Protocols as curriculum? Learning health advocacy skills by working with transgender patients in the context of gender-affirming medicine

  • Kinnon R. MacKinnonEmail author
  • Stella L. Ng
  • Daniel Grace
  • Suzanne R. Sicchia
  • Lori E. Ross


Evidenced by leading journals in academic medicine, health professions education has taken up the call to advance equitable healthcare. One pressing area where gaps and inequities are apparent is transgender (trans) people’s access to gender-affirming medicine such as hormones and surgeries. Reasons for the dire state of care include education gaps. While specific content knowledge has been identified as lacking in medical school curricula, less research has focused on the complex social practices required of clinicians and educators working in gender-affirming medicine, and how these skills are learned through practice. In order to inform health professions education in this key area of need, we conducted a study to better understand the social practices, and the learning that occurs therein, of gender-affirming medicine. We identified the work processes of 22 clinicians, clinician-educators, trans patients, and clinical care administrators with attention to how policies and protocols influenced practice, learning, and teaching. The results of our study elucidate: (1) that practicing of gender-affirming medicine is strictly dictated by standardized assessment protocols, which serve as a form of curriculum; and (2) how health professionals learn and teach health advocacy as a form of resistance to protocols identified as creating inequities. These findings suggest an opportunity to view protocols—and their inherent limitations—more deliberately as teaching and learning tools, specifically for learning advocacy.


Health advocacy Health professions education Institutional ethnography Protocols Standards of care Transgender 



We thank Dr. Ayelet Kuper for reviewing and providing commentary on an earlier draft of this manuscript. We also extend gratitude to our reviewers, and to Dr. Geoffrey Norman, for providing extensive thoughtful feedback on our original submission within the peer-review process.


  1. Alberti, P. M., Sutton, K., Cooper, L. A., Lane, W. G., Stephens, S., & Gourdine, M. (2018). Communities, social justice, and academic health centers. Academic Medicine, 93(1), 20–24.CrossRefGoogle Scholar
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.CrossRefGoogle Scholar
  3. Asscheman, H., Giltay, E. J., Megans, J. A., de Ronde, W. P., van Trotsenburg, M. A., & Gooren, L. J. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 164(4), 635–642. Scholar
  4. Bauer, G. R., Scheim, A. I., Deutsch, M. B., & Massarella, C. (2014). Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Annals of Emergency Medicine, 63(6), 713–720.CrossRefGoogle Scholar
  5. Berg, M. (1997). Problems and promises of the protocol. Social Science and Medicine, 44(8), 1081–1088.CrossRefGoogle Scholar
  6. Bouman, W. P., Richards, C., Addinall, R. M., Arango de Montis, I., Arcelus, J., Duisin, D., et al. (2014). Yes and yes again: Are standards of care which require two referrals for genital reconstructive surgery ethical? Sexual and Relationship Therapy, 29(4), 377–389.CrossRefGoogle Scholar
  7. Bourgois, P., Holmes, S. M., Sue, K., & Quesada, J. (2017). Structural vulnerability: Operationalizing the concept to address health disparities in clinical care. Academic Medicine, 92(3), 299–307.CrossRefGoogle Scholar
  8. Budge, S. L. (2015). Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients. Psychotherapy, 52(3), 287–297.CrossRefGoogle Scholar
  9. Cavanaugh, T., Hopwood, R., & Lambert, C. (2016). Informed consent in the medical care of transgender and gender-nonconforming patients. AMA Journal of Ethics, 18(11), 1147–1155.CrossRefGoogle Scholar
  10. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232.CrossRefGoogle Scholar
  11. Costa, R., & Colizzi, M. (2016). The effects of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: A systematic review. Neuropsychiatric Disease and Treatment, 12, 1953–1966.CrossRefGoogle Scholar
  12. Coutin, A., Wright, S., Li, C., & Fung, R. (2018). Missed opportunities: Are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents. Canadian Medical Education Journal, 9(3), e41–e55.Google Scholar
  13. Deutsch, M. B. (2012). Use of the informed consent model in the provision of cross-sex hormone therapy: A survey of the practices of selected clinics. International Journal of Transgenderism, 13(3), 140–146.CrossRefGoogle Scholar
  14. Dewey, J. M. (2013). Challenges of implementing collaborative models of decision making with trans-identified patients. Health Expectations, 18, 1508–1518.CrossRefGoogle Scholar
  15. Dobson, S., Voyer, Stephane, & Reghr, G. (2012). Perspective: Agency and activism: Rethinkinghealth advocacy in the medical profession. Academic Medicine, 87(9), 1161–1164. Scholar
  16. Dowshen, N., Nguyen, G. T., Gilbert, K., Feiler, A., & Margo, K. L. (2014). Improving transgender health education for future doctors. American Journal of Public Health, 104(7), e5–e6.CrossRefGoogle Scholar
  17. Ehrbar, R. D., & Gorton, R. N. (2010). Exploring provider treatment models in interpreting the standards of care. International Journal of Transgenderism, 12(4), 198–210.CrossRefGoogle Scholar
  18. Giffort, D. M., & Underman, K. (2016). The relationship between medical education and trans health disparities: A call to research. Sociology Compass, 10, 999–1013.CrossRefGoogle Scholar
  19. Grace, D. (2013). Transnational institutional ethnography: Tracing text and talk beyond state boundaries. International Journal of Qualitative Methods, 12, 587–605.CrossRefGoogle Scholar
  20. Hubinette, M., Dobson, S., Scott, I., & Sherbino, J. (2017). Health advocacy. Medical Teacher, 39(2), 128–135.CrossRefGoogle Scholar
  21. Jaffee, K. D., Shires, D. A., & Stroumsa, D. (2016). Discrimination and delayed health care among transgender women and men: Implications for improving medical education and health care delivery. Medical Care, 54(11), 1010–1016.CrossRefGoogle Scholar
  22. Kosenko, K., Rintamaki, L., Raney, S., & Maness, K. (2013). Transgender patient perceptions of stigma in healthcare contexts. Medical Care, 51(9), 819–822.CrossRefGoogle Scholar
  23. MacKinnon, K. R. (2018). Pathologising trans people: Exploring the roles of patients and medical personnel. Theory in Action, 11(4), 74–96.CrossRefGoogle Scholar
  24. LaDonna, K. A., Field, E., Watling, C., Lingard, L., Haddara, W., & Cristancho, S. M. (2018). Navigating complexity in team-based clinical settings. Medical Education, 52(11), 1125–1137. Scholar
  25. Martimianakis, M. A., & Hafferty, F. W. (2016). Exploring the interstitial space between the ideal and the practiced: Humanism and the hidden curriculum of system reform. Medical Education, 50(3), 278–280.CrossRefGoogle Scholar
  26. Martin, D., Hum, S., Han, M., & Whitehead, C. (2013). Laying the foundation: Teaching policyand advocacy to medical trainees. Medical Teacher, 35, 352–358. Scholar
  27. Moffett, P., & Moore, G. (2011). The standard of care: Legal history and definitions: The bad and good news. Western Journal of Emergency Medicine, 12(1), 109–112.Google Scholar
  28. Mykhalovskiy, E., & Farrell, K. (2005). ‘Nothing happens in medical school that prepares you for working with anyone who’s different’: Informal learning and socio-clinical knowledge amongst family physicians. Research in the Sociology of Healthcare, 23, 159–181.CrossRefGoogle Scholar
  29. Ng, S. L., Bisaillon, L., & Webster, F. (2017). Blurring the boundaries: Using institutional ethnography to inquire into health professions education and practice. Medical Education, 51, 51–60.CrossRefGoogle Scholar
  30. Ng, S. L., Kinsella, E. A., Friesen, F., & Hodges, B. (2015). Reclaiming a theoretical orientation to reflection in medical education research: A critical narrative review. Medical Education in Review, 49, 461–475.CrossRefGoogle Scholar
  31. Parker, D. L., & Lawton, R. (2000). Judging the use of clinical protocols by fellow professionals. Social Science and Medicine, 51, 669–677.CrossRefGoogle Scholar
  32. Patel, M. S., Davis, M. M., & Lypson, M. L. (2011). Advancing medical education by teaching health policy. The New England Journal of Medicine, 364(8), 695–697.CrossRefGoogle Scholar
  33. Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685–695.CrossRefGoogle Scholar
  34. Sharma, M., Pinto, A. D., & Kumagai, A. K. (2018). Teaching the social determinants of health: A path to equity or a road to nowhere? Academic Medicine, 93(1), 25–30.CrossRefGoogle Scholar
  35. Shiau, S. J., & Chen, C. H. (2008). Reflection and critical thinking of humanistic care in medical education. Kaohsiung Journal of Medical Science, 24, 367–372.CrossRefGoogle Scholar
  36. Shuster, S. M. (2016). Uncertain expertise and the limitations of clinical guidelines in transgender healthcare. Journal of Health and Social Behavior, 57(3), 319–332.CrossRefGoogle Scholar
  37. Smith, G. W. (1990). Political activist as ethnographer. Social Problems, 37(4), 629–648.CrossRefGoogle Scholar
  38. Smith, D. E. (1999). Writing the social: Critique, theory, and investigations. Toronto: University of Toronto Press.Google Scholar
  39. Smith, D. E. (2005). Institutional ethnography: A sociology for the people. Oxford: Rowman Altamira.Google Scholar
  40. Snelgrove, J. W., Jasudavius, A. M., Rowe, B. W., Head, E. M., & Bauer, G. R. (2012). “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research, 12(10), 110.CrossRefGoogle Scholar
  41. Tomita, K. K., Testa, R. J., & Balsam, K. F. (2018). Gender-affirming medical interventions and mental health in transgender adults. Psychology of Sexual Orientation and Gender Diversity, 6(2), 182–193. Scholar
  42. Turner, S. M. (2006). Mapping institutions as work and texts. In D. E. Smith (Ed.), Institutional ethnography as practice (pp. 139–161). Lanham, MD: Rowman & Littlefield.Google Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  2. 2.The Wilson Centre, Faculty of Medicine at University Health NetworkUniversity of TorontoTorontoCanada

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