Chapter 9 – Sexual Orientation and Gender Identity
Camilla Curren MD
Bias Toward Sexual and Gender Minorities and the Hidden Curriculum
In 2014, a study of lesbian, gay, bisexual or transgender (LGBT) general surgery residents determined that one-half of them actively concealed their sexual orientation or gender identity from colleagues due to fear of discrimination or reprisal in the workplace.1,2 In another study, 82% of heterosexual first-year medical students held at least some degree of implicit bias against gay and lesbian students.3 In the study on surgery residents, none of the trainees who experienced overt homophobic remarks or slurs reported these incidents; one of the reasons cited was the feeling that nothing would be done about it if the event is reported.2
Bias against LGBT persons can be embedded in the hidden curriculum of an academic institution.1,4 Hidden curriculum has been defined as “the attitudes and values conveyed, most often in an implicit and tacit fashion, sometimes unintentionally, via the educational structures, practices, and culture of an educational institution”5 and as the combination of implicit and explicit biases, institutional climate, and usual behaviors at an academic medical center.1 Discrimination and bias support ongoing identity concealment among sexual minorities, which in turn deprives others of LGBT faculty and peer role models. This leads to an institutional atmosphere that accepts or does not recognize biases and the need to reform attitudes toward LGBT learners, faculty, and patients.1
Effects of Professional Bias Toward LGBT Health Providers
John Davis, PhD MD, former Associate Dean for Medical Education at OSU College of Medicine and national expert on LGBT issues, now Associate Dean of Curriculum at the University of California at San Francisco, notes that he witnessed derogatory references to sexual minorities during his years in training. However, Davis feels that it did not hold him back in his career. In fact, he encountered mainly supportive behavior when he came out as a medical student (he was the only openly gay student in his medical school class). Davis adds that he did, however, choose a specialty (infectious diseases) and work environments that were supportive of rather than hostile toward LGBT physicians.
In contrast, a Columbus, Ohio primary care physician in private practice, who retracted permission to use his name after being interviewed for this publication, still is not open about his sexual orientation and fears that some of his patients might leave his practice were they to discover that he is gay. Now middle-aged, he notes that, although he never experienced explicit bias in medical training, he felt lonely and isolated as a medical student and resident, and afraid to share his sexual minority identity with peers or attending physicians at OSU Wexner Medical Center. Eventually, he did, however, find some support among faculty at Nationwide Children’s Hospital, which he believes had a more inclusive environment at the time.
Evidence of increased stress and burnout exists when health care providers experience discrimination or social bias in the workplace.1,6 In a 2011 study of self-identified LGBT physicians, 10% were denied referrals from heterosexual colleagues, 15% reported harassment by a peer, 22% experienced feeling socially ostracized, 65% witnessed derogatory comments about LGBT individuals, and 27% knew of discriminatory treatment of an LGBT coworker.6
Julia Applegate, Director of Center for LGBTQ Health Equity, Equitas Health Director of Center for LGBT Health Equity for Equitas Health, on “Sexual Minority Health Providers and Bias in Medicine” – YouTube Video
Effects of Sexual Minority and Gender Identity Bias in Physician/Patient Relationships
“Our relationship to medicine and health is one that is tension-filled,” opines Julia Applegate, Director of LGBTQ Health Equity for Equitas Health Care in Columbus, Ohio. Applegate describes a difficult road of 37 years duration as a lesbian patient seeking comfortable and appropriate health care services. Having originally held a variety of jobs which occasionally required her to go back into the closet to avoid discrimination, Applegate finally arrived at a professional position working with the state and city on HIV prevention in an accepting and affirming environment, before progressing to her current post.
Applegate notes that health providers do not ask enough specific questions when interviewing LGBT patients, and that unnecessary lectures on topics like birth control and pregnancy prevention, for example, interfere with an accurate discussion of sexual practices. In addition, such conversations make lesbian patients feel “invisible” and interfere with the perception of the medical office as a safe space in which to discuss, for example, sexual orientation and its relationship to fertility concerns–so these and other aspects of a healthy life and applicable preventive care may never be addressed. Some studies indicate that the majority of physicians rarely elicit sexual information from their patients and would feel uncomfortable attempting to meet the healthcare needs of a lesbian or gay patient.6
Data compiled by the Fenway Institute suggests that incidences like those described by Applegate lead to internalized homophobia and negative expectations of the health care system by LGBT patients, resulting in a 40% reduction in the seeking of necessary preventive and urgent care by transgender patients. This reaction, in turn, increases the many health disparities that are known to so seriously affect LGBT patients,7,8 a group which comprises an estimated 3.8% of adults in the United States or about 9 million Americans.9,10
Whereas lesbian, gay and bisexual patients are less likely than their heterosexual counterparts to receive preventive sexually transmitted infection (STI, including HIV) and cancer screenings, and are more likely to have substance abuse and mental health issues, often related to discriminatory behavior,10 transgender patients now frequently bear the brunt of discrimination in medical care.11 This includes overt provider refusal of care (19% of respondents to the 2011 National Transgender Discrimination Survey) based solely on transgender status.11 Many survey respondents reported postponing sick care due to worries about discrimination (28%¹¹ to 29.9%¹²). Race, poverty, and other social determinants of health additionally detracted disproportionately from the quality of life and accessibility of care for this cohort of persons.11
According to Ramona Peel, MA, Trans-patient Navigator at Equitas Institute for LGBTQ Health Equity, common fears of transgender patients include being asked to educate health care providers on transgender health issues (even if the healthcare problem for which care is sought has nothing to do with being transgender), called by inaccurate pronouns (“he” for a transwoman), and being “dead-named”, or called by their no-longer-accurate birth name, usually specific to a gender with which the patient no longer identifies. She believes that cisgender persons do not realize how bad the discrimination is, or how high the rates of sexual assault are for transmen and transwomen. Combined with the personal chaos that can ensue when a person comes out as transgender, Peel states, this type of treatment demoralizes and damages the mental health of transgender patients. It may add to the statistics which tell us that LGBT patients are 2-3 times more likely to commit suicide than are heterosexual counterparts10. Barriers to mental and physical healthcare for sexual minority or gender nonconforming patients include feeling unwelcome or not safe in the healthcare environment, often based on provider and staff interactions. In fact, an independent study has corroborated that transgender patients who need to educate their provider on transgender health issues are four times more likely to avoid medical care in the future.12
Reducing Bias Against LGBT Persons in Healthcare Settings
In recent years, several position papers and statements from major medical organizations have called for an end to differential care and to the stigma against LGBT patients, as well as for the implementation of specific guidelines and procedures that will help ensure uniform care.10,13,14 In addition, methods and concept outlines for teaching communication techniques and specifics needed to provide competent LGBT healthcare have been deemed necessary and have been implemented in some medical training systems.10,15
Julia Applegate agrees that these measures are helpful for reducing implicit bias and healthcare inequities. “LGBT patients have unique differences as do any marginalized group,” she emphasizes, and learning to address these differences in clinical encounters with patients across the lifespan will increase provider confidence and will thus decrease attitudinal biases that dissuade patients from accessing care. Currently, four or fewer hours of medical school training are typically devoted to LGBT patient care.10 Evidence exists that increased provider training will increase competence in providing LGBT specific care, and will help with bias reduction and, hopefully, with resolution of care inequities.15,16
Additionally, Applegate notes, consistent training on providing an accepting atmosphere, as well as on cultural humility, has been shown to have a positive effect on bias reduction. Dr. Davis agrees and notes that those health providers with stature and power in a given situation may help colleagues to be more sensitive and supportive by communicating respectfully regarding the erosive nature of offhand remarks and other microaggressions toward LGBT colleagues. Providing positive LGBT role models can additionally modify the hidden curriculum and has been shown to normalize the acceptance of LGBT peers in medical environments.1
Davis notes that failure to address disparities in healthcare toward any minority simply perpetuates the problem and reinforces biases toward all minorities; it is, therefore, the key to recognizing that there are still inequities in LGBT healthcare and in acceptance in the health setting despite early attempts to address these problems. And Applegate worries that reduced emphasis on gaining acceptance for LGBT patients and providers will be a “weird consequence” of early success in this area. In fact, it may be hard to gauge the successes made due to poor data collection over time, which is likely to leave the extent of this problem poorly-estimated, Davis acknowledges.