Medical Training in the Closet

“If I ever knew someone was gay, I’d shoot them. Gay people don’t deserve to live.”

I was 14 years old when my father said that. He was driving along the highway, looking straight ahead, and I’ll never forget how I felt as I glanced at him from the passenger’s seat. I knew he kept a handgun in the car. I also knew I was gay. Was his comment directed at me, or did he see someone driving in front of him who seemed flamboyant? Did he know I was gay? Was I going to die?

It turned out he didn’t know, and I didn’t die. Now, 15 years later, I’m a resident physician in psychiatry in Boston. My early years of hiding my identity feel like a lifetime ago. But the effects haven’t left me. From the time I realized I was gay in elementary school until I came out to friends in college, I thought that if anyone found out, I would be kicked out of my house, beaten, or killed.

U.S. society has made significant progress since I was a teenager. I can get married now. My boyfriend and I can walk around Boston holding hands without people taking a second look. In New England, we often forget how different things were just 15 years ago. People I work with probably imagine that being gay doesn’t affect me much. Unfortunately, they’re wrong.

I spent a lot of time as a child learning to hide aspects of myself. I changed my voice to make it sound “less gay.” I changed my mannerisms to seem less stereotypically feminine. The walking posture that I’ve been told is stiff comes from spending years trying to rid my gait of any characteristic that might seem gay. When people brought up homosexuality in conversation, I would panic — I didn’t want them to see me sweat and realize I was gay. So I learned to hide my anxiety, an instinct that hasn’t gone away: people don’t usually know when I’m anxious.

But I’m often anxious. Every day, and usually unconsciously, I carry around fear that I’ll be judged for my sexual orientation. This fear has affected my experience of medical training, and I suspect I’m not alone. Trainees in your own hospital may feel the same way.

Before every rotation in medical school, I was anxious. Would my new attendings judge me for being gay? Would it affect my grade? My fears may have been unfounded, but that didn’t matter. My childhood had conditioned me to be constantly wary, and the anxiety was intense.

The same thing happens on every new residency rotation — I’m constantly trying to analyze my attendings’ views about sexual orientation. At the start of a rotation, I unconsciously deepen my voice and avoid topics that might give me away. Over time, I grow more comfortable. I’ll slowly let down my guard, let slip some remark that suggests my sexual orientation, and see how people react. It usually takes a few weeks before I’m back to acting like myself. That sometimes means there are only a few days left until I’m off to restart the process on a new rotation.

A recent study surveyed 358 lesbian, gay, bisexual, transgender, and queer (LGBTQ) medical students and their non-LGBTQ peers about which medical specialties they were choosing.¹ The researchers also created a composite metric of specialty prestige, based on specialties’ degree of selectiveness and typical salaries. They found an inverse relationship between a specialty’s prestige and the likelihood of LGBTQ students choosing it. How accepting of LGBTQ people a specialty seemed was a strong predictor of whether medical students pursued it. Pediatrics and psychiatry scored as very inclusive, orthopedic surgery and neurosurgery as less inclusive. I don’t think it’s a coincidence that I’m now a child psychiatry resident.

During my training, some attending physicians and residents did small things that made me feel more at ease. The psychiatrists never asked if I had a girlfriend. They asked if I had a partner — a small but immediate indication of acceptance. They never made negative comments about other marginalized groups in front of me. In talking with patients, they expressed curiosity about issues of gender and sexuality. For the first time, I felt comfortable at work. I woke up in the morning excited to go in to the hospital.

Physicians in other specialties seemed less aware. I was asked why I didn’t have a girlfriend. I overheard people say that being transgender is a mental illness. I heard others use “gay” to describe things they thought were stupid. One attending made a racist comment to me about another medical student. My jaw tightened, and my shoulders ached with anxiety every day. I swore that I wouldn’t subject myself to a life in that culture.

It’s a problem that LGBTQ medical students are letting their gender identity and sexual orientation affect their specialty choice. Sometimes, when I think about how being gay may have affected me and my decisions, I feel ashamed. Most of my anxieties weren’t rational. The people who made me uncomfortable may not have been homophobic; they may just have made small slips of the tongue. But it didn’t matter. My childhood continues to affect me deeply. Attendings and residents, however, can do some things to change the environment in which we work.

As we train the next generation of physicians, I hope we are more mindful of LGBTQ trainees’ experiences. Academic medicine may be less homophobic than it was in the past, but the medical students and residents you work with have grown up in varied environments. Whereas some may come from communities where being LGBTQ was accepted, many have no doubt had experiences of homophobia similar to my own. Others have probably had even worse experiences of harassment based on their sexual orientation or gender identity, from being kicked out of their homes by their parents to being victims of physical assaults.

When they seem anxious or distant, consider that they may be trying to hide their identities. You can do small things to put them at ease: use the word “partner,” avoid making heteronormative assumptions, talk about the injustices faced by LGBTQ people when they make the news. For me, all it took most of the time was one gesture in this direction and I relaxed for the rest of my rotation.

Important signals can also be sent at the institutional level. During my final year of medical school, my school started working on an “out list” — a website listing physicians who were not afraid to publicly share their gender or sexual minority status. I recently looked at the ever-growing list of these proud physicians and felt a wave of relief like I’d never felt before.

Mentorship also makes a huge difference. I owe a great debt to the senior LGBTQ doctors who have guided me through the experiences they somehow made it through with little, if any, guidance. I have a weekly meeting with a gay attending and another gay resident to discuss career advice. It’s a safe haven where I always feel as if I belong in medicine.

Large initiatives focused on hospital-wide diversity and inclusion are important, but many people making small changes can also make a huge difference. As a medical professional reading this article, you have incredible power. A small gesture like inquiring about someone’s lack of a girlfriend could send people like me anxiously into the closet and scare us away from your specialty. An equally small effort such as using the word “partner” could set them at ease, allowing them to enjoy work and fall in love with your specialty. As U.S. medicine struggles to increase its diversity and honor the diversity of the patients we serve, it’s up to you how you’ll use that power.