LGBTQ2S+ diversity: leading and celebrating pride
Derek Puddester, MD
Organizations that actively promote diversity tend to be learning and practice environments of choice, excellence, and innovation. However, despite all our hard work and successful social equity efforts, discrimination still exists in Canadian health care and medical education. Leaders can influence diversity in their organization by taking four urgent actions.
KEY WORDS: diversity, LGBTQ2S+, health care, education, harassment, discrimination, leadership
Diversity promotes leadership success
The Harvard Business Review1 has identified diversity as a source of power, influence, and success that organizations ought to nurture and support. In particular, organizations that actively promote LGBTQ2s+ (lesbian, gay, bisexual, trans, queer, two-spirited, and other) diversity tend to be learning and practice environments of choice, excellence, and innovation. Promoting and enhancing LGBTQ2S+ environments are associated with three practical outcomes: recruitment and retention of top talent, improved quality of service and engagement with critical stakeholders, and enhanced creativity and innovation.
It simply makes good sense for Canada’s health care and education sectors to develop best practices that leverage diversity and inclusion to promote excellent clinical outcomes and outstanding workplace health and wellness. Fostering pride serves all members of the health care sector well and sends a powerful message of inclusion to the communities they serve.
Canadians are rightfully proud: a brief primer on LGBTQ2S+ history
Canada is among the most advanced nations of the world when it comes to human rights. Indigenous peoples held cultural norms and descriptors long before that; the land on which we live, work, and practise is rich in respect for diversity, inclusion, and equity. Canada’s post-colonial population declared same-sex sexual activity legal since 1969 when then Justice Minister Pierre Trudeau declared: “There’s no place for the state in the bedrooms of the nation.” In 1985, section 15 of the Canadian Charter of Rights and Freedoms2 came into effect, protecting sexual minorities from discrimination and, in the same year, the Canadian Criminal Code began to forbid hate-crimes against homosexuals. In 2005, Canada became the fourth nation on earth to allow same-sex marriage with equal rights for adoption quickly following.
Last year, Prime Minister Justin Trudeau, on behalf of the nation, formally apologized to the LGBTQ2S+ community, an apology worth considering carefully:
It is with shame and sorrow and deep regret for the things we have done that I stand here today and say: We were wrong. We apologize. I am sorry. We are sorry... To members of the LGBTQ2 communities, young and old, here in Canada and around the world: You are loved. And we support you. To the trailblazers who have lived and struggled, and to those who have fought so hard to get us to this place: thank you for your courage, and thank you for lending your voices. I hope you look back on all you have done with pride. It is because of your courage that we’re here today, together, and reminding ourselves that we can, and must, do better. For the oppression of the lesbian, gay, bisexual, transgender, queer, and two-spirit communities, we apologize. On behalf of the government, Parliament, and the people of Canada: We were wrong. We are sorry. And we will never let this happen again.3
Canada is, without doubt, a global leader when it comes to human rights and freedoms. But there is much more for us to consider, particularly in health leadership
Contemporary opportunities and challenges for the LGBTQ2S+ community
Last year, the Fondation Jasmin Roy commissioned a report4 on the values, needs, and realities of LGBTQ2S+ people in Canada. One of the first contemporary studies of sexual minorities in the country, the foundation reported many critical findings, including:
Generation and gender matter; there are more self-reported pansexual, asexual, and non-binary people among 15–24-year-olds, particularly women, than any other age group.
Having safe spaces and assertive positive role models is associated with more positive mental and physical health outcomes.
45% of respondents viewed Canadian society as still not open to sexual diversity, particularly in schools and workplaces.
75% of respondents reported bullying in the workplace or educational setting (compared with 45% of members of sexual majorities); sadly, this seems to increase the more open a person chooses to be, suggesting that tolerance, not acceptance, is a strong Canadian value.
A vast majority of respondents identified the health and education sectors as having the greatest capacity to influence ongoing integration, equity, and fairness.
The report also concluded that members of Canada’s LGBTQ2S+ community hold several core values in levels that distinguish them from the greater population: a great desire for fulfilment and authenticity and intentioned practice to find ways to express their true selves, a more developed creativity, which makes them more apt to think outside the box and adapt more easily, and heightened social and environmental awareness. This unique blend of authenticity, adaptivity, and social consciousness suggests that many members of the LGBTQ2S+ medical community have naturally developed leadership skills that can serve the greater good of the profession in Canada. Top
Opening medicine’s closet door
A recent study5 looked at sexual disclosure among sexual and gender minority students in the United States and Canada. Almost a third of them reported choosing to conceal their identity in medical school, with a marked difference between sexual minorities (67.5% out) and gender minorities (34.3% out). On the positive side, the rate of being “out” in medical school appears to have doubled in the past two decades.6 However, much work needs to be done to promote safety, respect, and inclusion for gender minorities. Indeed, almost half of respondents reported a strong fear of discrimination and lack of support, particularly during the matching process and in accessing mentorship and career advice.
In 2016, the British Medical Association7 looked at the experience of lesbian, gay, and bisexual doctors in the National Health Service in detail: 70% of respondents reported being subject to homophobic or biphobic abuse, more than 12% reported at least one form of harassment or abuse and more than 12% suffered some form of discrimination. Only 25% of victims reported maltreatment to their senior leadership, and only 20% chose to seek resolution. This study also found that fewer than 40% described their place of study or practice as encouraging of openness, and 33% chose their specialty based on their belief that it would be LGBTQ2S+ friendly. Finally, respondents identified senior medical or clinical colleagues as the most likely people to initiate harassment or abuse, with the next most likely sources peers, non-clinical managers, patients’ families, and fellow learners.
Tackling such complex issues will require more than legislation, policies and procedures, and codes of conduct. Developing and implementing named, staffed, and funded LGBTQ2S+ inclusion programs is a practical strategy used by many of North America’s largest and most successful enterprises.8 These programs typically advise leadership teams regarding recruitment, professional development, network building, and succession planning. Not only do such programs promote diversity across organizations, they are also associated with improved problem solving, enhanced sustainability and collaboration, and establishment of the organization as an employer of choice. The BMA study7 identified a number of practical action strategies for leaders to consider, such as ensuring that sexual-minority-themed diversity training is mandatory in all training programs, hospitals, and clinics; addressing bullying and intimidation of sexual minorities studying and practising medicine; and taking active part in pride celebrations in their communities.
Leaders may be well-advised to familiarize themselves with emerging best-practices in health care for the LGBTQ2S+ community. Rainbow Health Ontario (www.rainbowhealthontario.ca) is a province-wide program of Sherbourne Health that creates and disseminates clinical and educational resources, conducts research, and informs health policy. Its “safe-space” symbols are exemplars worth posting in any clinical or medical education setting in Canada.
Valuable work has also been done by the Canadian Federation of Medical Students9 on improving health care for LGBTQ2S+ populations. This study offers several practical suggestions to medical schools and teaching centres on promoting collaboration with LGBTQ2S+ peers and professionals, promoting excellence in the care of patients identified as sexual minorities, and ensuring a hate-free practice and learning space. The Royal College of Physicians and Surgeons of Canada10 has an excellent bioethics case module on sexual minorities that leaders and leadership teams may find helpful. Canadian leaders may also find it useful to attend the Gay and Lesbian Medical Association Annual Conference on LGBTQ2S+ Health at some point in their tenure; its focus on professionalism, system-based practice, leadership, and quality improvement may trigger useful insights and generate ideas for implementation at their home sites.
What will you do in your leadership practice?
I have served hundreds, perhaps thousands, of children and youth presenting with suicidal ideation, depression, anxiety, substance use, and trauma-related suffering. A disproportionate number of these patients are either questioning their sexual or gender orientation or have already identified as sexual minorities.11 Even in Canada, with all our hard work and successful social equity efforts, children and youth suffer, some fatally, from homophobia. We must continue to make all sectors of our health care system sensitive, respectful, and welcoming to sexual minorities across the lifespan. This demands ongoing diversity training, monitoring, and quality improvement efforts.
I have also cared for many medical students and physicians over the past 20 years. Every year, I am asked by medical students about how “out” they should be during the CaRMS match. Physician-patients have shared stories about their experiences with discrimination, stereotypes, and lack of positive role models. Many disclose how their careers were curtailed or derailed in the absence of any clear feedback about their performance or productivity, raising the possibility of active discrimination. Several felt forced, often under duress, to participate in “conversion therapy,” i.e., an unscientific and unethical psychological and pharmacological “treatment” designed to reprogram their orientation to heterosexual and/or cis-gendered — a form of medical abuse that has been banned by many provinces and all major medical organizations.12 These are but a few of the tragic stories that our learners and colleagues struggle with in contemporary Canadian medicine. Top
In that spirit, I encourage leaders to consider taking four urgent and important actions:
Canada is, without doubt, a world leader in LGBTQ2S+ diversity. However, there must also be no doubt that hate, both conscious and subconscious, is very much alive. What are you doing to influence diversity in your institution?
1.Hewlett S, Yoshino K. LGBT-inclusive companies are better at 3 big things. Harv Bus Rev 2016;2 Feb. Available: https://tinyurl.com/hp46b9d
2.Equality rights. In Constitution Act, 1982, Part 1: Canadian Charter of Rights and Freedoms, section 15. Ottawa: Government of Canada; 1982. Available: https://tinyurl.com/y8uohkm2
3.Rights of LGBTI persons. Ottawa: Government of Canada; 2018. Available: https://tinyurl.com/yahaa6lh
4.LGBT+ realities survey: the values, needs and realities of LGBT people in Canada in 2017. Montréal: Fondation Jasmin Roy; 2017. Available:
5.Mansh M, White W, Gee-Tong L, Lunn MR, Obedin-Maliver J, Stewart L, et al. Sexual and gender minority identity disclosure during undergraduate medical education: “in the closet” in medical school. Acad Med 2015;90(5):634-44. Available: https://tinyurl.com/y9cztpm8
6.Townsend M, Wallick M, Cambre K. Follow-up survey of support services for lesbian, gay, and bisexual medical students. Acad Med 1996;71:1012-4. DOI: 10.1097/00001888-199609000-00018
7.Experience of lesbian, gay and bisexual doctors in the NHS. London: British Medical Association; 2016. Available: https://tinyurl.com/ycg9cprm
8.Silva C, Warren AK. Building LGBT-inclusive workplaces: engaging organizations and individuals in change. Toronto: Catalyst; 2009.
9.Charles C, Haaland M, Kulkarni A, Webber J. Improving healthcare for LGBTQ populations. Ottawa: Canadian Federation of Medical Students; 2015. Available: https://tinyurl.com/y8r3m59h
10.Murphy TF. 2.4.5. Respect for difference — sexual orientation. Ottawa: Royal College of Physicians and Surgeons of Canada; 2013. Available: https://tinyurl.com/ycbargxf
11.Lesbian, gay, bisexual, trans & queer identified people and mental health. Toronto: Canadian Mental Health Association; 2018. Available: https://tinyurl.com/y94rg9yt
12.Gajdics P. I experienced ‘conversion therapy’ - and it’s time to ban it across Canada. Macleans 2018;6 June. Available: https://tinyurl.com/yarcwllw
Derek Puddester, MD, MEd, FRCPC, PCC, is an associate professor of psychiatry at the University of Ottawa. He is proud partner to his husband and father to their adopted son. He is very grateful to live in a democratic, inclusive, and innovative country that has been incredibly supportive. That said, he won’t quite forget being called a faggot in medical school, listening to homophobic jokes in residency, fabulously checking off the box on a marriage license form as a bride and on a birth certificate as a mother (the other guy checked the only groom and father boxes). He is incredibly proud of his son, who sees his family as no different from any other. Top
This article has been peer reviewed.
Web-based resources for Canadian Leaders
Gay and Lesbian Medical Association: www.glaad.org
Association of LGBTQ Psychiatrists: www.aglp.org
Gay and Lesbian Association of Doctors and Dentists: www.gladd.co.uk
Rainbow Health Ontario:
Royal College of Physicians and Surgeons of Canada, 2.4.5. Respect for difference – sexual orientation:
College of Family Physicians of Canada, Resources: Gay and lesbian health: https://tinyurl.com/yayct7u2