Healthcare workplace disclosure of LGBT identity: Survey of Physician Assistants Introduction Lesbian, gay, bisexual and transgender (LGBT) health care providers have historically faced discrimination at work even after professional group policy statements became more inclusive. Attitude, policy, and workplace culture are key indicators of work inclusivity. Attitude : Surveys of doctors’ & nurses’ attitude toward LGBT providers: 1980s 1,2 : Lesbians are molesters, unfit to provide nursing care Should deny medical school admission Refuse to refer, especially to gay psychiatrist, pediatrician Surgery most homophobic, would leave practice 1990s 3-7 : Improved attitudes, surgeons still most homophobic LGBT providers afraid of and experiencing job loss, loss of patients, harassment, feeling unequal Lesbians offered 12% fewer job interviews; gay or bisexual men earn least No attitude assessment of health providers has been conducted relating specifically to transgender providers or patients. Policy: “By encouraging diversity in their physician workforces, physician groups and health care systems can help ensure their ability to deliver culturally competent care to all segments of their patient populations.” – AAFP, In 1993, the American Medical Association paved the way for other professional health groups to prohibit discrimination on the basis of sexual orientation or gender identity. Furthermore, 21 states now include ‘sexual orientation’ and 15 states include both ‘sexual orientation’ and ‘gender identity’ in their current Equal Employment Opportunity (EEO) protections. In a 2010 EEO survey of 178 U.S. medical facilities, 93% included ‘sexual orientation’ and 52% included ‘gender identity’ in their non-discrimination policy. 9 Culture: “In a single day a gay doctor might ‘pass [as straight]’ to avoid homophobia but also reveal a homosexual identity to show affinity with a gay patient or as a desexualization strategy.” – BMJ, Hiding an LGBT status or other important identity markers negatively impacts stress levels, affect, productivity, and job satisfaction. 11 But, disclosure in a workplace with inclusive policies results in higher job satisfaction, performance, and lower job anxiety. 12 LGBT personnel fully ‘out’ in a medical facility more likely feel more included by peers, supported by top management, and are more confident reporting harassment. 13 The purpose of this study is to describe current workplace attitudes and culture, and to evaluate knowledge of workplace and professional policies regarding LGBT discrimination. Tiffany A. Ewton, PA-C, MSPAS, MPH 1 & Elena O. Lingas, DrPH, MPH 1,2 1 College of Education and Health Sciences, Touro University - California, Vallejo, CA School of Pharmacy, University of California San Francisco, San Francisco, CA  Cross-sectional, anonymous survey; convenience sample of 175 Touro University California Alumni Physician Assistants (PAs) across U.S.  26 validated survey questions (22 Likert-scale, 4 multiple choice); 1 open-ended question  Inclusion criteria: PAs currently working or employed as a Physician Assistant in the last 3 months.  Chi-square tests with Yates correction, Odds Ratio and Fisher Exact Test were used with dependent variables and demographic (predictor) variables to identify potential predictors of respondent answers and identify associations between policy knowledge and workplace culture and attitude. Methods Discussion To our knowledge, this is the first study assessing LGBT issues among Physician Assistants and the first surveying attitudes among providers since PAs are major stakeholders in the future of medicine with an expected growth rate of 39%, which is much faster than the average for all occupations. 14 Unlike previous studies, this sample strongly agreed it was acceptable for LGBT persons to practice medicine. Nonetheless, age, specialty, and gender continue to be important demographics related to an inclusive LGBT workplace. Policy awareness is associated with inclusivity and confidence reporting harassment.  Future Research  Delineate LGB and Transgender disclosure  Study disclosure outcomes with patients The first and only U.S. study done in 2007 found that 30% of respondents would change providers and 35% would leave the practice if they found out their provider was gay or lesbian. 15  Recommendations  Increased LGBT provider disclosure, advocate LGBT work ‘caucus’ at larger facilities  Conduct EEO/facility policy reviews  Top management support  Promote policy through training, workshops, feedback, modify forms re: marital status, gender  CME credit, include LGBT issues in medical curriculum Results The response rate was 33%; 58 surveys were included in the study. Respondents were primarily female, heterosexual, years old and worked in suburban, outpatient settings.  Attitude: Physician assistants had an overwhelmingly positive attitude toward LGBT providers: “sexual orientation should have no bearing on whether I think they are a good clinician.”  Policy: The majority of respondents were not aware of relevant policy statements from professional organizations (63%) nor at the institutions they worked (69-89%). Those most aware of policy statements worked in metropolitan, inpatient settings, while those least aware worked in rural settings. A significant association existed between policy awareness and LGBT inclusivity (p<0.025) and confidence reporting anti-gay harassment (P = 0.017). In fact, 22% of respondents did not feel confident reporting anti-gay harassment.  Culture: Disclosure generally would not impact how well providers work, train, get along with and trust each other. Over 80% report high levels of comfort with LGBT persons, but 18% stated that sexual orientation/gender identity influences how they interact with colleagues. One respondent shared “it would be risky to be ‘completely out’ regardless of laws or policies…discrimination would still exist and just be more subtle.”  21% agreed or were uncertain whether they would get fired or risk promotion if they disclosed an LGBT identity. Over half were not sure if management was supportive of LGBT personnel. Figure 1. PAs less than 30 years old were three times more likely to believe the workplace was not inclusive of LGBT staff as compared to older PAs (χ 2 = 4.16, p<0.05, OR = 3.43). Figure 2. PAs in surgical settings most frequently believe their workplaces are not inclusive of LGBT staff (P = FET). References 6. Smith, D., & Mathews, W. Physicians’ attitudes toward homosexuality and HIV: Survey of a California medical society- revisited (PATHH-II). Journal of Homosexuality, 2007; 52(3-4): Weichselbaumer, D. Sexual orientation discrimination in hiring. Labour Economics, 2003; 10: American Academy of Family Physicians. Compendium of AAFP positions on selected health issues: Discrimination, physician,1996. Retrieved from 9. Delpercio, A. Healthcare Equality Index The Human Rights Campaign Foundation, 2010; Washington, D.C. 10. Hughes, D. Disclosure of sexual preferences and lesbian, gay, and bisexual practitioners. British Medical Journal, 2004; 328(7450): Ragins, B., Singh, R., & Cornwell, J. Making the invisible visible: Fear and disclosure of sexual orientation at work. Journal of Applied Psychology, 2007; 86(6): Roberge, M., & van Dick, R. Recognizing the benefits of diversity: When and how does diversity increase group performance? Human Resource Management Review, 2010; 20: Van Vliet, A., & Swiszczowksi, L. Stonewall Top 100 Employers 2010: The Workplace Equality Index. Stonewall, the lesbian, gay and bisexual charity, London, England. Retrieved from http: Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Edition, Physician Assistants. 15. Lee, R., Melhado, T., Chacko, K., White, K., Huebschmann, A., Crane, L. The dilemma of disclosure: Patient perspectives on gay and lesbian providers. Journal of General Internal Medicine, 2007; 23(2): Results  Gender was a significant predictor of perceived patient loss (p<0.025). Overall, PAs were split in their estimation of patient loss after provider disclosure. States one PA, “some patients are uncomfortable with a gay nurse…it does involve a bit of education on the patient’s behalf; however, sometimes patients can be quite stubborn and continue to complain.” Figure 3. Male PAs were over five times more likely than females to agree that patients would leave a practice after disclosure (χ 2 = 5.88, p<0.025, OR = 6.0). References 1. 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