Beyond the Scalpel

Diversity has always been and will always remain a crucial component of our society and health care workforce. It is through diverse health care teams that our country’s diverse patient population can receive the highest quality care. The LGBTQ+ surgical trainee and faculty population represents just one facet of this diverse health care workforce, but it is one that has only recently come into the spotlight through new research and the creation of a new professional organization, the Association of Out Surgeons and Allies (AOSA). As shifting political landscapes threaten to reverse essential protections, the urgency of fostering inclusivity in health care has never been greater, particularly for the LGBTQ+ community. Now more than ever, it is critical to promote diversity among surgical professionals and continue to advance progress. This article aims to highlight the challenges faced by LGBTQ+ surgical trainees and faculty, discuss specific implementation and advocacy strategies, and continue to encourage inclusivity in light of recent political changes. WHAT IS THE CURRENT DATA ON LGBTQ+ SURGICAL TRAINEE EXPERIENCES THROUGHOUT TRAINING? Harassment, bullying, and mistreatment are known to be prevalent throughout medical training, especially in minority populations. LGBTQ+ individuals face increased rates of discrimination, sexual harassment, bullying, and suicidal thoughts compared with their non-LGBTQ+ peers. Recent data from the 2019 American Board of Surgery In-Training Examination, in which 4.8% (305 respondents) identified as LGBTQ+, revealed that 59.2% of LGBTQ+ surgical trainees reported experiencing discrimination compared with 42.3% of non-LGBTQ trainees. Similarly, 47.5% versus 29.3% reported sexual harassment, and 74.8% versus 66.9% faced bullying when comparing LGBTQ+ individuals to their non-LGBTQ counterparts.1 With high attrition and burnout rates within general surgery, it must be considered how this mistreatment of LGBTQ+ residents contributes to work dissatisfaction, burnout, and eventual attrition. These incidences of harm and mistreatment witnessed by medical students can potentially have a “trickle-down” effect, impacting students desire to even consider a surgical career. Students who do apply often grapple with the dilemma of whether to disclose their LGBTQ+ identity. A recent study demonstrated that 89% of LGBTQ+ surgery residents did not disclose their identity when applying for residency, and more than 30% did not disclose their identity due to fear of not being accepted into the program.2 From one author’s mentoring experience, several LGBTQ+ medical students endorsed worries about hostility in general surgery toward LGBTQ+ individuals. Another student was concerned they would have to “go back into the closet again” every time they came to work. HOW CAN PERSISTENT CODE-SWITCHING AND SELF-MONITORING AT WORK AFFECT A LGBTQ+ SURGEONS MENTAL WELLBEING AND PATIENT CARE? LGBTQ+ people, especially those in surgical fields, may face additional stress as a “silent” minority, which can impact mental health and work satisfaction leading to further downstream consequences. Often, these individuals have intersecting identities that can contribute to and magnify these challenges. While their outward-facing minority characteristics, such as race and gender, may be fully visible, many physicians choose not to disclose their sexual orientation or gender identity. This decision is often driven by fear of discrimination, lack of systemic support, or internalized shame and homophobia due to perceived ideas of societal norms. Many LGBTQ+ individuals continually self-monitor and code-switch to avoid being perceived as “too gay” and continuously “test the waters” with every new encounter in search of psychological safety. Constantly adjusting one’s behavior and speech to blend in with heterosexual colleagues to avoid professional ramifications3 can have detrimental effects on a trainee’s mental and emotional resilience. Exposure to this environment can lead to internalizing others’ negative societal attitudes, beliefs, and stereotypes about LGBTQ+ identities. Over time, individuals who experience internalized homophobia are more likely to suffer from mental health conditions, with effects worsening as they age,4 and increased rates of substance abuse, suicide, and early departure from the field.5 This cumulative cognitive strain can begin to affect a clinician’s “mental bandwidth,6” compromise the quality of patient care, and impact work satisfaction throughout an LGBTQ+ physician’s career. WHAT ARE SOME KEY INTERVENTIONS THAT CAN IMPROVE THE TRAINING AND WORK ENVIRONMENT FOR LGBTQ+ SURGICAL TRAINEES? To enhance the training experience for LGBTQ+ residents and cultivate a more inclusive surgical culture, support for these individuals should start early in their careers, even in medical school, with changes implemented at the individual, institutional, and systemic levels (Table 1). These interventions should target education, recruitment, psychological safety/support, mentorship, and equity research. Studies indicate that over 30% of surgical attendings exhibit overtly homophobic attitudes,3 highlighting the necessity of providing educational opportunities to address these biases, while enhancing diversity, equity, and inclusion (DEI), sensitivity, and pedagogical training.7 A LGBTQ+ competency curriculum implemented in a general surgery residency program demonstrated significant improvements in LGBTQ+ knowledge of patient care, with all trainees stating that they were better allies following the course.8 Even simple changes such as asking someone their pronouns, how they prefer to be addressed, or using neutral language to discuss a significant other can decrease assumptions and create more space for open dialogue. Other educational opportunities for trainees and faculty are afforded through the “ACS Inclusive Excellence Resource and Implementation Toolkit.9” Finally, harassment may arise from the patient populations served, making it vital for hospitals to reinforce codes of conduct and provide bystander training for all health care workers to address micro-and macroaggressions in real-time. TABLE 1 - Individual and Institutional Ways to Create a More Welcoming Environment for LGBTQ+ Trainees and Faculty Individual Institutional Foster curiosity and commitment to understanding LGBTQ+ experiences and staying updated on community issues Update promotion criteria and revise hiring practices to value contributions to DEI Explore current literature on LGBTQ+ trainee and faculty experiences, recruitment, and retention Creation of an LGBTQ+ curriculum for trainees and medical students Participate in bias training and learn strategies to address bullying, harassment, and microaggressions Provide mandatory training on explicit and implicit biases, focusing on LGBTQ+ issues Be an ally: actively challenge discrimination and support inclusivity for patients, trainees, and colleagues Enforce nondiscrimination policies through regular review and accountability by all staff Use correct pronouns (he/him/his, she/her/hers, they/them/theirs, etc.) and promote visibility (pronoun badges, rainbow pins, and lanyards) Increase LGBTQ+ visibility in communications (newsletters, marketing materials, etc.) Use inclusive language (“partner” or “significant other”) and avoid assumptions (asking male colleague about girlfriend/wife) Offer inclusive benefits and policies for LGBTQ+ employees and same-sex couples (parental leave in adoption/surrogacy) Engage in mentorship, advocacy, and sponsorship of LGBTQ+ medical students, trainees, and junior faculty Establish a mentorship network within the department consisting of LGBTQ+ surgeons, allies, trainees, and medical students Become a member of AOSA or other organizations (MSPA—Medical Student Pride Alliance, GLMA-Health Professionals Advancing LGBTQ+ Equality) Support AOSA initiatives and consider institutional membership Host expert speakers to discuss DEI and LGBTQ+ topics HOW CAN RESIDENCY PROGRAMS DEMONSTRATE INCLUSIVITY FOR LGBTQ+ APPLICANTS? Residency program websites and recruitment materials can do this by including more information about equity and inclusion efforts, especially LGBTQ+ resources and support. Faculty who identify as allies or LGBTQ+ should be encouraged to find ways to demonstrate that their program is a safe and inclusive place for training. Particularly in the era of virtual residency interviews, the assessment of program culture and diversity may have become more difficult for LGBTQ+ applicants. Whether this means wearing a rainbow pin with pride, pronoun tags, or displaying pictures of their partner in their office, these simple gestures can serve as identifying factors that reassures LGBTQ+ students about a program’s inclusivity. This is especially meaningful for applicants and trainees who choose not to disclose their identities and contributes toward building trust and creating psychological safety. Representation and allyship within the surgery department are also crucial for trainees and faculty members. Department leadership should seek to actively support initiatives to recruit and retain LGBTQ+ medical students, residents, faculty, and place greater value on work within the diversity, equity, and inclusion realms. WHY IS MENTORSHIP AND REPRESENTATION SO CRUCIAL FOR LGBTQ+ SURGICAL TRAINEES, AND HOW DO WE FOSTER THESE CONNECTIONS? Another key challenge faced by LGBTQ+ trainees is the lack of mentorship and representation of LGBTQ+ individuals in surgery. This is crucial, as 80% of LGBTQ+ residents responded that knowing of an LGBTQ+ faculty member or resident in a training program impacted their decisions to rank the program higher during the match process.2 On a larger scale, the Association of Out Surgeons and Allies10 will improve mentoring, sponsoring, and support for LGBTQ+ medical students, surgical residents, and faculty members nationwide. The organization’s mission is to decrease the bias surrounding the LGBTQ+ population and increase systemic support by providing a platform for institutional participation. With over 30 Department of Surgery programs as institutional members, this enhances the visibility of programs dedicated to the inclusivity of LGBTQ+ individuals. Furthermore, it fosters and supports allies who have made it a mission for their surgery programs to provide equitable training and support. Research in this field is still lacking, and there is little guidance in the development of inclusivity programs, especially given the recent scrutiny of diversity efforts. Despite the knowledge that an increase in the number of physicians improves patient care, optimal ways to accomplish this and increase opportunities for all individuals who wish to succeed in a medical career are still elusive. More funding, recognition, and support in this field of research as an academic discipline are needed, and even more so with recent political changes. Despite the uncertainty of the political landscape, the surgical community should stand firm and continue to make progress to support a just culture for surgeons in all phases of their careers and their patients. Ultimately, these research projects and the lessons learned can be extended to other marginalized and under-represented individuals in medicine and create more equitable pathways for success. Through individual, institutional, and systemic interventions, we can create opportunities for the inclusivity of different perspectives, cultivate a safer workplace environment, and increase representation and retention in surgery. This vision of a more accepting surgical culture starts with a call to action by increasing the visibility and struggles of the LGBTQ+ community and highlighting the changes that still need to be made. Only then can surgery become a more inviting career path for future LGBTQ+ surgeons and pave the way for a healthier surgical community that lives up to the shared ideals of excellence, lifelong learning, and meaningful change.