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From Patients to Providers: Changing the Culture in Medicine Toward Sexual and Gender Minorities

Mansh, Matthew; Garcia, Gabriel MD; Lunn, Mitchell R. MD

doi: 10.1097/ACM.0000000000000656
Perspectives

Equality for sexual and gender minorities (SGMs)—including members of the lesbian, gay, bisexual, and transgender communities—has become an integral part of the national conversation in the United States. Although SGM civil rights have expanded in recent years, these populations continue to experience unique health and health care disparities, including poor access to health care, stigmatization, and discrimination. SGM trainees and physicians also face challenges, including derogatory comments, humiliation, harassment, fear of being ostracized, and residency/job placement discrimination. These inequities are not mutually exclusive to either patients or providers; instead, they are intertwined parts of a persistent, negative culture in medicine toward SGM individuals.

In this Perspective, the authors argue that SGM physicians must lead this charge for equality by fostering diversity and inclusion in medicine. They posit that academic medicine can accomplish this goal by (1) modernizing research on the physician workforce, (2) implementing new policies and programs to promote safe and supportive training and practice environments, and (3) developing recruitment practices to ensure a diverse, competent physician workforce that includes SGM individuals.

These efforts will have an immediate impact by identifying and empowering new leaders to address SGM health care reform, creating diverse training environments that promote cultural competency, and aligning medicine with other professional fields (e.g., business, law) that already are working toward these goals. By tackling the inequities that SGM providers face, academic medicine can normalize sexual and gender identity disclosure and promote a welcoming, supportive environment for everyone in medicine, including patients.

M. Mansh is a fourth-year medical student, and investigator, Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group, Stanford University School of Medicine, Stanford, California.

G. Garcia is professor, Division of Gastroenterology and Hepatology, Department of Medicine, faculty advisor, Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group, Stanford University School of Medicine, and William and Dorothy Kaye University Fellow in Undergraduate Education, Stanford University, Stanford, California.

M.R. Lunn is clinical research fellow, Division of Nephrology, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, and founder, Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group, Stanford University School of Medicine, Stanford, California.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Mitchell R. Lunn, Division of Nephrology, Department of Medicine, University of California, San Francisco, School of Medicine, 521 Parnassus Ave., Suite C443, San Francisco, CA 94143-0532; telephone: (415) 476-2219; e-mail: mitchell.lunn@ucsf.edu.

The rights of lesbian, gay, bisexual, and transgender (LGBT) individuals have garnered national attention amidst a growing debate on the definition of marriage in the United States. These events have prompted critical analysis of how to address similar issues of equity in medicine. Sexual and gender minorities (SGMs), inclusive of all nonheterosexual and/or noncisgender individuals, continue to face unique health and health care disparities, including poor access to health care; increased incidence of a number of diseases, including certain forms of cancer, human immunodeficiency virus infection, and mental health disorders; and for those living in high-prejudice areas, a shorter life expectancy.1–3 A lack of inclusion and even explicit exclusion4 of these groups from clinical trials and epidemiological analyses has inhibited the study of these disparities. In addition, no large-scale longitudinal demographic and epidemiological cohort studies have been conducted involving these populations. To further compound these inequities, LGBT health-related education remains limited.5 Future health care providers often graduate from medical school lacking the cultural and structural competency6 training (i.e., the awareness of the factors—institutions, health care systems, neighborhoods, policies, transportation, distribution of wealth, access to food, etc.—that influence health in addition to individual patient–provider interactions) required to care for these diverse populations and without adequate exposure to these topics to develop the research needed to advance the field. In response to these insufficiencies, the Association of American Medical Colleges (AAMC) recently produced an extensive publication7 that details how medical schools can teach, train, evaluate, and support the medical school learning environment to improve the care for individuals who are LGBT, gender nonconforming, or born with a disorder of sex development.

The Institute of Medicine, at the request of the National Institutes of Health, conducted a comprehensive report on the state of LGBT health and recommended increasing sexual orientation and gender identity data collection in demographic surveys, medical records, and research to bring attention to these issues.8 To achieve change for and improve the health of these communities, we must adopt and prioritize practices that enhance transparency and understanding of the presence, magnitude, and root causes of inequities. We recognize, however, that these steps are necessary but not sufficient.

A persistent, negative culture in medicine toward SGM populations, manifested as stigma and discrimination, also exerts a powerful influence on health disparities. In a recent survey of LGBT patients, most believed that providers were not prepared to care for them, and more than half reported confronting discrimination (e.g., refusal of treatment, harsh/abusive language) when accessing health care.9 Others have reported outright denial of standard medical/surgical treatment due to the provider’s personal/religious objections, a lack of health professionals with appropriate training, denied admission to long-term care facilities, inappropriate questioning, unnecessary physical examinations, and blaming of LGBT patients for their health conditions.10 In a recent court case, a physician group in California denied a lesbian couple access to infertility treatment because the members felt that their religious beliefs afforded them the right to withhold care.11 In another recent case, a transgender female was deprived of her physician-prescribed hormone replacement therapy while in a residential center and juvenile detention facility in Connecticut.12 These failures not only contribute to poor provider-patient relationships but also likely have deterred providers from leading the way to tackle these issues.

SGM health providers are not immune to the ramifications of this culture. Transforming health care for SGM populations will require broad cultural interventions to create more equitable and inclusive environments in medicine for both patients and providers. By targeting SGM health providers, we can address cultural inequities that affect all SGM individuals in medicine. These efforts must include rethinking how we study, recruit, and train medical students, residents, and physicians. In this Perspective, we posit that SGM trainees and health professionals face discrimination in medicine and that these environments are ultimately connected to the inequities that our patients encounter when accessing care. We argue that we can overcome the negative culture in medicine towards SGM populations by (1) modernizing research on the physician workforce, (2) implementing new policies and programs to promote supportive training and practice environments, and (3) developing recruitment practices that ensure a diverse, competent physician workforce inclusive of SGM individuals.

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Barriers to Identity Disclosure in Medicine

Antigay and antitransgender attitudes in medicine have long affected health providers. Sexual minority providers did not move beyond an almost entirely covert presence in health care until the 1973 decision to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders. Since then, SGM providers have faced rarely discussed challenges throughout their careers—encouragement to remain closeted to avoid expulsion, denial of supportive recommendations from advisers, and blatant prejudices among colleagues that affect patient care.13 Although enormous strides have been made alongside societal shifts in perceptions of these communities, more progress is needed.

Identity disclosure in medicine remains challenging. Potentially severe personal and professional consequences still compel many SGM providers and trainees to remain hidden. The impact of this decision on health professionals is important, as identity concealment has been shown to have significant negative effects on physical and mental well-being.14,15 In a recent survey of LGBT physicians, 10% reported being denied referrals from and 15% being harassed by heterosexual colleagues. In addition, 22% reported being socially ostracized, and 65% heard derogatory comments about LGBT individuals in the workplace.16 SGM physicians also face discrimination from patients. More than 30% of patients indicated that they would change providers if they discovered their doctor was gay.17 As a result, SGM providers often must carefully juggle disclosure amongst colleagues and during clinical interactions to maintain close relationships with facing delayed promotion, negative stereotyping, or loss of practice and income.

Among SGM medical students, disclosure can lead to discrimination in admissions, evaluations, and residency matching; only a minority of students are “out” on undergraduate or graduate medical applications.18 In medical school, intense interpersonal interactions can be associated with inappropriate behaviors or mistreatment (e.g., humiliation, harassment, misuse of assessment/grading, emotional/physical abuse), including those based on sexual or gender identity. The mistreatment of all medical students has become such an important topic that the AAMC included specific questions on the issue on the Graduation Questionnaire (GQ)—an annual, national questionnaire administered to all students graduating from a medical school accredited by the Liaison Committee on Medical Education (LCME). The 2013 GQ results showed that 2.3% of the 13,072 respondents reported that they were “subjected to offensive remarks/names related to sexual orientation.”19 Given that 6.4% of young adults (18–29 years of age) in the United States are believed to identify as LGBT,20 a significant fraction (i.e., more than one-third) of today’s SGM-identified medical students may face mistreatment on the basis of their sexual identity. To address and protect SGM medical students’ needs and education, the AAMC recommended that all institutions “ensure a safe learning environment for all students, regardless of their sexual orientation or gender identity,”21 and the LCME forbids discrimination based on sexual orientation or gender identity in medical education programs.22

We acknowledge that our understanding of these problems stems from only a handful of published research studies, most with small sample sizes, scattered temporally across decades often with inconsistent follow-up. In reality, these inequities likely vary greatly by provider birth year, geography, sociocultural boundaries, specialty, or practice setting as they do in other professional fields.23 They also may be changing rapidly. However, these inequities remain poorly understood because we have not yet asked the right questions and studied ourselves as health care providers.

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Modernizing Research of the Physician Workforce

Physicians must lead the charge for equality by fostering diversity and inclusion in medicine. SGM physicians could effectively confront these issues, but they remain unengaged, often because of a fear of prejudice. If we increase SGM providers’ visibility by creating environments conducive to and supportive of disclosure, we can identify and overcome discriminatory practices that contribute to inequities in medicine and, in the process, empower a new generation of physicians to champion SGM health care reform. Failing to do so is dangerous because it not only relegates a subset of providers to face significant personal and professional hardships but also ultimately perpetuates the same exclusionary culture that patients face. Medicine must invest in the tools to ensure that positive change is taking place.

As physicians, we must study our patients, but we cannot forget to study ourselves. Although no current research instruments systematically collect sexual or gender identity information about health professionals, leading medical organizations already distribute large-scale questionnaires (e.g., AAMC Medical Student Questionnaire, AAMC GQ, AAMC/American Medical Association National Graduate Medical Education Census) with high response rates that follow trainees and faculty at discrete career milestones. Including questions on these surveys and on institutional instruments (e.g., admissions materials, training evaluations, employee surveys) will transform these tools into powerful agents of change.

In 2013, the AAMC piloted a new anonymous questionnaire, the Medical Student Life Survey (MSLS), designed to assess the well-being of all 19,555 second-year medical students attending LCME-accredited medical schools. For the first time, an AAMC survey specifically asked about sexual orientation, with 5.9% of the 3,466 respondents reporting a lesbian, gay, or bisexual (LGB) identity. Importantly, medical students were extremely receptive to disclosing this information; the response rate for the sexual orientation identity question (99.3%) was higher than that for the race/ethnicity identity question (98.8%). Responses to the 2013 MSLS also indicated that LGB medical students experienced increased levels of stress, social isolation, and financial concerns compared with heterosexual students. They also reported less social support and encountered a less positive emotional climate (i.e., “educational experience makes students value themselves”) during training.24 The study sample was, however, nonrepresentative of the second-year medical student population; further research then is needed to assess the representation of SGM students in undergraduate medical training. By linking identity data with measures of medical student well-being, this pilot questionnaire both provided unique but troubling insights into the lives of today’s LGB medical students and demonstrated the high value of collecting these demographic variables. The AAMC recognized the importance of collecting these data and decided to keep these questions on the 2014 MSLS; they also added them to the nonanonymous 2014 Matriculating Student Questionnaire.25

In their version of the AAMC Faculty Forward Engagement Survey (~48% response rate), the David Geffen School of Medicine at the University of California, Los Angeles, asked faculty if they “identify as lesbian, gay, bisexual, or transgender,” to which approximately 4% responded affirmatively. Although opinions about collegiality and collaboration were the same amongst LGBT and non-LGBT faculty, the LGBT faculty were less satisfied with their pace of advancement within the professoriate, less satisfied that the criteria for advancement were applied equally, and less satisfied with their department’s recruitment of minorities in general.26

Incorporating comprehensive, validated measures of well-being on all research instruments is unrealistic, but adding two questions on sexual and gender identity is practical and powerful. Although identity data alone will likely not increase the numbers of leaders committed to these issues, data regarding providers’ experiences (e.g., admissions, hiring, specialty preferences, mistreatment, promotion, job security) will highlight unmet needs, uncover conscious and unconscious biases, expose discriminatory practices, and, most important, increase the visibility of SGM individuals.

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Developing New Policies and Programs for Inclusion

In addition to collecting data using national survey instruments, studying the data collected by institution-based surveys will help identify issues unique to individual practices and hold organizations more accountable for devising targeted interventions to improve the culture toward SGM individuals at their institution and promote a commitment to equality. These solutions may include same-sex partner benefits; nondiscrimination policies for employees, students, and patients; zero-tolerance policies with well-communicated procedures and penalties for mistreatment; support for marriage equality; SGM patient-centered care training; and physical plant changes (e.g., gender-neutral restrooms), as first steps to demonstrate institutional dedication. Many of these policies have already been successfully implemented across the United States (see Table 1). Improving the environment for all providers through a better understanding of the barriers SGM individuals face as well as effective methods for overcoming them will ultimately help normalize sexual and gender identity disclosure and ensure that all patients encounter the same inclusive attitude when accessing care.

Table 1

Table 1

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Recruiting SGMs to Medicine

Acknowledging sexual and gender identity diversity also must be a part of the recruitment of health professionals to medical school, residency, and practice to ensure that the makeup of our provider workforce represents that of our patients. Because these data are not systematically collected, little is known about the sexual or gender identity diversity of the student, resident, fellow, or health professional (academic and nonacademic) workforce. As such, whether current recruitment practices effectively achieve sexual and gender identity diversity is unknown.

Current data, however, suggest that this diversity in medical schools may vary significantly by geography, sociocultural boundaries, and institution; a survey of over 5,000 undergraduate medical students in the United States and Canada found that SGM respondents were less likely than heterosexual respondents to report attending medical school in the AAMC-defined Central or South regions. Many students expressed concerns over practice geography and specialty choice in their career, such that they would likely avoid training in high-prejudice areas or certain specialties.27 Unfortunately, these areas are likely places where SGM patients face the most discrimination from the medical community and where SGM providers may be most needed. Although limited SGM diversity is likely not a problem at all medical institutions, it will require a national, standardized commitment to identify shortcomings and affect meaningful change when needed.

Sexual orientation and gender identity should be included as standard demographic variables (similar to race/ethnicity) collected on medical school (e.g., AAMC American Medical College Application Service [AMCAS]), residency (e.g., AAMC Electronic Residency Application Service [ERAS]), fellowship, and other employment applications, as well as on licensing applications, academic appointment applications, and professional society surveys. Specific questions about sexual identity with separate questions to gather gender identity will enable better delineation of lesbian, gay, bisexual, transgender, and other SGM populations to prevent the often-encountered inappropriate binning and overly generalized analysis of these populations as one group. The AAMC MSLS did this successfully with two separate “How do you self-identify?” questions for sexual and gender identity.24 Both questions also included an important free-text prompt: “If one of the above … identities did not best describe you, then with what identity do you feel more comfortable?” Additionally, validated methods to collect these data have already been studied in patient care settings and for use with electronic medical records.28 Collecting these data once during an individual’s career is insufficient. By asking the same questions at various points, individuals have the opportunity to report their then-current sexual and gender identity, both of which can evolve over time.

We do not advocate for specific quotas to achieve sexual and gender identity diversity. United States medical schools have long engaged in the targeted recruitment of members of racial and ethnic groups underrepresented in medicine, whose inclusion in the learning environment improves its value and whose presence in the profession enhances the care of racial and ethnic minority communities.29 The AAMC has already publicly supported continued use of such practices to ensure a “pipeline of physicians better equipped through personal experience and a diverse learning environment to provide the treatment and discover the cures for diseases that disproportionately impact minority populations.”30,31 We believe that the ability of applicants to self-identify as an SGM will allow medical schools to recruit a “critical mass” of members of SGM communities, acknowledge their participation in the profession, and similarly enhance the medical school learning environment and the ability of the profession to address SGM health inequities. These proposed efforts would align with the United States Supreme Court decision to “further a compelling interest in obtaining the educational benefits that flow from a diverse student body.”32 For institutions with poor representation of SGM individuals, institutional climate changes and/or improved recruitment efforts to promote sexual and gender identity diversity may be needed.

Existing data suggest that medical students are willing to self-identify as an SGM at least as frequently as they identify their race and ethnicity.24 We predict a similar, small and not significant nonresponse rate to optional sexual and gender identity questions on applications (e.g., AMCAS, ERAS), and that the impact of these nonresponses would be offset by the many benefits of identification for most other physicians, trainees, and the profession overall.

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Benefits of Recruitment

The recruitment efforts we detail here will provide notable benefits to all institutions. First, they will help identify and empower new leaders to address SGM health care reform. There is a growing movement in medicine to broaden our conceptualization of diversity and to adopt a more holistic framework for physician recruitment by placing greater emphasis on personal attributes that will contribute to the applicant’s professional career development.33,34 As academic leaders advocate for a more culturally and structurally competent6 physician workforce, ensuring SGM diversity in medical training and practice should be an essential element to achieving that goal. SGM health professionals may be uniquely connected to these marginalized communities and may possess a personal drive that makes them much more likely to address inequities in both research and practice. As medicine struggles for leaders to address issues of SGM equality, we should encourage the recruitment of individuals with the personal motivation to serve as advocates for these populations.

Second, ensuring SGM diversity may significantly improve the training and practice environments just as the inclusion of racial and ethnic minorities in medicine transformed the care of minority patients. The inclusion of racial minorities in medicine has improved diversity-related educational outcomes for all undergraduate medical students and has led to better relationships between minority patients and nonminority trainees when they enter practice. Caucasian students at the most racially and ethnically diverse medical schools feel significantly more prepared to care for minority populations than their peers at less diverse institutions.29 In addition, racial concordance between provider and patient can meaningfully improve patient satisfaction35 and patient participation in their own health care decisions.36 Similar benefits to the educational environment and to patient care may come from cultivating sexual and gender identity diversity in medicine. In fact, medical students with at least one sexual minority acquaintance have more knowledge about homosexuality and a more positive attitude towards these populations.37

Finally, implementing these changes will bring medicine into alignment with other professional and academic fields that have already done so. Among most major financial, legal, and business consulting firms, the active recruitment of SGM individuals has become standard practice. These efforts manifest as SGM-specific recruiting events, the collection of specific demographic information on admissions and/or employment applications, and the inclusion of these groups in national diversity rankings. Among academic circles, peer professional schools in business and law also have instituted these changes. Several of the top 20 law schools according to the U.S. News & World Report’s rankings now include sexual orientation identity questions on institution-specific admissions applications and as a standard demographic variable on the Law School Admission Council Common Application.38 Although a few medical schools have piloted or implemented similar policies, these efforts remain far from widespread. Medicine must not fall further behind.

Instituting these changes certainly may be challenging. Opponents will argue that existing questionnaires or applications have no extra space for such questions; that collecting sensitive information risks litigation and decreased response rates for the entire instrument; and that persistent identity concealment will render data inaccurate. As previously discussed, SGM providers also continue to face personal and professional discrimination. In light of this reality, there are legitimate concerns that data collection could be dangerous as disclosure may unintentionally enable discrimination. However, we posit that such discrimination already takes place regardless of formal data collection and that collection itself may serve as a powerful tool to address such issues. Institutions will remain unaccountable for addressing solutions to these problems unless standardized mechanisms to identify them are in place. These issues warrant careful examination to ensure safe and effective practices but should not deter implementation. Trainees and providers of all sexual orientations and gender identities will never be comfortable identifying themselves or expressing their support for all individuals until the medical community becomes comfortable asking such questions.

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A Call for Action

The U.S. government has taken an important step by committing to improve SGM health.8 Citizens, through the political process and a growing public conversation, continue to address issues of SGM equity. As a profession, we must go further. Medicine should be at the vanguard of change and serve as a respite from societal discrimination, not as a haven for its perpetuation. Although these shortcomings likely are not universal, they remain inappropriately common. Efforts to confront these issues need to address the unique health needs of our patients, but they must not overlook the parallel necessity of a visibly diverse, competent physician workforce that effectively cares for all populations. To achieve this goal, we must change the negative culture in medicine and promote a welcoming, supportive environment for trainees, faculty, and patients. SGM leaders and medical educators are uniquely poised to accelerate this change.

The tools necessary for the voluntary disclosure of sexual and gender identity among health professionals already exist. We must start using them to study ourselves, recruit SGM individuals into medicine, and develop innovative programs and policies that promote visibility and foster inclusion, respect, and dignity for everyone in medicine.

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References

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