The well-being of gay, lesbian, and bisexual physicians

INTRODUCTION

Gay, lesbian, and bisexual (GLB) physicians have long had a largely covert historical presence within the profession; their visibility is a relatively recent phenomenon. The American Psychiatric Association's landmark 1973 decision to remove homosexuality from the nomenclature of psychiatric disorders was a major catalyst in this regard, allowing GLB physicians to take tentative steps into the culture at large. A search of the medical literature yields information on attitudes within medicine toward GLB patients but little about GLB physicians themselves. Their challenges and triumphs are likely similar to those of other minority groups within the profession, with the exception that GLB physicians can choose whether or not to make their minority status known to patients and colleagues.^1,2

Table 1.

Questions that GLB physicians face in deciding whether to come out

If I come out during medical school, will it affect my grades or my ability to match into a competitive residency program? Will I have the support of my classmates, or will I be ostracized? Can I even be a GLB pediatrician, gynecologist, or urologist? If I become a subspecialist, will my openness negatively affect my referrals from colleagues? Will patients shun me? Can I practice in a small town, or am I consigned to a large metropolitan area?

Although societal tolerance toward sexual minorities has greatly improved since 1973, coming out as a GLB physician remains a difficult decision, with both personal and professional consequences. Gay, lesbian, and bisexual physicians have to ask themselves a number of unique questions in deciding whether to come out (see box).

Well-being implies personal and professional satisfaction, and the ability to effectively integrate the 2, to form satisfying relationships with patients and colleagues, and to attain both internal and external respect. In this article, we review the literature on those variables most likely to affect the well-being of GLB physicians: homophobia, the difficulties encountered by GLB medical students and house staff, and antigay discrimination. We conclude by suggesting directions for future research in this topic and offering suggestions for enhancing the well-being of GLB physicians.

METHODS

We conducted a search of the MEDLINE database from 1966 through June 2000 using the search terms gay or lesbian or bisexual or homosexual, physician or doctor or health professional, and professional practice. We limited our search to those papers written in English. The references of the articles selected were reviewed to identify studies missed by the initial search.

HOMOPHOBIA

A number of studies have looked at the existence of homophobia within the medical community. In 1982, a questionnaire was mailed to all members of the San Diego County Medical Society eliciting attitudes toward homosexual patients and colleagues.³ Using the validated Heterosexual Attitudes Toward Homosexuality (HATH) scale, 23% of respondents were judged to have homophobic attitudes (37% scored in the homophilic range; the remainder were neutral). In 4 specialty areas (orthopedic surgery, obstetrics and gynecology, general and family practice, and general surgery) more than 30% of respondents displayed homophobic attitudes. A 1988 survey of family practice residents at 9 university-based Southern California programs showed overall that 19.7% of male residents were homophobic (only 2.5% of females scored in this range).⁴

The rise of AIDS drew fresh attention to gay men and gave GLB concerns a new visibility. Some homophobic views were likely softened through empathy, while others hardened amid increasing vitriol directed at the gay community. A 1989 survey of 1,745 third-year residents in internal medicine and family practice looked at attitudes toward caring for patients with AIDS and toward homosexuals in general.⁵ Thirty-five percent agreed with or were unsure about the statement “Homosexuality is a mental disorder,” while 20% admitted they were not comfortable being around homosexuals.

Perhaps the most egregious example of homophobia within the medical literature is contained in a 1984 editorial in the Southern Medical Journal.⁶ The author speculates on the etiology of AIDS, and citing biblical passages, concludes that “homosexual men [are] reaping...[the] expected consequences of sexual promiscuity,” and that “homosexuality is a pathologic condition.” The author suggests that physicians should “seek reversal treatment for their homosexual patients just as vigorously as they would for alcoholics or heavy cigarette smokers.”

GLB ISSUES IN MEDICAL EDUCATION AND TRAINING

Given that homophobia is common in practicing physicians, how are GLB issues being addressed in the medical school curriculum? A 1991 study, with a 65% response rate, polled the directors of medical school education in psychiatry at all US medical schools and found that, on average, about 3.5 hours out of 4 years is devoted to the topic of homosexuality.⁷ The most common teaching technique used by the schools was lectures (80%); about 40% of the programs used direct contact with gays and lesbians.

Support services for GLB medical students and residents, while not ubiquitous, appear to be growing. A 1994 survey of 185 GLB medical students, representing 92 medical schools in 34 states, found that 70% of the students had a GLB support group at their school; 9 of the medical schools had an official liaison for GLB students (up from 4 in 1990).⁸

An interesting 1994 study of 291 family practice residency program directors and 67 GLB 3rd-year and 4th-year medical students looked at attitudes surrounding specialty choice, interviewing for residency, and the ranking of residents.⁹ Forty-seven (71%) of residents said their homosexuality affected their decision about specialty choice; 35 (52%) thought an openly GLB student would be ranked lower in a program's match list; less than half planned to disclose their sexual orientation during interviews; and 20 (30%) edited their curriculum vitae to remove activities or memberships that might reveal their homosexuality. Questions from the HATH scale were administered to the program directors; 8% scored in the homophobic range. (A few directors included comments that homosexuality was a “genetic defect,” a “psychiatric diagnosis,” or “an aberration.”) One quarter said they would rank an openly GLB candidate lower; another 25% thought disclosure of sexual orientation during the interview was inappropriate. Not surprisingly, the 32% of directors who had had recent experience with GLB residents in their programs had more homophilic HATH scores.

DISCRIMINATION

Anti-GLB discrimination represents homophobia in action. That action may be a callous off-hand remark or joke that belittles a GLB patient, or it may be denial of medical school admission to GLB students on the basis of their sexuality. It may also involve denying a grade of “honors” to a GLB student during a clerkship or a residency position to a GLB physician. Another form of discrimination is to refuse to refer patients to a GLB physician.

A 1994 survey of its membership by the American Association of Physicians for Human Rights—since renamed the Gay and Lesbian Medical Association, or GLMA—attempted to quantify and document instances of anti-GLB discrimination within medicine.¹⁰ Out of 1,311 total members at the time, 711 members (54%) returned questionnaires. Among the findings were that 17% had been denied referrals, 34% had experienced “verbal harassment or insult[s] by their medical colleagues,” and 67% felt that many GLB physicians would risk losing their practices if colleagues discovered their sexual orientation, while only 12% felt they were treated as equals within the profession. Even more compelling than these statistics were the many personal anecdotes offered by the respondents, detailing callousness, ostracism, insults, rescinded job offers, and invitations to undergo psychotherapy.

Table 2.

Questions, issues, and dilemmas still facing GLB physicians

Do GLB physicians feel accepted in their professional life? Would they advise a GLB premedical student to choose medicine as a career? Would they themselves do it again? What potential changes within medicine would improve their well-being? Are the majority of GLB physicians open about their sexual orientation to colleagues, office staff, and their patients? What are the professional ramifications of that decision to be open? Are openly GLB physicians happier and more successful, and do they suffer more or less stress? How many employers of physicians include “sexual orientation” in their non-discrimination statement? How many offer partner benefits?

These results were corroborated by a 1993 survey of lesbian physicians reporting rates of harassment because of sexual orientation: lifetime 41%; 18.2% during graduate medical education; 18.5% during medical practice; and 32.6% in any work setting after medical school.¹¹

Fortunately, there is some evidence that these negative attitudes are changing. A study of opinions of New Mexico physicians toward GLB colleagues, published in 1996,¹² paralleled the questions asked in 1982 by Mathews and colleagues in San Diego.³ Fewer physicians in the 1996 study would deny admission to medical school to a highly qualified GLB applicant (4.3% vs 29.7% in the 1982 study). In addition, less than 10% (vs 45% in 1982) would discourage a GLB physician from becoming a pediatrician. On the subject of referral practices, 91% indicated they would still refer patients to a psychiatrist colleague if they found out he or she was homosexual (as compared with only 57% in the San Diego study).

FUTURE RESEARCH AND POSSIBLE SOLUTIONS

Although there is evidence that the climate of acceptance has clearly improved over the past quarter century, GLB physicians still face many questions, issues, and dilemmas (see box).

Anyone conducting research on GLB issues will need to confront a larger issue: how to obtain a representative sample. If we conservatively estimate the percentage of GLB people in the general population at 3% and presume they are proportionately represented within the medical field, there would be more than 20,000 GLB physicians nationwide. Since the largest GLB physician organization has a membership of about 2,000, it is clear that sampling only members of GLB organizations is inadequate.

Makadon has suggested that GLB physicians' own openness and honesty in the health care setting depends on explicit attention to medical education on GLB and transgendered (GLBT) health issues in all aspects of training.¹³ Studies evaluating the effectiveness of medical school curricula on homosexuality have independently shown that students who are acquainted with a gay man or lesbian have improved attitudes toward them.^14,15 It is no surprise to find that, anecdotally, many GLB physicians participate in physician education on GLB health issues by disclosing their own sexual orientation and acting as the “acquaintance” resource for students, residents, and colleagues in their learning process. Katsufrakis has explored the risks and benefits of serving in this role.² The long-term effects of this strategy on well-being have not been researched but deserve further study, as more physicians are self-disclosing in the workplace.

From the limited data available, we cannot recommend that all GLB physicians come out en masse in the hopes of improving education, attitudes, and career life. Instead, we suggest that—whenever and wherever it feels safe—lesbian, gay, and bisexual physicians join others in the workplace in the casual, honest conversations that pertain to career, family, and personal choices. In our experience, these informal conversations are a great aid to physician well-being. We also suggest that the colleagues of GLB physicians listen respectfully to this shared information, realizing the cost at which it has been spoken, and welcome the physician to the conversation. For those who are not ready to come out, because of either a real or perceived threat to their livelihood, family, or personal safety, we advise tolerance and patience within the GLB physician community. Other practical suggestions are listed in the box.

CONCLUSION

Despite the encouraging indicators, at present it is difficult to assess whether GLB physicians have crossed a major threshold or will continue to struggle for equal treatment and respect from their peers, 2 essential components of well-being. The optimist in us trusts that the future will be considerably brighter.

Table 3.

Suggestions for enhancing well-being among GLB physicians

Where possible, come out Join a GLB organization; if none is available near you, form one If you work for a hospital or physician group, ask that “sexual orientation” be added to their nondiscrimination statement—if not for yourself, then for your patients Sponsor a booth at the local Gay Pride celebration Join a GLB e-mail list, such as glb-medical. To join, send an email message to listserv@listserv.utoronto.ca, and in the body of the message, write: subscribe glb-medical-l <Your Name> If you live near a medical school, volunteer to speak as part of the GLB curriculum Act as a mentor for a GLB medical student or resident

Table 4.

GLB physician resources
Several national organizations exist to provide emotional and professional support and advocacy for GLB physicians. Listed are 3 of the largest:
Gay and Lesbian Medical Association (GLMA)
Founded in 1981 (as the American Association of Physicians for Human Rights), GLMA currently has more than 2,000 physician and student members throughout the United States and Canada. Its many missions include education of its members and the public at large about GLBT issues; funding of lesbian health research; a program to assist HIV-positive health professionals; public policy advocacy; and a physician referral program to help GLBT patients find providers sensitive to their needs. In addition, GLMA has founded a medical journal devoted to GLBT issues (Journal of the Gay and Lesbian Medical Association).
www.glma.org
Phone: (415) 255-4547
Lesbian, Gay and Bisexual People in Medicine (LGBPM)
A standing committee of the American Medical Student Association, LGBPM forms a support network for GLB medical students. Each year the group polls its former members to produce the National LGBPM Residency Survey, which documents how supportive different residencies are toward GLB housestaff.
www.amsa.org/sc/lgbpm.html
Phone: (703) 620-6600, ext. 451 or 452
Association of Gay and Lesbian Psychiatrists (AGLP)
Originating in the mid 1970s as a caucus within the American Psychiatric Association, AGLP was officially formed in 1985 and has more than 500 members.
www.aglp.org/
Phone: (215) 222-2800

Summary points

• While research has been directed at the attitudes of physicians towards gay, lesbian, and bisexual (GLB) patients, relatively little attention has been paid to GLB physicians

• The factors most likely to affect the well-being of GLB physicians are homophobia, discrimination, the challenges of medical school and residency, and lack of support systems

• Homophobia has been documented among physicians and directors of medical school education

• GLB physicians experience verbal harassment or insults from their medical colleagues, and many believe that they risk losing their practices if colleagues discover their sexual orientation

• We suggest directions for future research and ways in which the well-being of physicians can be enhanced

Figure 1.

Gay, lesbian, and bisexual physicians share unique dilemmas and challenges…© Photonica/Robert Taylor