A Young Attending’s Perspective on LGBTQIA+ Representation and Inclusivity in Medicine

Interview with Ahmed Salama, MD by Parul Sarwal, MD

Please tell us a little about your background and what drew you toward this cause.

I was privileged to work with minority groups throughout my career – serving in remote areas of Egypt, I worked to help vulnerable migrants and victims of trafficking from several African countries who ended up being stranded in Egypt. When I came to the United States, I worked with the Black community in Harlem, New York . These experiences taught me to respect each patient’s individuality, appreciating their unique journey and the struggles that they faced.

During my residency training, I noticed that pre-exposure prophylaxis, or PrEP, could only be provided through a consult placed to the infection disease team – this is something I believe should be accessible through any primary care provider. I was fortunate to have a wonderful preceptor during this time with whom I worked to develop a strategy for more comprehensive care for our small panel of LGBTQIA+ patients.

Another time, during an emergency department rotation, I had a patient whom the staff were not sure how to address – this was very distressing for the patient. Entering the patient’s room, I realized that they were transgender – in fact, they were my first transgender patient. They were tearful and scared, so I approached them and gently inquired how they identified. This eased them up a bit and, as the conversation flowed, we talked about how far they were along in their hormone therapy and if they had any surgeries. Within the next few minutes, the patient became much more comfortable, allowing me to address their present medical concerns. I then passed this information over to the rest of the team. We were able to change the patient’s emergency department experience from one of uncertainty, vulnerability and fear to something much more like a safe zone where they could feel respected and cared for.

Are there any challenges you faced as a physician during your training years, either back home in Egypt or here in the U.S.?

We all face multiple challenges in our lives – that is what makes life interesting and worth living! I think the biggest challenge for any foreign medical graduate is getting an interview for residency. Unfortunately, many programs use automatic filters for interview selection, which may sometimes miss the unique stories of these applicants.

I believe a significant challenge that minorities may face is microaggression– subtle, hidden and happen on a daily basis. Microaggressions can be more powerful and hurtful than visible aggression. Unfortunately, you might sometimes face patients and coworkers who question your knowledge and skills, based on your sex, orientation, age or skin color instead of your work or level of training.

How can we empower physicians who identify as lgbtqia+ so that there is better representation and inclusivity in medicine? How do you think this would help?

Almost 18% of percent of Gen Z identifies as LGBTQIA+. That is nearly one in six people in that demographic. In light of this fact, I believe reinforcing workplace regulations that protect all minorities would be a major step toward establishing a safe work environment for all. Minority groups are not asking to be favored or receive special treatment – they just want to feel equal. Making sure that every staff member is treated with respect and professionalism, making sure they have access to the same opportunities and career progression, regardless of their individual gender, sexuality or color – these steps would go a long way in achieving these goals. It is not enough to just have this written on websites and pamphlets – it must be incorporated into the fabric and culture of any organization.

Even today, we sometimes see leadership positions among many organizations lacking representation for most minority groups or have representation just for the sake of it without actual advocacy for the minorities in question. True representation is especially important and is needed to break the yokes that shackle our communities and divide us for artificial, nefarious reasons.

Do you think self-identification among LGBTQIA+ physicians in leadership and faculty roles can help normalize workforce diversity among the newer trainees? Are there existing mentorship programs or support groups dedicated to this?

During residency, one of my favorite attending physicians used to be incredibly open about their life and personal experiences as an LGBTQIA+ physician. Seeing them so comfortable in their skin while being well-established made me feel confident myself – as a member of multiple minority groups, not just one. This is just one example of how representation for minorities in leadership positions can be impactful in medical training.

Being different is scary – it makes you feel constantly monitored and endlessly judged for being who you are. Representation and allies in leadership can make you feel safe, present and strong.

The Massachusetts Medical Society has an LGBTQIA+ chapter and before COVID-19 there used to be two major events each year where residents and students would get to connect with their peers as well as established attending physicians, make connections and get advice. The chapter also has a wonderful mentorship program which absolutely needs to be advertised and utilized more.

What aspects or nuances are overlooked by physicians who have limited experience working with these populations?

Affirming your patient’s identity is one of the main things that a health care provider needs to emphasize . A first step is using the patient’s preferred name and pronouns. LGBTQIA+ patients face a lot of trauma and rejection from both family members and society at large. Placing their care in the hands of a doctor involves a feeling of loss of control for any patient and only adds to their vulnerability. So, acknowledging the patient’s orientation, gender and preferred name is a great way to initiate the therapeutic alliance and offer a safe space to patients so that they can work with us to address their concerns, both medical and otherwise.

Some useful resources to start with for this include:

• Collecting Sexual Orientation and Gender Identity in Electronic Health Records available at www.lgbthealtheducation.org/lgbteducation/publications/.

• Do Ask, Do Tell: A Toolkit for Collecting Data on Sexual Orientation and Gender Identity in Clinical Settings: www. doaskdotell.org.

What are the major problems faced by your patients? What are some rapidly implementable solutions to these problems?

I think the LGBTQIA+ community faces a lot of discrimination from society and this extends to health care. Even simple changes such as medical records reflecting the patient’s preferred pronouns and name can help to narrow the gap between patients and physicians.

A fear of the unknown, and of something being different from what one is used to, can become fuel for unconscious microaggression and bias. For many providers, there has not been enough of an emphasis on education about LGBTQIA+ health. Introducing LGBTQIA+ issues in the curriculum in medical schools is particularly important for ensuring that future providers are sensitive to these concerns. At the same time, providing education to the current generation of practitioners is important as well. This could begin with requiring relevant CMEs during license renewal or increasing the number of LGBTQIA+ questions in the board certification and recertification exams. These steps would help present and future providers understand and familiarize with the issues and concerns that these communities face.

I’ve included some resources that touch on this topic below:

• National Transgender Discrimination Survey: www.transequality. org/issues/national-transgender-discrimination-survey

• Discrimination and Health in Massachusetts: A Statewide Survey of Transgender and Gender Nonconforming Adults: www.fenwayhealth.org/documents/ the-fenway-institute/policy-briefs/The- Fenway-Institute-MTPC-Project-Voice- Report-July-2014.pdf.

Are there any resources you would recommend for improving awareness and sensitivity among health careproviders – perhaps a podcast or guide that you favor for quick and easy access?

Fenway Health has lots of resources available for both providers and patients online at www.fenwayhealth.org, as well as publications – for example, there is The Fenway Guide to LGBT Health by the American College of Physicians, available here: www. amazon.com/Fenway-Lesbian-Bisexual-Transgender-Health/dp/1938921003.

Other resources that are available, and this is not an exhaustive list, include:

1. The National LGBT Health Education Center: www.lgbthealtheducation.org 2. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011. Available at www. nap.edu/catalog.php?record_id=13128 3. World Professional Association for Transgender Health Standards of Care: www. wpath.org

4. Center of Excellence for Transgender Health Primary Care Protocols: www.transhealth. ucsf.edu

5. Massachusetts Transgender Political Coalition: https://www.masstpc.org/health-care/

6. Transgender Law Center: Health Care Issues: www.transgenderlawcenter.org/ issues/health

A resource for insurance and billing issues: Human Rights Campaign: Finding Insurance for Transgender-Related Healthcare: www.hrc.org/ resources/finding-insurance-for-transgender-related-healthcare.

Resources for patients on legally changing their name and gender:

1. The Name Change Project from the Transgender Legal Defense and Education 2. Massachusetts Transgender Political Coalition: https://www.masstpc.org 3. Transgender Law Center: www.transgender-lawcenter.org

4. Health Care Rights and Transgender People: www.transequality.org/know-your-rights/ healthcare

There is a lack of representation of these populations in research studies. do you see this gap being bridged in the near future?

As a matter of fact, there has been an increase in LGBTQA+ research in recent years. Unfortunately, there is still a gap in the number of published studies – something which is common with research studies revolving around other minority groups as well. I hope to see an increase in well-designed, published research in the near future.

Dr. Salama is a graduate of Cairo University Faculty of Medicine and trained in Health Care Management at The American University in Cairo, Egypt. He then spent time at the International Organization for Migration, a branch of the United Nations, providing care to vulnerable migrants and victims of trafficking. He did part of his medical training at Harlem Hospital Center in New York City and completed his internal medicine residency at Saint Vincent Hospital in Worcester, before joining Fenway Health in Boston in 2018. With a focus on the LGBTQIA+ community as well as people living with HIV/AIDS, Fenway Health provides comprehensive and equitable access to health, in addition to research, education and advocacy for these communities.

Dr. Parul Sarwal is a PGY-III internal medicine resident at Saint Vincent Hospital.