Experiences of Transgender and Nonbinary Physicians During Medical Residency Program Application

A transgender person's gender identity differs from sex assigned at birth, and nonbinary people have a gender identity outside the traditional male/female binary.^1,2  US prevalence of transgender and nonbinary (TNB) people is 0.3 to 2.7%,^3–5  and the Association of American Medical Colleges reports rising matriculation of TNB medical students, from 596 in 2016 to 1010 in 2018.⁶  Thus, increasing numbers of TNB students are applying for residency positions.

In a 2019 report, 60% of physicians did not disclose their gender identity to residency programs due to lack of perceived support, discrimination fears, or not yet understanding themselves as TNB.²  About half of medical students do not disclose their gender identity during medical school.⁷ TNB applicants are vulnerable to discrimination if they have not legally changed their name and gender, or do not adopt societally expected gender expressions.^1,2  A TNB student's name could differ on prior academic work, inadvertently forcing gender identity disclosure during residency application.

Studies have described discriminatory, prohibited behaviors during the application process, including gender.^8–10  A 2012 survey of family medicine program directors (PDs; n = 172) reported that 39.8% had minor concerns and 8.5% had major concerns when ranking TNB applicants. Five PDs (2.8%) would not rank qualified TNB applicants.¹¹ Literature examining experiences of TNB people in medical training and practice is limited to one small study (36 medical students, residents, and attendings).² 

It is likely that discriminatory practices still exist, although programs may also have supportive mechanisms in place. In order to increase recruitment of TNB applicants, it is important to understand the current landscape. Therefore, the aim of this study is to better characterize experiences and needs of TNB individuals during the residency application process.

An online survey using a non-experimental design was administered from August to October 2019 via Research Electronic Data Capture.¹⁴  The survey questions were developed by the authors (2 are transgender) and informed by findings from an academic conference panel.¹  The survey consisted of 8 Likert-type, 15 multiple-choice, and 5 free-text responses (provided as online supplementary data). No directly identifying information was collected, and indirectly identifying questions (eg, subspecialty) were optional or omitted in the analysis. The survey was reviewed for comprehension by an external transgender clinician. No further testing was performed.

All TNB persons who were medical residents or recent graduates (< 3 years) of US programs were eligible to complete the survey and were recruited through social media (eg, TNB health care Facebook group), TNB professional groups (eg, World Professional Association for Transgender Health), and snowball sampling. Participants received a $10 gift card.

Quantitative responses were analyzed by descriptive statistics. Survey response rate could not be calculated due to the hidden population and unknown respondent denominator. Survey responses were collapsed for analysis. Free-text responses were coded into themes by the authors using an inductive, iterative process, which compared data within the project and across other literature.¹²  Data were coded individually by authors, compared, and disagreements were resolved by consensus.¹³ 

This study received approval from Memorial Medical Center Institutional Review Board (IRB) and Colorado Multiple IRB.

Twenty-seven respondents completed surveys; one respondent identified as cisgender was excluded. Respondent demographics are summarized in Table 1. The majority of respondents disclosed their gender identity in some way during residency application (n = 17 of 26, 65.4%). Approximately one-third of applicants (n = 8, 30.8%) disclosed their gender identity universally, one-third some of the time (n = 9, 34.6%), and another third never disclosed (n = 9, 34.6%). No respondents reported gender identity disclosure without their permission. Some participants described concern for negative repercussions with gender identity disclosure: “I did not disclose my gender identity if I thought it would affect my match.”

During residency interviews, similar numbers of respondents indicated they could discuss their gender identity safely (n = 6 of 26, 23.1%), as those who could not (n = 7, 26.9%). Eleven respondents (42.3%) had mixed experiences, reporting they could safely discuss gender identity with some programs, but not others. One participant described this as reluctance from interviewers: “I had some interviewers not even mention my identity…it felt like they avoided it.”

Twelve respondents (46.2%) stated affirming pronouns and name were always used during their application processes. More than one-third (n = 9 of 26, 34.6%) reported their pronouns/name were sometimes used, 2 (7.7%) stated they were never used, and 3 (11.5%) chose “other.” One respondent explained, “I never asked them to use they/them for me because I did not feel safe being out as nonbinary.”

Nearly half of respondents (12 of 26, 46.2%) agreed or strongly agreed they were treated differently in the application cycle due to gender identity, 7 disagreed (26.9%), and 7 were neutral (26.9%). Regarding program ranking, 7 respondents (26.9%) perceived they were ranked lower than their qualifications due to gender identity. Six respondents (23.1%) felt their gender identity helped them match more successfully, and the remainder (n = 11, 42.3%) felt gender identity did not affect their match.

Themes from respondents' free-text recommendations (Table 2) for residency programs include: (1) adopt gender-affirming practices (eg, consistent chosen name and pronoun use); (2) offer information about gender-affirming health benefits; (3) institute and advertise nondiscrimination policies; (4) understand experiences of discrimination of TNB students during medical training; and (5) value resident gender diversity.

This is one of 2 studies published to date evaluating experiences of TNB individuals during the residency application process. Our findings revealed nearly 70% of respondents did not feel safe some or all of the time disclosing gender identity when applying. Almost half were misnamed or misgendered some or all of the time during interviews. More than one-quarter (26.9%) felt they were ranked lower than their qualifications due to gender identity. While this could not be externally validated, this perception suggests an overall climate in which TNB applicants perceive unequal treatment due to gender identity biases and transphobia.

These findings echo national data describing workplace discrimination among TNB people.¹⁵  The thematic suggestions respondents made to programs to improve the application process for TNB applicants (Table 2) support previously published recommendations.¹  Specific actions that can be taken by programs which fall within the identified themes are to routinely ask name and pronouns for all applicants, offer gender neutral restrooms, review nondiscrimination policies and affirming health care benefits, and verbalize support for the LGBTQ health care workforce. None of these interventions require significant time or resources from programs, but they signal a supportive environment.

Residency programs have a responsibility to provide faculty and staff development to increase awareness, compassion, and sensitivity toward the unique experiences and intersectional needs of TNB applicants, and take steps to prevent potential discrimination during residency application based on gender identity.¹⁶  This ideally will improve health care workforce diversity, ultimately benefitting patient communities.^17,18 

This study is limited by a small sample size and an inability to determine the response rate or assess sample representativeness of the total population of TNB residency applicants. Recruitment targeted TNB health care groups, which may have overrepresented individuals strongly connected to TNB medical resources. Respondents were not racially/ethnically diverse and only a few specialties were represented, limiting generalizability. The survey lacks evidence of validity; thus, respondents may have interpreted questions differently than intended.

With the recommendation themes found in this study, next steps should focus on developing interventions to improve the residency environment and application process for TNB individuals, which may require longitudinal and/or qualitative research methods to evaluate effectiveness.

In this small sample, TNB residents and recent graduates perceived discrimination based on gender identity during the application process, which included feeling unsafe to disclose their gender identity and being misnamed or misgendered during interviews. Our findings suggest TNB individuals have mixed experiences of discrimination and support during the residency application process and may apply to diverse specialties and settings.

The authors would like to thank Andrew Miller for feedback on the project design, the Denver Health LGBTQ Center of Excellence for administrative support, the Denver Health Foundation for research funding, and, above all, the physicians who participated in this study. Your voices and experiences matter.