This is the first study to assess the training experiences of LGBTQ trainees in a southern training program utilizing a well-being framework (PERMA). To our knowledge, this is the only study that solely compared LGBTQ and Straight residents and fellows. Three percent of trainees identify as LGBTQ, consistent with the percent of LGBTQ residents in Alabama and the country as a whole.3,8 We also identified variability in experiences regarding professionalism/relationships between LGBTQ and Straight trainees at a single, large teaching institution, with some of the variability explained by intersectionalities such as race.
Assessment of well-being (Positive emotion & Meaning)
Our study found no evidence of differences in well-being/positive emotion between LGBTQ and Straight trainees. In addition, over 60% of respondents felt the institution and their respective department were LGBTQ friendly; however, it is unclear how many trainees identifying as LGBTQ shared this sentiment. Understanding LGBTQ trainees’ perspectives of their department’s environment is important because literature has found LGBTQ individuals are at an increased risk for problems with mental health (e.g., depression, suicide, psychosocial disorders).13–19 Also, having a supportive environment fosters more social interaction and allows LGBTQ individuals the ability to create bonds and potential mentorship.20,21
Fear of disclosure (Relationships)
LBTQ stigma in “The South” continues to be prominent and still plagues the minds of trainees considering moving to these areas. The fear of sexual orientation disclosure is a common concern among LGBTQ trainees and interferes with formation of relationships. Prior studies identify LGBTQ trainees do not desire to disclose their sexual orientation due to fear of harassment, discrimination, and missed career opportunities.5, 22–26 We did not identify any differences between LGBTQ and Straight trainees pertaining to being denied opportunities based on sexual orientation (p = 0.06).
Barriers in the workplace (Engagement & Accomplishment)
Lastly, institutions are only beginning to identify barriers to LGBTQ trainees’ experiences in the workplace. Most participants felt the institution and their department were LGBTQ friendly; however, we are unclear if this same perspective is shared by LGBTQ trainees specifically. Eliason, et al. found that LGBTQ physicians reported being denied referrals from heterosexual/Straight colleagues and were denied privileges or promotion based on their sexuality.22 Some studies have also shown that LGBTQ medical students, trainees, and physicians are likely to witness derogatory comments, substandard care, or refusal of care towards LGBTQ patients, which was also seen in our cohort.22,27 These barriers impede trainees’ abilities to fully engage in their work and achieve a sense of accomplishment, thereby inhibiting their ability to flourish in their environment. This is best illustrated by our study finding only 0.1% of trainees who identified as LGBTQ were willing to mentor LGBTQ individuals, suggesting individuals may not be able to dedicate themselves to something or someone for the greater good.
Intersectionalities (Positive Emotion, Engagement, and Accomplishment)
Our study also suggested intersectionality may be important. Ideally, each component of the PERMA theory is assessed individually; however, the complexity of the effects of intersectionality on individuals may impact their positive emotion, engagement, or accomplishment.
Despite the growing acknowledgment by the AAMC and LCME for a racially diverse workforce, there continues to be significant gaps in making training environments inclusive as is evidenced by 71% of survey respondents being White/Caucasian and 56% identifying as male. URiM trainees are more likely to care for underrepresented minorities,28,29 and are also more likely to experience burnout due to implicit and explicit racial biases compared to their White colleagues.30 Furthermore, according to the most recent 2020 AAMC U.S. Medical School Faculty report, Black and Hispanic physicians are less likely to be in faculty positions compared to Whites and Asians.31 Although, LGBTQ trainees’ experiences did not vary based on race secondary to low rates of self-reported identification as LGBTQ, understanding how LGBTQ and race intersect among trainees is crucial. These experiences, whether positive or negative, can be compounded in individuals who identify with multiple URiM groups (e.g., Black and Gay, Native American and Lesbian, Latino and Transgender, etc.).27
Limitations
This study should be viewed within the context of some limitations. Our cohort is from a single, academic institution within the Southeast and cannot be generalized to other academic centers in other geographic locations. The small cohort of LGBTQ trainees, those similar to other academic institutions, limits statistical power and assessment of intersectionalities based on race. Recall bias also may have influenced our findings due to the nature of the study. In addition, 110 (13%) responders were excluded due to lack of response to sexual orientation.
Future Studies
Future studies are needed to assess the LGBTQ experience at other large academic training institutions to identify common trends to guide universal changes in GME and provide optimal training environments for all individuals regardless of sexual orientation or background.