Kristen L. Eckstrand

Giving Context to the Physician Competency Reference Set: Adapting to the Needs of Diverse Populations.

Delineating the requisite competencies of a 21st-century physician is the first step in the paradigm shift to competency-based medical education. Over the past two decades, more than 150 lists of competencies have emerged. In a synthesis of these lists, the Physician Competency Reference Set (PCRS) provided a unifying framework of competencies that define the general physician. The PCRS is not context or population specific; however, competently caring for certain underrepresented populations or specific medical conditions can require more specific context. Previously developed competency lists describing care for these populations have been disconnected from an overarching competency framework, limiting their uptake. To address this gap, the Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development adapted the PCRS by adding context- and content-specific qualifying statements to existing PCRS competencies to better meet the needs of diverse patient populations. This Article describes the committee’s process in developing these qualifiers of competence. To facilitate widespread adoption of the contextualized competencies in U.S. medical schools, the committee used an established competency framework to develop qualifiers of competence to improve the health of individuals who are lesbian, gay, bisexual, transgender; gender nonconforming; or born with differences in sexual development. This process can be applied to other underrepresented populations or medical conditions, ensuring that relevant topics are included in medical education and, ultimately, health care outcomes are improved for all patients inclusive of diversity, background, and ability.

Heightened activity in social reward networks is associated with adolescents’ risky sexual behaviors

Adolescent sexual risk behavior can lead to serious health consequences, yet few investigations have addressed its neurodevelopmental mechanisms. Social neurocircuitry is postulated to underlie the development of risky sexual behavior, and response to social reward may be especially relevant. Typically developing adolescents (N = 47; 18M, 29F; 16.3 ± 1.4 years; 42.5% sexual intercourse experience) completed a social reward fMRI task and reported their sexual risk behaviors (e.g., lifetime sexual partners) on the Youth Risk Behavior Survey (YRBS). Neural response and functional connectivity to social reward were compared for adolescents with higher- and lower-risk sexual behavior. Adolescents with higher-risk sexual behaviors demonstrated increased activation in the right precuneus and the right temporoparietal junction during receipt of social reward. Adolescents with higher-risk sexual behaviors also demonstrated greater functional connectivity between the precuneus and the temporoparietal junction bilaterally, dorsal medial prefrontal cortex, and left anterior insula/ventrolateral prefrontal cortex. The greater activation and functional connectivity in self-referential, social reward, and affective processing regions among higher sexual risk adolescents underscores the importance of social influence underlying sexual risk behaviors. Furthermore, results suggest an orientation towards and sensitivity to social rewards among youth engaging in higher-risk sexual behavior, perhaps as a consequence of or vulnerability to such behavior.

Affirmative and Responsible Health Care for People with Nonconforming Gender Identities and Expressions

Although recent changes in health care delivery have improved routine and gender-affirming care for transgender people, common approaches to care are still often based on a binary (i.e., male/female) gender framework that can make patients with gender-nonconforming (GNC) identities and expressions feel marginalized. Binary representation perpetuates invisibility, discrimination, and victimization-and subsequent poorer health-among GNC patients. In response, clinicians and health care systems should extend their efforts to provide gender-affirming and responsible care to GNC people. This article reviews terminology related to gender, the limited research-and necessary directions for future research-on GNC communities, and provides strategies for health care professionals and systems to ensure provision of gender-affirming and responsible care to GNC patients.

The Priority of Intersectionality in Academic Medicine.

Recent societal events highlight inequities experienced by underrepresented and marginalized communities. These inequities are the impetus for ongoing efforts in academic medicine to create inclusive educational and patient care environments for diverse stakeholders. Frequently, approaches focus on singular populations or broad macroscopic concepts and do not always elucidate the complexities that arise at the intersection between multiple identities and life experiences. Intersectionality acknowledges multidimensional aspects of identity inclusive of historical, structural, and cultural factors. Understanding how multiple identity experiences impact different individuals, from patients to trainees to providers, is critical for improving health care education and delivery. Building on existing work within academic medicine, this Commentary outlines six key recommendations to advance intersectionality in academic medicine: embrace personal and collective loci of responsibility; examine and rectify unbalanced power dynamics; celebrate visibility and intersectional innovation; engage all stakeholders in the process of change; select and analyze meaningful metrics; and sustain the commitment to achieving health equity over time. Members of the academic medical community committed to advancing health equity can use these recommendations to promote and maintain meaningful changes that recognize and respond to the multidimensional voices and expressed needs of all individuals engaged in providing and receiving health care.

Obstetric and Gynecologic Care for Individuals Who Are LGBT

Obstetrics and gynecology (OB/GYN) has historically been defined as the provision of care to women, specifically their reproductive organs, across the lifespan and during pregnancy. In actuality, OB/GYN encompasses the provision of care irrespective of sex, sexual orientation, gender identity, and natal pelvic anatomy. Understanding the barriers to OB/GYN care faced by LGBT patients and how to perform a sensitive history and physical to reduce re-traumatization form the foundation for OB/GYN care. This chapter further discusses the risk and health disparities faced by individuals who identify as LGBT, recommendations for preventive screening, routine gynecologic care, family building, fertility and reproduction in order to improve care for LGBT patients.

Temptations of friends: adolescents’ neural and behavioral responses to best friends predict risky behavior

Abstract Adolescents are notorious for engaging in risky, reward-motivated behavior, and this behavior occurs most often in response to social reward, typically in the form of peer contexts involving intense positive affect. A combination of greater neural and behavioral sensitivity to peer positive affect may characterize adolescents who are especially likely to engage in risky behaviors. To test this hypothesis, we examined 50 adolescents’ reciprocal positive affect and neural response to a personally relevant, ecologically valid pleasant stimulus: positive affect expressed by their best friend during a conversation about past and future rewarding mutual experiences. Participants were typically developing community adolescents (age 14–18 years, 48.6% female), and risky behavior was defined as a factor including domains such as substance use, sexual behavior and suicidality. Adolescents who engaged in more real-life risk-taking behavior exhibited either a combination of high reciprocal positive affect behavior and high response in the left ventrolateral prefrontal cortex—a region associated with impulsive sensation-seeking—or the opposite combination. Behavioral and neural sensitivity to peer influence could combine to contribute to pathways from peer influence to risky behavior, with implications for healthy development.

Adolescents’ neural response to social reward and real-world emotional closeness and positive affect

Feeling emotionally close to others during social interactions is a ubiquitous and meaningful experience that can elicit positive affect. The present study integrates functional magnetic resonance imaging (fMRI) and ecological momentary assessment (EMA) to investigate whether neural response to social reward (1) is related to the experience of emotional closeness and (2) moderates the association between emotional closeness and positive affect during and following social interactions. In this study, 34 typically developing adolescents (ages 14–18 years) completed a social-reward fMRI task, a monetary-reward fMRI task, and a 2-week EMA protocol regarding their social and affective experiences. Adolescents with greater right posterior superior temporal sulcus/temporoparietal junction (pSTS/TPJ) response to social reward reported greater mean momentary emotional closeness. Neural response to social reward in the right pSTS/TPJ moderated how strongly momentary emotional closeness was associated with both concurrent positive affect and future peak happiness, but in different ways. Although emotional closeness had a significant positive association with concurrent positive affect among adolescents at both high and low right pSTS/TPJ response based on a follow-up simple slopes test, this association was stronger for adolescents with low right pSTS/TPJ response. In contrast, emotional closeness had a significant positive association with future peak happiness among adolescents with high right pSTS/TPJ response, but not among those with low right pSTS/TPJ response. These findings demonstrate the importance of neural response to social reward in key social processing regions for everyday experiences of emotional closeness and positive affect in the context of social interactions.

Trauma, Resilience, and Health Promotion in LGBT Patients

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Queer Frontiers in Medicine: A Structural Competency Approach

price are net prices, subject to local VAT. Prices indicated with * include VAT for books; the €(D) includes 7% for Germany, the €(A) includes 10% for Austria. Prices indicated with ** include VAT for electronic products; 19% for Germany, 20% for Austria. All prices exclusive of carriage charges. Prices and other details are subject to change without notice. All errors and omissions excepted. K.L. Eckstrand, J.E. Potter (Eds.) Trauma, Resilience, and Health Promotion in LGBT Patients