Juno Obedin-Maliver, MD, MPH, MAS, FACOG, is an Assistant Professor in the Department of Obstetrics and Gynecology at Stanford University School of Medicine.
Dr. Juno Obedin-Maliver is a board-certified obstetrician/gynecologist who provides excellent clinical care and strives to advance scientific knowledge through her research.
She practices full-spectrum gynecology including outpatient, in-patient, operative, and emergency care services. This specifically includes collaborative management of cervical dysplasia and abnormal pap smears, abnormal uterine bleeding, contraception and family planning, pelvic pain, abnormal discharge, sexually transmitted infection testing and treatment, and more. She specializes in the gynecological and reproductive health care needs of sexual and gender minority people which include but are not limited to lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ+) people. This interest and experience drives her research interests towards promoting the health and well-being and equity of LGBTQ people.
Dr. Obedin-Maliver, is the Co-Director of The PRIDE Study (pridestudy.org), a multi-site online prospective longitudinal cohort of sexual and gender minority individuals based at Stanford. She also serves on the medical advisory board of the University of California San Francisco Center of Excellence for Transgender Health and is helping to author the next version of the World Professional Association for Transgender Health (WPATH) Standards of Care. Dr. Obedin-Maliver has also been active in health policy including involvement in helping to legally redefine consideration of sexually intimate partner status and to remove the Medicare Non-Coverage Determination ruling on gender -affirming surgeries.
For more information about her research and career please see: pridestudy.org and http://med.stanford.edu/obedin-maliver.html
- Obstetrics and Gynecology
- LGBTQ+ Health
- Reproductive Health of Transgender People
- Family Planning
Honors & Awards
1st Place Expert Choice: Improving Wait Times and Care Integration for Transgender Patients, San Francisco Veterans Affairs (SFVA) Systems Improvement Fair (2018)
GET(Gene, Environments, Traits)y Diversity Award, GET Award Committee (2016)
Outstanding Resident Award, University of California, San Francisco - Nurse-Midwifery Student Award for Resident Physicians (2014)
Chancellor’s Award for Gay, Lesbian Bisexual and/or Transgender (GLBT) Leadership, University of California, San Francisco (2012)
Outstanding Resident Award in Medical Student Teaching - Obstetrics and Gynecology., University of California, San Francisco (2011)
Julius R. Krevans Award for Service as an Intern, San Francisco General Hospital (2011)
eQuality Scholarship for service to the LGBTQ community, The Kaiser Permanente Foundation (2010)
Scholarship for Lesbian, Gay, Bisexual, and Transgender (LGBT) Activism and Leadership, Markowski-Leach Memorial Fund (2008)
Cardinal Free Clinic - Student Member Service Award, Stanford University School of Medicine (2008)
Full Tuition Merit Scholarship, School of Public Health - Master's Program, University of California at Berkeley (2007)
Ingenuity Award for Community Service, Hampshire College (2004)
Reproductive Rights Activist Service Corps Internship Grant, Civil Liberties and Public Policy Program (2002)
Scholarship for Achievement in the Sciences, Canon-Jensen Memorial Fund (2001)
Scholarship for Academic Achievement in the Sciences, Monterey Bay Women In Science Fund (2001)
Residency: UCSF Obstetrics and Gynecology (2014) CA
Medical Education: Stanford University School of Medicine (2010) CA
Fellowship, San Francisco Veterans Affairs Medical Center & University of California, San Francisco, Women's Health and Clinical Research (2016)
MAS, University of California, San Francisco, Clinical Research (2016)
Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2015)
MPH, University of California, Berkeley, Masters in Public Health (2008)
Diversity and Identity
- Prepregnancy Counseling for People of All Genders: Enhancing Safe and Accessible Family Building for Transgender, Gender Diverse, and Non-binary Individuals CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020
Stakeholder Perceptions and Experiences Regarding Access to Contraception and Abortion for Transgender, Non-Binary, and Gender-Expansive Individuals Assigned Female at Birth in the U.S.
Archives of sexual behavior
Sexual and reproductive health (SRH) care often excludes the needs and experiences of transgender, non-binary, and gender-expansive (TGE) individuals. This study aimed to collect diverse stakeholder perspectives on barriers and facilitators to contraception and abortion for TGE individuals assigned female at birth (AFAB), assess knowledge and attitudes about unintended pregnancy prevention in these populations, and identify recommendations for improving SRH services for people of all genders. Between October 2017 and January 2018, we conducted 27 in-depth interviews with SRH stakeholders, including five TGE individuals who had obtained contraception or abortion care, and 22 clinicians, researchers, and advocates experienced in transgender healthcare. We iteratively developed a codebook and conducted thematic analysis to capture the spectrum of perspectives across interviews. Stakeholders reported a range of barriers to contraception and abortion access for TGE people AFAB, including inability to afford services, lack of gender-affirming clinicians, difficulty obtaining insurance coverage, and misconceptions about fertility and unplanned pregnancy risk. Deterrents to care-seeking included gendered healthcare environments, misgendering, and discrimination. Stakeholders described provider knowledge gaps and a perceived lack of medical education relevant to the SRH needs of TGE people. Recommendations included using gender-inclusive language and gender-affirming patient education materials and improving provider training on gender-affirming SRH care. Stakeholders identified substantial barriers to high-quality contraception and abortion care for TGE AFAB people in the U.S. They recommended specific interventions at the provider and institutional levels to improve experiences with care for TGE people and ensure broader access to gender-affirming SRH services.
View details for DOI 10.1007/s10508-020-01707-w
View details for PubMedID 32385584
Contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth.
Everyone of reproductive potential, no matter sex or gender, may have contraceptive needs. However, with no professional society guidelines and scant data on contraceptive use for transgender and gender-diverse (TGD) populations, clinicians' abilities to counsel patients on use, safety, side effects, and efficacy is severely limited. We know very little about how estrogen- and progestin-containing contraceptive methods interact with gender-affirming testosterone therapy. Consequently, providers must extrapolate from data on use of hormonal contraceptive methods in presumed cisgender women and rely on clinical expertise. Based on available literature and expert opinion, there are important considerations for each method that can help guide contraceptive counseling with TGD patients. Specific considerations include differential experience of side-effects in TGD patients, barriers to access, and potential misconceptions regarding menstruation and reproductive capacity. When counseling a TGD person about their contraception options, providers should engage in shared decision-making, acknowledging the spectrum of identities and experiences within these communities. In order to support gender-affirming patient-centered care, providers should also create a space that is welcoming, use language that promotes inclusivity, and perform physical exams that consider the potential physical and emotional discomforts specific to these patients. Given the lack of population-specific data and guidelines, we encourage providers to integrate what is known about contraceptive use in cisgender women with the unique needs of TGD persons to apply a shared decision-making contraceptive counseling approach with members of these communities.
View details for DOI 10.1016/j.contraception.2020.04.001
View details for PubMedID 32304766
The Imperative for Transgender and Gender Nonbinary Inclusion: Beyond Women's Health.
Obstetrics and gynecology
We aim to make evident that solely referencing cisgender women in the context of sexual and reproductive health-particularly pregnancy planning and care-excludes a diverse group of transgender and gender nonbinary people who have sexual and reproductive health needs and experiences that can be similar to but also unique from those of cisgender women. We call on clinicians and researchers to ensure that all points of sexual and reproductive health access, research, sources of information, and care delivery comprehensively include and are accessible to people of all genders. We describe barriers to sexual and reproductive health care and research participation unique to people of marginalized gender identities, provide examples of harm resulting from these barriers, and offer concrete suggestions for creating inclusive, accurate, and respectful care and research environments-which will lead to higher quality health care and science for people of all genders.
View details for DOI 10.1097/AOG.0000000000003816
View details for PubMedID 32282602
Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals: A Collaborative Multidisciplinary Team Approach In Reply
OBSTETRICS AND GYNECOLOGY
2020; 135 (2): 484–85
View details for Web of Science ID 000524416100046
Characterization of substance use among underrepresented sexual and gender minority participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study.
Background: Profiles of substance use among less commonly described subgroups of sexual and gender minority (SGM) people (e.g., queer, genderqueer) remain largely unknown. Objective(s): To identify substance use differences among less commonly described SGM identity-based subgroups. Methods: The PRIDE Study is a national, online, longitudinal cohort study of self-identified SGM adults living in the U.S. Between 2015-2017, an iPhone application was used to administer three cross-sectional health questionnaires to participants, one of which included questions about binge alcohol, marijuana, and other drug use (substance use). This study was a secondary data analysis of participant responses to substance use survey items. Logistic regression and generalized linear modeling assessed relationships between sexual orientation or gender and use of or reported problems with substances within the past year. Results: Among the 1790 participants included in this study, 51.0% reported binge alcohol use, 39.8% reported marijuana use, and 19.7% reported other drug use (65.9% endorsed use of one or more of these) within the past year. Over 30% indicated substance use had been a problem in their life. Asexual individuals had lower odds of reporting past year binge alcohol and marijuana use (aOR: 0.27, 95% CI: 0.12-0.61; aOR: 0.38, 95% CI: 0.15-0.96, respectively), and queer participants had higher odds of reporting past year marijuana use (aOR: 2.52, 95% CI: 1.58-4.03) compared to lesbian participants. Gender nonbinary participants had lower odds of reporting past year binge alcohol use (aOR: 0.48, 95% CI: 0.32-0.71) and transmasculine participants had higher odds of reporting past year marijuana use (aOR: 2.18, 95% CI: 1.10-4.31) compared to cisgender women. Conclusions: Substance use heterogeneity exists between SGM groups. Comprehensive assessment of sexual orientation and gender may improve understanding of substance use and increase equity within support and treatment services for SGM populations.HighlightsWe examined substance use among less represented sexual and gender minority groups.Alcohol and other drug use were examined by both sexual orientation and gender identity.Analyses included identities such as queer, pansexual, genderqueer and nonbinary.Alcohol use differed across asexual, genderqueer and gender nonbinary groups.Marijuana use differed across queer, asexual and transmasculine groups.
View details for DOI 10.1080/08897077.2019.1702610
View details for PubMedID 32032500
What Sexual and Gender Minority People Want Researchers to Know About Sexual Orientation and Gender Identity Questions: A Qualitative Study.
Archives of sexual behavior
Sexual and gender minority (SGM) people-including members of the lesbian, gay, bisexual, transgender, and queer communities-are understudied and underrepresented in research. Current sexual orientation and gender identity (SOGI) questions do not sufficiently engage SGM people, and there is a critical gap in understanding how SOGI questions reduce inclusion and accurate empirical representation. We conducted a qualitative study to answer the question, "For SGM people, what are the major limitations with current SOGI questions?" Focus groups probed reactions to SOGI questions adapted from prior national surveys and clinical best practice guidelines. Questions were refined and presented in semi-structured cognitive interviews. Template analysis using a priori themes guided analysis. There were 74 participants: 55 in nine focus groups and 19 in cognitive interviews. Participants were diverse: 51.3% identified as gender minorities, 87.8% as sexual minorities, 8.1% as Hispanic/Latinx, 13.5% as Black or African-American, and 43.2% as Non-white. Two major themes emerged: (1) SOGI questions did not allow for identity fluidity and complexity, reducing inclusion and representation, and (2) SOGI question stems and answer choices were often not clear as to which SOGI dimension was being assessed. To our knowledge, this represents the largest body of qualitative data studying SGM perspectives when responding to SOGI questions. We present recommendations for future development and use of SOGI measures. Attention to these topics may improve meaningful participation of SGM people in research and implementation of such research within and for SGM communities.
View details for DOI 10.1007/s10508-020-01810-y
View details for PubMedID 32875381
Screening gender minority people for harmful alcohol use.
2020; 15 (4): e0231022
This study identifies how to screen for harmful alcohol use among gender minority (e.g., transgender and gender-expansive) people using brief screening methods and identifies which screening methods perform best among gender-expansive, transfeminine, and transmasculine subgroups, as screening recommendations are not currently available. Using 2018 Annual Questionnaire data from The PRIDE Study, area under the curve (AUC) values were compared to identify which screening methods ("4 or more" or "5 or more" drinks on one occasion in the past year, or one or more items from the Alcohol Use Disorders Identification Test [AUDIT]) best predicted (i) harmful alcohol use and (ii) one or more past year alcohol dependence symptoms or consequences. Among 1892 participants, "5 or more" drinks on one occasion (AUC ranges: 0.82-0.86) performed better than "4 or more" drinks (AUC ranges: 0.78-0.81) in predicting harmful drinking. The screening methods "4 or more" drinks, "5 or more" drinks, and the consumption items of the AUDIT (AUDIT-C) using a cutoff score of 3 all maximized sensitivity and specificity to predict alcohol dependence symptoms or consequences in gender minority people overall (AUC: 0.77-0.78). Screening for "5 or more" drinks on one occasion within the past year performed as well as or better than other screening methods to detect both harmful drinking and alcohol dependence-related symptoms or consequences. This single-item screening method can identify if more extensive alcohol use assessment is warranted with gender minority people.
View details for DOI 10.1371/journal.pone.0231022
View details for PubMedID 32255781
Meeting the Patient Care, Education, and Research Missions: Academic Medical Centers Must Comprehensively Address Sexual and Gender Minority Health.
Academic medicine : journal of the Association of American Medical Colleges
While sociopolitical advances have improved the rights of sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, queer [LGBTQ+] persons), they continue to face a health system that discriminates against them and does not provide competent, comprehensive care. Despite calls for advancing research, there remains limited sexual and gender minority health research funding, mentorship, and institutional support. Academic medical centers are best suited to systematically tackle disparities and improve care for all sexual and gender minority people through their tripartite missions of patient care, education, and research. In this article, the authors outline discrimination experienced by LGBTQ+ persons and highlight the unique disparities they experience across access and outcomes. The authors posit that by systematically improving clinical care of, incorporating education and training about, and research with LGBTQ+ people into their core missions, academic medical centers can dramatically change the health care landscape. Academic medical centers can eliminate health disparities, expand necessary research endeavors about sexual and gender minorities, and prepare the health care workforce to address the unique needs of these overlooked populations.
View details for DOI 10.1097/ACM.0000000000003703
View details for PubMedID 32852319
Development of an affirming and customizable electronic survey of sexual and reproductive health experiences for transgender and gender nonbinary people.
2020; 15 (5): e0232154
To address pervasive measurement biases in sexual and reproductive health (SRH) research, our interdisciplinary team created an affirming, customizable electronic survey to measure experiences with contraceptive use, pregnancy, and abortion for transgender and gender nonbinary people assigned female or intersex at birth and cisgender sexual minority women. Between May 2018 and April 2019, we developed a questionnaire with 328 items across 10 domains including gender identity; language used for sexual and reproductive anatomy and events; gender affirmation process history; sexual orientation and sexual activity; contraceptive use and preferences; pregnancy history and desires; abortion history and preferences; priorities for sexual and reproductive health care; family building experiences; and sociodemographic characteristics. Recognizing that the words people use for their sexual and reproductive anatomy can vary, we programmed the survey to allow participants to input the words they use to describe their bodies, and then used those customized words to replace traditional medical terms throughout the survey. This process-oriented paper aims to describe the rationale for and collaborative development of an affirming, customizable survey of the SRH needs and experiences of sexual and gender minorities, and to present summary demographic characteristics of 3,110 people who completed the survey. We also present data on usage of customizable words, and offer the full text of the survey, as well as code for programming the survey and cleaning the data, for others to use directly or as guidelines for how to measure SRH outcomes with greater sensitivity to gender diversity and a range of sexual orientations.
View details for DOI 10.1371/journal.pone.0232154
View details for PubMedID 32365110
- Depression and Anxiety Changes Among Sexual and Gender Minority People Coinciding with Onset of COVID-19 Pandemic. Journal of general internal medicine 2020
Community norms for the eating disorder examination questionnaire (EDE-Q) among cisgender bisexual plus women and men.
Eating and weight disorders : EWD
Cisgender bisexual plus (including bisexual, pansexual, and polysexual) women and men experience unique health concerns including eating disorders. The purpose of this study was to develop community norms for eating disorder attitudes and disordered eating behaviors in cisgender bisexual plus women and men using the Eating Disorders Examination Questionnaire (EDE-Q).Participants were cisgender bisexual plus women (n = 462) and men (n = 93) participants in The PRIDE Study, an existing study of sexual and gender minority people.Mean and standard deviation of EDE-Q scores among cisgender bisexual plus women and men, respectively, were: Global (1.75 ± 1.26, 1.56 ± 1.18), Restraint (1.34 ± 1.44, 1.42 ± 1.53), Eating Concern (0.96 ± 1.13, 0.63 ± 0.96), Weight Concern 2.27 ± 1.55, 1.89 ± 1.46), and Shape Concern 42 ± 1.62, 2.30 ± 1.57). Among cisgender bisexual plus women and men, respectively, 27.5% and 22.6% scored in the clinically significant range on the Global score. Bisexual plus women and men reported any occurrence (≥ 1/28 days) of dietary restraint (19.3%, 23.7%), objective binge episodes (11.1%, 10.8%), excessive exercise (4.5%, 5.4%), self-induced vomiting (1.7%, 0.0%), and laxative misuse (0.4%, 1.1%), respectively. A lower percentage of age-matched cisgender bisexual plus women (18-25 years) reported any occurrence of objective binge episodes, self-induced vomiting, laxative misuse, and excessive exercise than previously published in young women. Age-matched cisgender bisexual plus men (18-26 years) reported higher weight concern subscale scores than previously published in young men.These norms should aid clinicians in applying and interpreting the EDE-Q scores of cisgender bisexual plus women and men.Level V: cross-sectional descriptive study.
View details for DOI 10.1007/s40519-020-01070-8
View details for PubMedID 33270173
Eating disorder attitudes and disordered eating behaviors as measured by the Eating Disorder Examination Questionnaire (EDE-Q) among cisgender lesbian women.
2020; 34: 215–20
The Eating Disorder Examination Questionnaire (EDE-Q) is a measure of eating disorder attitudes and disordered eating behaviors. Prior descriptive studies of the EDE-Q for women either did not assess or omitted reporting sexual orientation. This study's objective was to assess eating disorder attitudes and disordered eating behaviors as measured by the EDE-Q among cisgender lesbian women. We present mean scores and standard deviations for the EDE-Q among 563 self-identified cisgender lesbian women ages 18-77 who were recruited from The PRIDE Study in 2018. Among cisgender lesbian women, 3.4 % scored in the clinically significant range on the Restraint, 1.6 % on the Eating Concern, 9.1 % on the Weight Concern, 13.9 % on the Shape Concern, and 3.9 % on the Global Score scales of the EDE-Q. We found that 13.5 % of participants reported any occurrence (≥1/28 days) of dietary restriction, 8.7 % for objective binge episodes, 5.3 % for excessive exercise, .4% for self-induced vomiting, and .4% for laxative misuse. Participants reported a current (1.8 %) or lifetime (7.1 %) diagnosis of an eating disorder by a clinician. These EDE-Q descriptive data capture eating disorder attitudes and disordered eating behaviors among cisgender lesbian women and may aid clinicians and researchers in interpreting the EDE-Q in this specific population.
View details for DOI 10.1016/j.bodyim.2020.06.005
View details for PubMedID 32652490
- Response to Letter. Obstetrics and gynecology 2020; 135 (2): 484–85
Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among transgender men and women.
2020; 37: 101381
Transgender men and women may be at risk for eating disorders, but prior community norms of the Eating Disorders Examination Questionnaire (EDE-Q) are based on presumed cisgender men and woman and have not intentionally included transgender people. The objective of this study was to develop community norms for eating disorder attitudes and disordered eating behaviors in transgender men and women using the EDE-Q. Participants were 312 transgender men and 172 transgender women participants in The PRIDE Study, an existing cohort study of sexual and gender minority people. We present mean scores, standard deviations, and percentile ranks for the Global score and four subscale scores of the EDE-Q in transgender men and women. Transgender men and women reported any occurrence (≥1/week) of dietary restraint (25.0% and 27.9%), objective binge episodes (11.2% and 12.8%), excessive exercise (8.0% and 8.1%), self-induced vomiting (1.6% and 1.7%), and laxative misuse (.3% and .6%), respectively. Compared to a prior study of presumed cisgender men 18-26 years (Lavender, De Young, & Anderson, 2010), our age-matched subsample of transgender men reported lower rates of objective binge episodes and excessive exercise. Compared to a prior study of presumed cisgender women 18-42 years (Mond, Hay, Rodgers, & Owen, 2006), we found that an age-matched sample of transgender women reported higher rates of dietary restraint but lower rates of excessive exercise. These norms should aid clinicians in applying and researchers in investigating and interpreting the EDE-Q scores of transgender men and women.
View details for DOI 10.1016/j.eatbeh.2020.101381
View details for PubMedID 32416588
Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among gender-expansive populations.
Journal of eating disorders
2020; 8 (1): 74
Gender-expansive individuals (i.e., those who identify outside of the binary system of man or woman) are a marginalized group that faces discrimination and have a high burden of mental health problems, but there is a paucity of research on eating disorders in this population. This study aimed to describe the community norms for the Eating Disorder Examination Questionnaire (EDE-Q) in gender-expansive populations.The participants were 988 gender-expansive individuals (defined as neither exclusively cisgender nor binary transgender) from The PRIDE study, an existing longitudinal cohort study of health outcomes in sexual and gender minority people.We present the mean scores, standard deviations, and percentile ranks for the Global score and four subscale scores of the EDE-Q in this group as a whole and stratified by sex assigned at birth. Gender-expansive individuals reported any occurrence (≥1/28 days) of dietary restraint (23.0%), objective binge episodes (12.9%), excessive exercise (7.4%), self-induced vomiting (1.4%), or laxative misuse (1.2%). We found no statistically significant differences by sex assigned at birth. Compared to a prior study of transgender men and women, there were no significant differences in eating attitudes or disordered eating behaviors noted between gender-expansive individuals and transgender men. Transgender women reported higher Restraint and Shape Concern subscale scores compared to gender-expansive individuals. Compared to a prior study of presumed cisgender men 18-26 years, our age-matched gender-expansive sample had higher Eating, Weight, and Shape Concern subscales and Global Score, but reported a lower frequency of objective binge episodes and excessive exercise. Compared to a prior study of presumed cisgender women 18-25 years, our age-matched gender-expansive sample had a higher Shape Concern subscale score, a lower Restraint subscale score, and lower frequencies of self-induced vomiting, laxative misuse, and excessive exercise.Gender-expansive individuals reported lower Restraint and Shape Concern scores than transgender women; higher Eating, Weight, and Shape Concern scores than presumed cisgender men; and lower Restraint but higher Shape Concern scores than presumed cisgender women. These norms can help clinicians in treating this population and interpreting the EDE-Q scores of their gender-expansive patients.
View details for DOI 10.1186/s40337-020-00352-x
View details for PubMedID 33292636
Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States.
American journal of obstetrics and gynecology
Transgender, nonbinary, and gender-expansive (TGE) people who were assigned female or intersex at birth experience pregnancy and have abortions. No data have been published on individual abortion experiences or preferences of this understudied population.To fill existing evidence gaps on the abortion experiences and preferences of TGE people in the United States to inform policies and practices to improve access to and quality of abortion care for this population.In 2019, we recruited TGE people assigned female or intersex at birth and aged 18 years and older from across the United States to participate in an online survey about sexual and reproductive health recruited through The PRIDE Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for TGE people, and respondent sociodemographic characteristics.The majority of the 1,694 respondents were less than 30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all four United States Census Regions. Overall, 210 (12%) respondents had ever been pregnant; these 210 reported 421 total pregnancies, of which 92 (22%) ended in abortion. For respondents' most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (4.5%) used another method (primarily herbal). Most recent abortions took place at or before nine weeks gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion to surgical abortion three to one (n=703 versus n=217), but 514 (30%) respondents did not know which method they would prefer. Reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for TGE patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers utilize gender-neutral language, and that greater privacy be incorporated into the clinic.These data contribute significantly to the evidence base on individual experiences of and preferences for abortion care for TGE people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.
View details for DOI 10.1016/j.ajog.2020.09.035
View details for PubMedID 32986990
- Supporting sexual and gender minority health: Research priorities from mental health professionals JOURNAL OF GAY & LESBIAN MENTAL HEALTH 2019
Community norms for the Eating Disorder Examination Questionnaire among cisgender gay men.
European eating disorders review : the journal of the Eating Disorders Association
Prior norms of the Eating Disorders Examination Questionnaire (EDE-Q) among men have not considered sexual orientation. This study's objective was to assess EDE-Q community norms among cisgender gay men.Participants were 978 self-identified cisgender gay men from The PRIDE Study recruited in 2018.We present mean scores and standard deviations for the EDE-Q among cisgender gay men ages 18-82. Among cisgender gay men, 4.0% scored in the clinically significant range on the global score, 5.7% on the restraint, 2.1% on the eating concern, 10.5% on the weight concern, and 21.4% on the shape concern subscales of the EDE-Q. The global score as well as weight and shape concerns in a young adult subsample (18-26 years) from The PRIDE Study were higher than previously reported norms in young men (Lavender, 2010). Participants reported any occurrence (≥1/28 days) of dietary restraint (19.8%), objective binge episodes (10.9%), excessive exercise (10.1%), laxative misuse (1.1%), and self-induced vomiting (0.6%). Binge eating, excessive exercise, and self-induced vomiting in The PRIDE Study subsample were lower than previously reported in young men.We provide EDE-Q norms among cisgender gay men, which should aid clinicians and researchers to interpret the EDE-Q scores of cisgender gay men.
View details for DOI 10.1002/erv.2708
View details for PubMedID 31793119
The "All of Us" Research Program.
The New England journal of medicine
2019; 381 (7): 668–76
Knowledge gained from observational cohort studies has dramatically advanced the prevention and treatment of diseases. Many of these cohorts, however, are small, lack diversity, or do not provide comprehensive phenotype data. The All of Us Research Program plans to enroll a diverse group of at least 1 million persons in the United States in order to accelerate biomedical research and improve health. The program aims to make the research results accessible to participants, and it is developing new approaches to generate, access, and make data broadly available to approved researchers. All of Us opened for enrollment in May 2018 and currently enrolls participants 18 years of age or older from a network of more than 340 recruitment sites. Elements of the program protocol include health questionnaires, electronic health records (EHRs), physical measurements, the use of digital health technology, and the collection and analysis of biospecimens. As of July 2019, more than 175,000 participants had contributed biospecimens. More than 80% of these participants are from groups that have been historically underrepresented in biomedical research. EHR data on more than 112,000 participants from 34 sites have been collected. The All of Us data repository should permit researchers to take into account individual differences in lifestyle, socioeconomic factors, environment, and biologic characteristics in order to advance precision diagnosis, prevention, and treatment.
View details for DOI 10.1056/NEJMsr1809937
View details for PubMedID 31412182
Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals: A Collaborative Multidisciplinary Team Approach.
Obstetrics and gynecology
2019; 134 (5): 959–63
Little is documented about the experiences of pregnancy for transgender and gender-diverse individuals. There is scant clinical guidance for providing prepregnancy, prenatal, intrapartum, and postpartum care to transgender and gender-diverse people who desire pregnancy.Our team provided perinatal care to a 20-year-old transgender man, which prompted collaborative advocacy for health care systems change to create gender-affirming patient experiences in the perinatal health care setting.Systems-level and interpersonal-level interventions were adopted to create gender-affirming and inclusive care in and around pregnancy. Basic practices to mitigate stigma and promote gender-affirming care include staff trainings and query and use of appropriate name and pronouns in patient interactions and medical documentation. Various factors are important to consider regarding testosterone therapy for transgender individuals desiring pregnancy.
View details for DOI 10.1097/AOG.0000000000003506
View details for PubMedID 31599839
View details for PubMedCentralID PMC6814572
More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults.
The Journal of Sexual Medicine
2019; 16 (3): 347-350
View details for DOI 10.1016/j.jsxm.2019.01.308
- Opening the Ob/Gyn Door to Sexual and Gender Minority Patients Contemporary Ob/Gyn. Volume 64, No 01. 2019 11–15
A digital health research platform for community engagement, recruitment, and retention of sexual and gender minority adults in a national longitudinal cohort study--The PRIDE Study.
Journal of the American Medical Informatics Association : JAMIA
Sexual and gender minority (SGM) people are underrepresented in research. We sought to create a digital research platform to engage, recruit, and retain SGM people in a national, longitudinal, dynamic, cohort study (The PRIDE Study) of SGM health.We partnered with design and development firms and engaged SGM community members to build a secure, cloud-based, containerized, microservices-based, feature-rich, research platform. We created PRIDEnet, a national network of individuals and organizations that actively engaged SGM communities in all stages of health research. The PRIDE Study participants were recruited via in-person outreach, communications to PRIDEnet constituents, social media advertising, and word-of-mouth. Participants completed surveys to report demographic as well as physical, mental, and social health data.We built a secure digital research platform with engaging functionality that engaged SGM people and recruited and retained 13 731 diverse individuals in 2 years. A sizeable sample of 3813 gender minority people (32.8% of cohort) were recruited despite representing only approximately 0.6% of the population. Participants engaged with the platform and completed comprehensive annual surveys- including questions about sensitive and stigmatizing topics- to create a data resource and join a cohort for ongoing SGM health research.With an appealing digital platform, recruitment and engagement in online-only longitudinal cohort studies are possible. Participant engagement with meaningful, bidirectional relationships creates stakeholders and enables study cocreation. Research about effective tactics to engage, recruit, and maintain active participation from all communities is needed.This digital research platform successfully recruited and engaged diverse SGM participants in The PRIDE Study. A similar approach may be successful in partnership with other underrepresented and vulnerable populations.
View details for DOI 10.1093/jamia/ocz082
View details for PubMedID 31162545
Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities.
2019; 9 (10): e031099
Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.https://clinicaltrials.gov/ct2/show/NCT02986126.
View details for DOI 10.1136/bmjopen-2019-031099
View details for PubMedID 31641001
Using mobile technology to engage sexual and gender minorities in clinical research.
2019; 14 (5): e0216282
Historical and current stigmatizing and discriminatory experiences drive sexual and gender minority (SGM) people away from health care and clinical research. Being medically underserved, they face numerous disparities that make them vulnerable to poor health outcomes. Effective methods to engage and recruit SGM people into clinical research studies are needed.To promote health equity and understand SGM health needs, we sought to design an online, national, longitudinal cohort study entitled The PRIDE (Population Research in Identity and Disparities for Equality) Study that enabled SGM people to safely participate, provide demographic and health data, and generate SGM health-related research ideas.We developed an iPhone mobile application ("app") to engage and recruit SGM people to The PRIDE Study-Phase 1. Participants completed demographic and health surveys and joined in asynchronous discussions about SGM health-related topics important to them for future study.The PRIDE Study-Phase 1 consented 18,099 participants. Of them, 16,394 provided data. More than 98% identified as a sexual minority, and more than 15% identified as a gender minority. The sample was diverse in terms of sexual orientation, gender identity, age, race, ethnicity, geographic location, education, and individual income. Participants completed 24,022 surveys, provided 3,544 health topics important to them, and cast 60,522 votes indicating their opinion of a particular health topic.We developed an iPhone app that recruited SGM adults and collected demographic and health data for a new national online cohort study. Digital engagement features empowered participants to become committed stakeholders in the research development process. We believe this is the first time that a mobile app has been used to specifically engage and recruit large numbers of an underrepresented population for clinical research. Similar approaches may be successful, convenient, and cost-effective at engaging and recruiting other vulnerable populations into clinical research studies.
View details for DOI 10.1371/journal.pone.0216282
View details for PubMedID 31048870
Urinary Incontinence in a National Cohort of Older Women: Implications for Caregiving and Care Dependence
JOURNAL OF WOMENS HEALTH
2018; 27 (9): 1097–1103
Urinary incontinence (UI) can interfere with older women's ability to perform activities of daily living (ADLs), but little is known about factors that predispose incontinent women to become functionally dependent or compromise their ability to serve as caregivers to others.UI, caregiving, and care-receiving behaviors were assessed by questionnaire in a national sample of community-dwelling older women. Multivariable models evaluated associations between incontinence and care dependence, assessed factors associated with care dependence among incontinent women, and compared health among female caregivers with and without incontinence.Of the 1703 women, 27% reported weekly or more incontinence and 13% monthly incontinence. Women with weekly or more incontinence were more likely than women without incontinence to report receiving care for ADLs (AOR = 2.39, CI = 1.61-3.56) or instrumental ADLs (AOR = 1.94, CI = 1.42-2.63). Compared to 46% of women without incontinence, 60% of women with monthly or weekly incontinence reported unmet care needs (p = 0.0002). Factors associated with care dependence included more frequent incontinence, older age, marital status, and fair/poor health (p < 0.05 for all). Overall, 15% of women served as a caregiver for another adult, which did not differ by incontinence status (p = 0.84), but female caregivers with incontinence reported worse health than those without incontinence (p = 0.0004).In this national cohort, older women with incontinence were more likely to be functionally dependent and have unmet care needs than those without incontinence, after adjustment for other factors. At least one in ten incontinent women served as caregivers, despite having worse health than female caregivers without incontinence.
View details for DOI 10.1089/jwh.2017.6891
View details for Web of Science ID 000435559200001
View details for PubMedID 29902123
View details for PubMedCentralID PMC6148721
The new era of precision population health: insights for the All of Us Research Program and beyond.
Journal of translational medicine
2018; 16 (1): 211
Although precision medicine has made advances in individualized patient treatments, there needs to be continued attention on tailored population health and prevention strategies (often termed "precision population health"). As we continue to link datasets and use "big data" approaches in medicine, inclusion of diverse populations and a focus on disparities reduction are key components within a precision population health framework. Specific recommendations from the All of Us Research Program and the Precision Public Health Summit provide examples for moving this field forward.
View details for DOI 10.1186/s12967-018-1585-5
View details for PubMedID 30053823
View details for PubMedCentralID PMC6062956
From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers
BMC PREGNANCY AND CHILDBIRTH
2017; 17: 332
Some transgender men retain their uterus, get pregnant, and give birth. However, societal attitudes about gender have erected barriers to openly being pregnant and giving birth as a transgender man. Little research exists regarding transgender men's reproductive needs. Anecdotal observations suggest that social change and increasing empowerment of transgender men may result in increasing frequency and openness about pregnancy and birth. Specific needs around conception, pregnancy, and newborn care may arise from transphobia, exogenous testosterone exposure, or from having had (or desiring) gender-affirming surgery. We undertook a qualitative study to understand the needs of transgender men who had given birth.We interviewed 10 transgender men who had been recruited for a recently published online cross-sectional survey of individuals (n = 41). Subjects had given birth while identifying as male. Interviews were recorded, transcribed, and systematically coded. Analysis used a priori and emergent codes to identify central themes and develop a framework for understanding participant experiences.Participants reported diverse experiences and values on issues including prioritization and sequencing of transition versus reproduction, empowerment in healthcare, desire for external affirmation of their gender and/or pregnancy, access to social supports, and degree of outness as male, transgender, or pregnant. We identified structural barriers that disempowered participants and describe healthcare components that felt safe and empowering. We describe how patients' strategies, and providers' behaviors, affected empowerment. Anticipatory guidance from providers was central in promoting security and empowerment for these individuals as patients.Recognizing diverse experiences has implications in supporting future patients through promoting patient-centered care and increasing the experiential legibility. Institutional erasure creates barriers to transgender men getting routine perinatal care. Identifying this erasure helps shape recommendations for how providers and clinics can provide appropriate care. Specific information regarding reproduction can be helpful to patients. We provide recommendations for providers' anticipatory guidance during the pre-transition, pre-conception, prenatal, and postpartum periods. Ways to support and bring visibility to the experience of transgender men are identified. Improving clinical visibility and affirming gender will likely enhance patient experience and may support patient-centered perinatal healthcare services.
View details for DOI 10.1186/s12884-017-1491-5
View details for Web of Science ID 000415331900002
View details for PubMedID 29143629
View details for PubMedCentralID PMC5688401
- Gynecologic Care for Transgender Adults CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017; 6 (2): 140–48
Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco
2017; 95 (2): 186–89
Although many transgender men may be able to conceive, their reproductive health needs are understudied.We retrospectively reviewed charts of transgender men presenting to a clinic for sex workers to describe the proportion at risk for pregnancy, pregnancy intentions, and contraceptive use.Of 26 transgender men identified, half were at risk for pregnancy. Most desired to avoid pregnancy but used only condoms or no contraception. Two individuals desired pregnancy, were taking testosterone (a teratogen), and not using contraception.Further research is needed to explore how to best provide family planning services including preconception and contraception care to transgender men.
View details for DOI 10.1016/j.contraception.2016.09.005
View details for Web of Science ID 000392895300011
View details for PubMedID 27621044
Feasibility of Vaginal Hysterectomy for Female-to-Male Transgender Men.
Obstetrics and gynecology
2017; 129 (3): 457–63
To describe the hysterectomy data among a cohort of transgender men and nontransgender (ie, cisgender) women with a particular goal to evaluate the feasibility of vaginal hysterectomy among transgender men.This cohort study includes all hysterectomies performed for benign indications on transgender men and cisgender women at a single academic county hospital from 2000 to 2012. Hysterectomy cases and patient gender were identified by billing records and confirmed by review of medical records. Primary study outcome was the hysterectomy route among transgender men compared with cisgender women. We also examined risk factors and operative outcomes. Student two-sided t tests, χ analysis, and descriptive statistics are presented; sensitivity analyses using regression techniques were performed.Hysterectomies for benign gynecologic procedures were performed in 883 people: 33 on transgender men and 850 on cisgender women. Transgender men were younger, had fewer pregnancies and deliveries, and smaller uteri. The leading indication for hysterectomy differed significantly: pain (85%) was most common among transgender men (compared with 22% in cisgender women; P<.001), whereas leiomyomas (64%) was most common for cisgender women (compared with 21% in transgender men; P<.001). Vaginal hysterectomies were performed in 24% transgender men and 42% of cisgender women. Estimated blood loss was less among transgender men (P=.002), but when uterine size and route of hysterectomy were considered, the difference between gender groups was no longer significant. There was no difference in patients experiencing complications between the groups.Transgender men and cisgender women have different preoperative characteristics and surgical indications. Vaginal hysterectomies have been successfully completed among transgender men. Because vaginal hysterectomy is a viable procedure for this population, it should be considered in surgical planning for transgender men.
View details for PubMedID 28178042
- Transgender men and pregnancy OBSTETRIC MEDICINE 2016; 9 (1): 4–8
Lesbian, Gay, Bisexual, and Transgender Patient Care: Medical Students' Preparedness and Comfort.
Teaching and learning in medicine
2015; 27 (3): 254-263
Phenomenon: Lesbian, gay, bisexual, and transgender (LGBT) individuals face significant barriers in accessing appropriate and comprehensive medical care. Medical students' level of preparedness and comfort caring for LGBT patients is unknown.An online questionnaire (2009-2010) was distributed to students (n = 9,522) at 176 allopathic and osteopathic medical schools in Canada and the United States, followed by focus groups (2010) with students (n = 35) at five medical schools. The objective of this study was to characterize LGBT-related medical curricula, to determine medical students' assessments of their institutions' LGBT-related curricular content, and to evaluate their comfort and preparedness in caring for LGBT patients.Of 9,522 survey respondents, 4,262 from 170 schools were included in the final analysis. Most medical students (2,866/4,262; 67.3%) evaluated their LGBT-related curriculum as "fair" or worse. Students most often felt prepared addressing human immunodeficiency virus (HIV; 3,254/4,147; 78.5%) and non-HIV sexually transmitted infections (2,851/4,136; 68.9%). They felt least prepared discussing sex reassignment surgery (1,061/4,070; 26.1%) and gender transitioning (1,141/4,068; 28.0%). Medical education helped 62.6% (2,669/4,262) of students feel "more prepared" and 46.3% (1,972/4,262) of students feel "more comfortable" to care for LGBT patients. Four focus group sessions with 29 students were transcribed and analyzed. Qualitative analysis suggested students have significant concerns in addressing certain aspects of LGBT health, specifically with transgender patients. Insights: Medical students thought LGBT-specific curricula could be improved, consistent with the findings from a survey of deans of medical education. They felt comfortable, but not fully prepared, to care for LGBT patients. Increasing curricular coverage of LGBT-related topics is indicated with emphasis on exposing students to LGBT patients in clinical settings.
View details for DOI 10.1080/10401334.2015.1044656
View details for PubMedID 26158327
Sexual and Gender Minority Identity Disclosure During Undergraduate Medical Education: "In the Closet" in Medical School
2015; 90 (5): 634-644
To assess identity disclosure among sexual and gender minority (SGM) students pursuing undergraduate medical training in the United States and Canada.From 2009 to 2010, a survey was made available to all medical students enrolled in the 176 MD- and DO-granting medical schools in the United States and Canada. Respondents were asked about their sexual and gender identity, whether they were "out" (i.e., had publicly disclosed their identity), and, if they were not, their reasons for concealing their identity. The authors used a mixed-methods approach and analyzed quantitative and qualitative survey data.Of 5,812 completed responses (of 101,473 eligible respondents; response rate 5.7%), 920 (15.8%) students from 152 (of 176; 86.4%) institutions identified as SGMs. Of the 912 sexual minorities, 269 (29.5%) concealed their sexual identity in medical school. Factors associated with sexual identity concealment included sexual minority identity other than lesbian or gay, male gender, East Asian race, and medical school enrollment in the South or Central regions of North America. The most common reasons for concealing one's sexual identity were "nobody's business" (165/269; 61.3%), fear of discrimination in medical school (117/269; 43.5%), and social or cultural norms (110/269; 40.9%). Of the 35 gender minorities, 21 (60.0%) concealed their gender identity, citing fear of discrimination in medical school (9/21; 42.9%) and lack of support (9/21; 42.9%).SGM students continue to conceal their identity during undergraduate medical training. Medical institutions should adopt targeted policies and programs to better support these individuals.
View details for DOI 10.1097/ACM.0000000000000657
View details for Web of Science ID 000353879700027
View details for PubMedID 25692563
- Time for OBGYNs to Care for People of All Genders JOURNAL OF WOMENS HEALTH 2015; 24 (2): 109–11
Transgender men who experienced pregnancy after female-to-male gender transitioning.
Obstetrics and gynecology
2014; 124 (6): 1120–27
To conduct a cross-sectional study of transgender men who had been pregnant and delivered after transitioning from female-to-male gender to help guide practice and further investigation.We administered a web-based survey from March to December 2013 to inquire about demographics, hormone use, fertility, pregnancy experience, and birth outcomes. Participants were not required to have been on hormone therapy to be eligible. We used a mixed-methods approach to evaluate the quantitative and qualitative data.Forty-one self-described transgender men completed the survey. Before pregnancy, 61% (n=25) had used testosterone. Mean age at conception was 28 years with a standard deviation of 6.8 years. Eighty-eight percent of oocytes (n=36) came from participants' own ovaries. Half of the participants received prenatal care from a physician and 78% delivered in a hospital. Qualitative themes included low levels of health care provider awareness and knowledge about the unique needs of pregnant transgender men as well as a desire for resources to support transgender men through their pregnancy.Transgender men are achieving pregnancy after having socially, medically, or both transitioned. Themes from this study can be used to develop transgender-appropriate services and interventions that may improve the health and health care experiences of transgender men.
View details for DOI 10.1097/AOG.0000000000000540
View details for PubMedID 25415163
- Lesbian, Gay, Bisexual, and Transgender Health and Medical Education Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2011; 306 (21): 2326–27
Lesbian, Gay, Bisexual, and Transgender-Related Content in Undergraduate Medical Education
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2011; 306 (9): 971-977
Lesbian, gay, bisexual, and transgender (LGBT) individuals experience health and health care disparities and have specific health care needs. Medical education organizations have called for LGBT-sensitive training, but how and to what extent schools educate students to deliver comprehensive LGBT patient care is unknown.To characterize LGBT-related medical curricula and associated curricular development practices and to determine deans' assessments of their institutions' LGBT-related curricular content.Deans of medical education (or equivalent) at 176 allopathic or osteopathic medical schools in Canada and the United States were surveyed to complete a 13-question, Web-based questionnaire between May 2009 and March 2010.Reported hours of LGBT-related curricular content.Of 176 schools, 150 (85.2%) responded, and 132 (75.0%) fully completed the questionnaire. The median reported time dedicated to teaching LGBT-related content in the entire curriculum was 5 hours (interquartile range [IQR], 3-8 hours). Of the 132 respondents, 9 (6.8%; 95% CI, 2.5%-11.1%) reported 0 hours taught during preclinical years and 44 (33.3%; 95% CI, 25.3%-41.4%) reported 0 hours during clinical years. Median US allopathic clinical hours were significantly different from US osteopathic clinical hours (2 hours [IQR, 0-4 hours] vs 0 hours [IQR, 0-2 hours]; P = .008). Although 128 of the schools (97.0%; 95% CI, 94.0%-99.9%) taught students to ask patients if they "have sex with men, women, or both" when obtaining a sexual history, the reported teaching frequency of 16 LGBT-specific topic areas in the required curriculum was lower: at least 8 topics at 83 schools (62.9%; 95% CI, 54.6%-71.1%) and all topics at 11 schools (8.3%; 95% CI, 3.6%-13.0%). The institutions' LGBT content was rated as "fair" at 58 schools (43.9%; 95% CI, 35.5%-52.4%). Suggested successful strategies to increase content included curricular material focusing on LGBT-related health and health disparities at 77 schools (58.3%, 95% CI, 49.9%-66.7%) and faculty willing and able to teach LGBT-related curricular content at 67 schools (50.8%, 95% CI, 42.2%-59.3%).The median reported time dedicated to LGBT-related topics in 2009-2010 was small across US and Canadian medical schools, but the quantity, content covered, and perceived quality of instruction varied substantially.
View details for Web of Science ID 000294542600015
View details for PubMedID 21900137