Abstract
Background
LGBTQ medical students and surgery residents face myriad structural barriers. The American Civil Liberties Union (ACLU) reports 492 pieces of state-level legislation targeting Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) people in the past year. These bills including bans on medical care, “don’t say gay” bills, exclusion from anti-discrimination protections, and more. These bills may limit where medical students pursue surgical training
Study Design
The Movement Advancement Project and the ACLU legislative databases were consulted to determine whether states (plus Puerto Rico and the District of Columbia) currently had or were actively considering anti-LGBTQ legislation. This information was then mapped against data from the 2023 National Residency Match Program. US News rankings of top surgical training programs were utilized as well.
Results
There were 2803 general surgical training spots, of which 1597 (57%) were located in states which currently have anti-LGBTQ legislation in place. 245 (9%) of training spots are in states which do not have such legislation but are currently considering anti-LGBTQ legislation. Of the top 20 residency programs, 11 (55%) were in states with anti-LGBTQ legislation. In affiliated specialties, 50 (54%), 118 (57%), and 24 (49%) surgical training positions for integrated vascular, plastic, and thoracic surgery, respectively, are in states that currently have anti-LGBTQ legislation in place. In total, 63% of fellowship opportunities were in states with Anti-LGBTQ legislation in place
Conclusion
A majority of graduate surgical education occurs in states with anti-LGBTQ legislation, potentially limiting residency options for people who value protection of LGBTQ rights
Keywords: Education, Residency, Fellowship, LGBTQ, Equity
Introduction
The United States will face a projected shortage of 30,000 general surgeons by the year 2034 (1). ACGME-accredited residencies are a pathway for training a diverse population of surgeons qualified to care for the health needs of the United States. Surgical residencies must recruit from a diverse pool of medical students and compete for the candidates who can best meet the rigors of training and practice. In trying to recruit a diverse population of surgical trainees, inclusion of Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) applicants is a priority. LGBTQ trainees and surgeons contribute a necessary perspective in caring for the U.S. population (2).
Candidates and surgical residency programs must acknowledge that factors outside of the training environment impact decisions of matriculation. Amongst surveyed medical students, geographical location of a program was the most important factor in choosing where to apply for training and a critically important factor in the eventual ranking of programs 11/29/2024 5:36:00 PM. Those identifying as LGBTQ, those part of the community supportive of LGBTQ people, and those interested in protection of rights for all people should be aware of the various state laws where surgical training programs are located. State-level legislation includes, but is not limited to, bans on medical care for LGBTQ people, “Don’t Say Gay” bills, and exclusion from anti-discrimination protections. Passage of such anti-LGBTQ legislation can lead to broader increases in societal anti-LGBTQ sentiment, increasing the risk of interpersonal violence and discrimination (4). LGBTQ people are thus heavily disincentivized from living in states where these laws have passed or may be passed. As laws regarding LGBTQ rights impact both the receipt and the delivery of health care (2), candidates must match their own values regarding LGBTQ protection with their choice of location and type of residency. Furthermore, training programs and faculty must understand how state laws may influence candidates’ decisions in choosing a surgical residency.
Not known are the variation in laws regarding LGBTQ rights in different states that have general surgery training programs. To address this knowledge gap, we map the intersection of opportunities for graduate surgical education and contemporary LGBTQ legislation. We hypothesize that the majority of training programs are within states that have passed or are actively considering anti-LGBTQ laws.
Methods
The Movement Advancement Project (MAP) and the ACLU legislative databases were consulted to determine whether states, the District of Columbia (D.C.), and Puerto Rico currently had or were actively considering anti-LGBTQ legislation (5,6). MAP is a nonprofit organization that focuses on advancing equality, particularly for the LGBTQ community, through research, policy analysis and advocacy tools. MAP is known for tracking state laws that affect LGBTQ rights, highlighting policy disparities and supporting social justice initiatives to address inequalities.
MAP and the ACLU track proposed bills and existing laws that could negatively impact LGBTQ rights. Legal analysts deem legislation as anti-LGBTQ if the legislation has discriminatory elements based on its “text, potential impact, and restrictions or intrusions based on sexual orientation or gender identity” (7). While legislation may explicitly use terms such as “gay” or “transgender,” other sorts of legislation may be framed as broader “religious exemption” laws, making it less immediately apparent that it could significantly negatively impact LGBTQ people (8). Furthermore, many states either specifically exclude LGBTQ people from civil rights legislation, or lack legislative language mandating their inclusion thus allowing for discrimination to occur.
Anti-LGBTQ legislation includes laws that specifically limit or curtail the actions of LGBTQ people, and legislation that excludes LGBTQ people from existing civil rights protections. MAP categorizes different anti-LGBTQ legislation into 7 categories: relationship and parental recognition, state nondiscrimination laws, religious exemption laws, LGBTQ youth laws and policies, healthcare laws and policies, criminal justice law and policies, and the ability for transgender people to correct their name and gender marker on identity documents. This study focused on types of legislation felt to be most relevant to surgical trainees which were:
Laws specifically limiting freedom of expression for LGBTQ people or around LGBTQ subjects. This includes laws that limit drag and gender nonconformance in public spaces as well as so-called “Don’t Say Gay” laws that limit discussions regarding LGBTQ people and issues in certain settings.
Laws that limit access to LGBTQ-associated healthcare, most notably coverage and accessing to gender affirming treatment as well as HIV-related care.
Laws that exclude, or a lack of laws which include, LGBTQ people within family and medical leave rights.
Laws that exclude, or a lack of laws which include, LGBTQ people within employee non-discrimination rights.
This information was then mapped against data from the 2023 National Residency Match Program (NRMP) for general surgery programs, as well as the affiliated specialties of integrated vascular surgery, integrated plastic surgery, and integrated thoracic surgery, which includes training in cardiac, thoracic, and congenital surgery (3). US News rankings of top surgical training programs were utilized as well (9). A similar methodology was utilized for general surgery fellowship programs which participate in the NRMP (3). Data are reported as absolute numbers and percentages where appropriate.
Results
In 2022, there were 2,803 general surgery training positions, 93 integrated vascular surgery training positions, 207 integrated plastic surgery training positions, and 49 integrated cardiothoracic surgery training positions. Of all general surgery training spots, 1597 (57%) were in states that currently have anti-LGBTQ legislation in place and 245 (9%) of training spots are in states that do not have such legislation but are considering anti-LGBTQ legislation. This data is shown in Figure 1. Of the top 20 residency programs as reported by the US News and World Report, 11 (55%) were in states with anti-LGBTQ legislation (9).
Figure 1:
Chloropleth Map of Residency Position Density and Anti-LGBTQ Legislation
In affiliated specialties, 50 (54%), 118 (57%), and 24 (49%) surgical training positions for integrated vascular, plastic, and thoracic surgery, respectively, are in states that currently have anti-LGBTQ legislation in place. Of states in which such legislation does not exist but are currently considering, there are 9 (9.7%), 18 (8.7%), and 3 (6%) surgical training positions for integrated vascular, plastic, and thoracic surgery, respectively. This information is shown in Table 1.
Table 1.
Surgery Residency Training Programs Stratified by State Legal Status
| Residency Program | No. Positions | No. Positions in States with Existing Legislation (%) | No. Positions in States Considering Legislation (%) |
|---|---|---|---|
| General Surgery | 2803 | 1597 (57%) | 245 (9%) |
| Integrated Vascular Surgery | 93 | 50 (54%) | 9 (9.7%) |
| Integrated Plastic Surgery | 207 | 118 (57%) | 18 (8.7%) |
| Integrated Cardiothoracic Surgery | 49 | 24 (49%) | 3 (6%) |
| Total | 3152 | 1789 (56.7%) | 275 (8.7%) |
For general surgery fellowship programs that participated in the 2023 match, there were 511 total fellowship training programs: 68 colorectal surgery fellowship programs, 175 surgical critical care fellowship programs, 100 vascular surgery fellowship programs, 38 surgical oncology fellowship programs, 83 thoracic surgery fellowship programs, and 47 pediatric surgery fellowship programs. In total, 63% of fellowship opportunities were in states with Anti-LGBTQ legislation in place. The breakdown by fellowship is shown in Table 2.
Table 2.
Surgery Fellowship Training Programs Stratified by State Legal Status
| Specialty Fellowship Program | No. Programs | No. Positions | No. Positions in States with Existing Legislation (%) | No. Positions in States Considering Legislation (%) |
|---|---|---|---|---|
| Colorectal Surgery | 68 | 110 | 74 (67%) | 10 (9%) |
| Surgical Critical Care | 175 | 340 | 217 (64%) | 25 (7.4%) |
| Vascular Surgery | 100 | 136 | 89 (65.4%) | 10 (7.4%) |
| Surgical Oncology | 38 | 67 | 37 (55%) | 2 (3%) |
| Thoracic Surgery | 83 | 93 | 53 (57%) | 6 (6.5%) |
| Pediatric Surgery | 47 | 45 | 27 (60%) | 5 (11%) |
| Total | 511 | 791 | 497 (63%) | 58 (7.3%) |
Discussion
Through analysis of current data, this study shows that more than half of all residencies for surgical and affiliated surgical specialties are based in states that currently have or are actively considering anti-LGBTQ laws. Surgical education constitutes a minimum 5-year time commitment to one program during a formative period of an applicant’s adult life. Furthermore, data from the American Association of Medical Colleges find that a majority of residents eventually practice in the state where they completed their residency (16), further amplifying the significance of choice of residency program. Deciding which programs to apply to involves consideration of a multitude of factors. For LGBTQ medical students, there are additional considerations that include how diverse and accepting programs and their locale are, if there is access to the healthcare they require, and what legislation is in place that may affect their livelihood.
LGBTQ medical students and general surgery residents already face myriad forms of both structural and social discrimination(2,11). It is likely that LGBTQ medical students considering general surgery might not consider pursuing training in states with active anti-LGBTQ legislation. It is shown that while choosing a residency, a program’s location, culture, and organization are among the most influential factors in applicants’ decision-making, and surveys of sexual and gender minority applicants consider surgery and surgical subspecialties among the least welcoming (12,13).
LGBTQ general surgery residents have been found to experience more discrimination, sexual harassment, and bullying in comparison to their non-LGBTQ counterparts (11). Personal well-being is shown to consistently be one of the higher ranked wellness-related concerns among surgery residents, so it likely that the possibility of entering a hostile environment carries heavy weight in the decision-making process (14,15).
These legal implications compound the existing atmosphere of social stigma surrounding the LGBTQ community, which may influence the decisions made by students when applying for surgical residencies. In a volatile political environment, the likelihood of more anti-LGBTQ laws passing is unpredictable yet foreboding for those who will be most affected.
While LGBTQ surgeons make up a small percentage of the surgical workforce, this legislation has impacts beyond immediate members of the community, including allies and advocates, family members, and individuals who more broadly stand with the LGBTQ community. Many individuals become caretakers of aging parents or have other dependents, making the local environment and laws significant factors in their personal and professional decisions. For example, over half of parents of LGBTQ children in Florida have strongly considered leaving the state following the passage of Florida’s “Don’t Say Gay” bill, HB 1577 (17). If anti-LGBTQ legislation discourages where applicants apply and where LGBTQ surgeons and allies practice, it may further exacerbate the already critical workforce shortage in the future.
The implications of this research extend beyond applicants and residents. Surgery program directors play a crucial role in creating supportive and inclusive environments for all residents. It is imperative that program directors stay informed on any anti-LGBTQ laws in their state to communicate with residents about potential impacts to their lives and to advocate for policies that protect LGBTQ rights within the institution. The absence of LGBTQ physicians due to the conditions of local environments not only deprives patients of diverse perspectives and culturally competent care but also limits LGBTQ patients’ access to providers who may better understand and relate to their unique experiences. Additionally, the presence and visibility of LGBTQ physicians encourages acceptance and education of their colleges, nurturing a welcoming environment. While program directors may feel hesitant to explore LGBTQ issues, they should have data about local environments to support choices of candidates and their trainees. This requires proactive and ongoing commitment to fostering diversity, equity, and inclusion within the surgical community.
This study comprehensively analyzed all states and surgery residency programs; however, it does have some key limitations. Primarily, this study clustered anti-LGBTQ laws into broad categories, which may not accurately represent the disproportionate impact certain sorts of laws may have. Furthermore, while the analysis provides a cross-sectional representation of the current legislative landscape, the findings do not establish a causal relationship between anti-LGBTQ legislation and the quality or inclusivity of surgical training programs. Legislation may change at local, state and federal levels, potentially altering the impact on residency programs over time. Future research should utilize longitudinal data to better quantify the impact of legislative changes on residency application rates, comparing states before and after laws have been passed and comparing between states with and without such legislation. Qualitative research investigating the beliefs and behaviors of both program directors and applicants is also necessary to further understand the impact of statewide legislation on applicant decisions.
Conclusion
A majority of graduate surgical education occurs in states with anti-LGBTQ legislation, potentially limiting residency options for people who value protection of LGBTQ rights. The quality or number of applicants to states with LGBTQ restrictions may be impacted, exacerbating shortages of surgical specialists.
Highlights.
There were 492 pieces of anti-LGBT legislation proposed or passed in 2023
57% of general surgery residency positions are in states with anti-LGBT laws in place
63% of surgery fellowship positions are in states with anti-LGBT laws in place
Abbreviations
- ACLU
American Civil Liberties Union
- LGBTQ
Lesbian, Gay, Bisexual, Transgender, and Queer
- NRMP
National Residency Match Program
- MAP
Movement Advancement Project
Footnotes
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