‘That’s a bit gay for work’: medicine is not doing enough for LGBTQ+ colleagues

Medicine as a profession should reflect the population it is responsible for. Therefore, workforce diversity is essential to improve care for marginalised groups. Although significant steps have been taken to acknowledge the issues of gender discrimination, attainment gap and racism, the system still fails educating and taking comprehensive actions to address these inequalities. Furthermore, the literature offers meagre evidence on lesbian, gay, bisexual, transgender, queer, questioning, and other identities (LGBTQ+) representation in the profession and on the challenges faced by LGBTQ+ medical trainees. As a result, we must ask ourselves whether we fully understand the importance of proactive LGBTQ+ representation, inclusion and education in encouraging future trainees, students and applicants in joining our ranks.

This paper will explore current issues in LGBTQ+ policies and the known and hidden challenges faced by LGBTQ+ trainees. Finally, the paper will discuss potential steps to achieve LGBTQ+ inclusion in the medical profession to benefit colleagues and patients.

Terminology

We start by defining LGBTQ+ terminology adopted throughout the paper, which may be unknown to some readers due to lack of awareness, stigma surrounding some terms, and their scarce use in scientific and everyday literature.

• LGBTQ+—a commonly adopted acronym for lesbian, gay, bisexual, transgender, queer, questioning, and other identities, including asexual, pansexual, etc.

• Queer—a reclaimed umbrella term used by those who identify with multiple identities or as another individual identity in the community. Although initially used as a slur, the term was reclaimed in the late 1980s.

• Heteronormative—views which promote heterosexuality as the preferred sexual orientation.

• Cis-gender—relates to a person whose identity and gender correspond with their birth sex.

• Allyship—the status of someone who advocates and works for the inclusion of marginalised groups, who is not a group member but in solidarity with its struggle and point of view.

Where do we stand right now?

LGBTQ+ civil rights have significantly advanced in the past 20 years in the UK. This includes the repeal of section 28, which prohibited the ‘promotion of homosexuality’ within the UK from 1988 to 2000 in Scotland and until 2003 in England and Wales, as well as the legalisation of same-sex marriage and the removal of the ban on donating blood for men who have sex with men. Nonetheless, the international picture remains fragmented.

The International Lesbian, Gay, Bisexual, Trans, and Intersex Association-Europe has found that progress of LGBTQ+ rights in Europe has plateaued in the past decade and even regressed in some areas [1]. In the UK, reports of anti-LGBTQ+ hate crime increased in 2021, associated with a surge in antitransgender rhetoric in politics, persistent barriers to legal gender recognition and heightened delays for access to gender reassignment services. In contrast, the British government has banned conversion therapy for lesbian, gay and bisexual (LGB) individuals, but not for transgender people and is yet to discuss the recognition of non-binary gender. Alongside this, there have been debilitating cuts to funding LGBTQ+ education and antibullying programmes [2–4].

LGBTQ+ in the profession

LGBTQ+ representation in the medical workforce is an underdiscussed issue, often missed within the wider picture. In fact, there are no current data involving the proportions of LGBTQ+ representation in the NHS workforce. However, the 2021 National Census will be the first in British history to have lesbian, gay, and bisexual values within its results. In 2019 the British Government estimated that 2.7% of the UK population identified as lesbian, gay, or bisexual, increasing from 2.2% in 2018 [5, 6]. Similarly, from 2017 to 2019, graduating US doctors identifying as gay or lesbian rose from 3.6% to 3.8%, bisexual from 4.2% to 5%, and a difference in gender than that assigned at birth from 0.6% to 0.7% [7, 8].

Furthermore, available literature reports selected accounts from lesbian, gay or bisexual trainees but reflect a lack of evidence on experiences of other LGBTQ+ individuals, such as transgender, intersex, and non-binary identities. This is likely to result from the under-representation of these groups within our profession and the lack of education on LGBTQ+ populations received by researchers and organisations [7–9].

There is also a lack of evidence to discuss the intersectionality of LGBTQ+ identity with race, socioeconomic background, and religion among trainees. The 2018 National LGBT survey highlighted that the overarching majority identify as white (92.4%), earned less than £20 000 (47%), and did not have a religion or belief (69%) [10]. This suggests that the intersectionality among these mentioned characteristics will likely be further under-represented. In fact, individuals have multiple intersecting identities, and the level of inclusion or marginalisation within the profession will depend on the identity being analysed. As such, there might be cases where individuals will choose which fight to join: for example, gender equality, racism, or homophobia.

Similarly, there is a paucity of evidence outlining the distribution of LGBTQ+ trainees across specialities, which is reflected in the lack of self-reported data by the professional Royal Colleges regarding their LGBTQ+ membership. Comparable data from the USA highlighted that the intended specialities with the highest and lowest percentage of LGBTQ+ graduates were psychiatry (11.6%) and orthopaedic surgery (1.8%), respectively, with percentage uptake further decreasing from medical to surgical specialities. This was primarily based on perceived inclusivity of the intended specialty [11].

From everyday aggressions to queerphobia

‘That’s a bit gay for work’ is one of the most heard expressions reported by a participant from the Kennedy Report by the Royal College of Surgeons of England. This is one of the first reports exploring the experiences of LGBTQ+ surgical trainees who have witnessed or experienced discrimination or harassment in the workplace. This report proposes a framework to support and increase the profession’s diversity [12]. Although promising, we must acknowledge that we are still far from achieving LGBTQ+ diversity and inclusion in all branches of the workforce.

While the scientific literature fails to provide robust evidence, the age of social media has brought together a different medical community. #MedTwitter, the medical Twitter community, offers numerous self-reported accounts of bullying, harassment and discrimination from colleagues and patients, who work across the globe. This is a painful reminder that our workplaces can be unaccepting of LGBTQ+ colleagues, suffering from saturation with heteronormative, cis-gendered stereotypes.

In a 2016 report by the British Medical Association and the Association of LGBT Doctors and Dentists (GLADD), over 70% of 803 LGB doctors and medical students reported having endured harassment or abuse related to their sexual orientation within the NHS, ranging from being unable to talk about their private life to homophobic name-calling. In addition, 12% reported psychological abuse, verbal attacks or threats on social media. On the other hand, 12% had been offered fewer training opportunities or struggled to be provided with pastoral support because of their identity [9].A new BMA LGBTQ+ survey amongst doctors has been completed this year, although yet to be reported.

With only 59% of healthcare staff being openly ‘out’ at work, coming out can potentially have long-term career repercussions [13, 14]. Senior colleagues represent the most common source of environmental queerphobia, and only 40% of LGBTQ+ medical students and doctors report working in an environment which encourages openness [9 15]. Furthermore, around one-third of LGB doctors had, to some extent, chosen their specialty because of perceived inclusivity, while 4.1% had changed specialty because of negative experiences [14, 15]. This is also reflected in data from the USA on LGBTQ+ graduates [11].

Nonetheless, ‘coming out’ repeatedly with team members can cause exhaustion, mental suffering and recurrent trauma. Affected LGBTQ+ trainees detail having assumptions made about themselves based on their sexual orientation and feeling ‘unable to talk about their private life’ [9]. On the other hand, being out online may also not be an option for trainees due to the risk of one’s online activity being ‘outed’ in the physical workplace.

In 2017, the General Medical Council survey reported that 5.8% (n=2972) of trainees had experienced or witnessed bullying or harassment, with 24.4% (n=680) not believing that reporting will make a difference and 21.5% (n=599) fearing adverse consequences [14]. Similarly, LGBTQ+ trainees highlighted that reporting discriminatory behaviour is often not an acceptable option due to fear of not being taken seriously, receiving reprisals or further discrimination, or harming their career progression. Only 3.1% reported homophobic and biphobic incidents, with solely 20% of this minority being satisfied with the outcome [9]. As such, victims cannot distance themselves from perpetrators. Ultimately, due to its competitive nature and close-knit community, leaving training is often unimaginable, resulting in suppressing one own’s identity to perform well and deteriorating mental and physical health [15].

Where to go next?

To advance, we must first acknowledge that this issue still exists. It has not been fixed. We cannot pretend otherwise, or it will get worse. The lack of data available speaks for itself. This is the time for action. We must strive to change the culture and increase LGBTQ+ representation in medicine at individual, local and organisational levels.

First, language matters. LGBTQ+ people are not homogenous, and many will often have significantly different experiences. While the ‘gay’ umbrella term is widely accepted within the community, the past decades have brought the reappropriation of the stigmatised and contested word ‘queer’ within the community as an alternative to self-identify with multiple identities or as an umbrella term for the individual.

Inclusive language can strip away heteronormative, cis-gendered stereotypes to create open and accepting working relationships. For example, we may consider adopting gender-neutral terminology throughout our history taking and everyday conversations, such as ‘partner’ rather than ‘wife/husband/girlfriend/boyfriend’. Similarly, understanding and adopting the correct use of gender-neutral pronouns is imperative for non-binary people.

Second, we must create inclusive workplaces to support colleagues while providing LGBTQ+ inclusive care for patients. In 2018, the NHS Rainbow Badge was launched to send a message of inclusion and safety to our LGBTQ+ patients [16]. While striving to encourage conversations on LGBTQ+ topics, this initiative has also proven beneficial to queer colleagues by enabling colleagues to self-identify as community members or as someone showing visible allyship. The awareness of working within a welcoming and supportive team can spark numerously uncomfortable yet needed conversations and give the courage to challenge and report discriminatory behaviour.

Third, we need to normalise challenging unprofessional behaviour. Most incidents go under-reported, or victims fear providing evidence due to possible personal and professional retaliation [12]. This will require the creation of psychological safety and mechanisms to report discrimination and bullying. As outlined in the Vanderbilt model, isolated incidents may mandate an informal ‘cup of coffee conversation’, a pattern might require remedial awareness training, and then further escalation [17]. However, culture change will take time, and we must not underestimate the personal and professional impact on victims of facing one’s perpetrator, even if there is a long-term benefit. It is only with a supportive team and working environment that change can be achieved.

Fourth, we must strive for visible LGBTQ+ leadership. Trainees speak about the need for ‘mentors and role models from diverse backgrounds and communities’: this is a call for change toward inclusive leadership, visible LGBTQ+ role models, and proactive representation. Being a queer student or trainee can feel lonely, especially when one fails to find a senior figure to identify with [11–13].

Evidence highlights the lack of minority ethnic and female doctors in senior positions, but no data are available for LGBTQ+ doctors. This may be the result of few confident—and out—queer trainees applying for these positions or of the lack of opportunities available to them: this is not an equal playing field, let alone an inclusive one.

Fifth, in the context of the aforementioned points, we must recognise the added challenges of intersectionality in the fight towards equality, diversity and inclusion. We must address the under-recognised discrimination against minorities and diversity within the LGBTQ+ community, which has the potential to cause fragmentation within the community and slow the pace of advancement. As an example, we suggest an encompassing, holistic approach to involve marginalised groups, individuals who are not openly out, and those who are fighting against other forms of discrimination, therefore targeting marginalisation within the community itself and building on achievements by other marginalised or discriminated groups.

Lastly, as yet LGBTQ+ history months rolled by, this is a reminder that we must provide adequate, regular and ever-progressive training to colleagues in all branches of medicine. While LGBTQ+ professionals often volunteer and may be best placed to provide teaching and training, we cannot expect this to be the only solution due to its burden and exposure to prejudice and harassment. LGBTQ+ education must be embedded within the undergraduate curricula and regularly revisited during postgraduate training [18]. We do not need awareness. We need LGBTQ+ education that erases stereotypes, challenges discriminatory beliefs and provides remedial training while promoting inclusion among professionals and patients.

Working together

The authors hope this paper is a call to action, to be visible, to be active. This is not an attack on colleagues nor is this about blame. However, this is a confrontation of heteronormative and queerphobic places, physical and cultural, within our profession. Each healthcare team member has a duty to address this discussion, regardless of their role or individual experiences. It is not enough to be present: if you practice LGBTQ+ allyship, you should be an upstander.

If every queer doctor or patient must ‘come out’, we will have not achieved equality or inclusion. We must take action to raise awareness and educate current and future healthcare professionals. We must challenge discriminatory behaviour, protect colleagues and patients, and bring about an inclusive LGBTQ+ healthcare culture for all.

Acknowledgements

The authors would like to share their immense gratitude with their LGBTQ+ colleagues and friends who have shared their experiences, advice, and reviewed this paper. They have enabled this open letter to begin uncovering the daily realities of LGBTQ+ discrimination, raise awareness, and call for change within our profession.

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Vassili Crispi @VassiliCrispi and William Lawrence Ballard @ickyplod

Contributors

The idea for this paper was born in the desire to increase LGBTQ+ representation within undergraduate and postgraduate medical training, changing the shape of our profession and its culture. VC and WLB are both LGBTQ+ advocates and members of the community. As such, they have both openly spoken about their journeys and experiences in public forums, raising awareness and calling for action. VC has reached out to numerous colleagues and members of the LGBTQ+ community for input, advice and guidance with this paper. WLB has advised on the overall trajectory of this letter and its purpose.

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests

None declared.

Provenance and peer review

Not commissioned; externally peer reviewed.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.

References