In an ongoing series of commentaries, Lynette Reid describes the work done at Dalhousie University to diversify the case-based learning curriculum in the medical program.

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In the previous commentary I described the efforts of a committee at Dalhousie’s medical school to diversify the case-based learning (CBL) curriculum, as the cases relate to a patient’s sexual orientation and/or gender identity. Here I continue the description of the committee’s work. When it came to revising CBL curriculum, there were sometimes strong responses to stating gender identities and sexual orientations for children and youth. We didn’t do this in every case, and we did it in a variety of ways that illustrated that children manifest gender identities and sexual orientations at different ages. Families sometimes make choices to raise children as nonbinary until children decide for themselves, and sometimes assume cisheteronormative gender identities and sexual orientations for them. When we tried to describe the latter situation factually (“her family is raising her as a cis girl”), we got the feedback from allies who felt that we were saying the family was doing something wrong, rather than simply factually describing how normative structures work, which was our intention.

Student feedback gathered in the years before the project began had already raised questions about how medicine reinforces gender norms by the routine declaration of the sex/gender of newborns in cases. We took a case that included childbirth and portrayed the patient as a social media influencer who was planning a “gender” reveal during birth, and in that context discussed ways physicians might address the gap between factually communicating sex characteristics observed at birth versus speculating about the gender identity of the child, which only emerges over time.

Image Description: A AI generated colorful graphic highlighting the terms Sexual Orientation and Gender Identity in bold text.

In the bigger picture, medicine is now a place where people are expected to be able to discuss cisheteronormativity, which is in itself an enormous change in the culture of academic medicine. Scientists are working to clarify their language and make research more inclusive, using gender terms (men and women) for social roles and sex terms (male and female) for biology. We made some changes along these lines, but we didn’t assume that we knew which one researchers meant or that we would be justified in assigning differences to sex versus gender when researchers hadn’t distinguished these in their research design. CIHR’s work on this is insufficiently critical of the sex binary, but it has raised awareness with many biomedical researchers and they welcomed our conversations as helping them get their heads around more scientifically rigorous ways of approaching sex and gender in their own research, or helping them deal with CIHR’s review process.

We repeatedly reminded ourselves to pay attention to how physicians can help patients in concrete ways (in addition to language and communication concerns about being respectful and avoiding misgendering). Wherever sex/gender differences played a role in diagnosis or treatment, we would give some information about what is known (or not) for persons with variations in sex characteristics (whether due to intersex conditions or due to affirming surgical/hormonal care) and where to go to find updated information. Some asked whether content we proposed was too specialized for pre-clerkship, and we found it useful to consider: should a trans or intersex person get care in the context portrayed without referral? If so—include the information. Sometimes getting rid of binary assumptions was the approach; sometimes adding information specific to trans, nonbinary, and intersex patients was the approach. And sometimes both.

Our review also addressed sexist biases and stereotypes around disease presentation and social roles. For example, dated frameworks that pathologize female athletic activity had persisted in some cases. Sometimes we were trying to correct a gender-based invisibility (e.g. the existence of breast cancer and heart disease in all sexes) while challenging binary language. In one case, case authors had presented the “surprising possibility” that a patient might not be heterosexual. The case then unfolded on the assumption that the patient was straight after all. In the revised case, where all patients have their diverse sexual orientations stated, and we assume diverse sexual orientations among our faculty, staff, and students, the “othering” involved in this kind of awareness-raising was clear. We “made” the patient’s new relationship a same-sex one, and as the patient in the case was African Nova Scotian, we discussed the scenario with community partners, who were comfortable with the intersectionality and provided some insight into community ways of thinking about changes in core relationships across the lifespan.

We resisted artificially fixing sexual orientation by portraying how self-understanding sometimes changes over time, or how some reject labeling themselves or disclosing their self-understanding to others. We sometimes drew on relationships between expansive gender identities and expansive sexual orientations. The social identity statements in our cases are not meant to be recommendations for charting or indications of how to take a social history, and this was particularly important where patients may well have concerns that health care is not a safe context for them.

Even in a province where gender identity is less of a political wedge issue than it is in other parts of the country, we had to deal with some significant headwinds in this part of our project. A newly formed student group is already at work on recommendations for improving the work that the Working Group did. A constant concern of project participants (myself included) is that the revisions were completed by a temporary working group that was then disbanded. Follow-up is to be carried on within the (evolving) structure of the program. For Black and Indigenous health, there are now specific faculty persons responsible to carry on that work. For socio-economic status, newcomer health, and sexual orientation/gender identity, there are not.

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Lynette Reid is an associate professor in the Department of Bioethics at Dalhousie University.