https://orcid.org/0009-0008-0308-9799
ABSTRACT
Creating a positive workplace culture affects patient outcomes and force readiness. An inclusive workplace culture is especially important for lesbian, gay, bisexual, transgender, and queer (LGBTQ) military healthcare professionals, who have historically faced discrimination within the United States military. While research has examined LGBTQ service members’ experiences in the military as a whole, there is a gap in the professional literature regarding LGBTQ healthcare workers’ experiences within military medicine.
This qualitative phenomenological study explored the experiences of ten LGBTQ military healthcare professionals. We interviewed each participant for one hour. Our research team then coded each interview and came to a consensus on how to organize these codes into emerging themes. We used reflexivity and member checking to increase the credibility of our results.
Four themes emerged from our data analysis: (1) implicit bias; (2) explicit bias; (3) response to discrimination; and (4) recommendations for improving workplace culture. The participants described both the underlying and outright discrimination they faced at work. They made recommendations for reducing this discrimination through education, training, and increased leadership representation.
Our results revealed that LGBTQ healthcare professionals continue to face discrimination in the workplace. This discrimination must be addressed to create an inclusive workplace environment within military medicine, which will enhance force readiness.
Healthcare workplace culture, or the “way things are done through established attitudes, values, beliefs, and practices which are exhibited within a work environment,”1 directly impacts patient outcomes.2,3 Positive workplace culture has consistently been correlated with lower patient mortality rates and increased patient satisfaction.3 Ultimately, when healthcare professionals feel less stressed, they are more responsive to their patients and make less errors.4–6 Healthcare professionals who trust their supervisors also feel more motivated and empowered to excel in their roles.7
Supporting healthcare professionals who identify themselves as lesbian, gay, bisexual, transgender, or queer (LGBTQ) is an essential aspect of positive workplace culture.8 However, this population has historically faced discrimination within the military workplace. In 1993, the Don’t Ask, Don’t Tell (DADT) legislation prohibited LGBTQ service members from openly revealing their sexual identity, creating an anti-LGBTQ sentiment that permeated military culture.9,10 As a result of this legislation, more than 13,000 LGTBQ service members were discharged from the military for revealing their sexual identity at work.11 The DADT legislation was repealed in 2010, but recent research reveals that LGBTQ service members remain hesitant to reveal their sexual identity in the workplace due to continued discrimination throughout military culture.12–14
In addition to these workplace culture challenges brought on by DADT, LGBTQ service members have historically faced many challenges as patients within military and civilian medicine.12–17 Recent research has revealed that LGBTQ service members have poorer mental, behavioral, and physical health than their heterosexual counterparts.13,14,18,19 These healthcare disparities may result from the stress of discrimination, lack of support, and systemic bias, as well as lack of access to culturally competent healthcare providers within military medicine.13,18,19 Past research has found that 30% of LGBTQ service members do not reveal their sexual identity to their healthcare provider due to fear of discrimination and/or punishment.20
While these healthcare disparities for LGBTQ service members and the impact of the discrimination they have faced have been studied, no research has focused on military medicine’s workplace culture for LGBTQ healthcare professionals, who play an essential role in caring for the warfighter and ensuring force readiness.13 The purpose of this study, thus, was to:
Examine the experiences of active-duty LGBTQ healthcare professionals at work
Explore this population’s perceptions of their workplace culture
METHODS AND MATERIALS
Our research team chose the phenomenological approach in qualitative inquiry to explore the lived experiences of LGBTQ healthcare professionals and gather insight on their perceptions of military medical workplace culture. As phenomenological qualitative researchers, we aimed to describe and interpret our participants’ experiences from an insider perspective, which we gained through in-depth interviewing.21
The participants in our study were active-duty healthcare professionals who identified themselves as LGBTQ (see Table I for participant demographics). Seven of the participants identified as gay, one identified as lesbian, and two identified as bisexual. All of the participants were members of the military medical community(we will not disclose their specific roles in order to protect their privacy). The participants were both enlisted and officers, with ranks ranging from E4-06. To recruit for our study, we used purposeful and convenience sampling.22 We emailed potential participants in our professional network, providing them with information about the study and asking them to consider participating in our research or forwarding the information to others who may be interested. Ten service members responded via email and volunteered to participate in the study.
Participant Demographics
| Orientation | Ethnicity | Assigned sex | Identified sex |
|---|---|---|---|
| Gay | White | M | M |
| Gay | Asian | M | M |
| Gay | Black | M | M |
| Gay | White | M | M |
| Bisexual | White | F | F |
| Gay | Latino | M | M |
| Lesbian | Asian | F | F |
| Bisexual | Black | M | M |
| Gay | Mixed | M | M |
| Gay | White | F | F |
| Orientation | Ethnicity | Assigned sex | Identified sex |
|---|---|---|---|
| Gay | White | M | M |
| Gay | Asian | M | M |
| Gay | Black | M | M |
| Gay | White | M | M |
| Bisexual | White | F | F |
| Gay | Latino | M | M |
| Lesbian | Asian | F | F |
| Bisexual | Black | M | M |
| Gay | Mixed | M | M |
| Gay | White | F | F |
Participant Demographics
| Orientation | Ethnicity | Assigned sex | Identified sex |
|---|---|---|---|
| Gay | White | M | M |
| Gay | Asian | M | M |
| Gay | Black | M | M |
| Gay | White | M | M |
| Bisexual | White | F | F |
| Gay | Latino | M | M |
| Lesbian | Asian | F | F |
| Bisexual | Black | M | M |
| Gay | Mixed | M | M |
| Gay | White | F | F |
| Orientation | Ethnicity | Assigned sex | Identified sex |
|---|---|---|---|
| Gay | White | M | M |
| Gay | Asian | M | M |
| Gay | Black | M | M |
| Gay | White | M | M |
| Bisexual | White | F | F |
| Gay | Latino | M | M |
| Lesbian | Asian | F | F |
| Bisexual | Black | M | M |
| Gay | Mixed | M | M |
| Gay | White | F | F |
To collect our data, we first developed an interview protocol consisting of ten open-ended questions (see Table II). We then conducted and recorded one-hour virtual (audio only) individual interviews with our volunteer participants using a semi-structured approach to interviewing. We also asked our participants to complete three emailed follow-up questions. This study was approved by the Institutional Review Board at the Uniformed Services University.
Participant Interview Questions
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Our research team then followed the steps outlined by Giorgi et al. (1971) for phenomenological data analysis. First, we transcribed the interviews using an automated transcription service.21 We then read the transcriptions multiple times in order to become familiar with them as a whole. We coded each interview, labeling each word or phrase that seemed to be representative of the participants’ perceptions. We compiled these codes into a code book, which listed each code and the corresponding direct quote. We then organized these codes into major categories, which described the participants’ “structure of experience” and formed the themes of our study (see Fig. 1).21 Throughout this data analysis process, we resolved any dissenting viewpoints through ongoing discussion until we came to a consensus.23 We took notes during each of our research team meetings to document this process.24
Four major themes.
We took several steps to increase the credibility of our study. Our research team consisted of one active-duty military researcher and one Ph.D. civilian researcher with extensive experience in conducting qualitative research. We used a team approach to analyze the data, first analyzing the transcripts separately and then meeting to discuss them and come to a consensus on the emerging themes.23 We engaged in reflexivity by meeting on a weekly basis throughout the data collection and analysis processes to discuss and bracket our biases, an essential process to maintain objectivity as qualitative researchers.25,26 In addition, after we transcribed the interviews, we emailed the transcripts back to the participants so they could make any desired changes, a process known as member checking.27,28
RESULTS
Four themes emerged from our data analysis: (1) implicit bias; (2) explicit bias; (3) response to discrimination; and (4) recommendations for improving workplace culture.
Theme 1: Implicit Bias and Discrimination
The participants first described implicit bias they experienced within the military medical community. One participant, for example, described discrimination they observed in patient care.
There are a lot of assumptions made. “Like for instance, an individual who is single and wants to get on PrEP, HIV Pre-Exposure Prophylaxis, they have to go to their Primary Care Provider (PCM), and in their record, it has to denote that they engage in high risk sexual behaviors, whether that’s true or not…When you have a provider reviewing a chart, they see that, there’s automatically going to be this judgment of like, ‘Oh, this person engages in homosexual behavior. Oh, this person identifies with this sexual identity’ and with that can come a lot of implicit biases.”
The participants also described a lack of social inclusion for LGBTQ service members within the military medical community. One recalled how “there were some Marines that in particular didn’t like a fellow corpsman that was a gay male, and the implication being that they were uncomfortable around him, and you’d challenge them why. It was because of, ‘Well, you know.’” Another participant described their experience arriving at a new unit.
The people there knew that I was coming, apparently warning everyone ahead of time that, “Hey, watch out, there’s this gay guy that’s coming.” One of my roommates, he was warned ahead of time about me as well. He was hanging out with me and they were like, “Hey, you should watch out. People are going to start thinking things about you because you’re hanging out with this guy.”
Another participant reflected on their struggle to fit in socially with colleagues throughout their military career.
I haven’t had a lot of outward negativity towards me, but things that happened behind closed doors, little things that were said about me, that I heard or found out after the fact… I was like, oh, well that makes sense why it was so hard to make friends and why I didn’t seem to fit in as well.
Theme 2: Explicit Bias and Discrimination
The participants also discussed the explicit bias and verbal discrimination they faced at work. One recalled how they constantly heard “Oh that’s gay. This is gay. Stuff like that is synonymous with gay is lesser. It just makes you feel like you are not good, you are lesser.”
Another echoed this struggle with hearing these discriminatory comments.
We were marching back to our barracks and the person calling cadence was saying random and just outlandish stuff like, “So and so is gay” in the formation. At that point my military bearing just broke. I was like, “I cannot do this…” I just had to stand up in that moment. I said, “What you did is not right!”
One participant recalled facing this type of verbal discrimination from military leadership as well during the time period that DADT was repealed.
I remember attending meetings during the repeal of Don’t Ask, Don’t Tell. A Sergeant said something very homophobic and a Marine Captain who was leading it at the time, agreed with him. It went: “Hey, if we let in the faggots, we’re letting AIDS into the Marines.” The Marine Captain replied, “Yes, Sergeant, I agree with you. Unfortunately, this is where things are headed with Don’t Ask, Don’t Tell. So we just all gotta kind of get on board with it.”
Another described how more recently their supervisor made critical comments regarding their behavior and affect:
“I’ve received notes from people saying that you walk around and you’re pretty happy… you’re a bit bubbly.” Then he said, “Maybe I should give you more to do.” I replied by saying, “So, is the expectation that I’m supposed to be miserable?” My supervisor replied, “No, it’s just a little bit too out there.”
Finally, the participants recalled examples of explicit biases from their graduate medical education programs. One explained that “there are faculty members who are not as affirming, or not affirming at all…there was a faculty member who referred to trans-service members as a ‘project’ …definitely disheartened and discouraging.”
Theme 3: Response to Discrimination
As a result of this explicit discrimination, the participants described their hesitancy in revealing their sexual orientation at work. One revealed that
When I transfer to a new station, I do an assessment first to see what the culture is like, to see if they are accepting, if they are tolerant. And then from there I can start opening up more… So I kind of put on the heterosexual mask, if you will, when I first get to a place and then I can figure it out from there.
Another service member echoed this same sentiment of hiding their true identity from their colleagues.
“Initially wanting to hide it really does have to do with more of a personal idea of masculinity… as well as how I will be perceived… Because I don’t want to be perceived by my sexual orientation…Only by my merit and my work ethic.” Another participant described their hesitancy in introducing their spouse to work colleagues. “I would be nervous sometimes at first bringing her to events, just concerned that people might have a problem with it.”
In order to navigate these workplace challenges, the participants in our study described how they relied on the support of others who also identified as LGBTQ, both military and civilian. “I would stick with other gay people for the most part… I still have this unfortunate mindset of avoiding my heterosexual counterparts because I don’t want to deal with their negative stigmas about me.” The participants explained how these networks they have formed replaced common support traditionally found in the military community. “In terms of the formal command programs like the spouse organizations… we really haven’t been part of that because we’ve found support elsewhere.” The participants also described how they relied on their spouses for support and resilience. “I think that we are all really good at relying on each other when we need things. That’d probably be our biggest strength, being able to be like, ‘I’m not in this alone.’”
Theme 4: Recommendations for Improving Workplace Culture
After reflecting on these challenges they have faced, the participants recognized that progress has been made within military workplace culture regarding acceptance of LGBTQ service members within the military community.
The military went from Don’t ask, Don’t Tell to, there will be no negativity towards gay people. It’s taken a very firm stance that even the majority of society in the United States hasn’t really taken.
Despite this legislative progress, another participant described how military workplace culture is still catching up to this policy change. “The policy is changing, but it’s slow and it’s not really transformative enough… I see the efforts, I see the policy changes, but there’s just a need for more.”
The participants made several recommendations for continued work in promoting equality, affirmation, and inclusion within military medical culture through education, training, and representative leadership.
Outside of Pride Month, it all kind of goes to the wayside…There’s always going to be those senior, mid, or even junior officers who have certain perceptions about individuals in the LGBTQ community and that can create a very toxic command climate…So additional education, programming, and policies are needed.
The participants in our study noted that this training should be tailored specifically to meet the healthcare needs of the LGBTQ community. “It would be great to have access to professionals, such as in mental health and counseling, that are trained to support the LGBTQ community and their unique issues… There’s definitely a training area to gain.” They also noted that healthcare professionals need to be educated about transgendered service members. “We’re told to accept trans service members because senior leadership says so, but I just feel like there’s a lot of confusion and a lot of not clearly knowing.”
Finally, our participants emphasized the need for LGBTQ representation in military medical leadership positions. One summarized this sentiment. “I think as openly LGBTQ individuals continue to move up in the ranks and continue to assume command, just having that higher level visibility is only going to be positive for the LGBTQ community.”
DISCUSSION
While past research has focused on the experiences of LGBTQ service members as patients,12,14,29 the results of our study revealed the experiences of LGBTQ military health professionals within military medical culture and the ways in which they experience both implicit and explicit biases at work, even post DADT. These new findings mirror the results of past quantitative research that reveals the continuance of discrimination toward LGBTQ service members throughout the military after the repeal of DADT.9,12,14,18,19,30 This continued discrimination has resulted in high rates of separation from the military by the LGBTQ population due to the challenges and discrimination they have faced.18 Because retention of LGBTQ healthcare professionals helps to ensure force readiness, military medical leaderships are called to provide a respectful and equitable workplace environment where LGBTQ healthcare professionals feel included and thrive in their daily work.
Initial attempts at providing LGBTQ culturally sensitive training for military healthcare personnel have proved promising.12 As suggested by the participants in our study, more education and training is needed specifically focusing on increasing diversity and inclusion among military personnel, including ways to increase the awareness and support of the LGBTQ population impacted by the Military Healthcare System. This training may result in the added benefit of an increase in healthcare professionals’ cultural sensitivity toward patients, ultimately improving patient care and increasing force readiness.12,13
Military medicine might partner with professional organizations like the Modern Military Association of America, the nation’s largest organization of LGBTQ+ service members, spouses, veterans, their families, and allies.31 This non-profit organization recently created the Rainbow Shield program, which educates community service providers and advocates through three certification levels (basic, intermediate, and advanced). The Rainbow Shield program’s goal is to end negative experiences in service and advocacy settings based on sexual orientation and gender identity for service members, veterans, and their families.32 Adopting an annual Rainbow Shield-like program for the Military Healthcare System, and military at-large, may assist in growing the understanding, sensitivity, and affirmation of the LGBTQ population in the military.
In inclusive and equitable workplaces, LGBTQ healthcare providers are empowered to flourish.8 Because healthcare leaders directly impact workplace culture,33 they are called to demonstrate open acceptance of the LGBTQ population and become known allies and facilitators of LGBTQ support networks throughout the Military Health System.29 Military medical leadership is well positioned to model inclusivity not only within military medicine, but throughout the entire military. For example, leaders might encourage LGBTQ healthcare professionals to bring their spouses to workplace social events, demonstrating the acceptance of diverse family structures. Leadership might likewise celebrate LGTBT pride throughout the year and actively participate in pride events in order to show support for LGBTQ service members and their families.34 Senior Leaders might also facilitate staff education that focuses on health and workplace disparities and mentor junior leaders to create workplaces that model inclusive communication and support for all service members.34
Due to the uncertainty of future landscapes of war, force readiness is crucial.13 Military medicine must be prepared to provide quality healthcare during the next conflict. One step in ensuring this quality healthcare is creating a positive workplace culture within military medicine, including creating safe spaces during deployments for LGBTQ healthcare professionals. The results of our study revealed key improvement areas within military medical workplace culture to focus on for improving force readiness.
FUTURE RESEARCH
Future wide-scale quantitative research might survey a larger sample of participants within the LGBTQ military medicine community in order to further explore their perceptions and experiences and explore other variables that may impact their experience. Additional qualitative research might explore the experiences of this population both before and after the repeal of DADT. Program evaluation of current LGBTQ trainings within military medicine may reveal their strengths and areas for growth in effectively training military healthcare professionals to effectively support this population.
LIMITATIONS
None of the participants in our study identified him/her as transgender. Further research is needed to determine the experiences of transgender healthcare professionals in the military and the unique support they may need. In addition, larger scale quantitative research within military medicine may reveal further insight into the experiences of LGBTQ healthcare professionals within military medical workplace culture. Future research might also explore the differences in workplace culture within various professions and specialties.
CONCLUSION
The participants in our study described implicit and explicit discrimination they faced. Creating an inclusive workplace culture within military medicine for LGBTQ healthcare professionals through training, education, and leadership representation can increase force readiness and patient outcomes.
ACKNOWLEDGMENTS
None declared.
FUNDING
None declared.
CONFLICT OF INTEREST STATEMENT
None declared.
DATA AVAILABILITY
The data that support the findings of this study are available on request from the corresponding author. All data are freely accessible.
CLINICAL TRIAL REGISTRATION/IDENTIFIER
Not applicable.
INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)
This study was determined exempt by the Institutional Review Board at the Uniformed Services University (DBS.2022.457).
INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)
Not applicable.
INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT
RA and RC designed this research, collected and analyzed the data, drafted the original manuscript, and reviewed and edited the manuscript. Both authors read and approved the final manuscript.
INSTITUTIONAL CLEARANCE
Institutional clearance approved.
REFERENCES
Author notes
The views expressed in this material are those of the authors and do not reflect the official policy or position of the U.S. Government, the Department of Defense, the Uniformed Services University, or the United States Air Force.
