When Affirming Care Training Disappears, Simulation Has to Fill the Gap

Sixty percent of residency program directors report that their programs have no clinical rotation where residents directly work with transgender patients (Baylor University Medical Center Proceedings, 2023). In stable times, that number would be a problem. In 2026, with the federal government actively pulling funding from affirming care programs and institutions second guessing what they're even allowed to teach, it's something worse. A training crisis accelerated by federal policy.

This is the backdrop for work our team is presenting at the International Pediatric Simulation Society meeting in Rome this May. Gillian Brennan, Vinod Havalad, and colleagues developed an AI simulation approach for transgender communication training in pediatrics, built for a moment when traditional training pathways are contracting.

The training gap is measurable

The data here isn't ambiguous. A multicenter cross sectional study of OB-GYN and family medicine residents found that 62.4% had received no health education specifically tailored to transgender individuals. Among those surveyed, 68.3% reported inadequate knowledge of the clinical implications of gender affirming hormone therapy, and 74.1% said the same about gender affirming surgeries (Healthcare, 2025). Internal medicine tells a similar story: 97% of residents say transgender medical issues are relevant to their practice, but only 45% have had any prior education on the topic (Journal of General Internal Medicine, 2017).

Medical schools aren't filling this gap either. The median amount of LGBTQ+ specific education across U.S. and Canadian medical schools is 11 hours total, up from 5 hours in 2011 (Medical Education Online, 2024). That sounds like progress until you compare it to expert recommendations: 10 required hours, 25 supplemental hours, and clinical exposure to at least 35 LGBTQ+ patients during training. Nobody is close.

And these numbers predate the current federal policy environment. In January 2025, Executive Order 14168 directed federal agencies to cease funding for gender affirming care and required institutions receiving federal research or education grants to end affirming care for individuals under 19. A week later, Executive Order 14187 specifically targeted what it called "chemical and surgical mutilation," directing agencies to withhold federal funding from providers offering puberty blockers, hormone therapy, or surgery to minors. HHS followed through by terminating more than 500 research grants worth over $350 million tied to gender affirming care and DEI research, including a Seattle Children's Hospital grant for an online education tool designed to reduce violence and mental health disorders among transgender youth (HHS grant termination records, 2025).

By December 2025, CMS proposed rules that would prohibit hospitals enrolled in Medicare and Medicaid from providing any gender affirming care to minors, even when billed to private insurance or paid out of pocket. A separate proposed rule would ban Medicaid and CHIP from covering these services entirely (Federal Register, December 2025).

The effect on training is direct. A 2025 analysis found that 36% of the 210 pediatric residency programs in the U.S. sit in states with legislation limiting gender affirming care, and 40% of 756 family medicine programs face the same constraint (Journal of Osteopathic Medicine, 2025). Programs in these states face institutional hesitation about what affirming care content they can include in curricula, and that hesitation has only deepened as federal funding threats have become concrete.

Why simulation fills a specific need here

The typical response to a training gap is "add a lecture." But affirming care communication is a practice problem. A resident who can define gender dysphoria on an exam may still freeze when a 14 year old's parents are asking hostile questions about their child's identity in a clinical encounter.

That's a communication problem. And communication problems only get better with practice.

Standardized patients have been the gold standard for this kind of training, and they should remain part of it. But SP programs face real constraints. Recruiting transgender standardized patients raises ethical questions about emotional labor and representation that researchers are still working through (PMC, 2025). Scheduling enough encounters for residents to build genuine comfort requires resources most programs don't have. And in the current climate, some programs have quietly reduced their affirming care SP encounters rather than face institutional pushback.

AI simulation adds a practice layer that's always available, where residents can work through affirming care conversations repeatedly, on their own time, without the scheduling constraints or political visibility that make traditional approaches harder right now.

The work Brennan and Havalad are presenting in Rome uses AI patients designed for specific pediatric affirming care scenarios. These are structured encounters mapped to the communication competencies residents actually need, built by clinicians who understand both the clinical content and the educational scaffolding required to make practice transfer to the bedside.

The uncomfortable truth about timing

There's something worth saying directly: the need for this kind of training tool exists partly because the federal government has made other approaches harder. When HHS pulls $350 million in research grants and CMS proposes cutting hospitals off from Medicare if they provide affirming care to minors, the chilling effect on training programs is predictable. Programs that might have expanded affirming care curricula are instead quietly shrinking them. We'd rather programs had comprehensive affirming care education with plentiful SP encounters and supportive institutional backing. That's the honest context.

But 60% of programs don't have a single clinical rotation for this. And 84.7% of residents want formal education in transgender care (Baylor University Medical Center Proceedings, 2023). The demand exists, and the supply is shrinking.

AI simulation gives residents structured practice with conversations they're going to have regardless of whether their program has formally prepared them. That practice, available on demand from any device, closes a gap that's widening in real time.

The Rome presentation lays out how this works in practice. We'll share more after the conference. For programs looking to build communication competency in affirming care without waiting for the political environment to settle, free early access is available at clinicalsim.ai/practice.