A Curricular Audit Method: Addressing the Erasure of Intersex, Trans and Two-Spirit People and the Imprecise Use of Gender and Sex Concepts in Undergraduate Medical Education

Abstract

Phenomenon: Intersex, trans, and Two-Spirit people report overwhelmingly negative experiences with health care providers, including having to educate their providers, delaying, foregoing, and discontinuing care due to discrimination and being denied care. Medical education is a critical site of intervention for improving the health and health care experiences of these patients. Medical research studies, clinical guidelines, textbooks, and medical education generally, assumes that patients will be white, endosex, and cisgender; gender and sex concepts are also frequently misused. Approach: We developed and piloted an audit framework and associated tools to assess the quantity and quality of medical education related to gender and sex concepts, as well as physician training and preparedness to meet the needs of intersex, trans, and Two-Spirit patients. We piloted our framework and tools at a single Canadian medical school, the University of British Columbia, focused on their undergraduate MD program. We were interested in assessing the extent to which endosexnormativity, cisnormativity, transnormativity, and the coloniality of gender were informing the curriculum. In this paper, we detail our audit development process, including the role of advisory committees, student focus groups, and expert consultation interviews. We also detail the 3-pronged audit method, and include full-length versions of the student survey, faculty survey, and purpose-built audit question list. Findings: We reflect on the strengths, limits, and challenges of our audit, to inform the uptake and adaptation of this approach by other institutions. We detail our strategy for managing the volume of curricular content, discuss the role of expertise, identify a section of the student survey that needs to be reworked, and look ahead to the vital task of curricular reform and recommendations implementation. Insights: Our findings suggest that curricular audits focused on these populations are lacking but imperative for improving the health of all patients. We detail how enhancing curriculum in these areas, including by adding content about intersex, trans, and Two-Spirit people, and by using gender and sex concepts more accurately, precisely and inclusively, is in line with the CanMEDS competencies, the Medical Council of Canada’s Objectives for the Qualifying Examinations, many institutions’ stated values of equity, inclusion and diversity, and physicians’ ethical, legal and professional obligations.