Perspective: Fostering Safe Spaces in Otolaryngology

Sarah M. Russel, MD, MPH, on behalf of the Diversity & Inclusion Committee

Sarah M. Russel, MD, MPHMy path to being openly gay and “out” in otolaryngology was anything but straight. Growing up, I was told bisexuality was “just a phase,” so when I discovered late in medical school that my attraction to multiple genders was not something fleeting, I started to wonder how I would make space for this new piece of myself within my future medical specialty.

To add to this uncertainty, as I was about to come out and start my intern year, a global pandemic shut down the world. As someone new to the lesbian, gay, bisexual, transgender, intersex, or asexual (LGBTQIA+) community, I did not fully understand the power of affirming spaces or the queer community until I could not access them during this huge life transition. The subsequent isolation was crippling. 

Eventually, I confided in my associate program director, who started an email chain that led to finding LGBTQIA+ mentors. She recognized the unique needs I had as a queer resident and led me to the support I needed.¹ In doing so, she demonstrated the importance of such allyship and exemplified how to support LGBTQIA+ otolaryngologists. 

In recent years, the proportion of the U.S. population openly identifying as LGBTQIA+ has grown substantially. These demographic shifts are likely to continue as younger generations, namely Millennials and Generation Z, have greater proportions of “out” sexual and gender minorities (SGM) compared with older generations.² (Editor’s note: SGM, an umbrella term commonly used in academia, and LGBTQIA+, more commonly used in community settings, are treated interchangeably here.) However, it remains unclear how these shifts in the general population translate into LGBTQIA+ representation in otolaryngology.

The Association of American Medical Colleges (AAMC) recently started collecting sexual orientation and gender identity (SOGI) data in medical student questionnaires, but broad SOGI data collection is lacking in graduate medical education and among faculty.^3,4 In otolaryngology, SGM representation remains similarly murky. Other marginalized groups in medicine, such as Black and Latinx physicians, are disproportionately underrepresented in otolaryngology compared not only with the United States population but also with the rest of medicine.

This raises concerns that the LGBTQIA+ community is similarly underrepresented in our field. Moreover, SGM residents and physicians in surgical fields report more frequent mistreatment, higher rates of harassment, more burnout, and overall poorer institutional climates than do their cisgender, heterosexual counterparts—findings that could deter LGBTQIA+ trainees from choosing careers in otolaryngology.^5-8

Having LGBTQIA+ representation in otolaryngology leads to better outcomes for SGM patients. Many SGM patients report avoiding seeking healthcare owing to fear of discrimination, judgment, and/or violence.^9-11 Consequently, LGBTQIA+ patients who saw an LGBTQIA+ physician were more likely to adhere to treatment recommendations and had better overall health outcomes compared with when they saw cisgender, heterosexual physicians.¹² Thus, otolaryngologists should work to improve care for LGBTQIA+ patients not only through fostering safe workplaces for SGM otolaryngologists but also through creating welcoming spaces in healthcare for their LGBTQIA+ patients.¹³

To improve outcomes for LGBTQIA+ patients in otolaryngology, we first need to ensure that SGM trainees and physicians feel safe and welcome in our field. The alphabet soup of the LGBTQIA+ community can feel overwhelming to those outside of the group. If you are feeling this way as you learn more about the community, you are not alone. Resources such as The Trevor Project and the Human Rights Campaign have guides on many topics that can help you understand some of the basics of the queer community.  A paper that I co-authored, “Best Practices for LGBTQIA+ Patient Care in Otolaryngology” also provides many definitions of common LGBTQIA+ terms you may encounter.¹³  

SGM colleagues will notice your effort. If you make an innocent mistake in a conversation with a queer colleague, accept any gentle feedback they may provide. Also, understand that current views on professionalism may feel restrictive to some SGM trainees and physicians. Consider examining your views on gendered fashion, hair, makeup, and style broadly and whether these can expand to allow LGBTQIA+ otolaryngologists to show up as their truest selves. If SGM otolaryngologists feel safe at your workplace, LGBTQIA+ patients will likely feel safe under your care.

Creating welcoming spaces for your LGBTQIA+ patients begins when they set foot in your waiting room. This can include intake forms that list a wide range of gender identities and the patient’s chosen name/pronouns. Ideally, all staff, including front desk staff, would be trained in how to use inclusive, gender-neutral language, and they would use the information on the patient’s intake forms to make them feel safe and welcome. Staff can also document the patient’s preferred name and pronouns in the electronic medical record. In the exam room, try to use gender-neutral language, and steer away from assumptions about relationships. For instance, ask patients, “Who did you bring with you today?” rather than guessing the relationship between them and their support system present. Although these suggestions seem small individually, they aggregate into a welcoming clinic encounter for LGBTQIA+ patients and their families.

Identifying as part of the LGBTQIA+ community goes beyond who you date, how you dress, and which restroom you use. Inevitably, being a part of this community changes how you see the world and how the world sees you. It alters your relationship with gender, society, and yourself. If someone feels unsafe being out at work or with their care team, that person loses the opportunity to show up as the truest version of themselves. In censoring themselves, they will miss bonding with their colleagues or developing patient-physician rapport. This code-switching is not only costly but also mentally taxing—the mental energy required to fit into these spaces detracts from one’s capacity to contribute to their work lives and personal lives. For our LGBTQIA+ colleagues and patients to be able to reach their fullest potential, we must create safe spaces that allow them to flourish and feel supported.

References

1. Russel SM. The Power of Sponsorship. Academic Medicine. 2023;98(7):760. doi:10.1097/acm.0000000000005055
2. Jones JM. LGBT Identification Rises to 5.6% in Latest U.S. Estimate. Gallup, Inc.; 2021. 24Feb2021. Accessed 3Oct2021. https://news.gallup.com/poll/329708/lgbt-identification-rises-latest-estimate.aspx
3. Russel SM. Let me be perfectly queer: Improving sexual orientation and gender identity data collection. Medical Education. n/a(n/a)doi:https://doi.org/10.1111/medu.14844
4. Desai S, Russel SM, Berk G, Kimple A. LGBTQIA+ Outness in Otolaryngology Residency Applications. Journal of Surgical Education. 2024/03/28 2024;doi:https://doi.org/10.1016/j.jsurg.2024.02.004
5. Brown C, Daniel R, Addo N, Knight S. The experiences of medical students, residents, fellows, and attendings in the emergency department: Implicit bias to microaggressions. AEM Educ Train. Sep 2021;5(Suppl 1):S49-s56. doi:10.1002/aet2.10670
6. Heiderscheit EA, Schlick CJR, Ellis RJ, et al. Experiences of LGBTQ+ Residents in US General Surgery Training Programs. JAMA Surgery. 2022;157(1):23-32. doi:10.1001/jamasurg.2021.5246
7. Samuels EA, Boatright DH, Wong AH, et al. Association Between Sexual Orientation, Mistreatment, and Burnout Among US Medical Students. Article. JAMA network open. 2021;4(2):e2036136. doi:10.1001/jamanetworkopen.2020.36136
8. Sánchez NF, Rankin S, Callahan E, et al. LGBT Trainee and Health Professional Perspectives on Academic Careers--Facilitators and Challenges. Article. LGBT health. 2015;2(4):346-356. doi:10.1089/lgbt.2015.0024
9. Glick JL, Theall KP, Andrinopoulos KM, Kendall C. The Role of Discrimination in Care Postponement Among Trans-Feminine Individuals in the U.S. National Transgender Discrimination Survey. LGBT Health. Apr 2018;5(3):171-179. doi:10.1089/lgbt.2017.0093
10. Whitehead J, Shaver J, Stephenson R. Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations. PLoS One. 2016;11(1):e0146139. doi:10.1371/journal.pone.0146139
11. Lewis C. Rethinking access for minority segments in rural health: An LGBTQI+ perspective. Aust J Rural Health. Oct 2020;28(5):509-513. doi:10.1111/ajr.12660
12. McKay T, Tran NM, Barbee H, Min JK. Association of Affirming Care with Chronic Disease and Preventative Care Outcomes among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults. Am J Prev Med. Nov 29 2022;doi:10.1016/j.amepre.2022.09.025
13. Stone AM, Russel SM, Flaherty AJ, Faucett EA. Best Practices for LGBTQIA + Patient Care in Otolaryngology. Current Otorhinolaryngology Reports. 2023/09/01 2023;11(3):229-239. doi:10.1007/s40136-023-00481-2

WATCH | Award-winning AAO-HNSF Implicit Bias Video Series

Implicit bias can negatively impact the physician–patient relationship, resulting in lack of trust, higher rates of noncompliance, and poor outcomes. In 2021, the Academy created ten brief videos that explore common examples of implicit bias towards different patient groups. Learn more about how to avoid implicit bias when treating LGBTQ and transgender patients and access additional resources recommended by the Diversity & Inclusion Committee.