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It is essential for medical students to effectively communicate with patients of all gender identities. Nonverbal behaviors such as eye contact and nodding are key communication skills. Evaluating nonverbal behavior is one way to assess the quality of patient care, and examining providers’ behaviors while working with cisgender and transgender patients can identify potential biases linked to patient identity.


To evaluate nonverbal behavior, we analyzed video-recorded training sessions with medical students interviewing standardized patients who identified as cisgender or transgender women. All students identified as cisgender men or cisgender women. Ten nonverbal behaviors were rated from 1-7 using adapted nonverbal communication scales. We also observed whether nonverbal cues were perceived to detract from the encounter.


Average scores for nonverbal behaviors were similar between students working with cisgender and transgender patients. Nodding frequency showed the largest difference between cisgender (m=5.65) and transgender (m=4.93) patients. When considering student gender identity, men had lower facial expressivity and smiling frequency scores on average but higher scores for unnecessary silence compared to women across encounters. Detracting behaviors that negatively impacted the patient encounters were most likely to be self-touching/unpurposive movements (41%) and unnecessary silences (26%).


The consistency in nonverbal behavior during encounters with cisgender and transgender patients is encouraging. It is possible that LGBTQ health training in medical education contributed to this outcome; however, differences in verbal communication could be more important to health disparities for transgender patients. Additional practice with unpurposive movements and unnecessary silences could improve nonverbal communication skills.

Publication Date

Spring 2021


medical education; LGBTQ; communication; MERA


Medical Education

Comparing Medical Student Nonverbal Behavior With Cisgender And Transgender Standardized Patients