[Skip to Content]
[Skip to Content Landing]

Experiences of LGBTQ+ Residents in US General Surgery Training Programs

Educational Objective To determine the national prevalence of mistreatment and poor well-being for lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) surgery residents compared with their non-LGBTQ+ peers.
1 Credit CME
Key Points

Question  How do rates of self-reported mistreatment and sources of mistreatment vary between lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) general surgery residents and their non-LGBTQ+ peers?

Findings  In this survey study of 6381 surgical residents, LGBTQ+ general surgery residents reported higher rates of discrimination, harassment, and bullying than their non-LGBTQ+ peers, with attending surgeons as the most common source. Despite reporting similar career satisfaction, LGBTQ+ residents were twice as likely to consider leaving their program and/or have thoughts of suicide.

Meaning  Mistreatment is a common experience for LGBTQ+ general surgery residents, and multifaceted interventions are necessary to develop safer and more inclusive learning environments.

Abstract

Importance  Previous studies have shown high rates of mistreatment among US general surgery residents, leading to poor well-being. Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) residents represent a high-risk group for mistreatment; however, their experience in general surgery programs is largely unexplored.

Objective  To determine the national prevalence of mistreatment and poor well-being for LGBTQ+ surgery residents compared with their non-LGBTQ+ peers.

Design, Setting, and Participants  A voluntary, anonymous survey adapting validated survey instruments was administered to all clinically active general surgery residents training in Accreditation Council for Graduate Medical Education–accredited general surgery programs following the 2019 American Board of Surgery In-Training Examination.

Main Outcomes and Measures  Self-reported mistreatment, sources of mistreatment, perceptions of learning environment, career satisfaction, burnout, thoughts of attrition, and suicidality. The associations between LGBTQ+ status and (1) mistreatment, (2) burnout, (3) thoughts of attrition, and (4) suicidality were examined using multivariable regression models, accounting for interactions between gender and LGBTQ+ identity.

Results  A total of 6956 clinically active residents completed the survey (85.6% response rate). Of 6381 respondents included in this analysis, 305 respondents (4.8%) identified as LGBTQ+ and 6076 (95.2%) as non-LGBTQ+. Discrimination was reported among 161 LGBTQ+ respondents (59.2%) vs 2187 non-LGBTQ+ respondents (42.3%; P < .001); sexual harassment, 131 (47.5%) vs 1551 (29.3%; P < .001); and bullying, 220 (74.8%) vs 3730 (66.9%; P = .005); attending surgeons were the most common overall source. Compared with non-LGBTQ+ men, LGBTQ+ residents were more likely to report discrimination (men: odds ratio [OR], 2.57; 95% CI, 1.78-3.72; women: OR, 25.30; 95% CI, 16.51-38.79), sexual harassment (men: OR, 2.04; 95% CI, 1.39-2.99; women: OR, 5.72; 95% CI, 4.09-8.01), and bullying (men: OR, 1.51; 95% CI, 1.07-2.12; women: OR, 2.00; 95% CI, 1.37-2.91). LGBTQ+ residents reported similar perceptions of the learning environment, career satisfaction, and burnout (OR, 1.22; 95% CI, 0.97-1.52) but had more frequent considerations of leaving their program (OR, 2.04; 95% CI, 1.52-2.74) and suicide (OR, 1.95; 95% CI, 1.26-3.04). This increased risk of suicidality was eliminated after adjusting for mistreatment (OR, 1.47; 95% CI, 0.90-2.39).

Conclusions and Relevance  Mistreatment is a common experience for LGBTQ+ surgery residents, with attending surgeons being the most common overall source. Increased suicidality among LGBTQ+ surgery residents is associated with this mistreatment. Multifaceted interventions are necessary to develop safer and more inclusive learning environments.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: August 10, 2021.

Published Online: October 20, 2021. doi:10.1001/jamasurg.2021.5246

Corresponding Author: Yue-Yung Hu, MD, MPH, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL 60611 (yue-yung.hu@northwestern.edu).

Author Contributions: Dr Hu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Mr Heiderscheit and Dr Schlick contributed equally to this work.

Study concept and design: Heiderscheit, Ellis, Irizarry, Eng, Hoyt, Bilimoria, Hu.

Acquisition, analysis, or interpretation of data: Heiderscheit, Schlick, Ellis, Cheung, Amortegui, Eng, Sosa, Hoyt, Buyske, Nasca, Bilimoria, Hu.

Drafting of the manuscript: Heiderscheit, Hoyt, Hu.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Heiderscheit, Schlick, Eng, Bilimoria, Hu.

Obtained funding: Nasca, Bilimoria, Hu.

Administrative, technical, or material support: Ellis, Amortegui, Hoyt, Buyske, Nasca, Hu.

Study supervision: Ellis, Cheung, Sosa, Hoyt, Bilimoria, Hu.

Conflict of Interest Disclosures: Dr Sosa has received institutional research funding from Exelixis and Eli Lilly and is a member of the data monitoring committee of the Medullary Thyroid Cancer Consortium Registry, which is supported by GlaxoSmithKline, NovoNordisk, AstraZeneca, and Eli Lilly. Drs Bilimoria and Hu have received grants for serving as co–principal investigators of the SECOND trial from the American College of Surgeons and the Accreditation Council for Graduate Medical Education as well as nonfinancial support from the American Board of Surgery. No other disclosures were reported.

Funding/Support: Funding for this work was provided by the Accreditation Council for Graduate Medical Education and American College of Surgeons. The American Board of Surgery provided in-kind support. Dr Ellis was supported by a postdoctoral research fellowship from the Agency for Healthcare Research and Quality (grant 5T32HS000078).

Role of the Funder/Sponsor: The funding agencies had no role in the design and conduct of the study; analysis of data; preparation or review of the manuscript; and decision to submit the manuscript for publication. Authors affiliated with funding agencies were involved in the collection and interpretation of the data and review and approval of the manuscript.

Disclaimer: The views expressed in this work represent those of the authors only.

Meeting Information: This paper was presented at the Academic Surgical Congress; February 4 and 6, 2020; Orlando, Florida.

References
1.
James  SE , Herman  JL , Rankin  S , Keisling  M , Mottet  L , Anafi  M .  The Report of the 2015 US Transgender Survey. National Center for Transgender Equality; 2016.
2.
Sears  B , Mallory  C .  Documented Evidence of Employment Discrimination & Its Effects on LGBT People. The Williams Institute, UCLA School of Law; 2011.
3.
Bostock v Clayton County, 590 US ___ (2020).
4.
Turban  JL .  Medical training in the closet.   N Engl J Med. 2019;381(14):1305-1307. doi:10.1056/NEJMp1905829PubMedGoogle ScholarCrossref
5.
Cook  AF , Arora  VM , Rasinski  KA , Curlin  FA , Yoon  JD .  The prevalence of medical student mistreatment and its association with burnout.   Acad Med. 2014;89(5):749-754. doi:10.1097/ACM.0000000000000204PubMedGoogle ScholarCrossref
6.
Hu  YY , Ellis  RJ , Hewitt  DB ,  et al.  Discrimination, abuse, harassment, and burnout in surgical residency training.   N Engl J Med. 2019;381(18):1741-1752. doi:10.1056/NEJMsa1903759PubMedGoogle ScholarCrossref
7.
Kemper  KJ , Schwartz  A ; Pediatric Resident Burnout-Resilience Study Consortium.  Bullying, discrimination, sexual harassment, and physical violence: common and associated with burnout in pediatric residents.   Acad Pediatr. 2020;20(7):991-997. doi:10.1016/j.acap.2020.02.023PubMedGoogle ScholarCrossref
8.
West  CP , Shanafelt  TD , Kolars  JC .  Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents.   JAMA. 2011;306(9):952-960. doi:10.1001/jama.2011.1247PubMedGoogle ScholarCrossref
9.
Dewa  CS , Loong  D , Bonato  S , Trojanowski  L .  The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review.   BMJ Open. 2017;7(6):e015141. doi:10.1136/bmjopen-2016-015141PubMedGoogle Scholar
10.
Han  S , Shanafelt  TD , Sinsky  CA ,  et al.  Estimating the attributable cost of physician burnout in the United States.   Ann Intern Med. 2019;170(11):784-790. doi:10.7326/M18-1422PubMedGoogle ScholarCrossref
11.
Yuce  TK , Turner  PL , Glass  C ,  et al.  National evaluation of racial/ethnic discrimination in US surgical residency programs.   JAMA Surg. 2020;155(6):526-528. doi:10.1001/jamasurg.2020.0260PubMedGoogle ScholarCrossref
12.
Zhang  LM , Ellis  RJ , Ma  M ,  et al.  Prevalence, types, and sources of bullying reported by US general surgery residents in 2019.   JAMA. 2020;323(20):2093-2095. doi:10.1001/jama.2020.2901PubMedGoogle ScholarCrossref
13.
Dyrbye  LN , Burke  SE , Hardeman  RR ,  et al.  Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians.   JAMA. 2018;320(11):1114-1130. doi:10.1001/jama.2018.12615PubMedGoogle ScholarCrossref
14.
Fnais  N , Soobiah  C , Chen  MH ,  et al.  Harassment and discrimination in medical training: a systematic review and meta-analysis.   Acad Med. 2014;89(5):817-827. doi:10.1097/ACM.0000000000000200PubMedGoogle ScholarCrossref
15.
Lee  KP , Kelz  RR , Dubé  B , Morris  JB .  Attitude and perceptions of the other underrepresented minority in surgery.   J Surg Educ. 2014;71(6):e47-e52. doi:10.1016/j.jsurg.2014.05.008PubMedGoogle ScholarCrossref
16.
Bilimoria  KY , Chung  JW , Hedges  LV ,  et al.  National cluster-randomized trial of duty-hour flexibility in surgical training.   N Engl J Med. 2016;374(8):713-727. doi:10.1056/NEJMoa1515724PubMedGoogle ScholarCrossref
17.
Bilimoria  KY , Chung  JW , Hedges  LV ,  et al.  Development of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial protocol: a national cluster-randomized trial of resident duty hour policies.   JAMA Surg. 2016;151(3):273-281. doi:10.1001/jamasurg.2015.4990PubMedGoogle ScholarCrossref
18.
Conway  PM , Høgh  A , Nabe-Nielsen  K ,  et al.  Optimal cut-off points for the Short-Negative Act Questionnaire and their association with depressive symptoms and diagnosis of depression.   Ann Work Expo Health. 2018;62(3):281-294. doi:10.1093/annweh/wxx105PubMedGoogle ScholarCrossref
19.
Cook  DJ , Liutkus  JF , Risdon  CL , Griffith  LE , Guyatt  GH , Walter  SD .  Residents’ experiences of abuse, discrimination and sexual harassment during residency training. McMaster University Residency Training Programs.   CMAJ. 1996;154(11):1657-1665.PubMedGoogle Scholar
20.
Crebbin  W , Campbell  G , Hillis  DA , Watters  DA .  Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia.   ANZ J Surg. 2015;85(12):905-909. doi:10.1111/ans.13363PubMedGoogle ScholarCrossref
21.
Fitzgerald  LF , Gelfand  MJ , Drasgow  F .  Measuring sexual harassment: theoretical and psychometric advances.   Basic Appl Soc Psych. 1995;17(4):425-445. doi:10.1207/s15324834basp1704_2Google ScholarCrossref
22.
Badgett  MVL , Baker  KE , Conron  K ,  et al; The GenIUSS Group.  Best Practices for Asking Questions to Identify Transgender and Other Gender Minority Respondents on Population-Based Surveys. The Williams Institute; 2014.
23.
Jagsi  R , Griffith  KA , Jones  R , Perumalswami  CR , Ubel  P , Stewart  A .  Sexual harassment and discrimination experiences of academic medical faculty.   JAMA. 2016;315(19):2120-2121. doi:10.1001/jama.2016.2188PubMedGoogle ScholarCrossref
24.
Langford  PH .  Measuring organisational climate and employee engagement: evidence for a 7 Ps model of work practices and outcomes.   Aust J Psychol. 2009;61(4):185-198. doi:10.1080/00049530802579481Google ScholarCrossref
25.
Nagata-Kobayashi  S , Maeno  T , Yoshizu  M , Shimbo  T .  Universal problems during residency: abuse and harassment.   Med Educ. 2009;43(7):628-636. doi:10.1111/j.1365-2923.2009.03388.xPubMedGoogle ScholarCrossref
26.
Richman  JA , Flaherty  JA , Rospenda  KM .  Perceived workplace harassment experiences and problem drinking among physicians: broadening the stress/alienation paradigm.   Addiction. 1996;91(3):391-403. doi:10.1111/j.1360-0443.1996.tb02288.xPubMedGoogle ScholarCrossref
27.
Shanafelt  TD , Balch  CM , Dyrbye  L ,  et al.  Special report: suicidal ideation among American surgeons.   Arch Surg. 2011;146(1):54-62. doi:10.1001/archsurg.2010.292PubMedGoogle ScholarCrossref
28.
Shanafelt  TD , Noseworthy  JH .  Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.   Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/j.mayocp.2016.10.004PubMedGoogle ScholarCrossref
29.
Sullivan  MC , Yeo  H , Roman  SA ,  et al.  Surgical residency and attrition: defining the individual and programmatic factors predictive of trainee losses.   J Am Coll Surg. 2013;216(3):461-471. doi:10.1016/j.jamcollsurg.2012.11.005PubMedGoogle ScholarCrossref
30.
Yang  AD , Chung  JW , Dahlke  AR ,  et al.  Differences in resident perceptions by postgraduate year of duty hour policies: an analysis from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial.   J Am Coll Surg. 2017;224(2):103-112. doi:10.1016/j.jamcollsurg.2016.10.045PubMedGoogle ScholarCrossref
31.
Leiter  M , Maslach  C . Areas of work-life: a structured approach to organizational predictors of job burnout. In: Perrewe  PL , Ganster  DC , eds.  Research in Occupational Stress and Well-being. Emerald Group Publishing Limited; 2003:91-134.
32.
Zhang  LM , Cheung  EO , Eng  JS ,  et al.  Development of a conceptual model for understanding the learning environment and surgical resident well-being.   Am J Surg. 2021;221(2):323-330. doi:10.1016/j.amjsurg.2020.10.026PubMedGoogle ScholarCrossref
33.
Carr  PL , Ash  AS , Friedman  RH ,  et al.  Faculty perceptions of gender discrimination and sexual harassment in academic medicine.   Ann Intern Med. 2000;132(11):889-896. doi:10.7326/0003-4819-132-11-200006060-00007PubMedGoogle ScholarCrossref
34.
Boge  LA , Dos Santos  C , Moreno-Walton  LA , Cubeddu  LX , Farcy  DA .  The relationship between physician/nurse gender and patients’ correct identification of health care professional roles in the emergency department.   J Womens Health (Larchmt). 2019;28(7):961-964. doi:10.1089/jwh.2018.7571PubMedGoogle ScholarCrossref
35.
Stark  S , Chernyshenko  OS , Lancaster  AR , Drasgow  F , Fitzgerald  LF .  Toward standardized measurement of sexual harassment: shortening the SEQ-DoD using item response theory.   Mil Psychol. 2002;14(1):49-72. doi:10.1207/S15327876MP1401_03Google ScholarCrossref
36.
Sandler  BJ , Tackett  JJ , Longo  WE , Yoo  PS .  Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors.   J Am Coll Surg. 2016;222(6):1090-1096. doi:10.1016/j.jamcollsurg.2015.12.004PubMedGoogle ScholarCrossref
37.
Rangel  EL , Smink  DS , Castillo-Angeles  M ,  et al.  Pregnancy and motherhood during surgical training.   JAMA Surg. 2018;153(7):644-652. doi:10.1001/jamasurg.2018.0153PubMedGoogle ScholarCrossref
38.
Schlick  CJR , Ellis  RJ , Etkin  CD ,  et al.  Experiences of gender discrimination and sexual harassment among residents in general surgery programs across the US.   JAMA Surg. Published online July 28, 2021. doi:10.1001/jamasurg.2021.3195PubMedGoogle Scholar
39.
Eliason  MJ , Dibble  SL , Robertson  PA .  Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace.   J Homosex. 2011;58(10):1355-1371. doi:10.1080/00918369.2011.614902PubMedGoogle ScholarCrossref
40.
Badgett  MVL , Durso  LE , Kastanis  A , Mallory  C .  The Business Impact of LGBT-Supportive Workplace Policies. The Williams Institute; 2013.
41.
Yaghmour  NA , Brigham  TP , Richter  T ,  et al.  Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment.   Acad Med. 2017;92(7):976-983. doi:10.1097/ACM.0000000000001736PubMedGoogle ScholarCrossref
42.
Pachankis  JE .  The psychological implications of concealing a stigma: a cognitive-affective-behavioral model.   Psychol Bull. 2007;133(2):328-345. doi:10.1037/0033-2909.133.2.328PubMedGoogle ScholarCrossref
43.
Gonzales  G , Ehrenfeld  JM .  The association between state policy environments and self-rated health disparities for sexual minorities in the United States.   Int J Environ Res Public Health. 2018;15(6):E1136. doi:10.3390/ijerph15061136PubMedGoogle Scholar
44.
Feeney  BC , Collins  NL .  A new look at social support: a theoretical perspective on thriving through relationships.   Pers Soc Psychol Rev. 2015;19(2):113-147. doi:10.1177/1088868314544222PubMedGoogle ScholarCrossref
45.
Aggarwal  R , Brenner  AM .  #MeToo: the role and power of bystanders (aka us).   Acad Psychiatry. 2020;44(1):5-10. doi:10.1007/s40596-019-01173-0PubMedGoogle ScholarCrossref
46.
Ryan  AM , Wessel  JL .  Sexual orientation harassment in the workplace: when do observers intervene?   J Organ Behav. 2012;33(4):488-509. doi:10.1002/job.765Google ScholarCrossref
47.
Snowdon  S . Recommendations for enhancing the climate for LGBT students and employees in health professional schools: a GLMA white paper. Accessed September 17, 2021. http://www.glma.org/_data/n_0001/resources/live/Recommendations%20for%20Enhancing%20LGBT%20Climate%20in%20Health%20Professional%20Schools.pdf
48.
Shields  GS , Sazma  MA , McCullough  AM , Yonelinas  AP .  The effects of acute stress on episodic memory: a meta-analysis and integrative review.   Psychol Bull. 2017;143(6):636-675. doi:10.1037/bul0000100PubMedGoogle ScholarCrossref
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close