Affirming and Inclusive Care Training for Medical Students and Residents to Reduce Health Disparities Experienced by Sexual and Gender Minorities: A Systematic Review

Purpose: Providing inclusive and comprehensive gender-affirming care is critical to reducing health disparities (gaps in care) experienced by sexual and gender minorities (SGM). Currently, little is known about how medical students and residents are being trained to address the health needs of SGM persons or of the most effective methods. Methods: We conducted a systematic review of the research literature from 2000 to 2020 on the effectiveness of teaching medical students and residents on knowledge, attitudes, and skills in addressing the health of SGM persons and the strength of the research sample, design, and methods used. Results: We identified a total of 36 articles that assessed the impact of medical student and resident education on knowledge, comfort, attitudes, confidence, and skills in working with SGM patients. All studies utilized quasi-experimental designs, and found efficacious results. No study examined the impact of training on patient outcomes. Conclusion: Future studies will need to be powered and designed to assess the impact of training on patient outcomes.


Introduction
Sexual and gender minorities (SGM) experience a higher burden of health disparities compared to their heterosexual/cisgender counterparts (we use the term SGM throughout to represent all the acronyms used to represent lesbian, gay, bisexual, transgender, and queer people). 1 Some of the poorer health outcomes observed in SGM populations appear to be associated with increased prevalence of bullying, emotional dis-tress, alcohol and other drug use, intimate partner violence, sexually transmitted infections, including human immunodeficiency virus, and cancer. [1][2][3][4][5][6][7][8][9][10] In addition, transgender people, in particular, experience unique barriers to receiving both routine and gender-affirming health care such as acquiring hormones and genderaffirming surgeries. [11][12][13][14][15] Differences in access and utilization of care by patients who identify as sexual or gender minorities and the stress arising both from implicit and explicit bias, may be tied to discrimination as well as a limited knowledge of their specific needs or a lack of experience during medical training or practice. [16][17][18][19][20][21][22][23] A survey of 132 medical schools in the United States found the median time of training medical students in working with lesbian, gay, bisexual, and transgender (LGBT) patients is 5 h. 24 The barriers to implementing affirming training for SGM patients are at least partially driven by a lack of expertise among medical education faculty and preceptors. 1 This is true of undergraduate medical education (UME), and even more pronounced in graduate medical education (GME). [25][26][27] However, in 2007, the Association of American Medical Colleges (AAMC) published a report and provided recommendations acknowledging the need for medical students to receive additional training to more effectively manage the care of SGM patients to ensure the provision of ''excellent, comprehensive care.'' Furthermore, the AAMC report 28 and two reviews on the status of medical student training 22,23 noted the importance of affirming care training to reduce the disparities faced by this population.
Inclusive care for gender-diverse patients and genderaffirming care for transgender patients are designed to improve the health outcomes of SGM persons. Both approaches affirm the identities of SGM by making the health care system a more welcoming and inclusive environment.

Methods
We conducted a systematic review using PRISMA guidelines of educational interventions to identify original studies that focused on education to increase knowledge and comfort, as well as improve the attitudes, confidence, and skills of medical students and residents working with SGM patients.

Search strategy
We conducted database searches of Google Scholar, PubMed, OVID, ERIC, SCOPUS, Web of Science, CINAHL, PsycInfo, and MedED Portal, between 2000 and 2020 using Covidence software (Covidence Org, Melbourne, Australia). The full search strings for each database are provided in Table 1. All searches included some combination of the following terms (words used to represent affirming care separated by OR) AND (medical students OR residents OR medical education OR training OR curriculum). To ensure the most up-todate articles were included in the search, we established a system within each database to alert the team to any new article published since the end of the active search.

Eligibility criteria and study selection
A total of 27,090 articles were identified initially. This number was reduced to 21,063 using EndNote, to identify all duplicates and materials not published in peerreviewed journals (i.e., book chapters, serials, etc.). The remaining article abstracts were reviewed using the following inclusion criteria: (a) published between January 2000 and June 2020; (b) designed as a research intervention of medical education/curriculum; (c) reported quantitative or qualitative results of the effect of the educational interventions; (d) published in English; and (e) targeted medical students and/or resident physicians. The exclusion criteria used for screening the abstracts were as follows: (a) articles that focused on continuing education in genderaffirming care for health care provider and (b) articles that described gender-affirming care curriculum without implementation.
At this stage of the review, 12 additional articles were removed because they either lacked a focus on medical education or did not include an evaluation of the described educational interventions in the study. After LGBT OR Sexual Orientation the full text review, 36 articles were left to be included in this systematic review. Figure 1 provides a PRISMA diagram of each step in our systematic review process.

Data extraction
Data were extracted from all articles included: subject description, study design, sample/sample size, educational intervention, and intended outcome, as well as a summary of the findings and conclusions (all data  are summarized in Table 2).

Quality assessment
The quality of each study was evaluated according to published recommendations 65 using a rubric ranking article from 1 (low quality) to 5 (high quality). Each publication was assigned to two reviewers for independent ratings. When the ratings differed, the articles were assigned to an additional reviewer to provide a third perspective and help the original dyad reach consensus. Studies that used a nonexperimental or pre-experimental design were rated as 1 or ''Weak Quality,'' but this ranking also included studies that used only a qualitative or cross-sectional design. Studies that employed a pre-test/ post-test design only without a control or comparison group were rated as a 2-3 or ''Moderate Quality.'' Studies rated as 4 or 5 or ''Strong quality'' included a pre-/post-control design or a longitudinal design with a control group, coupled with assessments of changes in behavior/skills, a large sample size, or a high participation rate of students/residents. Studies were not excluded from the review based on research design; instead, their limitations (including lack of research rigor) were identified and rated.

Data analysis and synthesis
Meta-analysis of the studies reviewed was precluded by the lack of heterogeneity of research designs, assessment measures, and samples. Instead, a qualitative analysis of the training approaches and related findings was conducted.

Results
A total of 27,090 articles were initially identified with 36 remaining after 3 stages of review. Articles at this stage assessed the impact of educational evaluations in terms of course satisfaction, knowledge increases, changes in attitudes beliefs, trainee comfort when treating SGM patients, and finally skill acquisition. Table 2    Regarding etiology of gender identity, there was a significant increase of correct responses. Regarding cross-sex hormone therapy, there was also a significant increase in correct responses Brief didactic exposure to evidencebased gender identity training is associated with increases in knowledge.

Study characteristics
The small number of participants in the samples for both studies limit the generalizability of the findings (continued) Students' preparedness and comfort in providing care to the GSM group showed significant improvement. The intervention session improved students' knowledge and confidence to provide care; however, the response rate to the survey was low.
(continued) While knowledge and self-rated skill were significantly higher from pre-to post-test, the action plans associated with the case-studies indicated a disconnect between knowledge and actual skill. This could be due to the students being in pre-clinical years and not having experience working directly with patients.
(continued) Responses to the question regarding preparedness were positive, as were the qualitative responses that were reported.
The response rate was low, and the survey used to evaluate the course was not robust.    Knowledge, attitudes, and skills regarding work with GSM patients increased significantly after attending the certificate program training. Increases in agreement that same-sex sexual behavior and transgender identities were natural expressions of sexuality and gender increased similarly from pre-to post-test.
The social cognitive theory model of training used in this study exposed students to role models of affirming care and provided opportunities to practice. Exposure to this model of training was associated with improved outcomes even among those who did not complete all modules. Furthermore, the course was developed using local experts with existing expertise, and as such was a low-cost intervention.   studies reviewed, 27 included a sample of medical students and interprofessional cohort of students (i.e., nursing, social work, physical therapists, and health care administration students) only, 6 articles sampled residents only, and 3 assessed a combination of medical students and residents. The educational/training methods used a variety of methodologies, including didactic sessions, patient panels, standardized patients, small group discussions, and student-delivered presentations. The duration of trainings described in the studies ranged from 1 h to 10 weeks. Pre-and post-test designs were by far the most common research strategies used in the studies (n = 31), followed by post-test only evaluation (n = 4). One study using the Kern model, a six-step curriculum development approach, which ends with an evaluation of the developed curriculum. The quality ratings of the studies are summarized in Table 2.
Quality ratings of studies Studies included in the review had an average research quality rating of 2.4 on a five-point scale. Although the majority of studies in the review included both pre-and post-exposure evaluations, some studies contained no control or comparison group or only post-exposure evaluations. These were generally rated at a ''2'' due to threats to validity. One study was rated at a ''4'' owing largely to the use of a natural comparison group. 54 Three studies received a ''1'' rating due to the use of a post-test-only design (no control group) or a poor description of the research methodology. 53,59,61 No study received a rating of 5 as none utilized rigorous study designs. While the study ratings were moderate to low regarding study design quality, we included all articles as these types of designs are not uncommon in educational settings and capturing all the approaches to affirming care training was an important part of this project.
Pedagogical methods employed in the study Didactic training was the most frequently used pedagogical method, either as a stand-alone strategy (n = 6) or in combination with other methods (n = 19). The next most commonly used approach was group discussion, both in small and large groups (n = 17); in all cases, these interventions were combined with one or more other methods. Patient panels (n = 12) and case study reviews (n = 9) were commonly used as well, but always in combination with other approaches. Mock interviews with standardized patients or with fellow students/residents were employed in eight of the studies.
Four studies reported training outcomes of clerkship rotations as well as online modules. A problem-based learning activity was used in two studies and the remaining study included a student-led presentation. The phrase ''Sexual and Gender Minority (SGM)'' was used to describe patients in two of the studies, 31,38 in contrast to different versions of ''LGBTQ + '' in the remainder of the articles.
Seven assessment domains and 9 pedagogical approaches were identified across the 32 studies, but a study comparison (or meta-analysis) was not feasible because each study employed varying combinations of pedagogy and evaluation. However, multiple pedagogical approaches were found to be more effective among the studies that reported significant positive changes on multiple measurements combined. For instance, the Berenson et al.'s 33 study assessed knowledge regarding transgender health disparities and increasing confidence in providing hormone therapy to transitioning patients in second year medical students after providing content through a combination of didactic lectures, patient panels, and small group discussions. The authors found significant gains in both domains with similar results matching multimodal approaches to multiple assessment domains had similar positive outcomes. 33,40,56,60 Of the four interventions that included a clerkship rotation or resident rotation, three reported significant positive changes on a multiple assessment axis. Bakhai et al. 32 reported significant increases in knowledge, comfort, and skills in communicating and conducting physical assessments with SGM. Park and Safer 52 reported similar findings, significantly increasing knowledge confidence, and attitudes in working with transgender patients. The two remaining studies of rotation evaluation reported positive increases in two domains relative to SGM patients (knowledge and confidence). 63,66 Time allotted for training ranged from 1 to 11 h (excluding rotations that lasted for 4 or 8 weeks). While some curricula with longer durations ( > 9 h) had positive outcomes in more than one measurement domain, 34,56 others did not. 29,67 Several of the shorter trainings ( < 10 h) resulted in improvement on multiple evaluation axes. 30,33,36,37,39,42,44,45

Discussion
Our systematic review summarized the findings of 36 training interventions (UME and GME) and identified training approaches with positive outcomes in regard to increased knowledge, comfort, and skill, as well as improved attitudes of students in working with SGM patients. Satisfaction with SGM training materials was also reported in our review. In general, students reported high levels of satisfaction with SGM training material. Limited time allotted to gender-affirming care module in the curriculum is one of the constraints as learners will have less protected time to complete the module. 38,63,66 Therefore, several studies recommended an increase in the amount of time that is dedicated to the delivery of affirming/inclusive care to SGM patients in both the UME and GME curricula. 29,32,34,35,42,44,45,57 Furthermore, long-term follow-up to measure the efficacy of curricular interventions (retention of knowledge, skills, comfort, confidence, attitudes, etc.) and make the interventions generalizable to other health care professions is another barrier for inclusive and affirming care training during UME. 38,[60][61][62][63]66 The impact of curricular interventions on various domains is given below.

Impact of interventions on satisfaction
We also assessed participant satisfaction with the training interventions for our systematic review. Five studies that assessed satisfaction utilized 5-point Likert scale surveys as is typical of course evaluations, 31,33,40,49,55 while one used a 10-point scale. 67 All the interventions received generally high or positive ratings by participants in terms of satisfaction, with two studies reporting 90% or higher satisfaction rates. 49,55 These evaluation scores reflect high student satisfaction with affirming care training. High reported satisfaction (seeing the value in knowledge) is an important prerequisite to knowledge construction in that, it is an indication of student engagement (response rate). 32,42,59 Impact of interventions on knowledge Knowledge was the most frequently assessed outcome of affirming and inclusive care training. Short duration, didactic training in our review was shown to be effective, as well as multimodal approaches delivered over longer periods. Twenty-six of the articles reviewed included an assessment of student/resident knowledge acquisition. The measurement of knowledge covered several domains, including clinical knowledge, cultural competency regarding SGM patients, health disparities that SGM patients face, and health policies affecting SGM patients. Nine of the articles focused on knowledge acquisition about SGM. Twelve of the articles measuring knowledge focused on transgender patients. [30][31][32][33]38,43,61,63,64,[66][67][68] Two articles examined knowledge acquisition regarding hormone therapy for transgender patients. 39,56 Both reported significant knowledge gains. With one exception, the studies evaluating knowledge increases indicated significant positive improvement from pre-to post-test, save 1, in which only 2 of 16 knowledge measures improved from pre-to post-test. 44 Intervention impact on attitudes and beliefs Of the articles reviewed, eight included assessments of changes of attitudes and beliefs relative to care of SGM patients. 29,34,36,43,44,53,56,64 Six of the interventions targeted medical students only, primarily those in the pre-clinical years (years 1 and 2), while one intervention targeted resident physicians only 58 and one a combination of residents and students. 36 Delivery modalities varied across each intervention; however, most of the interventions were incorporated into existing curricula within the learning program.
Six of the studies highlighted interventions that focused on student/resident attitudes toward SGM health issues. Although knowledge about gender-affirming care increased, improving student attitudes regarding working with SGM patients proved to be a more difficult task in the studies we reviewed. One of the articles reported no significant change in attitudes regarding SGM health after the intervention. 29 Another demonstrated positive attitude changes regarding work with same-sex couples, 43 and two articles reported significant increases in general attitudes toward working with SGM patients. 56,64 Kelley et al. found only a slight improvement in student attitudes regarding work with SGM patients. 44 Finally, one article that used a qualitative assessment of student attitudes found students appreciated the opportunity to discuss unconscious bias regarding working with SGM patients. 53 A final article not only reported improvement in attitudes toward sexual behavior of SGM patients but also reported decreases in student attitudes toward conducting sexual histories with SGM patients. 34 The two articles addressed attitudes in working with transgender patients. The first found significant decreases in transphobic attitudes post-intervention. 34 Cherabie et al. conducted the only intervention that extended beyond student learners and included resident faculty. 36 Overall, there was a significant improvement in attitudes toward transgender health issues when comparing the pre-and immediate postintervention surveys. Of the three studies that did report significant changes in both attitudes and beliefs, two were longer than 10 h in duration, 34,56 while one was 2 h in duration and included multiple pedagogical approaches (patient panels, case studies, and small group discussions). 44 However, these significant gains were not maintained at a survey conducted 90 days post-intervention. The one study that examined longer term outcomes (90 days) indicated that attitude improvements may not be maintained across time. 36 These findings suggest that training intended to improve attitudes or challenge problematic beliefs among trainees may need to be longer and utilize more interactive approaches and direct exposure to SGM. More studies are needed, however, to clarify the critical elements of medical training that lead to improved attitudes and to examine reasons for the attrition over time, as in the one study that reported an extended assessment, most of the attitude change noted at immediate post-training assessment was lost at the 30-day follow-up assessment.

Impact of interventions on physician comfort
Few studies have evaluated the impact of training interventions on improving the comfort level of medical students working with transgender clients. 36,44,52,54 All the interventions that measured comfort resulted in significant improvement post-training. 32,36,37,48,52,54,58 Interventions have included delivery of didactic content, usually providing information about transgender experiences, delivery of care and hormone regimens, 36,52,54 and clinical experience. Only two 36,37 of these seven studies reported using a didactic approach as the sole pedagogical method employed, while the others reported patient panels, rotations, small groups, and standardized patients. For example, Sawning et al. examined the effect of added training in a fourth year Transgender Medicine elective, with students exposed to transgender patients seeking medical and surgical treatment. 56 At the Boston University School of Medicine, a dedicated lecture focused on treatment regimens and monitoring therapy for transgender people was given to second year students during their endocrinology unit. Questionnaires were administered three times. The first survey was given 1 month before the lecture and two surveys were administered 1 month and 90 days after the lecture. Before the lecture, 38% of second year students expressed discomfort at the idea of providing transgender care for a patient. Immediately after the training, this decreased to 12%. 54 At East Tennessee State University, participation in a half-day integrated grand rounds, including presentations by basic science and clinical faculty, patient presentations, and small group discussions, resulted in improved comfort interacting with transgender patients, increased knowledge base for providing care to the transgender population, and reduced the preference not to treat transgender people. Students also had improved scores on approval of the single statement ''learning from transgender patients will help me be a culturally competent medical student and future physician.'' 36 A 1-h didactic lecture on transgender medicine at the University of Kansas School of medicine included presentations by transgender people to faculty, residents, and medical students. This was evaluated with pre-and post-surveys (one immediately following the lecture and another at 90 days). Comfort levels significantly increased from pre-to post-survey and remained high at 90 days. Questions included ''I feel comfortable using language that respects gender identity'' and ''I feel comfortable discussing options for gender confirming hormone therapy.'' 36 Only one study evaluated change in comfort after a clinically based intervention. In the Boston University School of Medicine medical elective in transgender medicine for fourth year medical students, students were given pre-and post-elective surveys that included the question, ''What is your level of comfort with providing care to a transgender patient?'' Although this was a small sample size, the percentage of medical students who reported a high level of comfort providing care for transgender patients significantly increased from 45% (9/20) to 80% (16/20) post-intervention. 52 While training strategies that included exposure to SGM persons or being exposed to the beliefs of others as happens in small group discussions might hold particular promise in improving comfort, our findings are not conclusive on this point, but do support further study of these interventions.

Impact of interventions on confidence/readiness
All the studies that measured confidence post-training reported increases. 30,31,33,40,42,47,52,55,66 The studies were delivered at different points in student training as well as in graduate medical training. Various modalities ranging from classroom presentations, workshops, patient panels, online training sessions, including videos, were used across the different studies and all resulted in self-rated improved confidence.
One study focused on providing transgender health care for adults, adolescents, and children. 30 The intervention included a 1-h educational session conducted by a member of the transgender community targeting third year medical students, general practitioners, and internal medicine physicians. The content delivered in the interventions included transgender terminology, exploring the biological basis (genetic, genital, and neurological) of gender identity and diversity, the lived experience of a transgender individual, and their relationship with health care providers, supportive care for children, and other family members, adolescent puberty blockade, adult transition care, fertility options, and hormonal monitoring and surgery. The follow-up post-intervention survey revealed increasing confidence among participants in administering health care to transgender individuals.
In a similar manner, the Salkind et al.'s study incorporated a visit from a transgender patient in a mandatory teaching program on SGM health. 55 This educational intervention developed and delivered in collaboration with a representative from the SGM community was found to enhance students' confidence in using appropriate terminology during SGM patient encounters and also for clinical assessment of patients from these vulnerable populations.
Aside from faculty, student-driven interventions also yielded fruitful results. One of the student-led intervention studies was aimed at enhancing the sexual historytaking skills of the first year medical students. 31 The intervention was developed through collaboration between faculty and students. The intervention module that was integrated in the clinical skills course consisted of three modules: an e-lecture (14 min) on sexual history taking, a standardized patient interview (35 min), and a debrief (20 min) of standardized patient activity. The assessment appeared to improve confidence among students to tackle sexual orientation and gender identity after intervention.
Another student-led intervention (by second and fourth year medical students) was developed to enhance the understanding of first year medical students about SGM health issues. 42 The intervention session included a presentation, patient panel, and small group discussions. The intervention resulted in significant gains both in student knowledge of SGM and in confidence in providing care to SGM patients. Of the three intervention modalities, the patient panel was greatly appreciated by the participants as it helped them understand the clinical perspective. A similar student-led intervention approach was evaluated that included a classroom presentation on transgender health disparities, a small-group session viewing a physician, transgender patient communication, and a large group transgender patient-panel. 33 These student surveys also indicated greatly improved student confidence caring for transgender patients.
Although most of the studies involved more advanced students, an early introduction to SGM health in medical education also appears to benefit medical students. The impact of an interactive multimodal workshop primer on SGM health comprising a Power-Point presentation, sexuality survey, videos of providerpatient encounters, and community-based resources given to first year medical students was assessed in one study. 40 Student evaluations showed an increase in confidence comprehending multiple aspects of human sexuality, health issues for SGM patients, and promoting affirming care.
Another study sought to improve the clinical care of transgender patients through longitudinal curricular changes by adding a section on gender identity in an M1 Physiology course coupled with sessions on transgender hormone management in the M2 Endocrinology course and M4 clinical elective. 52 Post-intervention surveys revealed a significant improvement in students' knowledge and confidence regarding management of transgender patients. An additional study demonstrated an increase in confidence and readiness of students to care for transgender patients after introducing a didactic component on basic science principles applied to transgender patients and then staging a mock encounter between a health care provider and a patient with gender dysphoria. 47 Very few studies have focused on training received on SGM health care in GME curricula. In one study, an intervention was evaluated for fellows and learners in post-graduate medical education. 67 The intervention included the following four curriculum modules: (a) cultural humility introduction and patient introduction; (b) gender and sexual orientation identity development; (c) discussion of gender dysphoria and transgender youth health using a new patient case study; as well as a debate to explore SGM-related health and social policy issues. The learners expressed 324 COOPER ET AL.
increased confidence in identification of community resources, understanding of cultural humility, adolescent health, and interprofessional training and collaboration.
In a novel application of the Implicit Association Test, assessing one's personal implicit bias toward SGM patients was employed as part of a curriculum with study objectives taken from the AAMC and the Fenway guide to SGM health. 60 The internal medicine residents who took this course demonstrated increased knowledge and confidence in providing care to SGM patients.
Pediatric and psychiatric transgender care also require an additional array of expertise and skills. Vance et al. focused on enhancing the effect of training modules on self-perceived, objective knowledge, and clinical self-efficacy of pediatric interns, psychiatry interns, M4 medical students, and nurse practitioner students. 63 The intervention included transgender curriculum training at different intervals for a month. Post-tests showed that online learning was an effective intervention tool to enhance transgender-related knowledge and confidence in providing care to SGM patients. All the aforementioned studies yield promising findings, but as confidence is often used as a proxy measure for actual skill acquisition, further studies are needed to determine the correlation of selfreported confidence and actual skill.

Impact of intervention on skills/competency
Overall, six studies measured the impact of the intervention on student skill level treating SGM patients. 32,44,46,59,61,62 One study used a standardized patient to measure student's skill acquisition treating SGM patients. 61 In this study, 80% of students agreed that the curriculum increased their skills for working with transgender patients. All six of the studies showed significant increases in participant skills; however, five 32,44,46,59,62 of the studies' main measure of skill was participant knowledge and awareness of the skills necessary to treat SGM patients, not direct skills measurements. Standardized patients' interviews were used as part of the training in the Bakhai et al.'s 8week pediatric clerkship study, but again no objective measure of how those skills improved was assessed, only self-reported preparedness on the skills necessary. 32 An appraisal of various training domains revealed that for the conservation of valuable curriculum time, identifying training approaches that achieve desired goals is critical and early foundational exposures to affirming and inclusive care might well be accomplished through short didactic training. This is an area for further study, as an actual improvement in physician skills is the prerequisite to improved care for SGM patients. [68][69][70] Studies that examine student and resident skill objectively are sorely needed in the affirming and inclusive care training literature.

Limitations
This review provides a menu of potential measurement approaches for student knowledge, attitudes, comfort, confidence, and most importantly skills that can be used in further studies having a rigorous (with enough statistical power) experimental design. We did not identify any study that used either cross-sectional or longitudinal or case-control or randomized or retrospective experimental designs to evaluate the impact of affirming and inclusive care training modalities on knowledge, comfort, and skills of trainees in UME or GME.

Conclusion
Several effective training approaches were identified, which improved student knowledge and attitudes toward providing affirming and inclusive care for SGM persons. Attitude changes, however, were found to require more interactive exposure to the SGM population. This review did not identify any strategy for improving attitudes and change beliefs toward SGM persons over time. Results suggest that comfort, confidence, and skills in providing inclusive and affirming care are better achieved through practice (clerkships and rotations) or mock practice (role play, case studies, and standardized patients) than didactic approaches only.
There is a clear need for more rigorous study of affirming and inclusive care training that assesses changes in knowledge, attitudes, and skills over extended periods beyond post-training. In addition, there is a clear need to include affirming and inclusive care training in UME, GME, and allied health professions. In addition, there is a need to assess training effectiveness of teaching students to provide affirming care to SGM persons on patient outcomes. There currently is a dearth of such studies in the published literature.

Authors' Contributions
All authors contributed to the conceptualization, and conducting of the study, analysis of findings, interpretation, writing, and editing of this article.