Advocating for Diversity, Equity, and Inclusion in Dermatology and LGBTQ Health

At the 2021 Skin of Color Update, Dr. Andrew Alexis hosted a panel discussion on Diversity, Equity, and Inclusion (DEI), with dermatology powerhouses Dr. Susan Taylor and Dr. Klint Peebles. These two panelists have tirelessly advocated for their respective causes, advancement of knowledge within skin of color (SOC) and LGBTQ (lesbian, gay, bisexual transgender, queer) health.

Our first panelist, Dr. Susan Taylor, discussed the goals of DEI initiatives, the state of diversity in the U.S., the state of diversity within dermatology, and the importance of having a diverse workforce for patient care. A few important takeaways from Dr. Taylor’s introduction to the topic are below:

    • “The goals of DEI initiatives include the promotion of diversity and inclusion within dermatology organizations, improvement in the quality of dermatology education to encompass conditions across all skin colors, and to address health inequities and of course, increasing the number of underrepresented minority physicians in the field of dermatology and in leadership positions.”
    • “The U.S. is becoming an increasingly diverse country, both ethnically as well as racially, and currently the fastest growing racial group in the U.S. consists of people of two or more races. As of 2020, nearly 40% of the US population was nonwhite and by 2060 it’s projected that over 60% of children in the United States will be children of color.”
    • “The face of dermatology should reflect the faces of our patients. Although black Americans represent 12.8% and Latin X Americans 16.3% of the United States population, black and Latin X dermatology residents only represent 7% of dermatology residents combined. In 2020, black residents made up about 4.6% of dermatology residents and Latin X residents represented 6.6%. The numbers are even smaller for native Hawaiian and Pacific Islanders with 2% and American Indian or Alaskan natives with 0.7%.”
    • “Black dermatologists make up only 2.7% of academic dermatologists from recent data in 2018. From 1970 to 2018 the number of URM dermatology faculty members increased from 8 to 109, so although there was an increase, it was relatively small and not reflective of our population.”
    • “There have been multiple papers that had demonstrated the impact of diversity in dermatology. There is reported increased patient adherence to medical advice due to increased trust and the factor of cultural humility. It has also been demonstrated that there is increased patient satisfaction and a higher percent perception of physician support due to increased patient comfort and longer visits as well as feeling that their physician understands their skin and their hair. There’s also improved access to care due to black physicians being more likely to accept patients who have Medicaid insurance or patients who are uninsured. Lastly, there is an increase in research related to skin of color as residents interested in this area are more likely to do clinical research within this population.”

Dr. Taylor then discussed the barriers that many URM applicants have when applying to dermatology and the progress being made regarding DEI initiatives.

    • Barriers include lack of equitable resources in respect to limited or late exposure to the field, lack of institutional support, implicit bias toward URMs within standardized testing, financial constraints, lack of group identity, and lack of holistic review for residency applications.
    • Fortunately, many professional dermatologic societies have spearheaded diversity initiatives to overcome some of these barriers.
    • Some of the progress includes the SOC annual scientific symposium, Project Impact (initiative dedicated to reducing healthcare bias in patient with SOC), the SOC observership grant, multiple research grants for URM physicians, the AAD DEI plan (focus on early outreach to Black and Latino students, community mentorship, as well as development of a SOC curriculum), the annual diversity champions workshop, and many more from various groups such as WDS, ASDS, Society of Pediatric Dermatology, American Contact Dermatology Society, and ACGME.

Lastly, Dr. Taylor discussed key priorities for DEI in dermatology going forward.

    • Continue to strengthen the leaky pipeline from high school to medical school.
    • Transform and improve workforce diversity
    • Increase SOC education across various platforms
    • Continue training on cultural humility, ultimately making medicine anti-racist
    • Acknowledge the importance of DEI work being done by all, not just UIM physicians
    • For dermatologists in private practice, identify neighboring medical schools and work with the institution to mentor UIM students and support UIM students with scholarships or stipends.
    • For dermatologists in academia, reassess the election process with focus on holistic review, i.e., increased weight on grit, determination, as well as distance traveled for applicants, recruit and retain UIM faculty, integrate anti-racist and implicit bias training, increase SOC education, and support pipeline programs.

Our next panelist, Dr. Klint Peebles, defined sexual and gender minority, the concept of intersectionality and how it relates to DEI, as well as current knowledge on sexual and gender minority representation in dermatology.

    • Gender minority refers to individuals whose gender identity (man, woman, or other) or expression (masculine, feminine, other) is different from their sex (male, female) assigned at birth. Sexual minority refers to individuals who identify as LGB (lesbian, gay, or bisexual), or who are attracted to or have sexual contact with people of the same gender.
    • LGBT identification is rising with latest estimates being just under 6% of the US population and about 0.6% identifying as transgender. However, these estimates are challenging because there is very little systematic collection of data on sexual and gender identity. Furthermore, these data often exclude adolescents and children. The number of people identifying as transgender continues to increase, especially among younger generations, with as many as 2% of Gen Z adults identifying as transgender in some surveys. It’s important to understand that it remains unclear whether these numbers are truly increasing, per se, or whether there are simply differences in visibility, or both. In general, we are seeing improvements in nondiscrimination efforts, social acceptance, welcoming and affirming environments, and dedicated initiatives to improve safety. These advances along with improving access to healthcare and coverage of gender-affirming care as well as broader embrace of concepts and language to describe gender diverse identities have allowed for expanded visibility and an authentic embrace of identity.
    • For the first time, the 2020 AAD member satisfaction survey integrated questions focusing on sexual orientation and gender identity. The data showed that about 3.7% identify as LGBT and only 0.3% identify as transgender. LGBT respondents were more likely to be younger and in academics. Most LGBT respondents were “out” about their sexual orientation at home (70.5%) and at work with colleagues (80%). Less than half were “out” at work (48%).
    • For medical students, the 2016-2019 AAMC graduation questionnaire showed that the prevalence of graduating medical students identifying as LGB was less than that of the general population. However, when broken down by sex (male vs female), an even greater difference emerges with sexual minority female students underrepresented in undergraduate medical training and sexual minority males possibly overrepresented.
    • It’s important to understand that the sexual and gender minority population is not a monolith. There are numerous disparities and representation gaps evident within subgroups of this population as the aforementioned data illustrates. Even further, we need better understanding of how other aspects of identity, including race and ethnicity, intersect with sexual and gender minority identity in order to more fully understand these disparities and improve equitable representation. In summary, intersectionality must be prioritized in future research efforts.

Dr. Peebles then discussed DEI initiatives, groups focused on advancement of LGBT issues, and current progress.

    • Like SOC, many position statements related to DEI specifically for LGBTQ health have been approved in various dermatologic organizations
    • The AAD’s LGBTQ/SGM Expert Resource group is dedicated to education, research, mentorship, and advocacy on behalf of LGBTQ/SGM patients and physicians in dermatology and more broadly
    • Multiple mentoring initiatives
    • Increased representation in multiple dermatologic organizations, increased education efforts with lectures and symposia

Dr. Peebles concluded the presentation with the following call to action ideas:

    • Get involved and spread the word; think about everyday language used not only in your work but also more broadly that reflects on the appropriate distinctions between sex and gender
    • Encouraged prioritization of intersectionality; collaboration among groups, organizations, and societies mutually dedicated to DEI is essential.
    • Use inclusive, validating, and affirming language
    • Basic demographic data collection in all research efforts should incorporate sexual orientation and gender identity whenever possible. Further, investigators and authors should be explicit and transparent regarding their definitions of “sex” and “gender” in these demographic variables and articulate how this information was determined.

At the end of the panel, Dr. Andrew Alexis then addressed the panelists with a final question: How important is allyship in advancing diversity, equity and inclusion?

Dr. Taylor: “Allyship is critically important in advancing DEI. Much of the DEI efforts have fallen on the shoulders of people of color. We could advance exponentially with the help of others. For example, a seminal lecture by a pivotal ally really began people talking and focusing on these issues (SOC). Sometimes a lone voice doesn’t fully penetrate.”

Dr. Peebles: “It’s essential and we could not do this work without allies. This goes for not only LGBTQ vs non-LGBTQ issues but also within the LGBTQ community itself. Historically, the dominant vocal element of the LGBTQ community was gay white men at a time when sexual minority women and transgender individuals, particularly those of color, were stigmatized and marginalized even within the community. Much progress has been made in terms of bringing a heightened awareness to the rich diversity within the LGBTQ community. First and foremost, this is due in large part to the resilience and determination LGBTQ people of color, but we have also seen contributions from allies to bring attention to these issues. Specifically within the AAD, we would not have been able to get our position statement on LGBTQ/SGM health in dermatology across the finish line without supportive allies in the leadership and staff of the organization.”

This information was presented by Drs. Susan Taylor and Klint Peebles at the 2021 Skin of Color Update virtual conference held on September 10-12, 2021. The above highlights from their panel presentation were written and compiled by Dr. Starling Tolliver

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