The Influence of Anti-LGBTQIA+ Legislation on Graduate Medical Education

More than 400 state bills that discriminate against lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender diverse identities (LGBTQIA+) are active or have passed in the 2023 US legislative session.¹ Across the United States, 70% of state legislatures, largely concentrated in the Midwest and South, are considering at least one anti-LGBTQIA+ policy.¹ These bills target the rights of LGBTQIA+ people, who represent over 7% of US adults, in essential areas of life: health care, education, public space, free speech and expression, credit, and federally funded programs.² Examples include censoring of LGBTQIA+ content in education and media, restricting transgender students from participating in school activities, prohibiting individuals from using public bathrooms concordant with their gender identity, criminalizing gender-affirming care, allowing religious exemptions for discrimination against LGBTQIA+ persons, and restricting free speech and gender expression.¹ Accordingly, patients living in affected regions face outright discrimination in everyday life and are fearful about their access to health care.^3-6 Effects of anti-LGBTQIA+ legislation are relevant not only to patients but also to the health care workforce. Residents are an especially vulnerable population given their clinical and educational responsibilities and reporting roles.⁷ In response to the evolving sociopolitical landscape, we aim to describe the influence of anti-LGBTQIA+ legislation on graduate medical education (GME) and offer solutions for GME leaders to support their trainees and to advocate for change.

Educators and academic institutions should not underestimate the consequences and insidiousness of anti-LGBTQIA+ legislation. While it may seem that efforts to oppress LGBTQIA+ people affect only a minority of the workforce, most LGBTQIA+-identifying residents are not “out” to their peers, mentors, and supervisors.⁸ Meanwhile, physicians who do not identify as LGBTQIA+ will have patients, children, other family members, and friends who are affected by these policies. The constitutional ambiguity of many of these laws leaves enforcement at the discretion of subjective and bias-prone policing. For example, the Tennessee Senate Bill 0003 regarding “male or female impersonators” can be interpreted to broadly outlaw gender expression that is discordant from one's sex assigned at birth.⁹ Therefore, a resident assigned male at birth who wears traditionally feminine clothing, such as heels or a cropped shirt, could be charged with a misdemeanor or felony—risking their future medical license and hospital credentials. Such expression is part of the rich history and culture belonging to the LGBTQIA+ community. Because free speech and expression are protected US rights, it is unacceptable for residents to sacrifice their identity for their training and careers.

Bills aimed at silencing LGBTQIA+ voices and advocacy in education are also highly relevant to GME. Florida's proposed House Bill 999 law would force postsecondary institutions to restrict funding for and remove LGBTQIA+ affinity organizations, and any majors, minors, or concentrations related to diversity, equity, and inclusion.¹⁰ Furthermore, restrictions on LGBTQIA+-related health care, including bans on gender-affirming care, require programs to offer alternative training opportunities, such as simulations or clinical experiences in other states, for trainees in various medical (eg, primary care, endocrinology, infectious disease) and surgical (eg, urology, plastic surgery) specialties.

The Importance of Protecting LGBTQIA+ Rights

Although highly rewarding, practicing medicine is a high pressure, often stressful occupation that changes continuously in response to patient and societal expectations. In recent years, attention on physician mental health has increased with efforts underway to improve well-being throughout medical training.¹¹ Despite these efforts, mental illness is pervasive in health care—nearly one-third of physicians have clinically significant depressive symptoms, and suicide risk is at least 3 times greater than the general population.¹² Amid anti-LGBTQIA+ legislation, LGBTQIA+ residents face stressors associated with not only their physician roles, but also their gender and sexual identities. As a result of mistreatment and stigmatization in society, the risk of suicide in these individuals is 4 times higher than the general population.¹³ For an LGBTQIA+ resident, the intersection of roles and identities amplifies the already unacceptable mental illness burden in the physician population. Studies surveying residents and medical students show that LGBTQIA+ trainees report disparate rates of discrimination, mistreatment, and burnout compared with their heteronormative peers.⁸ Although we prioritize physician and trainee well-being to improve patient care, attrition and burnout are also financially devastating for health care institutions. A recent analysis found the annual cost of turnover and reduced clinical hours associated with burnout was approximately $7,600 per employed physician for an estimated total of $4.6 billion nationally.¹⁴ These findings demonstrate that supporting LGBTQIA+ residents and improving advocacy for LGBTQIA+ identities in GME have benefits beyond personal and patient care-related outcomes.

Lifestyle is increasingly important to senior medical students when choosing residency programs.¹⁵ Considering safety and mental health consequences, we expect many LGBTQIA+ medical students will avoid ranking programs in geographies with restrictive and discriminatory policies, such as the Midwest and the South.¹⁶ Even without legislation, there are serious threats to the safety of LGBTQIA+ individuals in many states and cities. Surveys show that up to 19% of lesbian women and gay men have been assaulted because of their sexual orientation, 40% have been threatened with physical violence, and 94% have experienced some type of victimization, including verbal abuse.¹⁷ Because no studies have examined how anti-LGBTQIA+ policy has influenced the Match process in recent years, further research should investigate whether LGBTQIA+ medical students are disproportionately more likely to avoid certain specialties or remain unmatched as a result of limited acceptable positions. This reality is harmful to students who are thus restricted in rank options, patients who deserve and benefit from a diverse health care workforce, and programs that seek to attract diverse and talented residents and fellows to advance their specialties. The consequences amplify an already limited pipeline to the diversification of faculty within academia and GME leadership positions. GME offices and program directors should consider several institutional- and systems-level actions, as the rights of their LGBTQIA+ workforce are increasingly threatened.

Institutional Strategies

Faculty mentoring is important for trainee wellness, especially as part of a structured program.¹⁸ By providing residents an opportunity to form longitudinal relationships with faculty, a safety net of community support within the residency program is created that can extend beyond the clinical environment.¹⁹ Some mentor-trainee relationships are substantially strengthened by concordant interests and identities; however, it may be difficult for LGBTQIA+ trainees to find a faculty mentor with similar identities and experiences. Active efforts should be made to recruit diverse and inclusive faculty who can offer this mentorship and to train allies to bolster this mentorship. Additionally, residents may feel less vulnerable and more supported if there is representation of LGBTQIA+ identities in program and institutional leadership. Faculty members are better equipped to educate peers, leaders, and trainees about the LGBTQIA+ experience in ways residents cannot in their subordinate roles. Although legislation in some states targets the formation of affinity groups for people with LGBTQIA+ identities, creating an institutionally backed organization to give a voice to LGBTQIA+ residents and faculty should be prioritized wherever possible. Finally, our institution developed a 1-year fellowship program in LGBTQIA+ health to provide focused clinical expertise, research experience, and leadership training.

Unfortunately, the politicization of LGBTQIA+ rights has created several barriers to supporting LGBTQIA+ trainees.²⁰ To remain apolitical or maintain certain partnerships, health care institutions may avoid committing to a formal stance on anti-LGBTQIA+ legislation, especially in states where these policies are strongly promoted by state leaders. However, GME offices that serve as liaisons between residents and the medical center administration have a responsibility to optimize the safety and well-being of residents and patients—all of whom are threatened by discriminatory policies. This is not a political issue but rather a public health concern.

Residents should be offered a reasonable amount of protected time to participate in advocacy activities and speak out about these issues. For example, legislators and activist organizations often invite medical trainees and other physicians to serve as experts in discussions of new policy. LGBTQIA+ trainees should be encouraged to form partnerships with local community organizations, which can be mutually beneficial through the exchange of resources and support. Moreover, trainees who are targeted by extremists because of their identity or advocacy should be connected with resources, such as institutional security, to ensure that they feel safe.²¹

When visiting rotations and in-person interviews were limited during the COVID-19 pandemic, residency and fellowship applicants relied heavily on online information about GME programs. Recent studies show that content about diversity, equity, and inclusion on program websites is often absent or provides little useful information about the program or GME office's commitment to sponsoring trainees who identify as LGBTQIA+.^22,23 Updating these resources to include efforts by GME to protect and empower LGBTQIA+ residents may help attract residents and foster community. Allocating funds for visiting student rotations, research, or other experiential learning opportunities at the institution should also be considered.²²

National Reform

To achieve its mission to accredit programs that train physicians who will provide high-quality care to patients, the Accreditation Council for Graduate Medical Education (ACGME) uses several outcome measures for program evaluation. These measures include the assessment of resident well-being, workforce diversity, engagement in quality improvement and patient safety, and recruitment and retention.²⁴ While some metrics may be objective, most measures are subjective, with programs having the ability to self-assess their achievement in reaching their aims. Accordingly, the ACGME should encourage GME stakeholders to develop, evaluate, and implement evidence-based performance metrics to assess programs in efforts to improve the quality of life for LGBTQIA+ people and other marginalized communities. If performance measures are determined, implementation through the ACGME Common Program Requirements and/or specialty-/subspecialty-specific Program Requirements are potential next steps. Supporting programs and GME institutions in improving the quality of life for LGBTQIA+ residents and fellows is an essential goal.

In addition, the ACGME should ensure that relevant training in LGBTQIA+ health is included as appropriate within program curricula (eg, sexual health, gender-affirming hormone therapy and surgery, expected radiological findings). Similar to obstetrics and gynecology programs in areas where abortion is banned that send residents to pursue rotations at other institutions, the same strategy may be necessary for gender-affirming care in many states.²⁵

There have been discussions and proposals for increased transparency in GME funding, with calls for shifts in how funds are allocated to improve workforce diversity and health equity.²⁶ GME programs are supported using federal, state, and independent funds. However, the primary source of funding is from the Centers for Medicare & Medicaid Services, which provides direct GME payments to cover direct teaching costs (eg, resident and faculty salaries) and indirect GME adjustments, which are designed to support teaching hospitals in providing care and learning opportunities in higher cost settings and to underserved populations.²⁶ With the implementation of performance-based metrics for GME programs, funding might be allocated, as appropriate, to support institutions and programs that are actively working to dispel misinformation about LGBTQIA+ health, promote inclusive attitudes and health equity in the community, and oppose anti-LGBTQIA+ legislation. Such activities could have powerful, lasting effects to improve public health.

National mandates for employee assistance programs for LGBTQIA+ trainees are needed, particularly in states with restrictive laws. LGBTQIA+ populations experience a disproportionate burden of mental illness and minority stress, and anti-LGBTQIA+ policy and attitudes have been shown to exacerbate these disparities.²⁷ A healthy workforce will require access to confidential counseling and resources for personal and professional challenges.

Conclusions

The rights of LGBTQIA+ people, which include both those of our workforce and our patients, should not be a partisan issue but rather a public health concern. As state legislatures introduce laws that seek to oppress LGBTQIA+ individuals, resident and fellow safety and quality of life are threatened, which affects recruitment, retention, and patient care. In addition to advocating for federal nondiscrimination protections, GME leaders and faculty have a duty to create learning environments in which all trainees have an equal opportunity to thrive. Such efforts may need to extend beyond medical centers to community, state, and national advocacy.