Confronting the Scope of LGBT Inequity in Surgery

Precis

This landmark paper traces anti-LGBT discrimination in surgery from history to present with particular analysis of discrimination against patients, providers, and within faith-based and military While research alone will not end healthcare iniquity, the work cannot begin until the “Don’t Ask Don’t Tell” era of scholarship on ends. institutions.

Discrimination against marginalized individuals is an epidemic in American Healthcare. Research regarding gender- and race- based discrimination in healthcare and surgery is robust; scholarship on anti-LGBT (Lesbian, Gay, Bisexual, and Transgender; see Table 1 for explanations of commonly used terms) discrimination is woefully lacking. A Pubmed search of the top 10 Surgical Journals by h-index for the terms “Gay” “Lesbian” “LGBT” or “LGBTQ” turns up a single relevant article (1). This is despite the myriad of inequities LGBT surgeons and LGBT surgical patients face. The history of LGBT identity and discrimination has led to inequitable systems at both the structural and interpersonal level which are mutually reinforcing and synergistically harmful to patients (see figure 1). Addressing such inequities in surgery will require continual individual, systemic, and structural changes. Delineating all these changes is beyond the scope of any one paper. However, improving and sustaining LGBT equity cannot begin without first providing a common background to create change upon.

This paper seeks to correct the discursive gap.

I. LGBT Identity from Pathology to Present

Just as the scope of surgery, and the very meaning of “being a surgeon”, has shifted dramatically over the years (2), so too have ideas of LGBT identity. Scientific theories of both sex and gender shifted dramatically throughout history. From antiquity through the early 1800s, human sex was theorized by many in a “one-sex” model in which womanhood was seen as the absence of male characteristics rather than a separate identity (3). Some contemporary gender theorists in fact still apply variations of Laquer’s one sex model (4). Moving from sex to sexuality, the notion of discrete, stable sexual identities did not emerge until the late 19th century (5)^. Prior to this era, homosexual acts were variably criminalized as part of broader mechanisms of social control. These actions, however, were something that anyone could engage in, rather than signifiers of distinct identities. In, for example, Renaissance Florence or 17^th century Paris one may face a fine for engaging in public sodomy, but individuals were not criminalized for being a sodomite (6). Consistent with broader biopolitical trends focused on categorization in the 19^th and early 20^th century, medical institutions were heavily involved in labeling people by their sexual actions and gender expression (5). From this, LGBT people came to be labeled as inherently deviant and diseased (5).

Throughout much of the 20th century, LGBT identity was not only considered pathologic, but it was also grounds for termination as a physician. This framework of legitimized discrimination against LGBT people continued unabated until 1972 when psychiatrist Dr. Fryer gave anonymous, masked testimony in front of the American Psychiatric Association. This testimony served as a catalyst for depathologization of LGBT identity (7). Despite the shockwaves this sent through the medical community, it was not until 1987 that homosexuality was fully removed from the Diagnostic and Statistics Manual (DSM). Although no longer grounds for termination as a physician as a sign of mental illness, LGBT identity in and of itself remained a legitimate reason for workplace termination for decades. LGBT workplace protections vacillated through time and varied widely by state, but it was not until 2020 that the US Supreme Court ruled that LGBT individuals are entitled to specific workplace protections (prior to which it was legal in most states to fire someone simply for being LGBT) (8).

II. Lack of Robust Research into LGBT Issues

Compared with inequity along lines of race, class, sex, immigration status, etc., LGBT inequities remain markedly uninvestigated. The reasons for this are myriad. Sexual and Gender Minority (SGM) patients (an umbrella term under which LGBT patients fall) generally speaking must disclose their identity to providers for data to be recorded appropriately for future research. There are many reasons this may not happen, ranging from lack of culturally component care to design limitations of the Electronic Health Record (EHR) which prevent inputting such data (9). Terminology surrounding SGM patients is also consistently evolving, preventing easy comparison between work. This paper, for example, utilizes the term “LGBT” to facilitate easier dialogue with historical scholarship which used the term, despite the fact that much of the contemporary scholarship uses the phrase “LGBTQ+” (9). Research on health disparities is also more likely to be carried out by members of marginalized groups (10). Such work is less likely to be valued as promotion-earning activities, resulting in a “minority tax” wherein marginalized physicians perform additional work for less benefit (10). While no data exists on this specific dynamic within LGBT equity research, it likely contributes to a self-reinforcing cycle of decreased LGBT representation within academic surgery, and subsequently less research into LGBT specific issues.

III. Anti-LGBT Discrimination in the Surgical Context

Despite the previously mentioned legal and societal advancements, LGBT medical students and physicians experience discrimination in the workplace. Over 30% of surgical attendings surveyed using a validated scale (the Heterosexual Attitudes towards Homosexuals or HATH scale) have overt homophobic attitudes (11). Additionally, of surveyed medical students, a majority reported explicit bias against LGBT individuals and over 80% were found to have implicit bias (12). 30% of LGBT medical students surveyed choose to remain closeted during medical training (13). Within surgery the situation is more dire, with a majority of LGBT surgical residents choosing to remain closeted at work due to concerns about both mistreatment and having fewer professional opportunities (14). Being able to be “out” has a myriad of well documented psychological and physical health benefits, however they are dependent on being in a supportive environment (15). Out LGBT people in the workplace find themselves constantly monitoring their behavior to avoid facing the professional ramifications of being too “too gay” (16). Out surgical residents report compounding effects of dealing with discrimination in the workplace and a lack of empathy and support for navigating discrimination in broader society (17). This is a substantial additional cognitive and emotional burden on top of the inherent demands of surgical practice and training. A recent national survey of surgical residents found that 60% of LGBT residents reported mistreatment at work (18). LGBT residents experienced significantly higher rates of suicidality than their heterosexual peers and were far more likely to consider leaving their training program (19).

Discrimination against LGBT physicians comes from multiple directions with 88% of LGBT physicians having overheard coworkers disparage LGBT patients, and 30% of LGBT physicians having in fact experienced discrimination from patients (19). 30% of Americans in a national survey would change physicians upon learning that the physician was LGBT and 35% would change practices upon learning that the practice employed LGBT providers (20). Experiencing such behavior is markedly harmful for physicians. Despite many proposed solutions, few systems exist to protect physicians from discrimination, abuse, and violence from patients (21).

Of course, LGBT individuals not only constitute a significant component of the surgical workforce, but they are also patients. Discrimination against LGBT patients within healthcare is all too common. Many LGBT people report experiencing healthcare discrimination, and over 25% of transgender patients report being outright refused needed care due to their identity (22). Gender Affirming Surgery is itself a field wrought with disparities, with such procedures only covered by Medicaid in 25 US States/Territories (23). Outside of such particular care, LGBT individuals experience the same spectrum of surgical disease as the cisgender-heterosexual population. However, there are specific considerations for surgeons.

To name only a few: homosexual and bisexual men have a higher prevalence of cancer diagnosis than the general population (24). This includes general cancer diagnosis (gay men have 1.9x the odds of life-time cancer diagnosis) and specifically higher incidence of (and often mortality from) anal and colorectal cancers as well as lymphoma (24). Lesbian and Bisexual women are significantly more likely to be obese and to have worse outcomes following bariatric surgery than heterosexual patients (25). Transgender individuals face dramatic rates of violence for which they often avoid seeking care at a hospital due to concerns of mistreatment from medical providers (26).

These differences and disparities compound with other well-documented social determinants of health within surgery (27). LGBT people are significantly more likely to be people of color, living in poverty, uninsured, and experiencing homelessness than their cisgender-heterosexual peers (22, 26). For those who inhabit multiple marginalized identities, such intersections are not simply additive but result in synergistic discrimination and multiple, layered barriers to care (28).

III. LGBT Healthcare in Military and Faith-Based Institutions

The experience of LGBT healthcare, like all healthcare, varies dramatically by context. Two specific contexts worth noting are military institutions and faith-based hospitals.

Prior to the 2011 repeal of Don’t Ask, Don’t Tell, open lesbian, gay, or bisexual identity was grounds for discharge from military service (29). Further, “concern for non-heterosexual activity” itself was grounds for investigation and discharge (29). Before 2016, transgender individuals were categorically barred from military service. Following a 2-year period in which service was allowed, the “transgender military ban” was enacted and transgender people were not able to serve openly or access gender affirming care within the military until April 2021 (30). Although presently there are no concrete bans on working in military hospitals for LGBT surgeons, this history of exclusion has resulted in a lack of structure and mentorship for trainees and young medical professionals. In 2014 the American College of Surgeons (ACS) announced a “strategic partnership” between the College and Department of Defense to formalize the “long standing” relationship between American surgery and the US military (31). The principles of the American College of Surgeons (32) clearly state that care offered to patients should not be affected by patient identity, which has not been the practice of the US Military. Without explicit comment or condemnation of the historical and present discrimination by the US military, the ACS partnership can be read as tacit approval. The notion that not speaking up in the face of discriminatory behavior enables the behavior to continue is fundamental to the academic study of inequality. The framework for such ideas can been seen in Gramsci’s analysis of Hegemony as early as 1926 (33). Within the medical context specifically, the notion of the “complicity of silence” has been previously published in the peer-reviewed literature (34,35). If the ACS does not wish to have its values conflated with organizations with which it chooses to form close partnerships, then the ACS should explicitly vocalize its commitment to equitable practices.

The number of faith-based healthcare institutions in the country has increased dramatically over recent years. Ten of the 25 largest hospital systems in the country are Catholic (36). In practice this means 1 out of 6 hospital beds in America are in Catholic hospitals (36). Catholic hospitals are required to adhere to the Ethical and Religious Directives (ERD) for Catholic Health Care Service, which restrict LGBT patients’ ability to access certain reproductive health and gender affirming services (36). For example, the ERD categorically forbids providing gender affirming hysterectomy for transgender men, and leading Catholic Bioethicists argue that it is immoral to provide Preexposure Prophylaxis for HIV (37). LGBT patients have significant apprehension regarding receiving care at faith-based institutions, exacerbating disparities in access to care (37). LGBT providers are as well less comfortable working in such settings (36). With fewer LGBT providers, and limitations on providing LGBT specific care, LGBT patients will face an even greater challenge accessing culturally competent care in these institutions (36). The healthcare impact of the recent Supreme Court Ruling (38) stating that cities cannot deny funding to Catholic Social Service programs which refuse to work with LGBT individuals remains to be seen. Given the landscape of American Healthcare, mergers of major, often publicly funded healthcare institutions with faith-based organizations are certain to continue. If ensuring LGBT equity is not explicitly part of the conversation in such mergers, conditions will invariably worsen for both LGBT patients and physicians.

IV. The Path Towards Equity

Medicine as a field does not simply reflect the discriminatory attitudes of the society in which it exists. Rather, the medical field was instrumental in creating, legitimizing, and reinforcing homophobic and transphobic beliefs which became commonplace. As such, physicians have a particular obligation to work towards LGBT equity. For surgeons who are often not on the frontline of community-based care programs, this task is complex. LGBT equity is not only an issue of social justice, but also essential to a productive workplace, adequate education, and quality patient care. Passive support of LGBT equity may perpetuate bias and structural inequity. Surgeons must take an active part in self-education, assessment of structural bias, and advocacy for change.

No one solution will address all the aforementioned issues. Nevertheless, concomitant action is urgently needed to change the course of supported or tolerated injustice toward LGBT people. Change from organizations (medical schools, health systems, professional societies) and amongst all members (faculty, students, trainees, clinical partners, administrators) can occur through existing Diversity, Equity, and Inclusion (DEI) frameworks (39). Approaches for implementing DEI initiatives within training programs (40) and Academic Surgery broadly (41) have been previously described. Through education, assessment, intervention, and maintenance of fundamental principles of DEI, our community will benefit from increased diversity on patient care and workplace experience (41). These benefits will only be enriched if we can include LGBT people and perspectives in the DEI movement. Structural and systemic inequity will require systems level interventions such as passage of The Equality Act which is currently being deliberated by congress. Within institutions, DEI initiatives can create safer and more productive workplaces for LGBT providers and all marginalized people. All providers need to receive LGBT-specific cultural competency training to address implicit and explicit bias which harms LGBT patients and colleagues. DEI initiatives within surgery and academic medicine have already had documented success improving representation for racial minorities (42). While racial inequity and LGBT inequity are not interchangeable, many of the same tools can be applied, and similar benefits would likely be seen.

This work for LGBT equity must happen in parallel with other equity initiatives. An undocumented transgender woman living in poverty will not benefit from her surgeon’s cultural competency training if she cannot afford to see a surgeon in the first place. A gay, Black faculty member may continue to experience racism in the workplace regardless of what LGBT-affirming policies the institution enacts.

The proposals put forth here should not be seen as an exhaustive list but rather a launching point for further empiric scholarship on promoting LGBT equity in surgery and beyond.

Figure 1:

Overview of the myriad factors contributing to the status quo of LGBT Inequity.

Table 1.

Definitions of Key Terms.

Gay	An individual who experiences same-sex attraction, often used to refer to both people of all genders and men specifically
Lesbian	A woman who experiences same-sex attraction
Bisexual	Individuals who experience attraction to more than one gender
Transgender	Individuals whose gender identity does not align with their sex assigned at birth
Cisgender	Individuals whose gender identity aligns with their sex assigned at birth
Queer	An overarching term used for individuals who identify as non-heterosexual and/or non-cisgender