This study provides a comprehensive characterization of attitudes toward gay men endorsed by students at a large U.S. medical school comprising a diverse student body. The majority of respondents were affirming of gay men and same-sex behavior. Overt disgust towards gay men was infrequent. However, most questions in the “behavior” scale had wide standard deviations suggestive of diverse attitudes. Substantial minorities of students expressed disgust to gay male behavior that correlated moderately with negative attitudes regarding civil rights and normative notions of male toughness. The results of this study reveal the need for assessing and revising current methods of or approaches to instruction in the care of sexual minorities.
Good doctor-patient relationships require trust and mutual respect. Clinical heterosexism, the assumption that the patient is heterosexual, interferes with the formation and maintenance of a healthy doctor-patient relationship, and important opportunities to engage a gay patient in healthful behaviors are likely to be missed [27
]. Though typically covert, biases such as those reported in this study can lead to subconscious actions. Prejudices have been shown to result in overt antigay behaviors [28
]. More worryingly, disgust toward gay men experienced by health care providers and respondents to our survey is particularly powerful [29
]. Such visceral responses are likely to undermine quality of care and reinforce stigma.
Homosexuality has been considered to be “a natural difference, like left-handedness.” [30
] However, when specifically asked, nearly one-third of medical students responded either negatively or ambivalently to the statement that male homosexuality is as natural a form of expression as heterosexuality. Our study demonstrates that some medical students find gay men and their behavior confusing. Studies have demonstrated the direct relationship between implicit and explicit measures of bias toward gay men that is most apparent among heterosexual men and based upon affective responses. Our study measured explicit bias. By its nature, unconscious bias goes unrecognized by people who see themselves as tolerant or at least hoping to “extract conformity with social norms.” [31
] Though individuals may feel “comfortable” with LGBT issues in theory, when they are explicitly presented them, it becomes disconcerting. Educational modules must therefore explicitly endorse the “normality” of homosexuality.
Our study has several strengths. The survey had a high response rate. Despite this, it is possible that those who did not respond are less comfortable with discussion of sexually and prejudice. Our results were consistent with a related study on exposure to LGBT patients conducted among medical students at the New York University School of Medicine [32
]. Our study sought additional components of beliefs about gay men to more comprehensively evaluate for the presence of bias. Since California is historically politically liberal, it is likely that a similar survey administered in a more conservative part of the country would find a higher prevalence of prejudicial beliefs. Although the University of California, Davis, School of Medicine, is a committed leader in the inclusion of LGBT issues in the curriculum, a lack of acceptance was found among a significant minority of students, thus highlighting the need to help students recognize and understand their own biases for better communicating in a socially- and culturally-appropriate manner with patients from all sexual orientations, races, ethnicities, and so forth. There was a discrepancy between the percent of students that let the school administration know they identified as LGBT (2.3%) and those who identified as such on the survey (5.3%). This underscores the notion that some students are more comfortable with their sexuality while others feel less forthcoming.
Several limitations should be considered when interpreting our findings. The results represent the views of a single medical school student population within the United States to a single stigmatized group. Our study did not evaluate a respondent’s
year in medical training to determine whether attitudes changed with increased amount of time in school. Most medical students are in their twenties, making conclusive statements regarding age and negative attitudes more difficult because the range is more narrow. The cross-sectional and correlational analyses preclude a broader generalization of how medical students in the United States and globally frame negative responses to gay men, and does not characterize their perceptions of lesbians, bisexual or transgender people, or intersex persons. Given that many questions used the word “disgust,” it is possible that even higher rates of bias would be seen if less extreme words such as “discomfort” or “unease” were used instead. In this study, we utilized explicit measures of bias. The questions exposed self-reported bias, which may not correspond to privately held beliefs. Some individuals may exhibit negative reactions to those different from themselves, but will not divulge this information when directly asked [34
]. Future work can augment this study to assess the relationship to beliefs that are explored through measurement of implicit measures to determine if there are discrepancies among students in higher education, where disguise of bias may be more apparent [35
Efforts to address prejudices, among other biases that may be covert, are needed to facilitate open discussions and thereby improve care. Previous research has shown that individuals who believe that homosexuality is “congenital” exhibit more positive attitudes toward sexual minorities. Labeling or constructing groups as different in speech, appearance, or socio-cultural background has deleterious effects on the ability to provide sound and culturally-adept treatment [36
]. Several innovative workshops have been developed that help to address the rich needs of this underserved group beyond sexual practice and pathology but more are needed [39
]. This includes tackling concepts of gender roles and confronting patient issues that would otherwise be unspoken.
We show that negative attitudes toward gay behavior were linked to more normative views on male gender roles, or how men are expected to act. Our study advances medical education for gay men by supporting the need for lectures to discuss masculinity due to documented correlations with heterosexism [40
]. Changing medical student attitudes cannot be done in isolation and should be a component of a comprehensive organizational approach that involves leadership and faculty role models to shape the culture throughout all the clinical and academic venues encountered by students.
There is considerable evidence that competency in dealing with populations experiencing health disparities require systematic development of a competency-based curriculum throughout all of medical school. Developing a comprehensive four-year curriculum around LGBT health is a critical first step. However, even the presence of LGBT patients and lectures disseminating facts may not adequately address underlying biases. More interactive methods that incorporate diverse fields of study, including anthropology and literature, could be used to invoke empathy. Incorporation of interdisciplinary efforts in current educational modules may attenuate biases seen not only towards sexual minorities, but the underserved from various ethnic and social backgrounds.