Abstract
Background
LGBTQ+ patients often face discrimination in a healthcare setting, and LGBTQ+ healthcare professionals experience disproportionately high levels of workplace stress. The purpose of this research is (i) to explore healthcare professionals' experiences about LGBTQ+ patients and colleagues and (ii) evaluate LGBTQ+ healthcare professionals' experiences, challenges, and concerns in their workplace.
Methods
The Sexual Orientation, Gender Identity, and Gender Expression (SOGIE) Project of the Japan Federation of Democratic Medical Institutions (MIN‐IREN) developed and distributed a questionnaire to assess staff experiences related to SOGI at their workplace.
Results
A total of 6216 professionals participated. Of these, 443 (7.1%) reported witnessing or hearing about discrimination against LGBTQ+ patients, and 330 (5.3%) reported similar incidents involving LGBTQ+ colleagues. The most common source of knowledge was mass media. Approximately half of the participants described their workplace as welcoming to LGBTQ+ patients and colleagues. While 705 (11.3%) participants openly identified as allies, 2129 (34.3%) considered themselves allies at heart without expressing it. Some initiatives were identified to be prioritized. Among 133 (2.1%) participants identifying themselves as LGBTQ+, 41 participants reported disclosing their SOGI to some members in their workplaces. The most common workplace difficulty was the assumption of heterosexuality in all events.
Conclusions
Discrimination against the LGBTQ+ population in healthcare settings is prevalent. Many healthcare professionals who hold allyship at heart face some barriers to express it. LGBTQ+ healthcare professionals face various difficulties at their workplaces. Collaboration with LGBTQ+ healthcare professionals is needed to foster inclusivity and support a more affirming healthcare environment.
Keywords: LGBTQ+, sexual orientation and gender identity, workplace
1. INTRODUCTION
The LGBTQ+ population faces significant health disparities, 1 , 2 often related to social marginalization. 3 Another key factor contributing to these disparities is barriers to healthcare. 4 LGBTQ+ patients are more likely to experience discrimination in healthcare settings, which can affect their willingness to seek care. 3 , 5 Meanwhile, most LGBTQ+ individuals still reported having primary care providers they could rely on. 5 This highlights the potential for healthcare professionals to reduce health disparities by providing LGBTQ+ inclusive care. Creating a safer and more supportive healthcare environment for LGBTQ+ patients can significantly improve their mental and physical health. 6 Considering that a lack of knowledge, stigma, and heteronormative attitudes often lead to discriminatory behavior and patient discomfort, 7 all professionals play a crucial role in improving the care experience for LGBTQ+ individuals and ensuring that they receive appropriate, inclusive care.
Healthcare professionals who identify themselves as LGBTQ+ (LGBTQ+ staff) also face various risks and are subject to unfair marginalization. 8 Such staff experience higher rates of depression, work‐related stress, 9 an increased risk of burnout, 10 and discrimination including bullying, sexual harassment, derogatory remarks, and microaggressions. 11 , 12 , 13 They also face career limitations due to imbalances in power dynamics. 14 Recognizing the importance of LGBTQ+ representation in healthcare is critical to ensuring diversity and advancing the protection of patients' human rights and dignity, which strengthen the well‐being of healthcare professionals and foster a more inclusive and resilient healthcare environment. 8 In addition, a diverse healthcare workforce improves the quality of care for diverse patient populations, promotes cognitive diversity, and helps reduce health inequities. 15 Therefore, understanding the extent of LGBTQ+ staff's presence in healthcare, their circumstances, and the challenges they face is critical.
Healthcare institutions thus face the dual challenge of providing patient‐centered LGBTQ+ care while also promoting policies that affirm and support LGBTQ+ staff. 16 Improving diversity and inclusion requires not only the development of LGBTQ+ inclusive policies but also comprehensive staff education and targeted initiatives. 7 However, current efforts often fail to address the nuanced challenges of promoting genuine inclusivity. Recommendations for anti‐discrimination policies frequently overlook how a prejudicial organizational culture or staff resistance can undermine these efforts and unintentionally perpetuate LGBTQ+ discrimination. 17 Instead, adopting a flexible, multifaceted approach at different stages and contexts may help establish a long‐term LGBTQ+ affirmative culture. 18 That is, LGBTQ+ inclusive care requires not only awareness and empathy, but also active engagement and feedback from LGBTQ+ individuals, a commitment to workforce diversity, and ongoing education and training. 19
To promote LGBTQ+ inclusion within healthcare settings, it is essential to investigate the experiences of healthcare professionals regarding the LGBTQ+ population, including those of LGBTQ+ staff members. However, such research remains limited in Japan, with particularly scarce studies focusing on the experiences of LGBTQ+ staff.
The purpose of this study is (i) to explore healthcare professionals' experiences with LGBTQ+ individuals and identify which initiatives are most likely to be accepted to foster a positive work environment in private medical institutions in Japan, and (ii) to evaluate LGBTQ+ staff's experiences, challenges, and concerns in their workplace.
2. METHODS
2.1. Setting
This descriptive study was part of the Sexual Orientation, Gender Identity, and Gender Expression (SOGIE) Project of the Japan Federation of Democratic Medical Institutions (MIN‐IREN). Established in 1953, MIN‐IREN strives to promote nondiscrimination and equity in healthcare and welfare. In June 2023, MIN‐IREN launched the Community, which aims to promote inclusive environments in all institutions—spaces where individuals can receive and provide care and work harmoniously, regardless of their sexual orientation and gender identity (SOGI).
2.2. Questionnaire
The SOGIE community developed a questionnaire to assess staff experience and workplace challenges related to SOGI. The questionnaire was developed based on findings from previous studies and surveys in Japan 20 , 21 , 22 , 23 , 24 and was finalized through collaborative discussions among the community members. Details are shown in Appendix 1.
The survey included questions for all participants and additional questions specifically for those who identify themselves as LGBTQ+. To maintain participants' anonymity, we did not collect identical information such as name, age, workplace, address, phone number, and e‐mail.
2.3. Analysis
We summarized the proportions of each response. In addition, we qualitatively analyzed participants' open‐ended comments using data‐driven thematic analysis. 25 All three authors were soaked in the data, repeated the discussion, and finally coded them. Missing data were deleted.
2.4. Participants
The questionnaire was distributed through Google Forms, and responses were collected from February to March 2024. MIN‐IREN employs approximately 82,000 people and has a network of more than 1700 medical and nursing facilities and numerous other offices throughout Japan. Notifications were sent to prefectural secretariats, which facilitated distribution to all affiliated offices. To increase the response rate, posters encouraging participation were created and prominently displayed.
3. RESULTS
A total of 6216 healthcare professionals participated in the study. The exact number of staff who received the questionnaire remains unknown. However, assuming an approximate total staff population of 82,000, the estimated response rate was calculated to be 7.6%. Participants' professions, years of experience, sex assigned at birth, sexual orientation, and gender identity are shown in Table 1. In total, 5259 participants (84.6%) identified as both cisgender (current gender corresponds to sex assigned at birth) and heterosexual, while 957 participants (15.4%) identified otherwise. Among all participants, 133 (2.1%) identified as LGBTQ+.
TABLE 1.
All participants' demographics (N = 6216) and sexual orientation and gender identity of the participants who reported themselves as LGBTQ+ (N = 133).
| All participants (N = 6216) | |
|---|---|
| Professions | |
| Nurse, assistant nurse, public health nurse, maternity nurse | 2364 (38.0%) |
| Clerk | 1198 (19.3%) |
| Caregiver | 852 (13.7%) |
| Rehabilitation therapist | 423 (6.8%) |
| Technician (radiological, clinical engineering, clinical laboratory) | 251 (4.0%) |
| Pharmacist | 205 (3.3%) |
| Social Worker | 147 (2.4%) |
| Doctor | 133 (2.1%) |
| Care manager | 111 (1.8%) |
| Cook | 88 (1.4%) |
| Nutritionist | 66 (1.1%) |
| Dental professions (e.g., dentist, dental hygienist) | 45 (0.7%) |
| Nursery teacher | 27 (0.4%) |
| Other | 156 (2.5%) |
| No answer | 150 (2.4%) |
| Years of experience | |
| 1–5 | 1645 (26.5%) |
| 6–10 | 1127 (18.1%) |
| 11–20 | 1678 (27.0%) |
| Over 21 | 1631 (26.2%) |
| No answer | 135 (2.2%) |
| Birth‐assigned sex | |
| Female | 4711 (75.8%) |
| Male | 1443 (23.2%) |
| No answer | 62 (1.0%) |
| Gender identity | |
| Cisgender | 6167 (99.2%) |
| Gender different from their sex assigned at birth | 17 (0.27%) |
| Gender dysphoria | 32 (0.51%) |
| Sexual orientation | |
| Heterosexual | 5295 (85.2%) |
| Homosexual | 26 (0.42%) |
| Pansexual | 75 (1.2%) |
| Bisexual | 74 (1.2%) |
| Asexual | 64 (1.0%) |
| Undecided or not want to decide | 422 (6.8%) |
| No idea about the question | 260 (4.2%) |
| Participants who reported themselves as LGBTQ+ (N = 133) | |
| Gender identity | |
| Cisgender | 106 (79.7%) |
| Gender different from their sex assigned at birth | 9 (6.8%) |
| Gender dysphoria | 18 (13.5%) |
| Sexual orientation | |
| Heterosexual | 26 (19.5%) |
| Homosexual | 24 (18.0%) |
| Pansexual | 21 (15.8%) |
| Bisexual | 32 (24.0%) |
| Asexual | 10 (7.5%) |
| Undecided or not want to decide | 16 (12.0%) |
| No idea about the question | 4 (3.0%) |
3.1. Experiences in the workplace
A total of 443 participants (7.1%) reported witnessing or hearing about discrimination against LGBTQ+ patients, while 330 (5.3%) reported similar incidents against LGBTQ+ colleagues. Details are shown in Appendix 2.
The most common source of learning about SOGI was through mass media, with 4102 participants (66.0%), followed by workplace training (3389 participants, 54.5%) and the Internet, including social media (2575 participants, 41.4%) (see Appendix 3).
Among participants, 3426 (55.1%) reported that their workplace was welcoming to LGBTQ+ patients, while 3114 (50.0%) felt the same about LGBTQ+ healthcare professionals. Details are shown in Appendix 4.
3.2. Ally expression
A total of 705 (11.3%) participants openly identified as allies in the workplace (explicit allies), and 2129 (34.3%) considered themselves allies at heart, although they had not explicitly expressed it. That is, among 2834 participants who had allyship, 24.9% were explicit allies. In the meanwhile, 913 (14.7%) denied their allyship, and 2426 (39.0%) reported no idea or opinion. Details are shown in Appendix 5.
3.3. Initiatives for LGBTQ+ staff
The most reported SOGI‐related initiatives for staff that workplaces were actively implementing included workplace training (1871 participants, 30.1%), visible workplace promotion such as rainbow flags or ally badges (1371 participants, 22.1%), and sponsoring events (817 participants, 13.1%). However, the initiatives that participants felt their workplaces should adopt included considerations for facility use such as restrooms and changing rooms (2786 participants, 44.8%), recognizing same‐sex partners as spouses for employee benefits (2177 participants, 35.0%; in Japan, same‐sex marriage is not legally recognized in 2024), and establishing consultation service for employees (1967 participants, 31.6%).
Participants identified several initiatives as challenging to implement in their workplaces. These included providing support during gender reassignment surgery and hormone therapy (1801 participants, 29.0%), consideration for facility use (1345 participants, 21.6%), and recognizing same‐sex partners as spouses for employee benefits (929 participants, 14.9%). Details are shown in Table 2.
TABLE 2.
Initiatives for LGBTQ+ staff (multiple answers).
| Initiatives | Currently implemented | Recognized as important to implement | Recognized as difficult |
|---|---|---|---|
| Workplace training | 1871 (30.1%) | 1879 (30.2%) | 136 (2.2%) |
| Visible workplace promotion (e.g., rainbow flag, ally badge) | 1371 (22.1%) | 902 (14.5%) | 137 (2.2%) |
| Sponsoring LGBTQ+ events outside the workplace | 817 (13.1%) | 1054 (17.0%) | 320 (5.1%) |
| Educational campaign (producing brochure, managing events) | 780 (12.5%) | 956 (15.4%) | 146 (2.3%) |
| Consideration for facility use (e.g., restrooms, changing rooms) | 556 (8.9%) | 2786 (44.8%) | 1345 (21.6%) |
| Establishing ethics and practice guidelines (e.g., clear statement of anti‐discrimination) | 463 (7.4%) | 1680 (27.0%) | 462 (7.4%) |
| Revising workplace rules on clothing and hairstyles | 360 (5.8%) | 1795 (28.9%) | 291 (4.7%) |
| Establishing consultation service for employees | 217 (3.5%) | 1967 (31.6%) | 264 (4.2%) |
| Allowing the use of aliases | 189 (3.0%) | 1426 (22.9%) | 304 (4.9%) |
| Activity support for LGBTQ+ and allies (e.g., support for community management) | 178 (2.9%) | 1176 (19.9%) | 274 (4.4%) |
| Recognizing same‐sex partners as spouses for employee benefits | 162 (2.6%) | 2177 (35.0%) | 929 (14.9%) |
| Ensuring fair recruitment practices | 96 (1.5%) | 1447 (23.3%) | 188 (3.0%) |
| Support during gender reassignment surgery and hormone therapy | 35 (0.6%) | 818 (13.2%) | 1801 (29.0%) |
| Not particular | 1154 (18.6%) | 380 (6.1%) | 787 (12.7%) |
| No idea | 2085 (33.5%) | 1378 (22.2%) | 2388 (38.4%) |
Several initiatives showed a large gap (over 15 percentage points) between the proportion of participants who felt they should be implemented and those who reported current implementation or perceived difficulty. These initiatives included consideration for facility use, establishing ethics and practice guidelines, revising workplace rules on clothing and hairstyles, establishing a consultation service for employees, allowing the use of aliases, recognizing same‐sex partners as spouses for employee benefits, and ensuring fair recruitment practices (see Figure 1).
FIGURE 1.
The proportion of responses about each initiative, which has a large gap between each response. The horizontal axis shows each initiative. The vertical axis shows each response rate. “Now doing”: Participants who reported that the initiative is currently implemented. “Should do”: Those who felt that the initiative should be implemented. “Difficult to do”: Those who felt that the initiative is difficult to perform.
3.4. LGBTQ+ staff's disclosure and consultation
Of the 133 LGBTQ+ staff, 41 participants (30.8%) reported disclosing their SOGI to some members in their workplaces. However, 8 of these 41 participants expressed concern that their SOGI was known to more members than those they had intentionally told. Peers were the most common recipients of the disclosure, with 31 (75.6%), followed by supervisors with 17 (41.5%). Details are shown in Appendix 6.
Other 87 participants (65.4%) reported not disclosing their SOGI to any member. However, 2 of the 87 participants felt that some members might know their SOGI. There were 5 nonrespondents. The most common reason for not disclosing their SOGI to some members was that being LGBTQ+ was not relevant to their work, cited by 64 of the 105 respondents (61.0%). (See Appendix 7).
Of the 64 participants who responded to questions about changes following disclosure or awareness of their SOGI in the workplace, 47 (73.4%) reported experiencing no change. Six participants reported an increase in comfort when communicating with colleagues, while none reported any discomfort. Details are shown in Appendix 8.
3.5. Difficulties and benefits faced by LGBTQ+ staff
The most reported workplace difficulty was the assumption of heterosexuality in all events, reported by 28 participants (21.1%). This was followed by difficulty in discussing personal matters (21 participants, 15.8%) and the need to present oneself as heterosexual (16 participants, 12.0%) (Table 3). Regarding the job search, questions and answers based on the assumption of heterosexuality were the primary problem (19 participants, 14.3%), followed by the need to show oneself in a way that was different from one's gender identity (12 participants, 9.0%) (Table 4).
TABLE 3.
Experience of difficulties in the workplace (multiple answers) (N = 133).
| Difficulties in the workplace | N (%) |
|---|---|
| The assumption of heterosexuality in every aspect of the workplace | 28 (21.1%) |
| Discomfort in talking about private matters | 21 (15.8%) |
| Having to act as heterosexual people | 16 (12.0%) |
| No benefit programs for same‐sex partners | 14 (10.5%) |
| No role model nor career plan | 8 (6.0%) |
| Witnessing and hearing insulting behaviors against LGBTQ+ people | 7 (5.3%) |
| No section for advice | 7 (5.3%) |
| Gender‐specific dress code | 5 (3.8%) |
| Access to facilities such as restrooms and changing rooms | 5 (3.8%) |
| Having to act in a gender different from my self‐identified gender | 5 (3.8%) |
| Being treated unfavorably in personnel evaluations | 4 (3.0%) |
| Inability to receive support during gender reassignment surgery or hormone treatment | 4 (3.0%) |
| Difficulty in undergoing medical checkups | 3 (2.3%) |
| Not being allowed to use alias | 2 (1.5%) |
| Not being assigned to the department of my choice | 1 (0.8%) |
| No difficulty | 58 (43.6%) |
| Others | 5 (3.8%) |
| No answer | 18 (13.5%) |
TABLE 4.
Experience of difficulties during the job search (multiple answers) (N = 133).
| Difficulties during the job search | N (%) |
|---|---|
| Response or question based on the assumption of being heterosexual | 19 (14.3%) |
| Having to behave in a manner different from my self‐identified gender | 12 (9.0%) |
| Having to write my gender on entry sheets or resumes | 9 (6.8%) |
| Difficulty in presenting myself | 9 (6.8%) |
| Question about career prospects or life plans | 8 (6.0%) |
| Witnessing or hearing discriminatory remarks against LGBTQ+ people | 7 (5.3%) |
| Gender‐related statements (e.g., “Male wanted,” “Female wanted”) | 7 (5.3%) |
| An unfairly low evaluation or a rescission of a job offer because of my LGBTQ+ status | 5 (3.8%) |
| Gender‐segregated events (e.g., information sessions) | 5 (3.8%) |
| Appearance during the selection process (e.g., wearing a suit) | 5 (3.8%) |
| Dissemination of information about my SOGI without my permission | 3 (2.3%) |
| No or little information about LGBTQ+ initiatives at the workplace | 2 (1.5%) |
| Other | 5 (3.8%) |
| No answer | 78 (58.6%) |
Twenty participants provided open‐ended comments about challenges in the workplace. In addition to general issues (such as employee benefit systems and treatment burden), a thematic analysis highlighted challenges unique to healthcare professionals: unintentional SOGI disclosure due to receiving healthcare services at work and patients' expectations of gender‐conforming roles that differ from their gender identity. In addition, although the form was intended to address these concerns, the belief that SOGI is irrelevant to professionalism was frequently mentioned. Illustrative data are shown in Appendix 9.
Twenty‐two participants provided open‐ended comments about positive experiences at work. A thematic analysis revealed that they felt a sense of security in belonging to the organization that is active in the SOGI initiative and relief in seeing staff members who were positive about the initiative. They felt comfortable in a workplace that was committed to nondiscrimination and equity of all kinds, not just SOGI. Illustrative data are shown in Appendix 10.
4. DISCUSSION
This study sheds light on the perspectives and experiences of healthcare professionals regarding LGBTQ+ issues in the workplace, as well as their attitudes toward existing and potential initiatives. Approximately 5–7% of participants reported witnessing or hearing about discrimination against LGBTQ+ individuals, a notably lower rate than that of LGBTQ+ physicians' reports of experiencing various discriminations (10% to 65%). 26 Considering that LGBTQ+ individuals are more likely to perceive or experience such discrimination, 27 this discrepancy suggests that many participants may be overlooking instances of discriminatory behavior in the workplace, or there may be an extreme lack of visibility of LGBTQ+ patients and healthcare professionals in Japan.
Approximately half of the participants had received workplace training on LGBTQ+ issues, a higher proportion than what has been reported in other workplaces in Japan. 20 This initiative has the potential of encouraging LGBTQ+‐friendly workplaces. Healthcare professionals show a gap in their knowledge of LGBTQ+ terminology and healthcare needs, highlighting the importance of training aimed at fostering a safe environment for both LGBTQ+ colleagues and patients. 28 To build a more inclusive healthcare environment, ongoing efforts to deepen accurate knowledge and understanding of LGBTQ+ issues are essential for institutions.
This study found that, even within healthcare institutions that actively promote LGBTQ+ initiatives, less than half of employees perceived their workplace as welcoming to LGBTQ+ individuals, and many faced barriers to openly expressing their allyship. Factors influencing healthcare professionals' stigmatization of LGBTQ+ people go beyond limited knowledge and education and include a workplace culture characterized by cisnormative structures, a tendency to deny responsibility among professionals, and a lack of clear, established procedures. 29 Leaders in healthcare institutions should recognize that current postgraduate education on LGBTQ+ issues has not significantly changed the attitudes or behaviors of many colleagues. As a result, broader initiatives aimed at fostering genuine inclusivity and inspiring concrete action are essential.
The top four most implemented SOGI‐related initiatives were also reported as difficult to implement by about 5% or fewer participants, indicating a tendency to prioritize initiatives that are easier to implement rather than those that might have a greater impact. In contrast, the initiatives identified as challenging by more than 10% of participants – support during sex‐reassignment surgery and hormone therapy, consideration for facility use, and recognizing same‐sex partners as spouses for employee benefits – all require financial resources, suggesting that budget allocations for these initiatives could enable more effective LGBTQ+ support efforts. Notably, of the seven initiatives where there was a significant gap between the number of participants who felt they should be implemented and those who reported current implementation or perceived difficulty, five were rated as difficult by 10% or fewer participants: establishing ethics and practice guidelines, revising workplace rules on clothing and hairstyles, establishing a consultation service for employees, allowing the use of aliases, and ensuring fair recruitment practices. These initiatives, being less resource‐intensive, may be easier to implement and could gain traction with support from hospital leaders. Collaborating with hospital leadership to advance these initiatives and incorporating them into postgraduate education could promote an inclusive workplace culture.
This study also explored the circumstances and experiences of healthcare professionals who identify as LGBTQ+. In this study, 2.1% of participants identified themselves as LGBTQ+. This proportion is lower than the 3.5% reported in the general population 30 and the 9.3–9.9% found in a study of university students in Japan. 31 In a healthcare setting, 4.8% of U.S. surgical residents identified as LGBTQ+, 11 and 3.0% of members of the American Academy of Orthopaedic Surgeons identified as a sexual minority. 32 These data suggest that some LGBTQ+ individuals in a healthcare setting in Japan encounter challenges in answering their SOGI.
Notably, 84.6% of participants answered both cisgender and heterosexual identities, so the remaining 15.4% did not. Previous research has estimated that 22–54% of individuals who select “undecided” regarding sexual orientation may be heterosexual. 33 Here, 6.8% of the whole participants declined to specify their sexual orientation, and 4.2% did not understand the meaning of the question about sexual orientation. Assuming about half of these respondents were assumed to be heterosexual, the estimated proportion of noncisgender or nonheterosexual individuals could approximate 10%, higher than the self‐identified LGBTQ+ group of 2.1%. Several factors may account for this discrepancy. First, some participants may not personally identify with or be comfortable with the LGBTQ+ label. Second, identifying as LGBTQ+ led to additional survey questions that may have caused hesitation or discomfort. Researchers should remain aware that responses to sensitive topics such as SOGI can be significantly influenced by question phrasing and structure.
In this study, most LGBTQ+ staff chose not to disclose their identity in the workplace. Disclosure can promote inclusivity or exacerbate discrimination, depending on the workplace environment. 34 For example, a qualitative study of LGBTQ+ physical therapists identified factors such as workplace heteronormativity, implicit and explicit risks of discrimination, and perceptions of being LGBTQ+ as unprofessional, all of which contribute to increased stress. 35 In a healthcare setting, where heteronormative norms are often deeply rooted, disclosure to patients may be perceived as a breach of professional boundaries, 34 leading many LGBTQ+ professionals to remain closeted. A study in the US found that nearly half of LGBTQ+ medical students and physicians withheld their identity, with over three‐quarters moderating their behavior and speech to avoid unintentional disclosure. 13 The study indicates that healthcare institutions in Japan also have a culture of heteronormativity. In addition, both qualitative and quantitative findings in this study suggest that participants who chose not to disclose their SOGI held a belief that being LGBTQ+ is unrelated to their professionalism. Previous studies indicate that a conservative culture and justification of the heteronormative system are associated with weaker expression about SOGI and less support for LGBTQ+ rights, and vice versa, or an open and positive culture of SOGI may be associated with its expression. 36 Considering a culture of heteronormativity in healthcare settings, professionals who denied the meaning of expressing their SOGI may be disempowered by the existing system in their workplaces. 36
Allowing LGBTQ+ staff to integrate their identities into their professional lives can help them provide care that aligns with the diverse needs of patients. All healthcare professionals can play a role in promoting inclusivity by engaging with LGBTQ+ staff. LGBTQ+ employees often report less positive work environments, 37 so it is important to actively listen to their perspectives when promoting LGBTQ+ initiatives. This study suggests that LGBTQ+ staff value not only broad, systemic changes but also interpersonal and grassroots efforts—such as affinity groups—that contribute to a supportive workplace culture. 37 For example, when it comes to sexual orientation, challenging heteronormative assumptions is essential to creating a more open and inclusive professional environment. 34 For gender minorities, workplaces can implement gender‐affirming practices. 38 It is necessary to ensure social security, promote nondiscrimination policies, and recognize the unique experiences and challenges faced by LGBTQ+ staff. 38 These combined efforts can help develop a supportive and affirming climate that empowers LGBTQ+ staff to achieve their professional goals while enabling the healthcare system to provide more comprehensive and inclusive care.
This study has several limitations. First, the questionnaire was not validated and may not have fully captured the range of experiences and initiatives relevant to healthcare settings. Second, although SOGI experiences may vary depending on geographic context (e.g., urban vs. rural areas), 39 this study did not account for participants' geographic data, which may lead to a potential bias in responses, reflecting the perspectives of specific workplaces or regions disproportionately. Third, the factors that motivate healthcare professionals to express allyship remain unclear, warranting further research on what fosters positive attitudes toward LGBTQ+ initiatives. This study also did not directly assess the effectiveness or efficiency of each specific initiative. Fourth, as noted above, some gender and sexual minority participants may have skipped questions specific to LGBTQ+ staff. Especially, LGBTQ+ staff with serious challenges may have opted out of the voluntary online survey, potentially affecting the results.
5. CONCLUSION
This study highlights the perspectives and experiences of healthcare professionals regarding LGBTQ+ individuals and the experiences and concerns of LGBTQ+ staff. The study also reveals a gap between initiatives that are currently being implemented and those that healthcare professionals consider important. All healthcare professionals can collaborate with LGBTQ+ staff and hospital leaders to design and implement effective LGBTQ+‐affirming initiatives that promote inclusivity at the workplace, thus leading to a more affirming healthcare environment.
AUTHOR CONTRIBUTIONS
Junki Mizumoto: Conceptualization; methodology; formal analysis; supervision; software; validation; visualization; funding acquisition; writing – original draft. Eriko Kono: Conceptualization; methodology; data curation; software; investigation; validation; writing – review and editing; project administration. Eriko Yoshida: Conceptualization; methodology; software; investigation; validation; writing – review and editing; project administration.
FUNDING INFORMATION
This work was supported by JSPS KAKENHI Grant Number 24 K23757.
CONFLICT OF INTEREST STATEMENT
None declared.
ETHICS STATEMENT
Ethics approval statement: The study was approved by the Research Ethics Committee of the Japan Federation of Democratic Medical Institutions (No. 45‐001) and adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. 40
Patient consent statement: Potential participants were assured that declining participation would not result in any disadvantage. All participants completed an informed consent form.
Clinical trial registration: None.
ACKNOWLEDGMENTS
The authors have nothing to report.
APPENDIX 1. Questionnaire
| What is your profession? |
| How long have you experienced your profession? |
| Which is your birth‐assigned sex? |
| Male; Female; No answer |
| Do you consider your current gender as the same as your birth‐assigned sex? |
| Same; Different; Experiencing gender dysphoria |
| Which best describes you? |
| Heterosexual; Homosexual; Pansexual; Bisexual; Asexual; Undecided or not want to decide; No idea about the question |
| Which opportunities have you had to learn about LGBTQ+? (multiple choices) |
| Mass media (e.g., television, newspaper) |
| Workplace training |
| Internet including social media |
| Book and magazine |
| Talking to an acquaintance who is LGBTQ+ |
| Classroom at school |
| Voluntarily participation in training or lectures |
| Talking to an acquaintance who is not LGBTQ+ |
| Do you express yourself as an LGBTQ+ understanding/supportive (allied) person in your current workplace? |
| Explicitly identified as an ally; Ally at heart, no expression; Not an ally; No idea/opinion |
| Does your workplace have an atmosphere of acceptance for LGBTQ+ patients? |
| Agree; Somewhat agree; Neutral; Somewhat disagree; Disagree |
| Does your workplace have an atmosphere of acceptance for LGBTQ+ colleagues? |
| Agree; Somewhat agree; Neutral; Somewhat disagree; Disagree |
| Which initiatives are currently in place at your workplace regarding LGBTQ+ staff? (multiple choices) |
| Workplace training |
| Visible workplace promotion (e.g., rainbow flag, ally badge) |
| Sponsoring LGBTQ+ events outside the workplace |
| Educational campaign (producing brochure, managing events) |
| Consideration for facility use (e.g., restrooms, changing rooms) |
| Establishing ethics and practice guidelines (e.g., clear statement of anti‐discrimination) |
| Revising workplace rules on clothing and hairstyles |
| Establishing consultation service for employees |
| Allowing the use of aliases |
| Activity support for LGBTQ+ and allies (e.g., support for community management) |
| Recognizing same‐sex partners as spouses for employee benefits |
| Ensuring fair recruitment practices |
| Support during gender reassignment surgery and hormone therapy |
| Not particular |
| No idea |
| Which initiatives do you think contribute to a comfortable work environment for LGBTQ+ staff? (multiple choices) |
| [Same choices] |
| Which initiatives do you think would be difficult to achieve? (multiple choices) |
| [Same choices] |
| Have you seen or heard any discriminatory behaviors toward LGBTQ+ patients in your current workplace? |
| Yes; No |
| Have you seen or heard any discriminatory behaviors toward LGBTQ+ colleagues in your current workplace? |
| Yes; No |
| Are you LGBTQ+? |
| Yes; No |
| (The following questions should be answered only by those who answered Yes.) |
| Do you tell anyone at your current workplace that you are LGBTQ+? (multiple choices) |
| Disclosing to |
| Peer; Boss; Subordinate; Personnel department; Labor union; Consultation service; Occupational counselor: Other |
| Not disclosing to but unintentionally known by |
| [Same choices] |
| Not known by |
| [Same choices] |
| Which are the reasons why you do not identify yourself as LGBTQ+ at your workplace? (multiple choices) |
| Being LGBTQ+ is not related to my profession |
| There is nothing that I would like other staff to take into consideration |
| Someone does or may express discrimination about LGBTQ+ |
| Disclosing SOGI will make me uncomfortable in interacting with other staff |
| People outside of my workplace, such as family, friends, or community members, may find out my SOGI |
| My workplace seems not to show the understanding of LGBTQ+ |
| I am concerned about bullying and harassment |
| I am concerned about being treated unfavorably in personnel evaluations, reassignments, and transfers |
| I think my SOGI is already known |
| No particular reason |
| Other |
| What changes have you seen in your current workplace as a result of being told or made known that you are LGBTQ+? (multiple choices) |
| Increase in comfort when communicating with colleagues |
| Decrease in comfort when communicating with colleagues |
| Reassignment/transfer in a favorable manner |
| Reassignment/transfer in an unfavorable manner |
| Use of facilities or support systems in a favorable manner |
| Disadvantages in promotion, advancement, or wages |
| Bullying or harassment from staff members |
| No change |
| Others |
| Do you have any difficulties working at your current workplace because of your LGBTQ+ status? (multiple choices) |
| Difficulties in the workplace |
| The assumption of heterosexuality in every aspect of the workplace |
| Discomfort in talking about private matters |
| Having to act as heterosexual people |
| No benefit programs for same‐sex partners |
| No role model nor career plan |
| Witnessing and hearing insulting behaviors against LGBTQ+ people |
| No section for advice |
| Gender‐specific dress code |
| Access to facilities such as restrooms and changing rooms |
| Having to act in a gender different from my self‐identified gender |
| Being treated unfavorably in personnel evaluations |
| Inability to receive support during gender reassignment surgery or hormone treatment |
| Difficulty in undergoing medical checkups |
| Not being allowed to use alias |
| Not being assigned to the department of my choice |
| No difficulty |
| Others |
| Any other difficulties? (free comment) |
| Have you ever had any difficulties in searching for a job because of your LGBTQ+ status? (multiple choices) |
| Difficulties during the job search |
| Response or question based on the assumption of being heterosexual |
| Having to behave in a manner different from my self‐identified gender |
| Having to write my gender on entry sheets or resumes |
| Difficulty in presenting myself |
| Question about career prospects or life plans |
| Witnessing or hearing discriminatory remarks against LGBTQ+ people |
| Gender‐related statements (e.g., “Male wanted,” “Female wanted”) |
| An unfairly low evaluation or a rescission of a job offer because of my LGBTQ+ status |
| Gender‐segregated events (e.g., information sessions) |
| Appearance during the selection process (e.g., wearing a suit) |
| Dissemination of information about my SOGI without my permission |
| No or little information about LGBTQ+ initiatives at the workplace |
| Other |
| Any other difficulties? (free comment) |
Note: If you have had a good experience at your current workplace, please share it with us (free comment).
APPENDIX 2. Witnessing or hearing about discrimination against LGBTQ+
| Against LGBTQ+ patients | Against LGBTQ+ colleagues | |
|---|---|---|
| Having experience | 443 (7.1%) | 330 (5.3%) |
| No experience | 5664 (91.1%) | 5785 (93.1%) |
| No answer | 109 (1.8%) | 101 (1.6%) |
APPENDIX 3. Source for learning about SOGI (multiple answers)
| Mass media (e.g., television, newspaper) | 4102 (66.0%) |
| Workplace training | 3389 (54.5%) |
| Internet including social media | 2575 (41.4%) |
| Book and magazine | 1307 (21.0%) |
| Talking to an acquaintance who is LGBTQ+ | 978 (15.7%) |
| Classroom at school | 606 (9.7%) |
| Voluntarily participation in training or lectures | 569 (9.2%) |
| Talking to an acquaintance who is not LGBTQ+ | 296 (4.8%) |
APPENDIX 4. Workplace welcomeness to LGBTQ+
| Welcome to LGBTQ+ patients | Welcome to LGBTQ+ colleagues | |
|---|---|---|
| Agree | 1135 (18.3%) | 908 (14.6%) |
| Somewhat agree | 2291 (36.9%) | 2206 (35.5%) |
| Neutral | 2370 (38.1%) | 2682 (43.1%) |
| Somewhat disagree | 218 (3.5%) | 246 (4.0%) |
| Disagree | 164 (2.6%) | 138 (2.2%) |
| No response | 38 (0.6%) | 36 (0.6%) |
APPENDIX 5. Identification and expression as an ally
| Identification and expression | N (%) |
|---|---|
| Explicitly identified as an ally | 705 (11.3%) |
| Ally at heart, no expression | 2129 (34.3%) |
| Not an ally | 913 (14.7%) |
| No idea/opinion | 2426 (39.0%) |
| No answer | 43 (0.7%) |
APPENDIX 6. Disclosure of SOGI at the workplace (N = 133)
| Peer | Boss | Subordinate | Personnel department | Labor union | Consultation service | Occupational counselor | Other | No answer | |
|---|---|---|---|---|---|---|---|---|---|
| Disclosing to | 31 (23.3%) | 17 (12.8%) | 4 (3.0%) | 4 (3.0%) | 2 (1.5%) | 2 (1.5%) | 1 (0.8%) | 4 (3.0%) | 93 (69.9%) |
| Not disclosing to but unintentionally known by | 2 (1.5%) | 4 (3.0%) | 4 (3.0%) | 3 (2.3%) | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | 123 (92.5%) |
| Not known by | 77 (57.9%) | 81 (60.9%) | 84 (63.2%) | 86 (64.7%) | 69 (51.9%) | 66 (49.6%) | 67 (50.4%) | 53 (39.8%) | 35 (26.3%) |
APPENDIX 7. The reason for the reluctance of disclosing SOGI at the workplace (multiple answers) (N = 105)
| Reason for reluctance | N (%) |
|---|---|
| Being LGBTQ+ is not related to my profession | 64 (61.0%) |
| There is nothing that I would like other staff to take into consideration | 49 (46.7%) |
| Someone does or may express discrimination about LGBTQ+ | 39 (37.1%) |
| Disclosing SOGI will make me uncomfortable in interacting with other staff | 38 (36.2%) |
| People outside of my workplace, such as family, friends, or community members, may find out my SOGI | 20 (19.0%) |
| My workplace seems not to show the understanding of LGBTQ+ | 18 (17.5%) |
| I am concerned about bullying and harassment | 16 (15.5%) |
| I am concerned about being treated unfavorably in personnel evaluations, reassignments, and transfers | 11 (10.7%) |
| I think my SOGI is already known | 4 (3.9%) |
| No particular reason | 22 (21.4%) |
| Other | 12 (11.7%) |
| No answer | 18 (17.5%) |
APPENDIX 8. Changes following disclosure or awareness of their SOGI in the workplace (multiple answers) [% out of the 64 respondents]
| Changes | N (%) |
|---|---|
| Increase in comfort when communicating with colleagues | 6 (9.4%) |
| Decrease in comfort when communicating with colleagues | 0 (0%) |
| Reassignment/transfer in a favorable manner | 4 (6.3%) |
| Reassignment/transfer in an unfavorable manner | 1 (1.6%) |
| Use of facilities or support systems in a favorable manner | 3 (4.7%) |
| Disadvantages in promotion, advancement, or wages | 0 (0%) |
| Bullying or harassment from staff members | 0 (0%) |
| No change | 47 (73.4%) |
| Others | 7 (10.9%) |
| No answer | 69 |
APPENDIX 9. Illustrative data indicating difficulty in working in a healthcare setting
| Theme | Illustrative data |
|---|---|
| Unintentional SOGI disclosure | I find it troublesome that my legal gender is pointed out every time I have a health check‐up at my workplace |
| Patients' expectations of gender‐conforming roles | I felt uncomfortable when patients mentioned my gender in providing a bathing care |
APPENDIX 10. Illustrative data indicating benefits derived from the workplace
| Themes | Illustrative data |
|---|---|
| A sense of security | I feel very encouraged that my workplace is doing some initiatives about LGBTQ |
| Relief in seeing staff members | My supervisors and coworkers showed understanding, which quickly eased my nerves |
| Nondiscrimination and equity of all kinds | My colleagues said that all discrimination should be omitted |
Mizumoto J, Kono E, Yoshida E. Healthcare professionals' experiences related LGBTQ+ patients and colleagues at their workplace: Descriptive research in Japan. J Gen Fam Med. 2025;26:312–325. 10.1002/jgf2.70012
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