Individuals identifying as lesbian, gay, bisexual, transgender, queer, or plus (LGBTQ+) are underrepresented in medicine. Although 2020 census data estimate that nearly 8% of the US population identifies as LGBTQ+, there is no tool to collect large-scale sexual orientation data for physicians (1). However, in 2018, the American Medical Association added sexual orientation and gender identity as an option for members to include in their demographic profiles. Nearly 15,000 members provided this information, with 4% identifying as LGBTQ+ (2). This underrepresentation amongst physicians may contribute to the inequitable health care that LGBTQ+ patients experience. One in 5 LGBTQ+ adults reports avoiding or delaying interactions with the healthcare system due to fear of experiencing discrimination (3). Providers' implicit and explicit biases towards LGBTQ+ patients contribute to this avoidance of healthcare for LGBTQ+ patients (4). Therefore, efforts to increase LGBTQ+ physicians should be at the forefront of diversity, equity, and inclusion action plans across all medical specialties.
The fear of discrimination transcends beyond the patient and even affects trainees who report experiencing harassment, verbal insults, or threats leading to increased stress and mental health-related issues (5). In fact, two-thirds of sexual gender minority physicians have heard disparaging remarks at work or experienced social ostracism (5). In a 2015 survey of nearly one-thousand LGBTQ+ medical students, almost 30% reported concealing their sexual identity during medical training (6). Just as trainees make a conscientious decision about being “out” in training, several factors affect their decision to pursue a particular specialty. Sitkin et al. (7) reported that the percentage of LGBTQ+ trainees in a specific specialty was inversely related to “specialty prestige” (as determined based on specialty competitiveness and income) but positively associated with perceived inclusivity of sexual gender minority. Although it is unclear where gastroenterology and hepatology may fall on this spectrum, LGBTQ+ individuals seem to be a small minority of total practicing gastroenterologists and hepatologists.
This article will highlight the challenges that 2 LGBTQ+ gastroenterologists, 1 current trainee, and 1 attending have faced in their medical training.
LIFE BEFORE MEDICINE: TWO PHYSICIANS WHO HAVE NEVER MET SHARE SIMILAR STORIES
As a Black woman and Asian man growing up in America, both authors, Dr. Barrow and Dr. Duong, were aware of their minority statuses. Their genders and ethnicities were congruent with their outward appearances and neither required explanation nor could be concealed. However, their sexual orientations were an additional level of minority status that required vulnerability to live truthfully and openly. Although their outward appearances may have affected inherent biases leading to potential disadvantages related to their pursuits of a medical career, disclosure of their sexual orientation was a choice.
NAVIGATING MEDICAL TRAINING
At each critical point along their paths toward becoming a gastroenterologist and transplant hepatologist, respectively, they decided whether to be “out” (Figure 1). For Dr. Barrow, it meant a choice that could open the doors to the possibility of discrimination, bias, or triple minority tokenism. When applying for a GI fellowship, being “out” was a decision she felt was not worth it for so long, especially when she was not yet as accepting of or secure with her own sexual orientation. Dr. Duong had similar fears of being “out” as early as medical school applications. When it came time for clinical rotations, he feared being discriminated against by senior team members. He feared receiving negative feedback from subjective evaluators, or worse, losing the trust of his patients who may be biased against him. He felt it was sometimes easier to live a double life—conforming to heteronormative behaviors and conversations in medicine while being openly gay amongst friends and family.
When applying for GI fellowships, both authors identified programs that would rigorously prepare them to reach their respective career goals. During the application and matching processes, location, a program's culture, and the surrounding community were essential considerations for both. Another decision point was whether to disclose one's sexual orientation in applications and during fellowship interviews. Dr. Duong's approach was to discuss how being openly gay has influenced his practice of medicine and taught him about courage, perseverance, and resilience. Dr. Barrow's approach focused on assessing a program's record in recruiting diverse fellows and faculty—including sexual orientation, gender, or race—to determine when she felt comfortable being “out” to co-fellows and attendings after matching.
These trainees matched at 2 fellowship programs in the South, which undoubtedly contributed to apprehension about being “out,” particularly in the local areas outside of their health systems. Although they were the only openly gay trainees in their respective gastroenterology departments, both programs welcomed the trainees with open arms and pride. However, being around other fellows in heterosexual relationships who were starting families contributed to feelings of “otherness” and was isolating at times. Both physicians found these years to be a formative time as young adults, and they often relied on support from LGBTQ+ friends outside of fellowship with whom they could more easily relate.
Throughout their training, there were opportunities for educational modules required by the overall health systems for interacting with LGBTQ+ patients or colleagues to deter bias. However, there was a lack of LGBTQ+ specific health topics in their gastroenterology training. For example, LGTBQ+ patients are more likely to suffer from anxiety and alcohol misuse, increasing risk for irritable bowel syndrome and cirrhosis respectively; yet, these associations were never broached. As LGBTQ+ community members, both gastroenterologists learned how to “read the room”—being able to relate quickly to LGBTQ+ patients and provide a safe space for them to be vulnerable and talk about their most sensitive symptoms relating to their gut and psychosocial health.
BEING “OUT” IN PRESENT-DAY
Dr. Barrow recalls receiving mentorship from Black mentors in preparation for medical school, residency, fellowship, and job interviews. While her experience as a gender and race minority has informed her ability to navigate as a sexual orientation minority, she has not had 1 LGBTQ+ mentor to coach her on how to exist as a gay woman in medicine. Dr. Barrow married her wife before beginning her first attending position. During the job interview process, she encountered multiple instances where it was assumed that she had an opposite gendered spouse; it was near guaranteed to occur. Managing those assumptions with grace is a crucial skill to have as an LGBTQ+ physician, as they will continue to happen in the various realms of life. As an early career gastroenterologist entering a practice with mostly senior gastroenterologists, it has become even more apparent that diversity dilutes as 1 climbs the career ladder. Meeting new colleagues has led to an increase in coming “out” to various individuals and emphasized the importance of representation of LGBTQ+ physicians in gastroenterology.
Dr. Duong recalls having the fortunate opportunity of being mentored by openly gay physician leaders in his residency program, despite training at a Jesuit hospital. He gave back by volunteering at a gay men's and women's clinic and engaging in formal mentorship programs with gay medical students. A gay gastroenterologist and transplant hepatologist now mentor him, and it has helped him realize he could achieve that level of success as a gay.
Increasing the representation of LGBTQ+ physicians in gastroenterology and hepatology will require intervention at every stage of medical training.
Foster a diverse training environment
Training programs should welcome diversity and encourage faculty to create an inclusive environment. We propose that fellowship applications include an option to identify one's preferred pronouns. In addition, programs can encourage staff and faculty to wear pins identifying their preferred pronouns, and rainbow pride pins to show their support as allies. Furthermore, a program may consider providing applicants access to “out” physicians within the health system that would be willing to speak to culture of the organization. Training programs should also provide all trainees with available LGBTQ+ resources in their welcome packets. Providing information to all applicants will (i) avoid singling out applicants in need of these resources, and (ii) demonstrate the program's dedication to diversity to non-LGBTQ+ applicants. Overall, establishing a community and identifying mentors early in medical training can improve a sense of belonging and connectedness for LGBTQ+ physicians (Figure 2).
Ultimately, programs will make their biggest impact with dedicated active recruitment efforts focused on increasing LGBTQ+ trainees and faculty. To facilitate recruitment, programs can recruit from local LGBTQ+ networking events, participate in LGBTQ+ organizations such as Medical Student Pride Alliance, and Gay and Lesbian Medical Association, and publicize the program's commitment efforts with widely visible messaging on online and in printed materials.
Create a supportive work environment for LGBTQ+ providers
Three ways to tangibly promote a supportive work environment include (i) increasing cultural awareness via LGBTQ+ awareness and ally training, (ii) increasing visibility of LGBTQ+ physicians in health system leadership roles, and (iii) creating formal national mentorship programs. Each of these action items may also potentially decrease implicit bias toward the LGBTQ+ patients that we all serve (4). Recently, Dr. Duong and a group of faculty founded a gastroenterology and hepatology specific national organization called Rainbows in Gastro, with the mission of Community, Healing, Advocacy, Research, and Mentorship (CHARM). There is a need for national societies to support and empower groups like Rainbows in Gastro.
Promote affinity groups
Health systems and professional associations should employ affinity groups dedicated to LGBTQ+ employees. Affinity groups offer employees or members an opportunity to exchange ideas, share best practices, meet colleagues across different specialties, and work to create an environment that is more inclusive to LGBTQ+ individuals. Affinity groups can improve employee satisfaction and retention, reduce burnout, and provide a community of belonging for LGBTQ+ employees in health systems. In professional associations, affinity groups can provide an avenue to network with other LGBTQ+ members in a professional setting.
LGBTQ+ patients face healthcare disparities, including GI related disorders, linked to discrimination, fear, and stigma. When seeking medical care, LGBTQ+ patients may bring the trauma of living in a not always welcoming community. Unfortunately, a curriculum in LGBTQ+ healthcare is lacking across medical training, particularly in the clinical approach to the LGBTQ+ patient. Programs dedicated to improving LGBTQ+ healthcare should devote more into developing curricula that not only foster an understanding of LGBTQ+ specific health topics, but also train physicians in providing trauma-informed care to LGBTQ+ patients. Trauma-informed care can benefit LGBTQ+ patients by allowing for a healthy, trusting communication pathway with their doctor, improving long-term health outcomes. Trauma-informed care can also benefit physicians by helping to reduce burnout and improve bedside manner (8).
Many issues unique to LGBTQ+ trainees and providers in medicine exist, and in this article, we provide only a few first-hand accounts. We also provide a framework of action items that training programs, health systems, and professional organizations can use to promote LGBTQ+ representation in gastroenterology and hepatology, and ultimately improve patient care.
CONFLICTS OF INTEREST
Guarantor of the article: Jasmine Barrow, MD.
Specific author contributions: Both authors contributed to the writing and editing of the submitted manuscript. Both have approved the final manuscript.
Financial support: None to report.
Potential competing interests: None to report.
3. Gonzales G, Przedworski J, Henning-Smith C. Comparison of health and health risk factors between lesbian, gay, and bisexual adults and heterosexual adults in the United States: Results from the national health interview survey. JAMA Intern Med 2016;176:1344–51.
4. Phelan SM, Burke SE, Hardeman RR, et al. Medical school factors associated with changes in implicit and explicit bias against gay and lesbian people among 3492 graduating medical students. J Gen Intern Med 2017;32:1193–201.
5. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay, and bisexual people. BMC Psychiatry 2008;8:70.
6. Samuels EA, Boatright DH, Wong AH, et al. Association between sexual orientation, mistreatment, and burnout among us medical students. JAMA Netw Open 2021;4(2):e2036136.
7. Sitkin NA, Pachankis JE. Specialty choice among sexual and gender minorities in medicine: The role of specialty prestige, perceived inclusion, and medical school climate. LGBT Health 2016;3:451–60.
8. Kuehn BM. Trauma-informed care may ease patient fear, clinician burnout. JAMA 2020;323:595–7.