Obstetrics and gynaecology

According to the American Board of Obstetrics and Gynecology (ABOG), which is responsible for issuing OB-GYN certifications in the United States, the first step to OB-GYN certification is completing medical school to receive an MD or DO degree.[1] From there doctors must complete a four-year OB-GYN residency program approved by the Accreditation Council for Graduate Medical Education (ACGME).[1][2] For the 2021 Electronic Residency Application Service (ERAS) match, there were 277 OB-GYN residency programs accepting applicants.[3]

In their fourth year of residency, with an affidavit from their director to confirm program completion, OB-GYN residents can choose whether to begin the board certification process by applying to take the ABOG Qualifying Exam, which is a written test.[4] If residents pass the Qualifying Exam, demonstrating they possess the knowledge and skills to potentially become certified OB-GYNs, they are then eligible to sit for the oral Certification Exam.[4] Prior to the Certification Exam, residents must also gather a list of patient cases they've worked on throughout their residency in order to demonstrate their competence and experience in OB-GYN patient care.[1]

Residents then sit for the three-hour oral exam at ABOG's test center, and if they pass the exam they become "board certified" OB-GYNs.[2] Since 2013 at least 82% of all Certifying Exam examinees have passed.[5]

This adds up to 11–14 years of education and practical experience. The first 7–9 years are general medical training.

Experienced OB-GYN professionals can seek certifications in sub-specialty areas, including maternal and fetal medicine. See Fellowship (medicine).

All doctors must first complete medical school and obtain a MBBS or equivalent certification.[6] This portion typically takes five years. Following this, they are eligible for provisional registration with the General Medical Council. They then must complete a two years of foundation training.[6][7] After the first year of training is complete, trainees are eligible for full registration with the General Medical Council.[6] After the foundation training is complete applicants take the Part 1 MRCOG examination[8] administered by the Royal College of Obstetricians and Gynaecologists. There are an additional seven years of training after this, and two more exams (Part 2 and Part 3 MRCOG exams) which adds up to nine years total minimum in training, although some trainees may take longer.[9]

Transgender, nonbinary people, and lesbian or bisexual women frequently face additional challenges—including structural and overt discrimination, accessing insurance coverage stigma, and cisnormativity—when attempting to access gynecologic and reproductive healthcare services and providers.[15] Obstetrics and gynecology is a field thought of as traditionally serving women because of its focus on the female reproductive system, leading care providers to make assumptions about patients' gender identity and expression in "women's health clinics" when many transgender or nonbinary patients may also seek care from OB-GYNs.[15] Additionally, LGBTQ+ patients are at risk for and experience unique health conditions which care providers may not be prepared to address—i.e. the providers lack cultural competence—without LGBTQ+ specific healthcare training.[15]

Interactions with care providers who are not prepared or knowledgeable enough to offer comprehensive and effective care can compound the "negative and traumatic experiences that many nonbinary and transgender people have had when accessing care", and drive them away from seeking necessary healthcare in the future.[15][16] Even if transgender or nonbinary patients have not had a personally negative of traumatic experience, collective trauma can also play into a fear of medical settings and providers.[15] This results in nearly 25% of transgender or nonbinary people reporting avoidance of healthcare services out of fear of being mistreated for their gender.[16] Care typically offered by OB-GYNs, like pelvic exams and procedures, can be "particularly difficult or traumatic" for transgender and nonbinary patients, which the provider can offset by engaging a trauma-informed care approach to exams.[15]

More research is gradually being done to establish the need for an LGBTQ+ healthcare curriculum for all medical students, residents, and doctors. Multiple researchers have also suggested that obstetrics & gynecology is the ideal field for this education to initially be implemented, since the nature of OB-GYN work ties it more directly to gender than other medical specialties.[15][17] OB-GYNs also historically have more cultural competency training around gender based issues.

Some common services LGBTQ+ folks may seek from OB-GYNs include:[18]

• Preventive services such as PAP smears
• Contraceptive counseling[15]
• Treatment for gynecologic conditions
• Support for family planning
• Risk/harm reduction
• Gender affirming surgeries like hysterectomies and oophorectomies[15]

If providers are not educated on LGBTQ+ healthcare they will not be aware of some of the health risks LGBTQ+ patients may be more vulnerable too, placing their patients at greater risk. Common chronic diseases the LGBTQ+ population is at risk for:[17]

• Chronic anovulation and polycystic ovarian syndrome
• Sexually transmitted infections including human papilloma virus (HPV) and human immunodeficiency virus (HIV) infections
• Intimate partner violence
• Substance abuse
• Cancer (anal, breast, cervical, colon, endometrial and oropharyngeal)

Most OB-GYN programs have a flexible curriculum that offers learning in a variety of contexts, including small group discussions, case study discussions, and structured patient exams.[17] The multifaceted nature of this teaching structure makes it easier for programs to begin initiating LGBTQ+ healthcare instruction in informal voluntary contexts, while simultaneously advocating for long-term structural change that would incorporate LGBTQ+ healthcare into all OB-GYN and medical school curricula.[17]

When initially instituting a LGBTQ+ healthcare curricula for OB-GYN residents or professionals, the Association of Professors of Gynecology and Obstetrics' (APGO) Undergraduate Medical Education Committee (UMEC) recommends that topics like patient education, screening standards, and common chronic diseases in the LGBTQ+ population are prioritized to ensure comprehensive and effective care for LGBTQ+ patients.[17]

APGO's UMCE poses that academic health centers are in an ideal position to drive the "curricular change that is needed to remove health disparities" for all patient populations in the LGBTQ+ community.[15]

Although not a requirement within the ACGME's standards for American OB-GYN residency programs curriculum, LGBTQ+ healthcare education is established in some OB-GYN residency programs throughout America. A web-based survey of approximately 100 Illinois OB-GYN residents a survey study found that 62% of their programs had spent 1-5 hours in the past year educating residents about lesbian and bisexual health, and 63% of the their programs had spent 1-5 hours in the past year educating residents about transgender health.[19]

APGO's UMEC identifies the third year of residency or "clerkship" as an ideal time to institute education if it hasn't already occurred, and ideally to reinforce competencies with LGBTQ+ patients through clinical experiences.[17]

In addition to instituting new educational policies for current and future OB-GYN residents, many programs are also looking to educate OB-GYNs that are already certified.[14]

For example, the University of Michigan OB-GYN program utilizes what they name "Continuing Medical Education" to instruct their OB-GYN care providers on the nuances of caring for transgender patients. Daphna Strousma, MD, MPH, is responsible for instituting and developing UM's transgender healthcare curriculum—"Improving Care for Transgender & Non-Binary Individuals"—in coordination with Michigan Medicine and the Council on Resident Education in Obstetrics and Gynecology (CREOG). The curriculum is offered to UM's OB-GYNs through a series of video modules covering the following topics:[20]

1. Gender Identity and Care of Transgender and Gender Non-Conforming Patients
2. Preventative Care for Transgender and Gender Non-Conforming Patients
3. Gender Affirming Treatment & Transition Related Care
4. Addressing Common Gynecologic Issues Among Transgender Patients
5. Health Records, Billing, Insurance, and Legal Documents in Transgender Medicine

Although the ACOG has called upon OB-GYN care providers to provide gender-affirming and inclusive care for all individuals, that doesn't mean there hasn't been resistance, particularly because there is no formal legislation mandating the inclusion of LGBTQ+ healthcare in OB-GYN curricula.

Many OB-GYN providers do not currently feel comfortable offering care to LGBTQ+ patients, either because of their personal beliefs or due to a lack of education on LGBTQ+ healthcare. One study of approximately 100 Illinois OB-GYN residents found that 50% of residents felt unprepared to care for lesbian or bisexual patients, and 76% of residents felt unprepared to offer care to transgender patients. The two main areas the residents identified as preventing the implementation of LGBTQ+ healthcare training were curricular crowding, 85%, and lack of experienced faculty, 91%. However, 92% of residents wanted to receive more education on how to offer care to LGBTQ+ patients.[19]