Michael H. O’Brien, BS
M.D. Candidate at University of South Carolina School of Medicine Greenville
Correspondence should be addressed to M.O. (mhenryobrein@gmail.com)
Clay illustration by Lily Offit; Photographed by Ben Denzer
Public opinion around LGBTQ issues in the United States has progressed rapidly over the last few decades [1]. This shift has occurred faster than it has for race, disability, and even elder bias. In fact, support for marriage equality and equal adoption opportunity doubled in just one decade. As of 2014, a majority of Americans reported support for anti-discrimination laws for gay and lesbian workers [1]. As early as 1990, less than 30% of Americans viewed marriage equality and same-sex adoption favorably, but as of 2014 greater than 50% viewed marriage equality favorably and greater than 60% viewed same-sex adoption favorably [1]. While this overall trend is beneficial to LGBTQ Americans, we cannot ignore pockets of extreme bias that continue to persist and remain in the shadows.
I am a 25-year-old gay medical student in the Deep South. My medical school sits in the middle of a county that, in many ways, has remained in those “shadows”. Our county made national news in the Spring of 2019 for attempting to pass what came to be known as “The Anti-Gay Resolution.” This resolution decreed that LGBTQ people in our county were unwelcome to live, own businesses, or raise families. Although a resolution of this nature would not hold legal standing, it had the potential to impact the health and well-being of the entire LGBTQ+ community. Luckily, after months of protests and divisive rhetoric at County Council Town Halls, this resolution was removed with a 6-5 vote [2,3]. In the end, our efforts brought the LGBTQ community closer together than ever before. However, the necessity of public uprising to prevent its passage lingers as evidence of stigma and discrimination.
The persistence of homophobia is not isolated from medical education, nor from within the walls of clinic. I have seen the impact of discrimination on my role as a medical student and future physician. I have also experienced the impact of homophobia as a community member in the Deep South. Despite my own personal efforts to support equitable healthcare for people who identify as LGBTQ+, I have repeatedly observed discriminatory behavior. During one particularly grueling week, I witnessed physicians: 1) mock pronouns in the EMR; 2) state that a 16-year-old’s bisexual identity would “deflower” the innocence of his peers; 3) assume gay patients were HIV-positive; and 4) refer to LGBTQ+ as “LGB...ABCDEFG or whatever.” This type of behavior directly impacts patient outcomes [4]. Additionally, this has a dual impact on my personal identity. This environment is not a place where I can freely be my whole self: a gay man and a medical student.
Being a gay man and a medical student are two critical parts of my identity. However, for most people, my sexuality is invisible. I have the privilege of concealing or revealing my identity to avoid the microaggressions and macroaggressions others with visible identities experience daily in clinic. Attendings often meet me and see a young, white male, assuming that I share their conservative ideology. The privilege of my worn identity – including my ability to “pass” as heterosexual - also opens up the opportunity for unfiltered homophobic or transphobic remarks that expect to meet agreeable ears. In these situations, I am faced with another internal struggle: Do I speak up to defend my identity and risk the assessment that I am being “unprofessional”? If I do not speak up, am I failing LGBTQ+ students who will follow me? If I do not perform perfectly today, will I contribute to this physician’s biases?
When LGBTQ+ students face such unnecessary encounters, it is disruptive to our education. It causes internal conflict, raises our awareness of stereotype threat, and hurts our performance [5-7]. The experience of increased performance anxiety is all too common for LGBTQ+ students as well as for many populations who have experienced oppression, including racial and ethnic minorities and people with disabilities [5]. Just as the HRC survey [8] revealed, LGBTQ+ people who fear discrimination report negative impacts on productivity, satisfaction, and wellbeing. These impacts are pervasive, and they noted that upward of 35% of LGBTQ+ professionals lie about their personal life at work. Medical schools and clinical learning environments alike are not immune to these forces.
Bias and discrimination are common experiences among various LGBTQ+ medical professionals, and in many ways we are still waiting for medical education to catch up to public opinion [7-11]. Students, residents, and attending physicians alike report experiencing similar hardships throughout their careers and report these hardships as perceived barriers to success [9]. Almost a third of sexual minority medical students conceal their sexual and gender identity, and this is often rooted in the threat of discrimination [7]. In fact, first-year medical students self-identifying as a sexual minority have higher risk of depressive symptoms, anxiety symptoms, low self-rated health, and increased incidence of social stressors such as harassment [6]. Beyond medicine, the need to conceal sexual and gender identity at work persists across America.
I have personally found the fears of those surveyed to be validated through my own experiences. The classroom is often the equivalent of my workplace, and as the only LGBTQ+ student in my class I am constantly aware of my identity. For example, once a classmate told me they did not “support my lifestyle choices” and that any family other than “the traditional family” was less-than-ideal. Another classmate consistently used the expression “that’s gay as AIDS” for months until being confronted.
Witnessing homophobia from physicians and colleagues alike led me to feel deep discomfort in coming out to medical professionals involved in my personal care. This fear was validated when I attempted to establish care with a local physician. They asked me for my sexual orientation, but immediately followed up with “you’re not gay are you?” before I could answer. When I told them I was gay, their first words were “Okay, we will add HIV testing to your bloodwork for today” before taking any further sexual history. My frustration only worsens as I study for examinations, reading practice questions on the most popular online study programs that link homosexuality to HIV, Kaposi Sarcoma, Pneumocystis pneumonia, and even spousal abuse. I have never once read a vignette that includes a homosexual couple without linking their identity to disease.
I reflect on these experiences often and I recognize that the presence and persistence of homophobia has been unnecessary and disruptive to my education. I am constantly managing these delicate scenarios when my sole focus should be on learning medicine. I love myself and am proud of my identity. However, the prejudice I experience has an impact on my happiness. It steals my peace. It robs me of my focus.
These trends in the classroom, in clinic, and at home only reinforce sexuality stereotypes. This leads to minimization and invalidation of the sexualities of providers, students, and patients alike.
In adding my voice to what many braver and bolder students and physicians before me have expressed and advocated, I hope to remind my colleagues about the opportunity we have as the next generation of physicians to change medical culture for the better. This will require creating an inclusive culture that values diversity in all forms to advance health equity. I suggest the following as first steps in that process.
First, increase the number of LGBTQ+ medical students and faculty, and ensure that they are celebrated and valued. While Harvard recently announced an incoming M1-class that is 15% self-identified as LGBTQ+, this is not the reality nationwide [6]. While New England and West Coast medical centers have relatively high LGBTQ+ matriculation compared to national demographics, many other institutions such as my own, have a much lower rate.
Second, as medical schools become increasingly – and necessarily – diverse to meet the needs of all of our communities, it is all-the-more essential to create spaces that support all learners, including LGBTQ+ students. To this end, medical schools can ensure that there is some form of allied organization designated for fostering acceptance between LGBTQ+ students and their peers. There is a protective role in having these organizations [10]. Whether they are independent or part of a larger organization such as the Medical Student Pride Alliance (MSPA), such places are needed. We have a new MSPA chapter at my medical school, creating a more official voice that is linked to the medical school and creating a safer space for learning and growth. Additionally, allied faculty and students can demonstrate support. Simple actions such as wearing an allyship pin, putting up welcome or safe-space signage, or having a pride flag in an office window can make a big difference.
Third, all members of a learning community should engage in ongoing training around the social determinants of health. This should include but not be limited to implicit bias training. Oftentimes discussing LGBTQ+ mistreatment in medicine alongside racism, xenophobia, sexism, and other forms of discrimination only occurs in the context of implicit bias training. In isolation, implicit bias training may obscure other necessary actions that provide long-lasting cultural improvements [12]. Medical schools need to expand training about the social determinants of health and the impacts of mistreatment of communities within the medical environment, and these training sessions must be mandatory and interactive [4,6,13].
The steps I have laid out above can be used to mitigate homophobia at any medical school or other clinical learning setting. Though I am under no illusion that homophobia will be resolved any time soon, I plan to return to the South someday. I believe there is still hope in the “shadows” where homophobia and other blatant forms of discrimination persist. There is hope because there is work to be done.
In anticipation that my story and my call to action resonate with medical educators across the country, I repeat the demands of community activists and LGBTQ physicians alike: we must be treated fairly, we must be respected, and we must be included in institutional leadership. Together, let us build a truly inclusive medical culture.
ACKNOWLEDGMENT: I extend my gratitude to Dr. Ann Blair Kennedy LMT, DrPH and Dr. Julie Linton MD for their constant support and guidance. Their leadership in the field of medical education keeps me hopeful for a brighter future. I also thank Dr. Chase Anderson MD for encouraging me to find my voice.
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Connor, Eric. (March 2020). Greenville County anti-gay resolution a relic of history after council vote. Greenville News. Retrieved from greenvilleonline.com.
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