The current pace of change in public views on the equal rights and responsibilities of lesbian, gay, bisexual, and transgender (LGBT) individuals in the United States is remarkable.1 It may be tempting, therefore, to assume that attitudes toward LGBT people have also changed dramatically and that LGBT people can now be “out,” or open about their identity, in nearly any setting. Academic health centers—with their focus on up-to-date research and improving patient satisfaction—seem poised to lead the way in changing the health care experience for LGBT patients.
In this issue of Academic Medicine, however, Burke et al2 present a different picture of the medical school climate in their study investigating both explicit and implicit attitudes of medical students toward gay men and lesbian women. The distinction between explicit and implicit attitudes is important: Explicit attitudes are highly susceptible to social desirability bias and are likely to be influenced by the advancement of LGBT rights in recent years, whereas implicit biases are more ingrained beliefs and attitudes that might not even be recognized by those who hold them.3 Burke et al found that 46% of heterosexual first-year medical students in a large U.S. sample expressed at least some explicit bias, and 82% held at least some degree of implicit bias against gay and lesbian individuals.
Whether these biases affect LGBT patient care remains to be studied, but given evidence that implicit racial bias affects physician decision making, it is reasonable to assume that LGBT patients remain at risk of discrimination from even well-meaning providers. The three aims of this Commentary are (1) to briefly review LGBT health and health care disparities as well as medical education disparities with regard to LGBT health, (2) to consider the implications of physician bias for both LGBT patients and the climate of the medical profession, and (3) to suggest a research and intervention agenda that may serve as a starting point for modifying the cycles of influence that implicit bias imparts on the climate and the hidden curriculum of medical education.
LGBT Disparities in Health, Health Care, and Medical Education
It is well known that LGBT people suffer health disparities, particularly concerning cigarette smoking, mental health, substance abuse, and sexually transmitted infections, including HIV.4 Although health care utilization and experiences among LGBT individuals are difficult to determine because of the lack of assessment of sexual and gender identity in clinical and health services research settings, studies have shown evidence of disparities in health care access as well.5,6 In survey studies, for example, sexual minority women were less likely than heterosexual women to report lifetime or routine Pap tests despite having higher-risk sexual practices.7,8 A small study examining reasons for lack of screening found that fear of discrimination and failure to disclose sexual orientation were significantly related to not receiving routine Pap tests.9
There is substantial evidence that LGBT patients perceive discrimination in the health care environment.10–12 Providers’ lack of training in interacting with diverse patient populations and in LGBT health issues in particular likely contribute to this perception. Providers may express stigma or discriminate despite having good intentions; they may not be aware of sexual minority health issues and terminology, or they may be lacking communication skills. Recent studies have found that providers feel unprepared to give quality care for LGBT patients. Kitts et al,13 for example, found that 75% of physicians surveyed agreed that sexual orientation should be covered more often during training. Almost 40% of physicians responding to the 2010 Gay and Lesbian Medical Association–American Medical Association Collaborative Survey on Physician Experiences Caring for LGBT Patients reported that they had no formal training on LGBT health in medical school or residency, whereas the majority of those who reported some background in LGBT health described that training as “not very” or “not at all” useful in preparing them to care for patients.14 In addition, 15% of responding physicians had witnessed discriminatory care for LGBT patients, and nearly 20% had witnessed disrespect toward the partner of an LGBT patient.
Training in medical schools likely contributes to this discomfort and lack of preparation. In a recent survey study assessing LGBT curricula in undergraduate medical education, medical school deans reported a median of two hours of such training during the clinical years. When asked about the quality of the content, 26% of the deans described it as “poor” or “very poor.”15 In a companion study by the same research team, 28% of non-LGBT medical students and 55% of LGBT medical students rated their school’s LGBT health curriculum as “poor” or “very poor.”16
Implications of Physician Bias
Bias and patient care
As Burke et al2 indicate, provider bias against LGBT individuals still exists, and therefore likely plays a role in patient care. Both explicit bias and implicit bias have been repeatedly linked to differential treatment of patients based on race,17 although the relationships are complex and not necessarily predictable. In one study, pediatricians’ implicit biases were associated with their decisions concerning postoperative pain control by patient race.18 In a study looking at outcomes in patients with spinal cord injury, patients’ disability, depression, and life satisfaction were associated with the implicit racial biases of their physicians.19 In a recent study of decision making based on clinical vignettes, Oliver et al20 found that physicians held strong implicit preferences for white patients over black patients and beliefs that white patients were more adherent. These biases, however, did not correlate directly with explicit biases, nor did they predict treatment recommendations. Therefore, the degree to which existing racial health disparities are the result of racial biases among providers remains unclear. Consequently, the impact of specific training to reduce provider bias on racial health disparities also remains unknown.
Although most studies of provider bias to date have focused on racial bias, there is also evidence of implicit bias and treatment bias against obese patients, female patients, and elderly patients.21 One small study examined implicit bias regarding sexual minority individuals, finding that heterosexual substance abuse treatment providers, especially those with few LGBT friends, had stronger negative biases toward LGBT individuals than did LGBT providers, and there was considerable variability in outcomes of an attitude scale among the providers on the whole.22
Bias and professional climate in medicine
Providers’ implicit attitudes have implications that go beyond patient care to affect the general professional climate in medicine. In the case of bias against sexual minorities, the scant extant literature16,23,24 has focused on the “outness” of LGBT health professions students and providers. The degree to which these persons feel comfortable to disclose their sexual or gender minority status to their colleagues is considered a marker of the “hidden curriculum”25 surrounding attitudes toward sexual minorities and could reasonably be equated with the effects of both explicit and implicit bias on the professional climate. In a recently published study, Lee et al23 surveyed general surgery residents and found that over one-third of LGBT residents had not revealed their sexual orientation when applying for residency because of concerns about being rejected for that reason, and over one-half reported actively concealing their sexual orientation from fellow residents and attendings. LGBT residents were more likely than non-LGBT residents, by a wide margin, to feel uncomfortable discussing their partner or bringing their partner to events. The majority of all respondents had witnessed homophobic remarks in the workplace. In another study,16 16% to 17% of gay and lesbian, 50% of bisexual, and 60% of transgender medical students reported that they did not disclose their sexual orientation or gender identity in at least some contexts related to medical school. The reasons most commonly cited for this lack of disclosure included fear of discrimination, concern over career options, and the opinion that their identity was “nobody’s business.”
Although the literature on the health implications of sexual and gender identity disclosure is beyond the scope of this Commentary, the evidence is strong that concealment increases stress for most people and negatively affects health behaviors and outcomes.26–28 There is no reason to believe that medical students, residents, and practicing physicians would be exceptions to the effects of concealment in the workplace. Although it has not been studied, LGBT students may be more likely than their heterosexual or gender-conforming peers to not apply to medical school or to drop out of medical school. Similarly, LGBT physicians could reasonably be expected to experience more burnout due to the added load of minority stress.
When the level of implicit bias (or explicit bias) is high within the individual employees or the culture of an institution, LGBT individuals likely fear coming out to their colleagues. Subsequently, those colleagues have few personal, meaningful interactions to challenge their biases against LGBT people. In addition, without direct challenges from LGBT individuals, there is little driving force to overcome the inertia of existing institutional culture, and heterocentric policies will remain in place, further discouraging disclosure. (In Lee and colleagues’23 study of surgical residents, none of the LGBT residents who had experienced homophobic remarks directed toward them reported the incidents because of fear of reprisal, not wanting to cause trouble, or the sense that nothing would be done.)
As a consequence, negative attitudes, complacency toward LGBT equity, and even unprofessional behavior toward LGBT people may have a tendency to continue unchecked. Thus, implicit bias creates a second cycle of self-perpetuating bias and behavior affecting the professional climate of medicine.
The cycle of bias and the hidden curriculum
The persistence of bias against LGBT people in academic medicine contexts—which resists the trend toward societal acceptance of sexual minorities—is likely related to this tendency of implicit biases to create multiple self-perpetuating cycles that are manifested via norms of professional behavior and expectations.
The compilation of implicit biases, explicit biases, institutional climate, and ingrained behaviors at an academic health center also form the foundation of the institution’s hidden curriculum, or what health professions trainees learn from what they observe and experience rather than what they are overtly taught.25 The particular risk of implicit bias in an academic health center is that it extends to become a cycle of professional climate that then extends into a third cycle of professional influence. Learners absorb and emulate what they see and experience; therefore, not only are they likely to take the biases, behaviors, and expectations they learn via the hidden curriculum with them when they move into practice, but they are also likely to recycle them back into the academic environment when they become teachers themselves.
In their report, Burke et al2 explore strategies that may hold promise for reducing implicit bias against gay and lesbian people. Their finding that frequency and positivity of contact with gay and lesbian people were the strongest predictors of positive implicit attitudes toward sexual minorities among medical students reinforces the need for LGBT providers to be open about their identity in the professional environment. Such openness and the continued contact with LGBT individuals that disclosure would make possible would presumably allow heterosexual health care professionals to unlearn generalizations and stereotypes and expose them to a more diverse array of LGBT people. Having professional colleagues and role models who disclose their LGBT orientation, therefore, has potential to impose a break in the cycle of bias that affects the professional climate and the cycle of influence that the professional climate imparts to students.
A Research and Intervention Agenda
Although the effect sizes reported by Burke et al2 are small, they are an important wake-up call for a society in which it may seem as though LGBT discrimination is no longer relevant. Whether implicit or explicit, even small degrees of bias against sexual minorities can have major implications when considered in the context of the influence a physician will have in patient care, in professional interactions, and in the education of future health professionals during the course of his or her career. Any level of bias can contribute to the hidden curriculum by contaminating ethical and professional standards and helping perpetuate the cycle of bias in medicine, particularly in academic health centers where the training of future physicians occurs.
Burke et al2 concentrated their analysis on their primary findings, but the differences in bias they found by gender and race deserve further study because different interventions may be needed to address the biases of different subgroups. Studies on education and on bias should address the perspectives of both LGBT and non-LGBT students. Most important, Burke and colleagues’ exploratory results concerning personal contact with LGBT individuals, empathic concern (emotional empathy), and perspective-taking (cognitive empathy) deserve targeted research given their potential for guiding interventions and change. This research must be integrated, however, with studies addressing visibility of and respect for LGBT individuals in medicine. For example, researchers in bias modification have provided evidence that the way to break cycles of implicit bias is to confront them.29 In academic health centers, this process of confrontation can be thought of as recognizing and working to change the hidden curriculum. Identity disclosure, curricula, patient outcomes, and the wording of sexual and gender identity questions on forms all contribute to the hidden curriculum; all of these elements of health center climate and education must be understood and improved to break the cycle of implicit bias.
Fortunately, there are already opportunities to start breaking the cycle in medical schools. Burke et al2 supply the crucial first step: raising awareness that bias against LGBT individuals still exists among medical students. We can begin to integrate LGBT health into curricula now, especially by focusing on exposing students to a diversity of LGBT patients and community organizations. We can encourage teaching hospitals to engage in practices supported by the Joint Commission30 and the Human Rights Campaign’s Healthcare Equality Index.31 Lastly, as health professionals, those of us who are in a position to disclose our LGBT orientation can do so, armed with Burke and colleagues’ evidence suggesting that being open about our identities may help reduce implicit biases in ourselves and others.
Acknowledgments: The author wishes to acknowledge William White and the Stanford Medical Education Research Group for provision of preliminary data.
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