Attitude and Perceptions of the Other Underrepresented Minority in Surgery

Objective

To perform a national climate survey of general surgery residents regarding attitudes and perceptions of the influence of sexual orientation on the training experience.

Methods

A cross-sectional voluntary online survey was distributed to all Accreditation Council for Graduate Medical Education–accredited general surgery programs. Residents self-identified as heterosexual, lesbian, gay, or bisexual. Descriptive statistics were performed. For the purposes of further analysis, respondents were classified as heterosexual or LGBT. Demographic characteristics and survey responses were examined by sexual orientation using the Fisher exact test.

Results

Of 388 resident respondents, 10 identified as lesbian (2.6%), 24 as gay (6.3%), and 9 as bisexual (2.4%). More than 30% of LGBT residents did not reveal their sexual orientation when applying for general surgery residency owing to fear of not being accepted. No statistical differences were found between LGBT and heterosexual residents regarding future career plans, happiness at work, good program fit, and rapport with fellow residents. Although no differences were found in relationship status between LGBT and heterosexual residents, more LGBT residents reported feeling uncomfortable openly discussing their spouse/partner with fellow residents (36% vs 3.0%, p < 0.001) and with surgical attending physicians (59% vs 9.3 %, p < 0.001) when compared with heterosexual peers. Additionally, LGBT residents felt more uncomfortable bringing their spouse/partner to formal surgery department events (42% vs 2.7%, p < 0.001). Among all respondents, 54% (n = 206) witnessed homophobic remarks by nurses and residents and 30% (n = 114) by surgical attending physicians. Of LGBT residents, 57% reported actively concealing their sexual orientation from fellow residents owing to fear of rejection and 52% from surgical attending physicians owing to fear of poor evaluations. LGBT residents reported experiencing targeted homophobic remarks by fellow residents (21%) and by surgical attending physicians (12%). None of the surgical residents who experienced directed homophobic remarks reported the event to their supervisors for reasons including fear of reprisal (13%-17%), not wanting to create more “trouble” (25%-50%), and a belief that nothing would be done about the event (17%-25%).

Conclusion

Now, more than ever, issues related to sexual orientation have been at the forefront of political and public attention. No data exist that explore how these issues affect the training experience of general surgery residents. Our study showed that although there was no difference overall in reported work happiness or program fit, LGBT residents reported a greater need to conceal their personal lives from their surgery program peers and attending physicians. Whether these differences affect patient care, team work, career satisfaction, and personal cost of surgical training warrants further study.

Introduction

Over the past decade, lesbian, gay, bisexual, and transgender (LGBT) issues ranging from same-sex marriage to workplace discrimination have received increased national public and political attention. The repeal of the Don’t Ask, Don’t Tell policy, the overturning of Defense of Marriage Act by the US Supreme Court, the recent veto of the Arizona bill SB-1062 that would have allowed businesses to deny services to LGBT individuals on religious grounds, and the announcement of the first openly gay male professional athletes in both the NBA and the NFL are just a few examples of the increased visibility of LGBT issues in the United States today.

The intersection between the health care system and LGBT concerns has been, until very recently, precarious at best. Until 1973, homosexuality was categorized as a diagnosable pathological disorder according to the Diagnostic and Statistical Manual of Mental Disorders. Even to this day, there are frequent reports of LGBT individuals being denied access to their partner or children in hospitals,¹ such that a Presidential Memorandum on Hospital Visitation was issued in 2010 directing all hospitals participating in Medicare or Medicaid to “respect the rights of patients to designate visitors.”² Even though significant progress has been made in the past several decades, societal bias against LGBT individuals persists and continues to affect not only LGBT patients but also LGBT care providers.

In medicine, much of the recent focus, both in policy and research, has been on concerns of LGBT patients and the effect of sexual orientation and transgender status on health disparities, specific health needs, health care access, visitation policies, and medical decision making.3, 4, 5, 6 In 2011, the Institute of Medicine released a landmark report titled “The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding,” which acknowledged the paucity of data on the health needs of LGBT individuals and recommended that the National Institute of Health “create a comprehensive research training program that would raise awareness of LGBT health issues among researchers.”⁷ Despite recent increased policy and research initiatives for LGBT patients, few studies have considered the issues encountered by LGBT physicians and even fewer on LGBT residents. A paucity of literature exists regarding the influence that sexual orientation/transgender status can play on the educational experience, career choices, instructional climate, and working relationships of this minority population.8, 9

A national cross-sectional survey in 2008 of 500 randomly chosen US adults found that 30% of respondents would change their health care provider if they found out their provider was gay or lesbian, and 35% would change practices if the practice employed a gay/lesbian health care provider.¹⁰ In another study published in 2011, investigators surveyed more than 400 LGBT physicians regarding their workplace experience as related to their sexual orientation/gender identity, and 10% reported being denied patient referrals by their heterosexual/straight colleagues, 15% reported harassment from colleagues, and 22% reported feeling socially ostracized by their peers as a result of being LGBT.¹¹

The historical and present consequences of a physician revealing his/her LGBT identity to either colleagues or patients cannot be understated. Some fields of medicine, such as surgical specialties, have traditionally being characterized as endorsing a more conservative working environment than other disciplines such as psychiatry or family medicine. One statewide survey in New Mexico in 1998 queried 1027 attending physicians across all medical fields regarding their attitudes toward LGBT physicians and found that “medical specialties with higher percentages of physicians who would have discouraged gay and lesbians from entering their own fields included surgery (16.2%) and obstetrics-gynecology (12.1%).”¹² Undoubtedly, this attitude might influence the surgical residency experience.

We hypothesized that LGBT surgical residents do not experience the same safe training environment compared with their heterosexual counterparts.