As a physician assistant (PA) who is also a lesbian, I am one among many lesbian, gay, bisexual and transgender (LGBT) people who observe National Coming Out Day on October 11. Its purpose is to encourage discussion on the challenges of living openly among sexual and gender minorities and our supporters. This week's JAAPA blog is intended to bring these discussions into the realm of professional practice for LGBT PAs. As society has yet to agree on an accepted text for talking with family, friends and coworkers about sexual orientation and gender identity, these discussions are most often ineloquent. However, we should not be deterred by this obstacle in our attempts at greater understanding.

The most significant barrier is the unrealistic belief that this discussion should not be occurring at all, especially not in the workplace. I suspect that those who say sexual orientation has no place at work are referring to sex per se, not to sexual orientation. While heterosexuals commonly link sexual orientation or gender identity to sex, LGBT people more commonly see discussions about their own relationships, spouses and personal lives as a natural part of their environment. The reality is that we know the sexual orientation of most of our coworkers; we learn about their spouses, their children and their families over the normal course of business in conversation and in family photos displayed within the office. What PA doesn't start the work week with at least one colleague asking about the past weekend? These social interactions comprise an unavoidable part of workplace culture that informs our comfort and confidence in the environment and each other.

In addition, your LGBT PA coworkers don't have the same freedoms and supports that heterosexual coworkers take for granted. Whether living openly or otherwise, LGBT people suffer real consequences at home, at school, at work and in service to our country. Those who attempt to keep their sexual orientation hidden at work find that professional advancement is arduous while hiding such a fundamental part of who you are. Morale and productivity are often compromised. Workplace surveys reveal up to 30% less productivity among LGBT workers who are unable to live openly.1,2 It takes a tremendous amount of energy to hide something so innate. For employers without intentional workplace policies to support LGBT employees, talent recruitment and retention are also impacted.

LGBT PAs who are living openly have yet another set of challenges to navigate which make coming out and living openly acts of courage. Currently, federal law provides legal protection against employment discrimination on the basis of race, sex, religion, national origin, age and disability, but not on the basis of sexual orientation or gender identity. Without inclusion in employment nondiscrimination laws, sexual minority PAs can legally be fired in 28 states, gender minorities in 37 states, for no reason of merit related to competence or performance but simply for being LGBT.3

LGBT PAs may contend with biased physician and patient attitudes. A 1986 survey of physician attitudes that found 40% would not refer patients to gay or lesbian colleagues.4 In 2008, Lee and colleagues found that more than 30% of patients surveyed would change physicians if they found out that theirs was gay or lesbian. These are likely to be some of the most pressing professional issues for LGBT PAs, and it is unlikely findings would significantly differ for PAs. However, research on the PA profession has yet to explore the unique professional experiences of LGBT PAs.

Given what appears to be a damned-if-you-do and damned-if-you-don't situation, why would any LGBT PA choose to live openly? As I suspect this is a decision that each person makes on an individual level, I defer to my LGBT PA colleagues and welcome responses within the comment section below this blog entry. Nonetheless, data correlate psychological adjustment and the number of areas of one's life in which one chooses to self-disclose sexual orientation. Concealment of sexual orientation leads to problems forming social networks and with self-esteem. In other words, concealment is incongruent with living to your fullest potential.

So while all PAs seek to practice to the fullest extent of our education and experience, ideal practice regulations alone won't achieve this for LGBT PAs. Still, employment nondiscrimination is just one of four vital measures of equality in health care that also includes patient nondiscrimination, visitation and cultural competency training. I look forward to your comments on employment nondiscrimination and to exploring the other measures of health care quality in future blog posts.

Diane Bruessow practices in Middle Village, New York.

REFERENCES

1. Citak A. GLBT competitive edge: imagined or real? www.network.ch/t3/uploads/media/lgbt_forum/Andreas%20Citak_04062009.pdf. June 4-5, 2009. Accessed October 27, 2010.

2. Stonewall: the lesbian, gay, and bisexual charity. Workplace equality index 2011. www.stonewall.org.uk/workplace/1477.asp. Accessed October 27, 2010.

3. Human Rights Campaign. Statewide employment laws and policies. http://www.hrc.org/documents/Employment_Laws_and_Policies.pdf. July 26, 2010. Accessed October 27, 2010.

4. Mathews WC, Booth MW, Turner JD, Kessler L. Physicians' attitudes toward homosexuality—survey of a California County Medical Society. West J Med. 1986;144(1):106-110.