Letter re: Achieving Equitable Representation For Minorities and Underrepresented Members of the Surgical Community

We have read the article titled, “The State of the LGBTQ+ Community in Surgery” by Pascarella, and we applaud him for addressing the current plight of sexual and gender minorities (SGM, i.e., non-heterosexual and transgender/gender-expansive individuals) within medicine. We agree that the continuing marginalization, discrimination, and stigma against the SGM community adversely impact both SGM providers and patients. ¹ It is with the great support of Pascarella’s thoughtful discourse and recommendations that we would like to make some contributions, further expanding on the disparities in medicine for physicians and patients.

Promoting equity for SGM providers includes intentional efforts from professional societies, which play an integral role in empowering physicians and furthering careers. In a recent study, Sutherland, et al found that the majority of professional surgical societies did not explicitly promote SGM membership or prohibit anti-SGM discrimination within their mission statements/constitution/bylaws. ² Without explicit specifications, current, and future members may feel unwelcomed in these spaces. ² Additionally, the lack of active involvement and visible leadership of SGM providers in surgical societies can lead to the loss of professional connections and scholarship opportunities that are important for career advancement. ² Considering the already limited representation of this population in surgery, we suggest that surgical societies amend their mission statements/constitution/bylaws to be more inclusive and intentional in their efforts to increase SGM membership and leadership. Further, a literature search by Sutherland, et al aimed at identifying the unique experiences of SGM surgeons yielded a scarcity of articles, highlighting the need to further investigate possible disparities that SGM surgeons experience in their field. ²

Another important area of focus noted by Pascarella, ¹ given the history of anti-SGM attitudes and discrimination in medical training programs, is in increasing SGM representation and cultivating an inclusive culture in graduate medical education (GME). In a 2014 survey, Lee, et al reported that 89% of SGM surgical residents did not disclose their sexual orientation/gender status when applying to general surgery programs. Furthermore, more than 30% cited fear of not being accepted due to this disclosure. ³ Additionally, the majority of SGM surgical residents concealed their sexual orientation from fellow residents and attending physicians for fear of rejection and/or poor evaluations. ³ To combat this, one suggestion is for the establishment of an admissions team that includes SGM committee members. This diversity of SGM professionals on admissions teams is important as they may be able to better advocate for SGM applicants. However, simply increasing the number of SGM individuals applying and matriculating into GME positions may not be sufficient without creating an atmosphere for members of the SGM community to thrive. Therefore, similar to recommendations for surgical societies, the visibility of SGM individuals in surgical residencies as faculty and leaders is important. ³ Openly out SGM surgeons in academia sets the standard for social acceptance of SGM residents. Thus, the selection of applicants by diverse residency leaders and faculty can help alleviate the worries of applicants and attract a robust number of SGM individuals.

While representation and social acceptance are vital, we should also incorporate learning opportunities dedicated to SGM patients into medical school and residency curricula. One important topic may be education on trauma-informed approaches for medical students and physicians as SGM individuals may have higher rates of traumatic events related to their SGM experience. Morris et al.’s systematic review supports the efficacy of SGM-focused programming, noting how various interventions can lead to increased knowledge and comfort around SGM topics, as well as more tolerant attitudes among medical students and residents. ⁴ Given that many programs still lack curricular time dedicated to these health issues, strategically incorporating SGM programming would help physicians be more equipped to manage future patients. However, Morris et al also emphasize the limited research on reducing implicit bias, which is notoriously difficult to change without consistent, intentional work. Given the substantial effect implicit bias can have on patient interactions and clinical decision-making, we reiterate the need for future medical education research in this area.

Finally, uplifting the experiences of SGM patients in this discussion is also important, particularly when considering the numerous health disparities that SGM populations face in both healthcare access and delivery. ¹ When compared to heterosexual/cisgender counterparts, SGM individuals have higher rates of cardiovascular disease, diabetes, obesity, asthma, certain cancers, substance use disorders, cigarette smoking, and suicide. ⁴ In part, these disparities are due to factors within the healthcare system, such as previous negative experiences, perceived discrimination, provider biases, and lower or limited access to care. ⁴ Additionally, Flentje et al spotlights the minority stress model, describing the stress burden specific to one’s minority status, as SGM individuals often experience minority stress as it relates to anticipated/experienced prejudice or discrimination, concealment of SGM status, and internalized stigma. ⁵ Within these components, Flentje et al identified that the two most important predictors of physical health for the majority of SGM participants were safe past/present community environment and experiences of victimization. ⁵ Suggested interventions from the study have included individual psychoeducation that incorporates mindful awareness strategies in assessing their current environment and developing coping strategies for minority stress, while also addressing relevant health outcomes. ⁵ Overall, this study reiterates how prevailing SGM health disparities do not solely originate within the healthcare system and providers should acknowledge the greater impact of other social determinants when caring for SGM patients as well as provide resources for managing stress.

Pascarella has done well to provide significant and insightful points highlighting and addressing the issues of the SGM community. We have shown that the need for deliberate efforts for inclusion and support of SGM individuals is critical. Thus, we hope that future studies incorporate these discussions and further investigate the experiences of SGM medical students, trainees, physicians, and patients to identify needs that have yet to be addressed.