A Call to Action: Promoting Visibility, Inclusion, and Empowerment of LGBTQIA+ Medical Trainees

A Growing SGM Physician Workforce

Inclusion and empowerment of sexual and gender minority (SGM) medical trainees is integral to reducing health disparities of the LGBTQIA+ community. SGM medical professionals are more involved in academia and conduct more LGBTQIA+ health education, research, and community service than non-SGM counterparts.¹ Academic health centers have a social responsibility to inclusively recruit and foster positive climates for SGM health professionals and empower these professionals to pursue LGBTQIA+ scholarship. However, trainees and faculty found lack of mentorship, poor recognition of LGBTQIA+ scholarship, and hostile institutional climates to be significant barriers in their own academic careers.¹

LGBTQIA+ identification is increasing amongst Millennial and Gen Z populations and concomitantly within our patient population and community of medical trainees.² In service of our ever-diversifying patients, it is now a professional expectation amongst physicians to provide sexual and gender diverse care in culturally competent ways. Institutions have responded with increased LGBTQIA+ health and health equity training. However, not much attention has been given to recruitment, retention, and empowerment of LGBTQIA+ medical trainees. Studies on underrepresented minorities in medicine (URM) and female medical professional participation have established that their inclusion and visibility results in more equity-based scholarship and improved population health outcomes in marginalized communities served by these physicians.

This perspective piece discusses processes for recruitment and retention of SGM medical students and trainee physicians and explores select strategies that medical institutions can adopt to better address the needs of this growing trainee population.

Improve Self-Identification and Support for SGM Medical Students

Medical schools have a responsibility to collect sexual orientation/gender identity (SO/GI) data that ensures privacy while explicitly stating institutional commitment to an inclusive learning environment. To recruit a representative physician workforce, medical schools must codify inclusive recruitment strategies. Allopathic medical schools employ the American Medical College Application Service® (AMCAS®) for medical school applications. As of 2022, there is currently no demographic data input to declare sexual orientation or gender identity (SO/GI) within AMCAS. Secondary applications sent after medical-school specific screening algorithms may or may not allow for applicants to provide SO/GI information.

During my own application cycle, I described my work in SGM equity as a motivation to pursue medicine as a lesbian, South Asian woman. Without a demographic input to identify SO/GI, I felt my lived experience as a SGM would not have been accounted if it had not related to my professional work. This is still the current system in place and SGM trainees are potentially constrained in a scholarly capacity if their principal mechanism to be “professionally out” is to conduct scholarship or activities for LGBTQIA+ communities. This also reinforces false stereotypes regarding the SO/GI of professionals who conduct LGBTQIA+ scholarship. Relying primarily on subjective, narrative mechanisms (e.g., application essays) to recruit SGM trainees is inadequate and opt-in SO/GI self-identification within AMCAS would present a more equitable mechanism. However, AMCAS demographic data without institutional privacy commitments are insufficient as SGM applicants often possess legitimate fear that SO/GI identification may not remain private or potentially harm to their application, even if it is optional. Therefore, medical schools also need to adopt policies that ensure opted-in applicant privacy and eliminate negative impact of SO/GI to a student’s application. The anonymous AAMC Graduation Questionnaire, tendered in a medical student’s fourth year after matching into residency currently provides some of the most robust SO/GI medical student data available. This survey illustrates how privacy curtails the threat of institutional bias and results in more representative data collection. Medical schools must accordingly provide secure mechanisms for SGM trainees to self-identify.

Medical schools should establish and support LGBTQIA+ Medical Student Groups as vehicles of equity in scholarship, education, and community for SGM medical students. Once medical students have enrolled, institutions can display their commitment to an equitable learning environment by strengthening LGBTQIA+ Medical Student Groups. During my medical school, there were specific conference funds available for Women in Medicine and SNMA student conference attendees. However, there was no funding allocated specifically for LGBTQIA+ conferences which reflected institutional divestment from LGBTQIA+ scholarly activities. LGBTQIA+ medical student groups often lack the institutional backing that is standard amongst other diversity-oriented groups. For example, Student National Medical Association (SNMA) has a mission of increasing URM representation in medicine and is strengthened through its national structure, including involvement of students in regional and national meetings. Many medical schools have specific financial commitments to their SNMA chapters. Similarly, national professional conferences exist for SGM trainees and physicians (e.g., GLMA) and medical schools must empower medical student groups and SGM students to participate in LGBTQIA+ scholarship.

Medical schools should strengthen zero-tolerance policies on harassment and maltreatment of SGM students, with equitable resources available for individuals who have been affected by SO/GI-based bias and stigma. Institutions have a responsibility to establish safe learning environments for all learners. The AAMC Graduation Questionnaire in 2016-17 showed that SGM students experienced 50% or more mistreatment—including humiliation and mistreatment specific to gender, race/ethnicity, and sexual orientation—compared to non-SGM peers.³ Thus, SGM medical students are set up to begin their careers as physicians with substantially more burnout than non-SGM peers. Institutions should address factors that exacerbate the stigma and minority stress experienced by SGM medical students including lack of mental health infrastructure and presence of SGM faculty in the evaluation of discriminatory conduct against SGM students.

Strengthen Inclusive Climate, Education, and Mentorship for SGM Residents and Fellows

As a standard, residency and fellowship programs should outline SGM-relevant institutional policies that provide benefits and protections for SGM physicians, and/or highlight institutional-level advocacy on behalf of SGM physician employees. Amongst SGM physician trainees, choosing residency and fellowship includes special social and economic considerations such as institutional protections of employment for SGM employees or medical benefits such as hormone therapy or fertility treatment.⁴ SGM trainees are aware of historical inequities and conduct exhaustive online research seeking inclusive workplaces that have defined policies of protection and empowerment. Currently, competitive residencies delineate these within their recruitment.

Academic health centers should develop LGBTQIA+ clinical experience and incorporate the experiences and expertise of SGM physicians in the design of these rotations. Although not available at the start of my residency, an LGBTQIA+ elective is currently in the final stages of implementation at my institution. My involvement in curricular development was invaluable as a trainee, and ingrained that both established LGBTQIA+ curriculum and the process curriculum development have positive impacts on SGM residents. Overall, graduate medical education has a vested interest of including SGM physician voices when developing LGBTQIA+ clinical experiences this process exhibits institutional commitment to equity-based work and holistic education.^4,5

Academic institutions should develop SGM mentorship infrastructure to improve institutional inclusion and encourage interprofessional collaboration in LGBTQIA+ health equity-based work. Strengthening institutional commitments to LGBTQIA+ mentorship and scholarship is integral to the professional development of SGM trainees. SGM physicians cite strong mentorship programs as an important factor enabling collaborative scholarly activities and equity work and generating more inclusive institutional cultures.⁵ One barrier can be low numbers of openly identified SGM faculty, particularly within concordant specialties to the SGM residents. However, interprofessional collaboration can often be advantageous in equity-based scholarship. I experienced SGM mentorship through involvement in my house staff union, where cross-specialty engagement with SGM faculty was encouraged. In many institutions, SGM-specific mentorship is informal and lacks the structure and resources for success. There is institutional incentive to foster these collaborations, as they often lead to equity-based scholarly activities and community service.

A Vision for SGM Medical Trainee Inclusion

These recommendations demonstrate a vision of equity for SGM physicians. The recruitment, retention, and empowerment of SGM trainees and physicians is a necessary step to establishing a more equitable workplace environment in medicine and addressing looming systemic health disparities facing the SGM community. The future of our healthcare system will have more LGBTQIA+ patients and physicians, and structural changes are necessary to accommodate this shift.