Why LGBTQ Physicians Want to Be 'Visible'

John Whyte, MD, MPH; Jesse M. Ehrenfeld, MD, MPH; Nicolas Leighton


August 26, 2020

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  • Being visible as an LGBTQ physician provides doctors a way to connect with patients. Clinical recommendations for gay and lesbian people can be different, and patients need to feel comfortable opening up to their physicians.

  • Role models can be hard to identify for LGBTQ medical students and physicians.

  • The American Medical Association has fought for nondiscrimination action at the federal level. For example, the Trump administration eliminated LGBTQ antidiscrimination protections in section 1557 of the Affordable Care Act, although a federal judge has halted the rollback.

  • Marriage equality helped usher in more acceptance for gay and lesbian people, and LGBTQ discrimination now tends to focus more on transgender people.

  • We won't have more equity for LGBTQ patients without having more LGBTQ clinicians as well as facilities with the cultural competency and willingness to treat LGBTQ patients.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr Whyte, chief medical officer at WebMD.

We spend a lot of time on the show talking about bias and discrimination, but one community we haven't talked about is the lesbian and gay community.

Today I'm joined by two special guests, Dr Jesse Ehrenfeld, an immediate past chair of the American Medical Association (AMA) board of trustees and professor of anesthesiology at the Medical College of Wisconsin in Milwaukee, Wisconsin; and Nicolas Leighton, a second-year medical student at George Washington University School of Medicine in Washington, DC.

Gentlemen, thanks for joining me.

Jesse M. Ehrenfeld, MD, MPH: Thanks for having us.

Whyte: Nick, you've talked about whether or not you needed the visibility of being a gay physician, and whether or not you should wear a rainbow lapel on your jacket. Why is this visibility important to you?

Nicolas Leighton: Becoming a physician is an incredibly personal journey for anybody. When I started medical school, I had the mentality that being gay doesn't define who I am or my career as a physician. I didn't understand the importance of visibility. But now, I have recognized how much I search for those signals as I try to figure out what kind of physician I want to be.

What is good about conversations like this is that we can start thinking less about what it means traditionally to be a physician and move to what it means to be a physician on our own terms. Not just an emergency room (ER) doctor who happens to be Black or a surgeon who happens to be a woman, but what does it mean to be a Black ER doctor or a gay medical student?

To me, it means that I can connect with patients and ask them to be vulnerable with me and to trust me, knowing that I trust them enough to be my true, authentic self.

Whyte: Dr Ehrenfeld, how is sexuality different from race or ethnicity when we're thinking about bias and discrimination?

Ehrenfeld: It's a great question. I think the fundamental challenge is that LGBTQ people are often invisible. Unlike the visibility that a difference in skin color by definition brings to the table, no one knows I'm gay unless I come out.

As a physician, I want to do everything that I can to make sure that we can get patients the best possible care that they're able to get. The care recommendations are different if you happen to be LGB or T. If we don't ask those questions [about sexuality], if patients don't come in and are not willing to share that information about themselves, then we can't get them the best possible care.

Whyte: Nick, do you feel that there's still bias and discrimination? Have you or your colleagues experienced that that you can share with us?

Leighton: While there certainly are comments that are made that I think are off-putting in any sphere, I think the distance that we have to go is just the visibility — the unapologetic visibility, as Dr Ehrenfeld just greatly described. You do have to kind of opt in to sharing that kind of stuff or, as they say, disclosing that kind of information to your patients.

Being able to disclose that information is beneficial to the doctor-patient relationship. It is very hierarchical as it is — especially to minority communities — that in certain situations, being open and visible can signal acceptance of themselves and, I believe, lead to better patient satisfaction and better outcomes.

Whyte: Do you have enough role models?

Leighton: I think there could always be more. It's something that you don't actively see or that is broadcast to other people, especially in a professional setting. I just met the first gay surgeon a month ago. That's a specialty that I'm very seriously considering, and just to be able to see somebody that is out, gay, has a rainbow flag in his signature, it really meant a lot to me as I consider that specialty.

Whyte: Is it fair to say that he may be the first surgeon that you knew was gay? You may have met other gay surgeons.

Leighton: Of course.

Whyte: Your point was about this awareness that you wouldn't have known. Dr Ehrenfeld, you have served at the highest levels of organized medicine, as chair and member of the board of trustees and other leadership roles. Can you share with us your personal journey?

Ehrenfeld: Sure. It's interesting that medicine has had this complex relationship with LGBTQ people throughout history. About 50 years ago, 25 years ago, I couldn't have been an AMA member as an out gay physician because of discriminatory policies and stigma in the DSM [Diagnostic and Statistical Manual of Mental Disorders], which has been addressed.

I was able to be an out gay person elected to the board and to serve as its chair. We have to acknowledge that history; we can't erase it. We need to embrace it and learn from it as we move forward and understand the role of stigma and what it does to prevent people from coming into the profession, whether that's an LGBTQ person or another minority or marginalized community. There's certainly a long way that we have to go.

Whyte: Nicolas sent me this statistic that I want to read and get your reaction to: 30% of non-LGBTQ patients last year said they would feel very or somewhat uncomfortable learning that their doctor was gay. What's the impact of that statement?

Ehrenfeld: You have to take that in the context that it is. How you interact with a patient is critically important, right? So the relationship that I've got with any person in front of me is going to be influenced by what I bring to the table. My identity as a gay person, a person of faith, and a conservative all have the potential to influence the effectiveness of that interaction.

What's important is that any patient who walks through the door knows that they have a space and a place that they can get high-quality care that they need. What's challenging for us is that so many LGBTQ patients over the years have never found that place. They have never been able to walk into a hospital and feel like they're not going to be put down, discriminated against, or exposed. We have to rectify that.

While that statistic is certainly interesting, I think that it goes to the larger question: What does the interaction between an individual physician and their patient look like? How do we make sure that we can reach across all communities so that it's not so much about me as a gay physician? It's about me as a provider of excellent care to the individual in front of me.

Whyte: What is the AMA doing to protect LGBTQ patients as well as physicians?

Ehrenfeld: How much time do you have?

Whyte: Well, give us what you're most proud of. And then I'm going to ask Nick what they should be doing.

Ehrenfeld: From a policy standpoint, we have been fighting for nondiscrimination action at federal levels. We have been working with our state partners to remove discriminatory laws.

Whyte: What's an example for our audience of what a type of discriminatory law might be? Everyone might not be fully aware of the discrimination.

Ehrenfeld: There's been a lot in the past few months around parts of the Affordable Care Act that provide nondiscrimination protections for transgender patients and LGBTQ individuals. That section, Section 1557, was basically eliminated in June by the current [presidential] administration — and actually, just this week, enjoined by a federal court who has now said that it is inappropriate to remove that important protection. The AMA has been at the center of trying to make sure that those protections remain so that it is illegal to discriminate against LGBTQ people in a healthcare setting, based on a federal statute.

We've also done a lot of work around the issue of conversion therapy. It turns out that it is still legal in many states today, although ethically questionable and not a valid approach medically, to perform conversion therapy. We've worked with many state partners to try to get those things banned. Unfortunately, there hasn't been federal activity in that space, but more and more states — two this past year — have said that it should not be legal to perform conversion therapy.

Whyte: Nick, what do you think still needs to be done?

Leighton: I fully support everything that the AMA is doing. I've been following what they've been weighing in on, particularly with the 1557 waiver. I think that's a huge barrier to many vulnerable patients. Specifically, what we've seen is that over the past few years, the LGBTQ community has been carved out, I would say, [into] gay people and lesbian people who have become more socially accepted ever since equality in marriage.

In the other bucket are transgender patients. What we've seen is transgender patients being actively targeted in some of these policies. I think absolutely what the AMA has been saying is very strong, and it's a very important signal to providers and to patients across the country. I also think that there is always more room to take up that fight and to protect those vulnerable patients.

Whyte: So what do you say to those LGBTQ viewers who are interested in medicine? Will they be embraced? Are they embraced? Nick, let's start with you.

Leighton: As I said at the beginning, medicine is an incredibly personal journey. You have to make it whatever it means to you, you know? You can go into that space and you can just get by and you can just be gay. If that works for you, then that's great.

If you want to be more visible, if you want to disclose that information to your patients, then that also is awesome — that's a great step, too.

I think that there is a need for LGBTQ providers in this space. Medicine is only going to really change when more of us enter this space. Even though the field of medicine has made room for diversity over the past few decades, I also think that we need to respectfully elbow our way into some places to make room for ourselves and to make room for others that follow.

Whyte: Dr Ehrenfeld, doesn't an implicit bias still exist in some specialties, in some areas of the country? It's great that Nick is saying people should come out and disclose, and that's an important point, but we also have to address some of those issues when there will be implicit and sometimes explicit bias. It still exists, so there's still work to be done. Is that right?

Ehrenfeld: We'd be fooling ourselves if we didn't think that explicit and implicit bias weren't there, against Black, LGBTQ, and lots of other folks. You asked the question: Should LGBTQ people consider a career in medicine? The answer is yes; we need them.

We won't ever have health equity across LGBTQ communities unless we have more LGBTQ providers, unless we create practices, facilities, hospitals, and clinics that are welcoming, that embrace LGBTQ health, have the cultural competency and the skills needed to take care of all of those people.

In many cases, that starts with those who come from the community. We know that minority and underrepresented physicians often — not always, but often — go back and serve those communities at a higher proportion. We absolutely need LGBTQ people in medicine.

Whyte: Now, Nick, you're just starting your career. Dr Ehrenfeld and I are old. We've been around for a while.

Ehrenfeld: Speak for yourself.

Whyte: Older. So tell us, what are you hopeful for?

Leighton: I'm hopeful for making those spaces, and to encourage other people to be more visible. That is something that — I'm not going to say "your generation," but I'll say generations that preceded mine — just to be in those spaces [was] a privilege. There is a larger journey for us to go on.

I'm excited to see where that goes and to really explore what it means to be a physician of an identity that was traditionally not included in what a professional physician means. So I'm really excited to see where it goes, to explore what it means to be a gay physician, a gay surgeon, whatever it is that I choose to do, and see where it takes us in the medical field.

Whyte: Where can viewers go to get more information? Dr Ehrenfeld, does AMA have resources online?

Ehrenfeld: Yes, the AMA has great resources. We have a very active committee on LGBTQ issues that has great links to lots of things. The only other thing I have to talk about, because we're in the middle of a pandemic and it's really becoming a growing issue, is the issue of data. We started our conversation about visibility and how it is different being an LGBTQ person because, often, that visibility isn't there until you actively do something, come out.

We have little data today about what's happening across the LGBTQ communities with respect to COVID-19 and its impact. We think that it's disproportionately impacting LGBTQ people because they're at higher risk, and there are lots of structural issues that have led to health inequities. Until we start to get data about LGBTQ people and healthcare, LGBTQ in medicine and LGBTQ patients, we won't have an understanding. That's an issue that hopefully will move forward in the coming months.

Whyte: Well, gentlemen, I want to thank you both for joining me. We certainly have to address all forms of bias and discrimination, and I know we all appreciate the insights you've given us today.

Ehrenfeld: Thanks for having us.

Leighton: Thank you very much.

Whyte: And thank you for watching Coronavirus in Context.

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