Just Read: Eliminating physician biases against gay and lesbian people, don’t forget the “T”

This is a study from Yale University about medical students’ explicit and implicit attitudes toward people who are gay and lesbian. Not surprisingly, medical students reflect the biases of the society around them:

Explicit and implicit attitudes among medical students 54443
A lot of bias: Explicit and Implicit attitudes among medical students against gay and lesbian individuals (Where’s the “T”?) (View on Flickr)

I created the chart above from the study data which shows that a little less than half of medical students today harbor openly negative attitudes toward gay and lesbian people. When looking at their unconscious attitudes, that jumps to 82 %.

This is about the same percentage as adult physicians’ negative implicit attitudes toward latino individuals, but more negative than adult physicians’ attitudes toward african american people. (see: Blair I V, Havranek EP, Price DW, et al. Assessment of biases against Latinos and African Americans among primary care providers and community members. Am. J. Public Health. 2013;103(1):92–8.)

What you do with it that matters

This data obviously doesn’t make people feel good about their potential treatment in health care, which can be hostile bordering on brutal (I’ll post on that in the near future).

What’s more important is that physicians and the profession in general should desire to know their biases, and do something about them. The researchers in the first paper correlated attitudes to prior contact with gay or lesbian individuals, and found that, indeed, having had positive contact was protective, as has been shown in the literature for many years.

In other words, there are things that can be done, we should not be disappointed that bias exists, we should be disappointed if it is allowed to continue unmodulated.

Enter the “hidden curriculum”

The commentary piece attached to this one brings up, again (for the nth time this month alone – must be newly popular?), the concept of the “hidden curriculum,” which has been foreign to me as a non-academic, so I appreciate it being defined here:

The compilation of implicit biases, explicit biases, institutional climate, and ingrained behaviors at an academic health center also form the foundation of the institution’s hidden curriculum, or what health professions trainees learn from what they observe and experience rather than what they are overtly taught.

This doesn’t strike me as good news, since recent research shows that the hidden curriculum seems to be promoting rather than eliminating bias (see: Just Read: Sexual and Gender Minority Identity Disclosure: “In the Closet” in Medical School | Ted Eytan, MD). For example this quote:

On my surgery rotation, we saw a male- to-female transgender patient who had “do-it-yourself ” silicone breast implants which had become infected. He [sic] was treated like a freak by the residents and attendings behind closed doors, joking at his [sic] expense. (25-year-old, third-year, lesbian, white, female, U.S. MD student)

I’d like to point out that the researchers in the study above didn’t get the pronouns right themselves when they transcribed the quote, so bias is quite pervasive.

There’s no “T” in this discussion of “LGBT”

I used the quote above to point out that while the topic of the commentary piece is “anti-LGBT” bias, bias against people who are transgender or non-conforming is not mentioned once.

The study of medical student bias did not address this bias (against transgender or gender non-conforming individuals) at all. There is currently no implicit attitudes test for people who are trans or gender non-conforming, but I understand one is being developed. It would have been useful to at least ask about explicit bias for this group, because if we think about the harm to gay and lesbian people in health care, imagine the special harm that people who are transgender face. I diagrammed it out here to assist:

Impact of implicit and explicit bias in the health of transgender persons 54442
Impact of implicit and explicit bias in the health of transgender persons (View on Flickr)

I’m wondering if academic medicine is going to follow, rather than lead, in changing the profession.

In my glass 3/4 fullness, that’s okay, the rest of us are here and we have accountability too. We have to change the health care industry’s position on providing medically necessary care, so that care is provided routinely in the first place.

In addition we need to bring a human understanding to the lives of the people we are serving, which seems quite lacking. That’s what #KPLantern is working to accomplish. Watch this space for updates 🙂 .

Papers cited:

Burke SE, Dovidio JF, Przedworski JM, et al. Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study. Acad. Med. 2015.

Fallin-Bennett K. Implicit Bias Against Sexual Minorities in Medicine: Cycles of Professional Influence and the Role of the Hidden Curriculum. Acad. Med. 2015.


Ted Eytan, MD