A Call for LGBTQ+ Inclusion in Medicine’s Definition of “Underrepresented”

Medicine loves a definition. It defines diseases, diagnoses, competency, professionalism, and, sometimes with a straight face and a spreadsheet, who counts as underrepresented. That last definition matters more than it may seem. In academic medicine, the word underrepresented is not just a tidy label for diversity brochures and orientation slides. It shapes recruitment priorities, scholarship pathways, mentorship programs, faculty development, workforce planning, and the moral imagination of institutions that say they want to reflect the people they serve.

For years, the phrase “underrepresented in medicine” has been anchored to race and ethnicity. That focus remains essential and should remain protected. Racial inequities in medicine are real, persistent, and deeply structural. But medicine’s current definition has a blind spot large enough to drive a teaching hospital through: LGBTQ+ people are still largely left outside the formal frame, even though evidence keeps piling up that they face distinctive barriers in training, workplace climate, mentorship, retention, and patient care.

This is the heart of the argument: medicine does not need to choose between racial equity and LGBTQ+ inclusion. It needs a bigger table and fewer false dilemmas. Expanding the definition of “underrepresented” to explicitly include LGBTQ+ people would not erase race. It would recognize an additional form of underrepresentation that has long been visible in lived experience, even when institutions have preferred to squint.

Why This Definition Matters More Than It Sounds

Definitions in medicine are rarely neutral. Once a group is named in an official framework, schools start measuring, leaders start planning, grant programs start adapting, and accountability becomes a little harder to dodge. When a group is left unnamed, the opposite tends to happen. Problems get relabeled as anecdotes. Exclusion gets mistaken for bad luck. And “we care about everyone” becomes a polite way of caring very specifically about no one.

That is why the current debate is not academic in the dismissive sense of the word. It is academic in the literal sense: it affects who gets recruited into medicine, who feels safe staying there, who gets mentored into leadership, and who eventually stands at the bedside when a patient is searching for someone who understands their life without requiring a twelve-slide orientation.

The case for LGBTQ+ inclusion is not built on symbolism alone. It rests on three overlapping realities: representation remains difficult to measure and likely incomplete, training environments are often less inclusive than institutions imagine, and LGBTQ+ clinicians and trainees may be especially likely to serve populations that medicine already describes as underserved.

The Case for Expanding the Definition

1. You cannot fix what you refuse to count

One of the strangest features of this conversation is that medicine has spent years debating whether LGBTQ+ people are underrepresented while only recently improving the way it asks who is actually in the room. That is a problem. Underrepresentation is partly a numbers question, but it is also a visibility question. If trainees and physicians do not feel safe disclosing their sexual orientation or gender identity, the workforce can look more representative on paper than it feels in real life.

That uncertainty should not be used as an excuse for inaction. In fact, it should be treated as evidence that the current system is incomplete. A category does not become unimportant because institutions have been bad at measuring it. If anything, a data gap this large is a sign that medicine has avoided asking better questions for too long.

Recent AAMC data and related scholarship suggest that more students are openly identifying as LGBTQ+ than in previous years, which is encouraging. But increases in self-identification do not magically solve underrepresentation across specialties, faculty ranks, leadership pathways, or geographic practice settings. Visibility at the admissions stage is not the same thing as equity across the profession. A full waiting room does not mean the house has enough chairs.

2. The learning environment is still doing too much “character building” and not enough building

If the goal were to design a system that quietly discouraged some LGBTQ+ trainees from thriving, medicine has occasionally shown a disturbing talent for accidental precision. National studies of U.S. medical students have found that lesbian, gay, and bisexual students report more mistreatment than their heterosexual peers, including higher rates of discrimination related to sexual orientation. Other studies have linked these experiences to worse burnout and less favorable perceptions of the learning environment.

That matters because climate is not a side issue. It is not decorative. A school can hang a rainbow flag in the student center, add one elective on LGBTQ+ health, and still produce an environment where students hear offensive remarks on clinical rotations, avoid disclosure around attendings, or learn very quickly which specialties seem safe and which ones feel like a weekly audition for invisibility.

Inclusion in medicine is often discussed as though it were an “extra,” like whipped cream on a latte. Nice if available, not essential if missing. But for trainees navigating bias, mentorship scarcity, and identity management, institutional climate affects well-being, specialty choice, retention, and professional confidence. That is not garnish. That is the meal.

3. LGBTQ+ trainees are not just asking for support; many are drawn to service

There is also an important workforce argument here. Research on graduating medical students has found that bisexual and gay or lesbian students were more likely than their heterosexual peers to report plans to practice in underserved areas. That finding should have landed louder than it did. Medicine often frames underrepresentation partly in terms of who is likely to serve marginalized communities. By that logic, LGBTQ+ inclusion does not sit outside the mission. It fits squarely inside it.

Many LGBTQ+ trainees understand, often from personal experience, what it means to navigate systems that are technically available but emotionally unsafe. They know the difference between being tolerated and being welcomed. They know how quickly patients can withhold information when trust is thin. That does not make every LGBTQ+ clinician automatically better, nor should it romanticize minority identity as a superpower. But lived experience can deepen empathy, sharpen cultural humility, and influence where clinicians choose to work and whom they feel called to serve.

4. Patients do not benefit from “inclusive values” if the workforce is still structurally narrow

Academic medicine increasingly recognizes that diverse learning environments improve education and can strengthen care for varied patient populations. That principle should not stop at the edge of LGBTQ+ identity. Patients benefit when clinicians are trained to provide affirming care, when institutions collect relevant sexual orientation and gender identity data respectfully, and when health care teams include people whose lives make them less likely to reduce LGBTQ+ patients to a checkbox, a curiosity, or a coding challenge in the electronic health record.

This is especially important because LGBTQ+ health is still too often treated as niche medicine. It is not. It involves primary care, psychiatry, pediatrics, emergency medicine, surgery, reproductive health, geriatrics, oncology, and practically every other corner of the profession. The idea that LGBTQ+ inclusion belongs in one office of diversity and not in the core definition of workforce equity is outdated on arrival.

What Critics Get Wrong

The most common objection is that expanding the definition would dilute efforts to address racial inequity. That concern deserves respect, but it does not require agreement. The answer is not to keep LGBTQ+ people outside the framework. The answer is to build a framework sophisticated enough to hold multiple truths at once.

Race-based underrepresentation in medicine has a long history tied to exclusion, segregation, inequitable admissions practices, wealth gaps, and structural racism. None of that changes if LGBTQ+ people are explicitly recognized as underrepresented in their own way. An expanded definition does not need to flatten different forms of disadvantage into one generic diversity smoothie. Institutions can distinguish between categories, track them separately, examine intersectionality carefully, and still pursue both goals with seriousness.

Another weak objection is that some LGBTQ+ people are already present in medicine, so the category cannot be underrepresented. That argument confuses visibility with equity. A few out faculty members, a student affinity group, and one panel during Pride Month do not prove structural inclusion. They prove that some people have been doing the work despite structural exclusion.

There is also the claim that numbers are uncertain, so institutions should wait. But medicine rarely demands perfect measurement before acting on a pattern of harm. When repeated studies show mistreatment, burnout, climate concerns, educational gaps, and workforce retention issues, caution starts to look less like rigor and more like procrastination wearing a tie.

What Inclusion Should Actually Look Like

Keep race central, but expand the frame

The smartest path forward is additive, not competitive. Medicine should preserve race- and ethnicity-based efforts aimed at historically excluded communities while explicitly recognizing LGBTQ+ people as another underrepresented population in the profession. This is not semantic inflation. It is institutional accuracy.

That shift would allow schools and health systems to develop clearer recruitment and retention strategies, create better benchmark data, and build programs that acknowledge distinct forms of marginalization without pretending they are interchangeable. It would also make intersectionality easier to address honestly. A queer Black student, for example, should not have to choose which part of their reality the institution is willing to recognize on a Tuesday.

Invest in anonymous, respectful data collection

If academic medicine wants better workforce planning, it needs better data collection from admissions through faculty leadership. That means voluntary, privacy-conscious questions about sexual orientation and gender identity, along with transparency about how the information will and will not be used. The goal is not surveillance. The goal is visibility with safeguards.

Better data would help answer practical questions that still linger: Where do LGBTQ+ students cluster? Which specialties lose them? What climates retain them? Where are the mentorship deserts? Which institutions are good at support, and which ones are just good at brochures? Right now, too much of that picture is guessed rather than known.

Link recruitment to climate, curriculum, and mentorship

Recruitment without climate reform is just fancy marketing. Schools should not pat themselves on the back for admitting LGBTQ+ trainees if the curriculum still treats gender diversity like a bonus chapter and the clinical environment still rewards silence. Inclusion has to show up in required curriculum, faculty development, visible mentorship, student support, benefits, reporting systems, and leadership accountability.

Curricular progress has happened, and that should be acknowledged. Medical schools today generally devote more time to LGBTQ+ health topics than they did a decade ago. But recent studies show wide variation in both the number of hours taught and the topics actually covered. In plain English, some schools are building thoughtful, integrated education while others are still offering the pedagogical equivalent of a sticky note that says, “Remember the gay patients.”

Experiences Behind the Policy Debate

Policy arguments can sound abstract until you remember what they feel like on the ground. Across medical education, the experiences described by LGBTQ+ trainees and physicians are often not dramatic in a movie-script way. They are cumulative, quiet, and exhausting. A student hears a joke during anatomy lab and does the rapid mental math: say something, stay silent, laugh weakly, or become “the issue” in a room that keeps insisting it has no issues. Another student notices that every form, every orientation session, and every “standard patient” scenario assumes the same neat story about sex, gender, and family life. A resident decides not to mention a partner on rounds because the attending has already described trans care as “political,” which is a remarkable way to refer to another human being’s endocrine system.

Then there is the mentoring gap. Students from groups formally recognized as underrepresented may at least be able to point to named pipeline initiatives or faculty programs built with them in mind. LGBTQ+ trainees, by contrast, often piece together support through informal networks, whispered recommendations, or the sacred medical tradition of finding one kind attending and hoping they do not move away. In some places, there are thriving affinity groups and visible faculty champions. In others, there is a lonely spreadsheet, a Pride month panel, and a dean who believes institutional warmth can be measured by the number of rainbow cupcakes in the lobby.

These experiences also shape career decisions. A student may love orthopedics, surgery, or another highly competitive field but quietly decide the climate is too chilly. Another may gravitate toward psychiatry, family medicine, adolescent medicine, or community-based practice not only out of passion, but because those spaces seem more survivable. That is not free choice in the fullest sense. That is choice under atmospheric pressure.

For faculty and practicing physicians, the experience can shift from concealment to fatigue. Some describe being the “first openly queer” person in a department, which sounds flattering until you realize it usually means doing unpaid diversity labor while also trying to keep up with clinical work, scholarship, and promotions. Others describe the professional tax of constant translation: deciding when to correct assumptions, when to educate colleagues, when to document bias, and when to conserve energy because tomorrow starts at 5:30 a.m. and the ICU is not going to care that your department still has not figured out pronouns on conference badges.

And then there are the patients. Patients notice more than institutions think. They notice intake forms that do not fit, staff who stumble over names, clinicians who ask about partners with visible discomfort, and the rare moments when someone gets it right without turning the encounter into a social science field trip. For LGBTQ+ patients, affirming care is not a luxury add-on. It can determine disclosure, adherence, trust, and whether a person comes back at all. When institutions fail to support LGBTQ+ trainees and physicians, they are not only failing workers. They are shrinking the chances that patients will find care that feels safe, competent, and human.

Conclusion

The call to include LGBTQ+ people in medicine’s definition of “underrepresented” is not a plea for trendy wording. It is a request for medicine to describe reality more honestly and respond to it more effectively. The current definition has done important work, especially in centering racial and ethnic inequity. But it no longer captures the full landscape of exclusion inside the profession.

If medicine is serious about building a workforce that reflects society, serves underserved communities, and produces clinicians who can care for patients with competence and dignity, then LGBTQ+ inclusion belongs inside the definition, not in a footnote beside it. The profession already has enough euphemisms. What it needs now is clarity, courage, and the institutional maturity to admit that underrepresentation can have more than one face.