Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Protocols as curriculum? Learning health advocacy skills by working with transgender patients in the context of gender-affirming medicine


Evidenced by leading journals in academic medicine, health professions education has taken up the call to advance equitable healthcare. One pressing area where gaps and inequities are apparent is transgender (trans) people’s access to gender-affirming medicine such as hormones and surgeries. Reasons for the dire state of care include education gaps. While specific content knowledge has been identified as lacking in medical school curricula, less research has focused on the complex social practices required of clinicians and educators working in gender-affirming medicine, and how these skills are learned through practice. In order to inform health professions education in this key area of need, we conducted a study to better understand the social practices, and the learning that occurs therein, of gender-affirming medicine. We identified the work processes of 22 clinicians, clinician-educators, trans patients, and clinical care administrators with attention to how policies and protocols influenced practice, learning, and teaching. The results of our study elucidate: (1) that practicing of gender-affirming medicine is strictly dictated by standardized assessment protocols, which serve as a form of curriculum; and (2) how health professionals learn and teach health advocacy as a form of resistance to protocols identified as creating inequities. These findings suggest an opportunity to view protocols—and their inherent limitations—more deliberately as teaching and learning tools, specifically for learning advocacy.

This is a preview of subscription content, log in to check access.


  1. Alberti, P. M., Sutton, K., Cooper, L. A., Lane, W. G., Stephens, S., & Gourdine, M. (2018). Communities, social justice, and academic health centers. Academic Medicine,93(1), 20–24.

  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

  3. Asscheman, H., Giltay, E. J., Megans, J. A., de Ronde, W. P., van Trotsenburg, M. A., & Gooren, L. J. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology,164(4), 635–642. https://doi.org/10.1530/EJE-10-1038.

  4. Bauer, G. R., Scheim, A. I., Deutsch, M. B., & Massarella, C. (2014). Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Annals of Emergency Medicine,63(6), 713–720.

  5. Berg, M. (1997). Problems and promises of the protocol. Social Science and Medicine,44(8), 1081–1088.

  6. Bouman, W. P., Richards, C., Addinall, R. M., Arango de Montis, I., Arcelus, J., Duisin, D., et al. (2014). Yes and yes again: Are standards of care which require two referrals for genital reconstructive surgery ethical? Sexual and Relationship Therapy,29(4), 377–389.

  7. Bourgois, P., Holmes, S. M., Sue, K., & Quesada, J. (2017). Structural vulnerability: Operationalizing the concept to address health disparities in clinical care. Academic Medicine,92(3), 299–307.

  8. Budge, S. L. (2015). Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients. Psychotherapy,52(3), 287–297.

  9. Cavanaugh, T., Hopwood, R., & Lambert, C. (2016). Informed consent in the medical care of transgender and gender-nonconforming patients. AMA Journal of Ethics,18(11), 1147–1155.

  10. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism,13(4), 165–232.

  11. Costa, R., & Colizzi, M. (2016). The effects of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: A systematic review. Neuropsychiatric Disease and Treatment,12, 1953–1966.

  12. Coutin, A., Wright, S., Li, C., & Fung, R. (2018). Missed opportunities: Are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents. Canadian Medical Education Journal,9(3), e41–e55.

  13. Deutsch, M. B. (2012). Use of the informed consent model in the provision of cross-sex hormone therapy: A survey of the practices of selected clinics. International Journal of Transgenderism,13(3), 140–146.

  14. Dewey, J. M. (2013). Challenges of implementing collaborative models of decision making with trans-identified patients. Health Expectations,18, 1508–1518.

  15. Dobson, S., Voyer, Stephane, & Reghr, G. (2012). Perspective: Agency and activism: Rethinkinghealth advocacy in the medical profession. Academic Medicine, 87(9), 1161–1164. https://doi.org/10.1097/ACM.0b013e3182621c25.

  16. Dowshen, N., Nguyen, G. T., Gilbert, K., Feiler, A., & Margo, K. L. (2014). Improving transgender health education for future doctors. American Journal of Public Health,104(7), e5–e6.

  17. Ehrbar, R. D., & Gorton, R. N. (2010). Exploring provider treatment models in interpreting the standards of care. International Journal of Transgenderism,12(4), 198–210.

  18. Giffort, D. M., & Underman, K. (2016). The relationship between medical education and trans health disparities: A call to research. Sociology Compass,10, 999–1013.

  19. Grace, D. (2013). Transnational institutional ethnography: Tracing text and talk beyond state boundaries. International Journal of Qualitative Methods,12, 587–605.

  20. Hubinette, M., Dobson, S., Scott, I., & Sherbino, J. (2017). Health advocacy. Medical Teacher,39(2), 128–135.

  21. Jaffee, K. D., Shires, D. A., & Stroumsa, D. (2016). Discrimination and delayed health care among transgender women and men: Implications for improving medical education and health care delivery. Medical Care,54(11), 1010–1016.

  22. Kosenko, K., Rintamaki, L., Raney, S., & Maness, K. (2013). Transgender patient perceptions of stigma in healthcare contexts. Medical Care,51(9), 819–822.

  23. MacKinnon, K. R. (2018). Pathologising trans people: Exploring the roles of patients and medical personnel. Theory in Action,11(4), 74–96.

  24. LaDonna, K. A., Field, E., Watling, C., Lingard, L., Haddara, W., & Cristancho, S. M. (2018). Navigating complexity in team-based clinical settings. Medical Education, 52(11), 1125–1137. https://doi.org/10.1111/medu.13671.

  25. Martimianakis, M. A., & Hafferty, F. W. (2016). Exploring the interstitial space between the ideal and the practiced: Humanism and the hidden curriculum of system reform. Medical Education,50(3), 278–280.

  26. Martin, D., Hum, S., Han, M., & Whitehead, C. (2013). Laying the foundation: Teaching policyand advocacy to medical trainees. Medical Teacher, 35, 352–358. https://doi.org/10.3109/0142159X.2013.770453.

  27. Moffett, P., & Moore, G. (2011). The standard of care: Legal history and definitions: The bad and good news. Western Journal of Emergency Medicine,12(1), 109–112.

  28. Mykhalovskiy, E., & Farrell, K. (2005). ‘Nothing happens in medical school that prepares you for working with anyone who’s different’: Informal learning and socio-clinical knowledge amongst family physicians. Research in the Sociology of Healthcare,23, 159–181.

  29. Ng, S. L., Bisaillon, L., & Webster, F. (2017). Blurring the boundaries: Using institutional ethnography to inquire into health professions education and practice. Medical Education,51, 51–60.

  30. Ng, S. L., Kinsella, E. A., Friesen, F., & Hodges, B. (2015). Reclaiming a theoretical orientation to reflection in medical education research: A critical narrative review. Medical Education in Review,49, 461–475.

  31. Parker, D. L., & Lawton, R. (2000). Judging the use of clinical protocols by fellow professionals. Social Science and Medicine,51, 669–677.

  32. Patel, M. S., Davis, M. M., & Lypson, M. L. (2011). Advancing medical education by teaching health policy. The New England Journal of Medicine,364(8), 695–697.

  33. Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher,31(8), 685–695.

  34. Sharma, M., Pinto, A. D., & Kumagai, A. K. (2018). Teaching the social determinants of health: A path to equity or a road to nowhere? Academic Medicine,93(1), 25–30.

  35. Shiau, S. J., & Chen, C. H. (2008). Reflection and critical thinking of humanistic care in medical education. Kaohsiung Journal of Medical Science,24, 367–372.

  36. Shuster, S. M. (2016). Uncertain expertise and the limitations of clinical guidelines in transgender healthcare. Journal of Health and Social Behavior,57(3), 319–332.

  37. Smith, G. W. (1990). Political activist as ethnographer. Social Problems,37(4), 629–648.

  38. Smith, D. E. (1999). Writing the social: Critique, theory, and investigations. Toronto: University of Toronto Press.

  39. Smith, D. E. (2005). Institutional ethnography: A sociology for the people. Oxford: Rowman Altamira.

  40. Snelgrove, J. W., Jasudavius, A. M., Rowe, B. W., Head, E. M., & Bauer, G. R. (2012). “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research,12(10), 110.

  41. Tomita, K. K., Testa, R. J., & Balsam, K. F. (2018). Gender-affirming medical interventions and mental health in transgender adults. Psychology of Sexual Orientation and Gender Diversity, 6(2), 182–193. https://doi.org/10.1037/sgd0000316.

  42. Turner, S. M. (2006). Mapping institutions as work and texts. In D. E. Smith (Ed.), Institutional ethnography as practice (pp. 139–161). Lanham, MD: Rowman & Littlefield.

Download references


We thank Dr. Ayelet Kuper for reviewing and providing commentary on an earlier draft of this manuscript. We also extend gratitude to our reviewers, and to Dr. Geoffrey Norman, for providing extensive thoughtful feedback on our original submission within the peer-review process.

Author information

Correspondence to Kinnon R. MacKinnon.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

MacKinnon, K.R., Ng, S.L., Grace, D. et al. Protocols as curriculum? Learning health advocacy skills by working with transgender patients in the context of gender-affirming medicine. Adv in Health Sci Educ 25, 7–18 (2020). https://doi.org/10.1007/s10459-019-09899-0

Download citation


  • Health advocacy
  • Health professions education
  • Institutional ethnography
  • Protocols
  • Standards of care
  • Transgender