Improving the Experiences of Sexual and Gender Minority-Identifying Trainees in Gastroenterology and Hepatology

Abstract

I don’t believe in gay marriageThe words reverberated off the endoscopy walls and echoed through us. It was unprompted and felt like a sucker punch to the gut. We believed this to be a safe space where we could learn and be ourselves. But the statement instantaneously made the safety disappear. A tsunami of self-talk littered with doubt and fear rushed through our minds. “Do they think differently of us? Could we work with them again and feel like a respected member of the team? How do we go back to work and still be comfortable being our authentic selves?” We froze and could not come up with words. Leaving the endoscopy room, we tried to move on to the next colonoscopy. But the words and the sentiment lingered. Our program director stepped in to ensure we felt valued and that we mattered. They reached out to hospital leadership to ensure this would never happen again. We are grateful to be in supportive training environments, but know that others are not as lucky. Even with such support and good intentions, we have continued to experience misgendering of ourselves and our partners. We fear losing the respect of colleagues and superiors, or being subjected to questions about our personal lives because of our identities as sexual and gender minorities. Deeply embedded within the medical hierarchy, we are less likely to speak up when these events occur. Instead, we internalize these emotions because there simply are few colleagues we can identify with who have had similar experiences in medicine. Sexual and gender minorities (SGM) encompass a vastly diverse population that includes, but is not limited to, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other (LGBTQIA+, here interchangeable with SGM) identities. In the United States, more than 7% of individuals (approximately 23 million) identify as LGBTQIA+.1Jones J.M. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17 2022.https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspxDate accessed: November 9, 2022Google Scholar In generation Z (born 1997–2003), more than 20% identify as members of the SGM community.1Jones J.M. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17 2022.https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspxDate accessed: November 9, 2022Google Scholar There is great heterogeneity of experience within the SGM community, and bias can exist even between subgroups within the community. However, experiences of oppression and inequity affect all SGM people. The situation we faced is unfortunately not uncommon for SGM communities as they interface with every facet of society from housing, employment, education, the legal system, and health care, among others. Medicine also has contributed to the marginalization and discrimination of SGM populations, from theories that being homosexual was a psychological disorder characterized in the Diagnostic and Statistical Manual of Mental Disorders in 1952 (revised in 1973), to the Food and Drug Administration banning blood donation from men who have sex with men (a lifetime ban in 1983, recently revised in 2020 to require 3 months of celibacy).2Drescher J. Out of DSM: depathologizing homosexuality.Behav Sci (Basel). 2015; 5: 565-575Crossref PubMed Scopus (244) Google Scholar,3Marks P. Coronavirus (COVID-19) update: FDA provides updated guidance to address the urgent need for blood during the pandemic. April 2, 2020.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-provides-updated-guidance-address-urgent-need-blood-during-pandemicDate accessed: November 9, 2022Google Scholar Other countries, such as Canada, have removed such bans.4Sexual behaviour-based screening. Canadian Blood Services. 2022.https://www.blood.ca/en/blood/am-i-eligible-donate-blood/sexual-behaviour-based-screeningDate accessed: December 18, 2022Google Scholar Such discrimination leading to fear of bias and mistreatment from medical providers, intersecting with social determinants of health, have led to significant health disparities and delays in seeking care within SGM populations, including increased rates of substance use disorders, mental health issues, obesity and eating disorders, and anorectal and breast cancers.5Lund E.M. Burgess C.M. Sexual and gender minority health care disparities: barriers to care and strategies to bridge the gap.Prim Care. 2021; 48: 179-189Abstract Full Text Full Text PDF Scopus (20) Google Scholar,6Vélez C. Casimiro I. Pitts R. et al.Digestive health in sexual and gender minority populations.Am J Gastroenterol. 2022; 117: 865-875Crossref PubMed Scopus (4) Google Scholar This perspective discusses the important issues surrounding being an SGM trainee and outlines steps that training programs can undertake to create more inclusive environments, and, more broadly, how we can make the future for the SGM community brighter. Although the general public has an increasing acceptance of gay rights and same sex marriage, medicine still conforms to a heteronormative matrix, a view that generally promotes heterosexuality as normal or preferred.7Pew Research CenterAttitudes on same-sex marriage. 2019.https://www.pewforum.org/fact-sheet/changing-attitudes-on-gay-marriageDate accessed: November 9, 2022Google Scholar SGM persons who are in medicine have endured challenges, discrimination, and implicit biases at every level, from student to trainee, to attending physician. In 2015, nearly 30% of medical students in the United States and Canada who identify as SGM reported concealing their sexual orientation and gender identity because of fear of discrimination.8Mansh M. White W. Gee-Tong L. et al.Sexual and gender minority identity disclosure during undergraduate medical education: “in the closet” in medical school.Acad Med. 2015; 90: 634-644Crossref PubMed Scopus (72) Google Scholar In addition, a 2021 cross-sectional study of almost 26,000 graduating medical students found that SGM students had less favorable perceptions of their learning environment compared with their heterosexual counterparts.9Ryus C.R. Samuels E.A. Wong A.H. et al.Burnout and perception of medical school learning environments among gay, lesbian, and bisexual medical students.JAMA Netw. 2022; 5e229596Google Scholar Hearing disparaging remarks from colleagues about the LGBTQIA+ community unfortunately also remains common among 65% of physicians surveyed.10Eliason M.J. Dibble S.L. Robertson P.A. Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace.J Homosex. 2011; 58: 1355-1371Crossref PubMed Scopus (164) Google Scholar Such secrecy and stigma contributes to mistreatment and burnout among LGBTQIA+ identifying providers.9Ryus C.R. Samuels E.A. Wong A.H. et al.Burnout and perception of medical school learning environments among gay, lesbian, and bisexual medical students.JAMA Netw. 2022; 5e229596Google Scholar,11Samuels E.A. Boatright D.H. Wong A.H. et al.Association between sexual orientation, mistreatment, and burnout among US medical students.JAMA Netw Open. 2021; 4e2036136Crossref Scopus (30) Google Scholar It is imperative to have physicians who identify as SGM for our trainees and patients who identify within these populations. We need to create a medical community of acceptance so trainees can feel comfortable being their authentic selves, without fear of discrimination, and to ensure they do not feel alone in medicine. This not only is important for us as physicians, but integral to our work toward equity in patient care. SGM patients are less likely to seek care as a result of fears of persecution and insensitivity. By increasing visibility of more providers who are like them, we may further overcome existing health care disparities and improve patient care within the LGBTQIA+ community. As noted previously, more than 20% of generation Z (born 1997–2003) in the United States identify as SGM.1Jones J.M. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17 2022.https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspxDate accessed: November 9, 2022Google Scholar Not surprisingly, we expect to see more physicians who identify as part of this community in coming years. However, it is unknown how many medical students, trainees, and faculty physicians identify as SGM, largely because of a lack of data. The Association of American Medical Colleges started collecting data on gender identity in the Graduation Questionnaire in 2016. Currently, 5.4% of graduating medical students identify as SGM, although this is likely an under-representation given the fear and stigma associated with coming out.12Sitkin N.A. Pachankis J.E. Specialty choice among sexual and gender minorities in medicine: the role of specialty prestige, perceived inclusion, and medical school climate.LGBT Health. 2016; 3: 451-460Crossref PubMed Scopus (44) Google Scholar One 2016 study found the specialties of psychiatry, family medicine, and pediatrics were perceived by medical students as more inclusive of SGM applicants while orthopedic surgery, neurosurgery, and thoracic surgery were thought to be less inclusive. This may be related to the proportion of SGM already in each specialty. Medicine subspecialties such as gastroenterology and hepatology were not included in this study.12Sitkin N.A. Pachankis J.E. Specialty choice among sexual and gender minorities in medicine: the role of specialty prestige, perceived inclusion, and medical school climate.LGBT Health. 2016; 3: 451-460Crossref PubMed Scopus (44) Google Scholar Of note, specialties viewed as less inclusive are more procedure-oriented, a characteristic also seen in gastroenterology. However, a recent study found that sexual minority female students were more likely to practice in surgical specialties compared with heterosexual female students, whereas sexual minority male students were less likely to do so compared with their heterosexual counterparts.13Mori W.S. Gao Y. Linos E. et al.Sexual orientation diversity and specialty choice among graduating allopathic medical students in the United States.JAMA Netw Open. 2021; 4e2126983Crossref Scopus (15) Google Scholar Fortunately, there appears to be a culture shift with more affinity groups being created within more procedural specialties, such as Pride Ortho and Pride in Surgery Forum, whose missions are to create inclusive environments for trainees and improve patient care for SGM populations.14Pride in Surgery Forum. @PRiSM_Surgery.https://twitter.com/PRiSM_SurgeryDate accessed: November 3, 2022Google Scholar,15Pride Ortho. @pride_ortho.https://twitter.com/pride_orthoDate accessed: November 3, 2022Google Scholar In the field of gastroenterology and hepatology, a diverse group of physicians from varied SGM ethnic and social backgrounds and different areas of clinical interest formed Rainbows in Gastro in 2022 ([email protected]; @RainbowInGastro on Twitter), an affinity group for members of the gastroenterology and hepatology community who identify as SGM with the purpose of improving the trainee experience and improving SGM patient care. We are united through the mission statement of CHARM: Community, Healing, Advocacy, Research, and Mentorship.16Rainbows in Gastro. @RainbowinGastro.https://twitter.com/RainbowinGastroDate accessed: November 3, 2022Google Scholar Without more data, we will never know the actual number of SGM providers in different specialties, as well as the decision-making process students use while determining their specialty. This is needed to create opportunities to enact change. This is crucial for future trainees and increasing overall diversity because we need SGM in all medical specialties for the benefit of both patients and future trainees. Currently, it is difficult to find role models in leadership positions that openly identify as SGM. We are left wondering who we can speak with as mentors with intimate knowledge about what it means to be medical leaders who also identify as SGM. One qualitative study in the SGM medical community found that a formalized mentorship program was beneficial to students in the form of role-modeling behavior and reassurance that they, too, can be leaders in medicine. Mentors gained the perspective of what being an SGM trainee and learner is like in current times. They also found increased value in being a role model in both their personal and professional lives to trainees.17Beanlands R. Robinson L. Venance S. An LGBTQ+ mentorship program enriched the experience of medical students and physician mentors.Can Med Educ J. 2020; 11: e159-e162Google Scholar There is a specific vulnerability during periods of transition that can especially benefit from increased mentorship and support. The periods between levels of training, from medical school to residency to independent practice, are filled with uncertainty about what the next step may bring, and what decisions will best support their professional and personal goals. Although medical school and postgraduate training provides the relative protection of academic institutions and training program leadership oversight, the physician job market often lacks the transparency, knowledge, and openness to know how a SGM might be supported at any given practice. Mentorship is vital to the future careers of trainees in minority groups, and by increasing our networks of self-identified SGM in medicine, we can create connections for trainees to find role models and peers. Although there remain hurdles to navigate for SGM trainees, there is great opportunity for growth and change. The following are 5 concrete steps that can be taken today to create more inclusive training environments (Table 1).Table 1Action Items for Training Programs to Improve the Experiences of SGM-Identifying Trainees, Along With Examples of How to Meet These GoalsAction itemsExamplesInclude pronoun and gender identity information on training program applicationsAdd gender identity options outside of man and woman (such as nonbinary, transgender, gender-fluid, and so forth)Allow for applicants to delineate their pronouns (he/him, she/her, they/them, ze/zir, and so forth)These are both not required but optionalOpenly discuss inclusivity and diversity during recruitmentInclude statement on LGBTQIA+ inclusivity on program websiteVerbal statement during interviews that program encourages diversity in trainees, including SGMInterviewers undergo implicit bias trainingDisplay visuals that emphasize SGM inclusivityInclude progress pride flag on program website in addition to clinics, administrative officesEncourage applicants and interviewers to wear pronoun badges or include pronouns in Zoom nameAdvocate for gender-neutral restrooms with signageAvoid posting match lists before discussing preferred name and pronouns with matched applicantsEngage in training on cultural humility and sensitivity toward SGM communitiesHave annual educational sessions on patient care for the SGM communityInclude diversity, equity, and inclusion training for faculty and trainees to ensure this is a point of emphasis in recruitmentAdvocate for institutional changes to improve the lives of SGM trainees and facultyMore inclusive insurance care and parental leave benefits for nontraditional family structuresInclude transgender health care in health insurance benefitsLGBTQIA+, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other; SGM, sexual and gender minorities. Open table in a new tab LGBTQIA+, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other; SGM, sexual and gender minorities. First, in the application process, inclusion of personal pronouns and gender identity as optional would level the playing field for SGM applicants, particularly those whose gender does not fit into the male/female binary. It shows a willingness of an institution to not make assumptions about an individual based solely on their name or their physical appearance. It also gives applicants reassurance that their gender identity will be acknowledged and honored. The Association of American Medical Colleges added the option to include gender identity and personal pronouns in their medical school application in 2018.18AMCAS 2018 application: new questions.AAMC. 2018; https://students-residents.aamc.org/media/10906/downloadDate accessed: December 13, 2022Google Scholar The Electronic Residency Application Service has added an additional option for “other gender identity” as well, in some residency applications.192023 ERASMyERAS residency user guide.AAMC. 2022; https://students-residents.aamc.org/media/9716/downloadDate accessed: December 13, 2022Google Scholar This demonstrates the potential for growth in this area and we encourage continued outreach to these organizations, as well as all programs and institutions to include gender identities and space for pronouns in all their application materials, including documents for faculty recruitment. Second, residency and fellowship program faculty should explicitly discuss inclusivity and openness to recruiting a diverse group of trainees. As noted previously, medical students perceive some specialties as more or less inclusive toward LGBTQIA+ individuals.12Sitkin N.A. Pachankis J.E. Specialty choice among sexual and gender minorities in medicine: the role of specialty prestige, perceived inclusion, and medical school climate.LGBT Health. 2016; 3: 451-460Crossref PubMed Scopus (44) Google Scholar Discussing these topics assures applicants they will be welcomed warmly by a given program and that diversity is a priority, which is important for members of a minority community. This can be done via a statement on the program’s website, as well as verbally on interview days during program introductions. It is also vital that interviewers undergo implicit bias training to ensure interviewers are aware of their own biases in the selection process. Third, visuals during an interview such as identification badges with pronouns or the updated progress pride flag (which includes the transgender and Black and Brown communities) can be a marker of safety and inclusivity within an institution, as are pronouns on Zoom (manufactured by Zoom Video Communications, Inc) identities during virtual interviews (Figure 1).20Quasar D. Progress initiative. 2022.https://progress.gayDate accessed: November 11, 2022Google Scholar,21Trans Student Educational ResourcesGender pronouns. 2022.https://transstudent.org/graphics/pronouns101Date accessed: November 11, 2022Google Scholar We advocate that interviewers include their pronouns in their Zoom name for virtual interviews and introduce themselves with pronouns if the interview is in person. For in-person interviews, gender-neutral restrooms also are vital not only for applicants, but for all patients and staff. Training programs also may enthusiastically post the names and pictures of trainees that matched into their program and share it widely through their institution or social media. However, although well-meaning, care should be taken because some transgender trainees may use times of transition to come out as transgender.22Westafer L.M. Freiermuth C.E. Lall M.D. et al.Experiences of transgender and gender expansive physicians.JAMA Netw Open. 2022; 5e2219791Crossref Scopus (2) Google Scholar Instead, we suggest asking trainees their preferred names and pronouns and giving them the option to be included in such postings. Alternatively, programs may wish to publish a more general posting describing their excitement about a new class of physician trainees. Fourth, on an institutional level, training on cultural humility and sensitivity toward SGM communities represents another achievable goal. An open discussion on this topic not only allows SGM trainees to answer questions and be heard, but also can improve patient care because these skills can be translated from discussion to bedside. Although small in number, there now are leaders in gastroenterology and hepatology with a focus on this area, and we encourage involving these individuals in developing programming to meet this goal, along with institutional diversity, equity, and inclusion officers. These educational sessions should be focused not just on patient care, but increasing inclusivity of LGBTQIA+ providers within the fabric of the division. Fifth, on an administrative level, more inclusive benefits packages that encompass different family structures regarding medical care, maternity, paternity, and leaves of absence would combat the erasure SGM trainees have felt with heteronormative policies. Insurance plans that cover medical and procedural care for our transgender-identifying colleagues who are in the process of, or contemplating, transitioning also are essential. These decisions require broader administrative support, but are key areas that show institutional support for SGM employees, and discussions with program and institutional leadership are strongly encouraged. Finally, we hope other SGM-identifying physicians consider publicly identifying themselves if they are comfortable and it is safe to do so. In addition, LGBTQIA+ allies are equally important and there should be spaces in which allies can identify themselves. Some institutions have public websites that identify both LGBTQIA+ faculty and allies. This is just one way to increase visibility. We acknowledge our privilege to be trainees in welcoming hospitals and cities. Many gastroenterology and hepatology fellows are not afforded this luxury. We recognize the discrimination and bias previous generations of SGM physicians have experienced for much of their lives, along with the fears and stigma associated with the coming out process. We do not advocate for the outing of individuals because coming out is a personal decision. We hope that by identifying ourselves as SGM we can set an example and show others who are not yet comfortable sharing this aspect of themselves that it can be safe to do so, and that they have support. Doing so will help build a community of SGM leaders in gastroenterology and hepatology, promote a culture of mentorship and sponsorship, and establish role models with shared lived experiences that SGM trainees can look to when needing both professional and personal advice. We are proud to be SGM and proud to be part of the gastroenterology and hepatology training community. Although there remain issues to be addressed so that the field of medicine is more inclusive to all, there is also a wealth of opportunity and growth that we have seen in our short time as physicians. We now feel comfortable being at work again because of steps taken by our program leaders to create a more inclusive environment for SGM gastroenterology trainees and the community created by Rainbows in Gastro. We feel less fear of discrimination. Things are in no way perfect, but we are hopeful for a brighter future for SGM trainees.