Many LGBT Medical Students Stay in the Closet

Pauline Anderson

February 18, 2015

About one third of medical students with a sexual orientation other than heterosexual and about two thirds of those with a gender identity other than male or female do not reveal this information during medical training, results of a new survey show.

Dr Mitchell Lunn

One of the most common reasons for not "coming out" is fear of discrimination from faculty, peers, or patients.

"What the study highlights is that there is still enough fear of discrimination, either at the current stage or later in their career," said study investigator Mitchell Lunn, MD, clinical research fellow, Division of Nephrology, Department of Medicine, University of California, San Francisco.

"Medicine is such a hierarchical field that one person really has the power to wreck your career, so it makes a lot of sense [to hide sexual and gender identity], so why would anyone want to risk that?"

The survey results were published online February 18 in Academic Medicine.

Internet Survey

The 23-item Internet-based survey was designed to be completed within 20 minutes by students at 176 institutions granting MD and DO degrees in the United States and Canada during the 2009-2010 academic year. An estimated 101,473 students were eligible to participate.

Respondents were asked about their sexual and gender identity. Sexual minorities were defined as those identifying as other than "straight/heterosexual," including lesbian, gay, bisexual, or questioning. Gender minorities were those selecting a gender other than "female" or "male."

Students who reported a sexual or gender minority (SGM) identity were asked about whether they were "out," which was defined as "the state of having disclosed and continuing to disclose one's sexual orientation and or gender identity to oneself or others."

Those who reported not being "out" were asked the reasons for not disclosing this information.

Of the eligible respondents, 5.7% completed the entire survey. Of these, 15.8% identified as SGM. Recent estimates suggest that about 6.9% of the US population aged 18 to 29 years identifies as lesbian, gay, bisexual, or transgendered (LGBT).

The likely reason for the higher number in this survey is that it was billed as investigating SGM health education issues.

Sexual Minorities

Of sexual minority respondents, 29.5% said they concealed their sexual identify in medical school. Although most (67.5%) were "out" about their identity, the authors note that this is not all that much better than the estimate of 44% 2 decades ago. (Some respondents declined to answer this question).

Sexual identity concealment was lowest among gay and lesbian (14.7%) and queer (22.2%) respondents. Most bisexuals (53.9%) and questioning (92.0%) respondents reported concealing their sexual identify in medical school.

Dr Lunn was not surprised that many bisexuals are reluctant to be open about their sexuality.

"They have been shunned in society even more than LGBT people," he said.

The results also showed that East Asian respondents were significantly less likely than their white counterparts to disclose their sexual identity.

Compared with those in the Northeast region of North America, respondents attending medical school in the Southern region had significantly decreased odds of being "out" about their sexual identity (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.32 - 0.85; P = .009). The same held for those in the Central region (OR, 0.55; 95% CI, 0.35 - 0.88; P = .01).

Of the 35 respondents who reported a gender minority identity, 34.3% were "out."

Nobody's Business

The most common reasons for concealing sexual identify in medical school were that it was regarded as being "nobody’s business" (61.3%), fear of discrimination (43.5%), social or cultural norms (40.9%), and concerns about future career options (36.8%). For gender identify, fear of discrimination was the top reason for remaining in the closet (42.9%).

Respondents were given the opportunity to make comments on the survey questionnaire. From these comments, it appears that medical students feel least comfortable revealing their sexual or gender identity within certain specialities.

"Some respondents specifically mentioned, for example, that they were going into a surgical specialty so they didn't think they could come out, or they wanted to go into rural medicine and didn't think they could be out in that environment," said lead author Mathew Mansh, a fourth-year medical student at Stanford University, in California.

Macho Specialties

From his experience as a family doctor and then as an internal medicine resident, Dr Lunn said that anecdotally, fields such as internal medicine, psychiatry, and family medicine are more accepting of sexual minorities and that surgical subspecialties such as orthopedics might be "more macho."

Environmental changes are needed to remove discrimination, said Mansh. And just as medical schools now actively recruit ethnic minorities, they should also try to attract SGM students.

But establishing quotas of LGBT students does not seem to be a popular idea. For his part, Dr Lunn would rather see a "critical mass" being built that can start breaking down stereotypes and biases.

"It's about making sure sexual and gender minorities feel valued and welcomed, faculty and staff are being informed about LBGT student issues, and institutional policies are protecting against discrimination," he said.

The aim is to establish a varied learning setting, he added.

"It's creating an institutional and educational environment made up of diverse people ― for example, different races, ethnicities, sexual orientations, etc. Students learn in a variety of ways, not just in the classroom, not just at the hospital, but also from their colleagues and peers."

Some medical schools, such as those at Yale and Stanford, where he was a student, are relatively welcoming, said Dr Lunn. When he was interviewed for medical school, a flyer included in his information package indicated that the school was interested in "the whole you" and that it did not matter whether a student identified as lesbian, gay, bisexual, transgendered, or anything else, he said.

A limitation of the study is that the sample represents a small proportion of eligible US and Canadian medical students. As well, the study was not powered to detect some relationships, and the authors did not investigate factors that promote disclosure in medical school.

Invisible Students

In an accompanying commentary, authors, including Dr Lunn and Mansh, argue that to remove barriers to disclosure, collecting SGM identify data must be standardized and included in national and institutional research and recruitment instruments.

"People who are gay or lesbian in medical school are still pretty much invisible right now because medical schools don't ask their students to identify," said Mansh. "There is no formal data collection about it, so you can't do any of those other studies to figure out which problems or areas you need to address."

According to Dr Lunn, the Association of American Medical Colleges already carries out national surveys at different stages throughout medical school. He suggests adding questions in these surveys about sexual and gender orientation.

"Because sexual orientation and gender identify are fluid, are dynamic and can change over time, it's important to do this not just once" but throughout medical training, he said.

The authors report no relevant financial relationships.

Acad Med. Published online February 18, 2015. Abstract, Commentary


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