Enhanced Skills Program: LGBTQ Health Program Goals and Objectives

Medical Expert

At the end of the program, the resident will be able to:

1. Recognize the importance of a patient’s sexual orientation, gender identity, and sexual practices in their primary care and overall medical management.

Describe the differences between gender identity, gender expression, sexual orientation, and biological sex, and recognize that these parameters occur on a spectrum within the human population
Demonstrate an understanding of the culture and language of LGBTQ communities and why this knowledge is essential in providing optimal primary care to members of this population
Demonstrate an understanding of the barriers to the delivery of optimal primary care to the LGBTQ population in Canada o Describe the specific health disparities experienced by the LGBTQ population and understand the mechanisms by which these disparities occur
Describe the factors that influence the decision by LGBTQ patients to disclose their orientation/identity to healthcare professionals
Demonstrate an understanding of how cultural factors may impact on a patient’s self-identity
Describe the ways that homophobia, heterosexism, transphobia, and cissexism can adversely affect the development of a therapeutic patientprovider alliance
Define intersectionality and describe how it relates to the health and wellness of LGBTQ patients who belong to multiple minority groups
Describe the differences in incidence and prevalence of common and serious illnesses amongst members of the LGBTQ community

2. Apply knowledge of the clinical, socio-behavioral, and fundamental biomedical sciences relevant to LGBTQ health.

2.1. Transgender/Non-binary (NB) Primary Care

Perform an appropriate and culturally sensitive general medical history with transgender/NB patients
Perform an appropriate and culturally sensitive gender history in patients presenting with gender-related concerns
Perform an appropriate and culturally sensitive physical examination of transgender/NB patients
Demonstrate knowledge of evidence and expert opinion regarding cancer risk and cancer screening recommendations in transgender/NB populations based on hormonal and surgical status
Perform an internal visual examination of the neovagina, and accurately identify the post-operative location of the urethral meatus
Perform digital-vaginal examination of the prostate in post-operative transwomen
Perform a culturally sensitive pelvic examination of transmen/trans masculine patients
Identify unexplained vaginal bleeding in a transman/trans masculine patient as malignancy until proven otherwise and initiate appropriate investigations and referrals as needed
Interpret the results of bone mineral density testing and identify indications for bisphosphonate treatment in transgender/NB patients
Identify strategies that may be used to adapt the Framingham risk calculator in estimating cardiovascular risk in transgender patients
Identify indications for ASA prophylaxis in transgender/NB patients
Identify unique considerations for STI screening and treatment in transgender/NB patients
Recommend vaccinations specific to a trans patient’s risk factors and identify the criteria for public funding of Hepatitis A, Hepatitis B, and HPV vaccines

2.2. Cross-sex Hormone Therapy

Review the physiologic functioning and feedback loops within the hypothalamic-pituitary-gonadal axis
Demonstrate knowledge of the criteria for cross-sex hormone therapy according to current World Professional Association for Transgender Health (WPATH) standards of care
Discuss the approaches of ‘informed consent’ versus the evaluation of ‘eligibility and readiness’ as they apply to the initiation of hormone therapy o Consistently utilize collaborative decision-making that fosters rapport in the therapeutic relationship with patients seeking hormone therapy
Identify the initiation of hormone therapy as an opportunity to reduce high-risk behaviours and encourage positive lifestyle changes
Complete a full assessment, including gender history, focused physical exam, and appropriate investigations in a patient seeking hormone therapy
Assist the patient in optimizing preparedness and social supports prior to the initiation of hormone therapy, and provide ongoing support throughout the transition process
Select an appropriate route of hormone administration based on patient preference, risk factors, pre-existing medical conditions, and financial means/funding
Demonstrate comfort and confidence with the initiation of hormone therapy in transgender/NB patients
Demonstrate knowledge of monitoring parameters and identify indications for dose adjustments in the ongoing care of patients on hormone therapy
Summarize the existing knowledge of the effects of cross-sex hormones on cardiovascular risk and contributing risk factors, counsel patients on preventative measures, order appropriate monitoring investigations, and manage these risk factors when indicated
Summarize the existing knowledge of the effects of cross-sex hormones on bone mineral density, counsel patients on measures to counteract bone loss, and order bone mineral density testing as indicated
Summarize the existing knowledge of the effects of cross-sex hormones on VTE risk, counsel patients on preventative measures as well as warning signs and symptoms
Support patients for whom hormone therapy is contraindicated in exploring nonpharmacologic means of aligning their gender presentation with their felt gender

Feminizing Regimens

Discuss the options for androgen blockade and their respective side effects, risks, and monitoring parameters, as well as a timeline of expected physiologic changes
List the absolute and relative contraindications for the available methods of androgen blockade
Demonstrate knowledge and counsel patients appropriately regarding treatment with exogenous estrogen, including timeline of expected therapeutic effects, potential unwanted side effects, risks, and monitoring parameters
Discuss the options for estrogen formulations and routes of administration, as well as their respective benefits and risk profiles
List the absolute and relative contraindications to estrogen therapy
Interpret serum hormone levels and apply these results to recommend dose adjustments that are aligned with patient goals for therapy
Monitor for and effectively manage side effects and complications arising from feminizing hormone therapy, including fatigue, sexual dysfunction, hyperprolactinemia, and elevated thromboembolic risk
Demonstrate knowledge and counsel patients appropriately regarding the use of progesterone as part of a feminizing hormone regimen

Masculinizing Regimens

Recognize and offer, when appropriate, the option for therapeutic cessation of menses in the absence of masculinizing therapy
Discuss the options for testosterone formulations and routes of administration, as well as their respective benefits and risk profiles
List the relative and absolute contraindications to testosterone therapy
Demonstrate knowledge and counsel patients appropriately regarding treatment with exogenous testosterone, including timeline of expected therapeutic effects, potential unwanted side effects, risks, and monitoring parameters
Interpret serum hormone levels and apply these results to recommend dosing adjustments that are aligned with patient goals for therapy
Monitor for, and effectively manage, complications arising from masculinizing therapy, including acne, male-pattern baldness, dyspareunia/dryness, and polycythemia

2.3. Gender-affirming Surgeries

Demonstrate knowledge of the criteria for surgical treatments for Gender Dysphoria, according to the current version of the WPATH standards of care
Conduct all aspects of gender-affirming surgery planning (assessment, review of options, preparation, funding application, and referral) with a patient seeking surgical intervention(s) that are covered by provincial health programs
Consistently utilize collaborative decision-making that fosters rapport in the therapeutic relationship with patients seeking gender-affirming surgery
Identify pre-operative measures to optimize surgical outcomes for genderaffirming surgeries
Demonstrate an understanding of individual-level and systems-level barriers that make it difficult for some patients to access surgical interventions

Feminizing Surgeries

List the feminizing surgeries available for transwomen/trans feminine patients, and identify those that are covered by provincial health insurance
For each of the provincially-funded surgeries available for transwomen/trans feminine patients (see below), describe the procedure and its intended results, review techniques and options, list the common and serious side effects and complications, and describe the expected preand post-operative course (Breast augmentation, Orchiectomy/scrotectomy, Penectomy, Vulvoplasty, Vaginoplasty)
Diagnose and manage post-operative complications arising from feminizing surgery that are within the scope of primary care (including but not limited to wound infection, wound dehiscence, UTI, urinary retention, pain with dilation/penetration, vaginitis)

Procedure-Specific Objectives: Vaginoplasty

Describe in detail the steps in the surgical process of penile inversion vaginoplasty (as performed in Canada) and demonstrate knowledge of the tissue origins of all post-op genital structures
Counsel a patient on the technique and importance of post-operative neovaginal dilation
Use cauterization in the treatment of neovaginal granulation tissue and active hair follicles

Masculinizing Surgeries

List the masculinizing surgeries available for transmen/trans masculine patients, and identify those that are covered by provincial health insurance
For each of the provincially-funded surgeries available for transmen/trans masculine patients (see below), describe the procedure and its intended results, review techniques and options, list the common and serious side effects and complications, and describe the expected pre- and postoperative course (chest reconstruction, hysterectomy, bilateral salpingo-oophorectomy, scrotoplasty, mons resection, clitoral release, metoidioplasty, phalloplasty)
Diagnose and manage post-operative complications arising from masculinizing surgery that are within the scope of primary care (including but not limited to wound infection, seroma/hematoma, urinary tract infection, urinary retention, hypertrophic scarring, pain)

Procedure-Specific Objectives:

Chest Reconstruction - Provide direct wound care to patients who are post-op chest reconstruction including dressing and drain management - Differentiate normal post-operative healing of the nipple-areolar complex from nipple necrosis

Phalloplasty - Describe in detail the macro- and micro-surgical steps of forearm flap phalloplasty (as performed in Canada) and demonstrate knowledge of the tissue origins of all post-op genital structures

2.4 Fertility Medicine

Describe and interpret the parameters used to assess and predict fertility in both people with ova and people with sperm
Demonstrate knowledge of the pathophysiology, diagnosis, and management of common medical conditions that may affect fertility
Identify the options for cycle monitoring and effectively communicate the process for home- and clinic-based monitoring to patients
Interpret parameters measured during in-clinic cycle monitoring and synthesize this information with patient factors to determine treatment plans
Identify indications for, and select appropriate pharmacologic therapy in the treatment of infertility
Describe the procedural options available to assist reproduction and identify clinical scenarios in which these may be indicated
Counsel LGBTQ patients on their various options for starting a family as well as their respective risks and benefits, appropriate to a patient’s/family’s particular set of circumstances
Demonstrate a basic understanding of the legal issues regarding the use of donors and surrogates, and counsel patients to seek legal support when indicated
Demonstrate an awareness of the community resources available to support LGBTQ patients considering starting a family
Counsel patients on the options, process, and cost of preservation of gametes for those considering gender transition
Discuss common fertility-related ethical dilemmas faced by physicians and by patients
Perform intra-uterine insemination under supervision

2.5 Sexually Transmitted Infections (STIs)

Cite the unique epidemiological, physiological, and social factors that impact STI incidence and prevalence in members of the LGBTQ population
Counsel patients regarding STI risk reduction based on a patient’s anatomy and sexual behaviours in a culturally sensitive manner
Based on knowledge of patient and public health factors, select the most appropriate lab media, detection modality, and timing in relation to exposure for screening and diagnosis of gonorrhea, chlamydia, syphilis, herpes, Hepatitis A and B, and HIV
Select the appropriate therapeutic regimen for the treatment of gonorrhea, chlamydia, syphilis, herpes, and genital warts in a patient with or without concomitant HIV infection
Interpret and manage the results of treponemal and non-treponemal syphilis screening tests including sequential results of the RPR titer
Correctly diagnose, and perform cryotherapy as appropriate, for anogenital warts
Demonstrate an understanding of the epidemiology, pathophysiology and natural history of oncogenic HPV infection and related cellular changes o Discuss options for anal cancer screening, appraise the anal Pap smear as a screening tool, and demonstrate an understanding of the barriers and limitations to routine screening
Describe the procedure of an anal Pap smear and perform basic anoscopy
Discuss the indications and observe and describe the procedure for high resolution anoscopy
Demonstrate a basic understanding of the staging and treatment options for anal cancer

2.6 Children and Youth

Differences in Sexual Differentiation (DSDs)

Summarize the organogenesis of the reproductive system
Discuss the basic etiology, physiology, clinical features, diagnosis, treatment principles, and primary care considerations of DSDs, including androgen insensitivity syndrome, gonadal dysgenesis, 5-alpha-reductase deficiency, testosterone biosynthetic defects, and congenital adrenal hyperplasia
Identify ambiguous genitalia in the neonate and recognize the need to rule out life-threatening conditions (e.g. salt-losing CAH)
Provide appropriate psychological support and counseling of a patient and/or family members of a patient with DSD
Compare the viewpoints from the medical community and members of the intersex community on the practice of surgical revision for DSDs during infancy and childhood

Gender Non-Conformity and Dysphoria in Children

Describe the range of presentations of gender independence in childhood
List the diagnostic criteria for Gender Dysphoria in Childhood
Describe the mental health issues which can co-exist with gender nonconformity and Gender Dysphoria in Childhood, often due to stigma, social ostracization and bullying by peers
Support gender-independent children and their families in understanding and navigating gender variance, including exploration of the option and indications for social transition
Support parents to develop advocacy skills as an important part of safety planning in schools and other settings

Gender Dysphoria in Youth

Review and be able to identify the Tanner stages of pubertal development and describe the LHRH stimulation test to confirm the onset of central puberty
List the indications and contra-indications, as well as the advantages (i.e. reversibility) and disadvantages (i.e. insufficient penile growth for penile inversion vaginoplasty), of pubertal suppression
Describe the physical and psychological benefits of puberty suppression in youth with gender dysphoria
Discuss the impact of lack of parental support for hormonal treatments in youth
Discuss the pharmacologic options for menstrual suppression, partial and total hormone suppression in youth
List and describe the management of common side-effects of puberty suppression (e.g. hot flashes, injection site pain, sterile abscess)
List and counsel patients regarding the signs of sterile abscess
Describe the impact of GNRH analogs on bone growth and maturation and bone mineral density and counsel patients regarding the need to optimize calcium and vitamin D intake
List the baseline investigations indicated when considering puberty suppression with a GNRH analog
List the monitoring parameters for GnRH analogs including physical examination, bloodwork, and BMD
Discuss the factors impacting the decision of timing for the transition from puberty suppression to cross-sex hormones in adolescents, and list relevant the investigations to be done when considering this transition

2.7 Mental Health and Counseling Skills

Develop basic skills in supportive and cognitive behavioural therapy to aid the exploration of issues and coping skills development for patients dealing with complex issues that may present in relation to LGBTQ identities
Describe the psychological steps in the coming out process
Demonstrate an understanding of the impact of minority stress on LGBTQ patients and tailor health counseling appropriately to boost resilience and selfesteem
Describe interactions and associations between LGBTQ identities and depressive disorders, anxiety disorders, substance abuse disorders, risk-taking behaviours, eating disorders, domestic violence, and suicidality
Identify the barriers that LGBTQ patients face in accessing culturally competent treatment for mental health issues (e.g. pathologization of sexual orientation and gender identity, religion-based substance abuse treatment programs, gendersegregated inpatient treatment programs)
Summarize the potential impact of HIV infection on various aspects of mental health
Demonstrate an understanding of the importance of supportive family and community in mental health outcomes for LGBTQ patients
Discuss and explore, when appropriate, the potential impact of a patient’s LGBTQ identity on the illness experience

Trans and Non-binary-specific mental health

Conduct a mental health assessment of a patient presenting with gender concerns
Demonstrate an understanding of the process of gender identity development across the lifespan and the consolidation of gender identity
Apply the DSM-V criteria to make the diagnosis of Gender Dysphoria
Identify psychiatric disorders that may exist with Gender Dysphoria and assess the impact that these disorders may have on decisions related to hormone therapy and surgical interventions

2.8 HIV Medicine

Cite the unique epidemiological, physiological, and social factors that impact HIV incidence and prevalence in members of the LGBTQ population
Demonstrate understanding of the laboratory tests used in the diagnosis of HIV and their respective sensitivities and window periods
Perform an HIV point of care test with comprehensive pre-and post-test counseling
Perform a focused history and physical exam relevant to a patient presenting with initial HIV infection or follow-up visit
Interpret results of laboratory investigations including lymphocyte markers, HIV viral load, and genotype/resistance testing
Evaluate indications for the initiation of ARV therapy
Identify common adverse effects of ARV therapy and demonstrate knowledge of their management
Select appropriate ARV medications for the initiation of therapy and for modification of existing therapy
Demonstrate knowledge of the current recommendations for health promotion and preventative care for HIV positive patients (i.e. vaccinations, cancer screening, cardiovascular risk)
Identify opportunistic infections and demonstrate knowledge of their prevention/prophylaxis and management
Identify malignancies and other chronic complications related to HIV/AIDs o Identify and counsel patients appropriately regarding pre- and post-exposure HIV prophylaxis (PrEP/PEP), demonstrate comfort with the initiation and monitoring of treatment
Demonstrate knowledge of unique concerns in the management of HIV patients co-infected with Hepatitis B and/or Hepatitis C
Describe the complex relationships between HIV, stigma, psychosocial factors, and mental health

Communicator

At the end of the program, the resident will be able to:

Demonstrate awareness of and willingness to explore one’s own feelings and possible biases in regards to sexuality and gender, and recognize any personal reactions which may be detrimental to the physician-patient relationship
Consistently develop rapport with patients to promote respectful and affirming interpersonal exchanges
Exhibit effective communication skills, including verbal and written presentation of patient consultations with the respectful and culturally sensitive use of language to describe patients of diverse sexual orientation and gender identity
Demonstrate sensitivity in determining the constitution of a patient’s family and/or other main social supports, communicate well with a patient’s supports and encourage their involvement in shared decision making when appropriate
Sensitively manage the communication of patient information regarding sexual orientation and gender identity and demonstrate understanding of the consent requirements for communication with third party agents
Obtain informed consent, providing sufficient information regarding risks and benefits of treatment alternatives
Demonstrate skills in working with other providers and patients to overcome communication challenges, including anger, confusion, sensory or cognitive impairment, socio-economic or ethno-cultural differences

Collaborator

At the end of the program, the resident will be able to:

Demonstrate an understanding of the roles and specific expertise of endocrinologists, pediatricians, psychiatrists, urologists, gynecologists, plastic surgeons, infectious disease and other specialists in the care of LGBTQ patients
Consult with other professionals in a timely manner, when needed for optimal care of the patient
Actively involve appropriate members of a patient’s health care team, including allied health workers, in the assessment, planning, and provision of care
Collaborate with community agencies, when appropriate, to optimize patient care
Demonstrate ability to function as part of a multi-disciplinary health-care team by contributing to team effectiveness, managing differences, resolving conflict and asking for assistance appropriately when needed
Identify and implement strategies for safe handovers and transfer of accountability for ongoing patient care

Leader

At the end of the program, the resident will be able to:

Contribute to the improvement of LGBTQ health care delivery in teams, organizations, and systems o Assist a patient in accessing public health insurance funding for treatments related to gender transition
Assist a patient in accessing public funding for anti-retroviral medications
Demonstrate awareness of resources available to support LGBTQ patients
Demonstrate fiscally responsible allocation of government resources in support of patients’ needs
Set realistic priorities and use time effectively in order to optimize professional performance while balancing professional, personal and institutional commitments

Health Advocate

At the end of the program the resident will be able to:

Recognize special needs, impairments, disabilities, and resource limitations of patients o Identify and, when appropriate, inform patients of available specialized resources and community supports
Describe the scope of actions taken and progress made to date by organizations advocating for LGBTQ health
Advocate for optimal provision of care to individual LGBTQ patients
Advocate for unbiased and sensitive care of all LGBTQ patients by healthcare professionals
Encourage health care professional’s self-examination of biases that may affect the provision of optimal care, and self-evaluation of needs for change and adaptation
Advocate for the use of LGBTQ-inclusive intake forms, questionnaires, and other information-collecting tools in clinical practice and medical research

Scholar

At the end of the program, the resident will be able to:

Recognize the need for research in LGBTQ health and identify ways to advocate for the allocation of resources to fund such research
Apply lifelong self-directed learning skills to keep up-to-date on advancements in medical practice and enhance areas of professional competence
Appropriately apply evidence-based approaches and knowledge of the current literature to inform clinical decision-making
Critically appraise medical information and successfully integrate information from a variety of sources
Contribute to the creation, dissemination, and application of knowledge on LGBTQ health issues

Professional

At the end of the program, the resident will be able to:

Identify and appropriately respond to unique ethical issues arising in the care of the LGBTQ patient
Respect personal/professional boundaries with patients, residents, and faculty
Demonstrate a commitment to excellence in clinical care and personal ethical conduct
Demonstrate insight into his/her/their limitations and respond appropriately to constructive feedback
Demonstrate a commitment to patients and their families, as well as to their profession, to the LGBTQ community and to broader society