Lesbian, Gay, Bisexual, and Transgender Identity and Disclosure Among Dermatologists in the US

Abstract

This survey study used data from a 2020 American Academy of Dermatology member satisfaction survey to assess lesbian, gay, bisexual, and transgender identity and disclosure among US dermatologists.

Lesbian, gay, bisexual, and transgender (LGBT) individuals experience numerous health care disparities, some of which are specific to dermatology. For example, LGBT individuals tend to experience higher rates of sexually transmitted infections (eg, HIV, syphilis), and those with chronic skin diseases (eg, acne vulgaris, psoriasis) tend to cite a lower quality of life and higher rates of depression. Transgender and gender-diverse individuals also report having poor access to gender-affirming, minimally invasive procedures such as laser hair removal.

Workforce diversity is essential to ensure a pipeline of physicians equipped through personal experiences and diverse learning environments to improve care for all populations.¹ However, LGBT physicians may be less likely to pursue competitive, high-income specialties² and face unique professional barriers¹ that may limit their visibility, including higher levels of mistreatment during medical training, fears of discrimination in residency applications and job placement, and discrimination from patients. This study used data from an American Academy of Dermatology (AAD) member satisfaction survey to assess LGBT identity and disclosure among US dermatologists.

Methods

This survey study was deemed exempt by the University of Minnesota Institutional Review Board because it was a secondary analysis of previously collected, deidentified data. The study followed the American Association for Public Opinion Research (AAPOR) reporting guideline.

We conducted a secondary analysis of the AAD 2020 Member Satisfaction Survey, a cross-sectional survey distributed in print and electronically to 10 060 member dermatologists between January 3 and January 31, 2020 (eAppendix in the Supplement). Survey respondents who lived outside the US, were retired or semiretired, or were adjunct or lifetime AAD members were excluded. Dermatologists were defined as LGBT if they self-identified as nonheterosexual (based on response options of “lesbian, gay, or homosexual,” “bisexual,” or “something else”) or transgender. We compared the following: (1) demographic factors by LGBT identity using a Wilcoxon-type trend test or χ² tests, (2) calculations of LGBT identity prevalence among all participants and in sex-stratified analyses, and (3) disclosure of LGBT identities in personal or professional settings. To assess nonresponse bias, we compared demographic characteristics between survey respondents and nonrespondents using AAD member profile data. Analyses were performed using STATA software version 16.1.

Results

Of the 10 060 dermatologists who received the AAD survey, 1339 (13.3%) completed it. The 1339 survey respondents and 8721 nonrespondents did not differ by sex (female sex: 704 [52.6%] vs 4574 [52.5%], respectively; P = .93). However, survey respondents were older than nonrespondents (aged 18-35 years: 136 [10.1%] vs 870 [10.0%]; 36-50 years: 494 [36.8%] vs 3804 [43.6%]; 51-65 years: 510 [38.1%] vs 3058 [35.0%]; and >65 years: 199 [14.9%] vs 989 [11.3%]; P for trend < .001). Survey respondents also differed in practice settings compared with nonrespondents (academic medicine: 201 [15.0%] vs 1291 [14.8%]; nonacademic medicine: 1053 [78.6%] vs 6638 [76.2%]; retired or semiretired: 40 [3.0%] vs 297 [3.4%]; and missing: 45 [3.4%] vs 495 [5.7%]; P = .004).

This study included 1271 of the 1339 survey respondents (94.9%); 47 (3.7% [95% CI, 2.7%-4.9%]) identified as LGBT. Of these 47 individuals, 43 (3.4% [95% CI, 2.5%-4.5%]) identified as nonheterosexual and 4 (0.3% [95% CI, 0.1%-0.8%]) identified as both nonheterosexual and transgender. An LGBT identity prevalence was stated for 40 of 593 male respondents (6.7% [95% CI, 4.8%-9.1%]) and 7 of 675 female respondents (1.0% [95% CI, 0.4%-2.1%]). Compared with non-LGBT dermatologists, LGBT dermatologists were more likely to be male, to be younger, and to practice in academic settings (Table 1). Most LGBT dermatologists were open about their sexual orientation at home and with colleagues, but fewer than half were open about their sexual orientation with patients (Table 2).

Table 1. Demographic Characteristics by Lesbian, Gay, Bisexual, or Transgender Identity.

Characteristic	No. (%)			P valueb
	All respondents (N = 1271)	Non-LGBT (n = 1224)a	LGBT (n = 47)a
Transgender identity				NA
No	1056 (83.1)	1014 (82.8)	42 (89.4)
Yes	4 (0.3)	0	4 (8.5)
Prefer not to say	102 (8.0)	101 (8.2)	1 (2.1)
Missing	109 (8.6)	109 (8.9)	0
Sexual orientation				NA
Heterosexual	987 (77.7)	987 (80.6)	0
Lesbian, gay, or homosexual	37 (2.9)	0	37 (78.7)
Bisexual	6 (0.4)	0	6 (12.8)
Something else	4 (0.3)	0	4 (8.5)
Prefer not to say	129 (10.2)	129 (10.5)	0
Missing	108 (8.5)	108 (8.8)	0
Sexc				<.001
Male	593 (46.7)	553 (45.2)	40 (85.1)
Female	675 (53.1)	668 (54.6)	7 (14.9)
Missing	3 (0.2)	3 (0.3)	0
Gender				<.001
Man	479 (37.7)	444 (36.3)	35 (74.5)
Woman	585 (46.0)	579 (47.3)	6 (12.8)
Genderqueer, nonbinary, or gender other than man or woman	4 (0.3)	0	4 (8.5)
Additional gender category	5 (0.4)	4 (0.3)	1 (2.1)
Prefer not to say	97 (7.6)	96 (7.8)	1 (2.1)
Missing	101 (8.0)	101 (8.3)	0
Age, yc				.04 for trend
18-35	168 (13.2)	158 (12.9)	10 (21.3)
36-50	480 (37.8)	461 (37.8)	19 (40.4)
51-65	454 (35.7)	439 (35.9)	15 (31.9)
>65	169 (13.3)	166 (13.6)	3 (6.4)
Regionc,d				.31
Northeast	295 (23.2)	283 (23.1)	12 (25.5)
Midwest	251 (19.7)	238 (19.4)	13 (27.7)
South (including Puerto Rico)	446 (35.1)	435 (35.5)	11 (23.4)
West	276 (21.7)	265 (21.7)	11 (23.4)
Missing	3 (0.2)	3 (0.3)	0
Practice settingc,e				.04
Academic medicine	199 (15.7)	187 (15.3)	12 (25.5)
Nonacademic medicine	1028 (80.9)	995 (81.3)	33 (70.2)
Missing	44 (3.5)	42 (3.4)	2 (4.3)

Abbreviations: LGBT, lesbian, gay, bisexual, or transgender; NA, not applicable.

^a LGBT dermatologists were defined as individuals who self-identified as nonheterosexual, including a response of “lesbian, gay, or homosexual,” “bisexual,” or “something else” to a question on sexual orientation or a “yes” to a question on transgender identity. Non-LGBT respondents were defined as individuals who identified as “straight or heterosexual” to a question on sexual orientation or “no” to a question on transgender identity. Individuals who responded “prefer not to say” or with missing data on questions on sexual orientation or gender identity were also defined as non-LGBT dermatologists.

^b Participants with missing data or who responded “prefer not to say” for individual demographic variables were excluded from that individual analysis.

^c Data were prepopulated using existing data previously collected in the American Academy of Dermatology member profile.

^d Regions were based on medical school regions defined by the Association of American Medical Colleges.

^e Academic medicine practice was defined as dermatologists practicing in an academic or university setting. Nonacademic medicine practice was defined as dermatologists practicing in the following settings: clinic or hospital, dermatology group, industry (pharmaceutical or cosmetic), military, multispecialty group, or solo practice.

Table 2. Sexual Orientation and Transgender Identity Disclosure Among Lesbian, Gay, Bisexual, and Transgender Dermatologists.

	No. of respondents	No. (%) open about identity
		At home	At work, with colleagues	At work, with patients
Sexual orientation identity disclosure among nonheterosexual respondentsa	45	32 (71)	36 (80)	21 (47)
Transgender identity disclosure among transgender respondentsb	2	1 (50)	2 (100)	2 (100)

^a Based on the response of nonheterosexual dermatologists to the following question: “If you identify as a sexual minority person (lesbian, gay, bisexual, or something else other than straight or heterosexual), are you open about your sexual orientation… [in specific personal and professional settings]?” Of 47 nonheterosexual dermatologists, 2 selected “not applicable” and were excluded from the analysis.

^b Based on the response of transgender dermatologists to the following question: “If you identify as transgender, are you open about being transgender… [in specific personal and professional settings]?” Of 4 transgender dermatologists, 2 selected “not applicable” and were excluded from the analysis.

Discussion

This study assessed LGBT identity and disclosure among US dermatologists based on the 2020 AAD survey data. Compared with the result of a recent Gallup survey of 15 349 adults among the general adult population, in which 4.9% of men and 6.9% of women identify as LGBT,³ our data suggest that LGBT women may be underrepresented among US dermatologists. Few comparative data exist in other specialties, although 3.0% of American Academy of Family Physicians members identify as lesbian, gay, or bisexual (LGB),⁴ and 9.9% of American Academy of Neurology members were found to identify as LGB, queer, or questioning.⁵ In the training pipeline, LGB women may also be underrepresented in undergraduate medical training, and dermatology currently has the lowest percentage of female medical students pursuing the specialty who identify as LGB.⁶ In our study, most LGBT dermatologists reported not disclosing their sexual orientation to patients, and only 1 in 5 reported disclosing it to their colleagues at work. This lack of disclosure may be related to fears of discrimination, which likely has adverse effects on physicians’ well-being and may limit their visibility to patients.¹

The limitations of this study include the inclusion of only AAD-member dermatologists, nonresponse bias, potential misclassification bias as a result of missing or undisclosed LGBT identity data, and possible variation in LGBT identity prevalence over time.³ Future studies with higher response rates are needed.

Sexual orientation and gender identity data collection should be standardized in all trainee and physician workforce surveys to better identify and close diversity gaps.¹ Dermatology residency training programs and medical organizations should explicitly include LGBT identity in recruitment and diversity efforts to cultivate a visibly diverse and inclusive workforce.

Supplement.

eAppendix. American Academy of Dermatology 2020 Member Satisfaction Survey