84.8 (13.6)/86.8 (15.4), p < 0.001; Knowledge 73.7 (18.1) / 87.9 (15.7), p < 0.001; Judgement 69.8 (16.5)/ 74.4 (18.8), p = 0.01; Experience 77.0 (16.5)/ 82.6 (16.8), p = 0.002

Our study suggests that even a 1-hour lecture can improve students’ knowledge about LGBT health needs.

10.5

Zheng, 2022⁴³

Questionnaire - confidence discussing specific topics (0 to 100). Attitudes and beliefs 5- or 7-point Likert scale (1 = not at all comfortable or strongly disagree, and 5 and 7 = extremely comfortable or strongly agree). Pre/ Post session.

1st -year medical students; n = 33

(#) Knowledge 2.4 (1.6)/ 5.0 (1), p < 0.001; Gender identity 50.6(16)/ 70.9(16), p < 0.001; Hormone therapy 22.7(10)/ 58.1 (10), p < 0.001; Trans patients deserve the same level of care as cis patients 6.5(1)/ 6.8(0.7), p > 0.05; Comfortable being known among patients as clinician who treats trans patients 4.6 (0.7)/ 4.7 (0.7), p > 0.05

This 2-hour session encouraged students to actively discuss trans health care with one another. The cooperative learning was effective at disseminating knowledge and creating an enjoyable experience.

10