And then I would ask about institution leadership and mentorship: "As an LGBTQ medical student, are there any LGBTQ faculty in leadership positions in your health sciences center, hospital or department?"

I often got blank stares and some form of "I have no idea."

Every program I visited could speak to its LGBTQ patient population, curriculum and educational experiences. But only one could point me toward an openly LGBTQ physician in a leadership position who could serve as a role model.

Although finally acknowledging the need for LGBTQ curriculum in medical education is a huge improvement from where medical education used to be, it isn't enough. LGBTQ patients are historically marginalized and have higher rates of inequitable health care and worse outcomes. It is imperative to develop a physician workforce that reflects the population it serves, and this is especially true for historically disenfranchised and marginalized populations. A 2017 study demonstrated that positive role modeling by, and increased interaction with, LGBTQ physicians decreased both implicit and explicit bias among medical students toward the LGBTQ patients they serve.

The AAFP, Association of American Medical Colleges and many other medical organizations recognize the importance of equitable representation in the physician workforce in better serving diverse patient populations, and they have expanded the definition of diversity to include sexual and gender identity.

But how many medical school deans identify as LGBTQ? How many faculty, professors and hospital administrators?

The medical community has rallied against the lack of diversity in medicine, both in medical education and leadership. This got me wondering: Where are the LGBTQ physicians and how are we progressing toward an LGBTQ physician workforce that reflects our diverse communities?

According to 2017 data from a Gallup poll, approximately 4.5% of Americans identify as LGBTQ. This is likely an underrepresentation because there is a significant skew toward younger generations, potentially indicating a generational difference in self-identification based on changes in societal acceptance.

The AAMC has only recently started to collect information regarding sexual orientation and gender identity from medical students. Since 2016, the organization has included two SOGI questions in its annual Matriculating Student Questionnaire and Medical School Graduation Questionnaire. From 2017 to 2019, the percentage of graduating medical students identifying as bisexual increased from 4.2% to 5%, and those identifying as gay or lesbian increased from 3.6% to 3.8%. In the same time, the number of graduating medical students who had a different gender than that assigned at birth increased from 0.6% to 0.7%.

This data is incredibly important, and I applaud the AAMC for tracking it. But there is currently no large-scale data collection on SOGI among resident physicians, practicing physicians or physician leaders.

We don't know how many LGBTQ docs there are, what specialties they are in or where they practice.

The AAFP, AAMC and numerous other professional medical organizations have declared that more underrepresented minority physicians and more female physicians are needed. Can the same be said for LGBTQ physicians? This is a more difficult question to answer because there isn't comprehensive data.

The AAFP's National Conference of Constituency Leaders includes a special constituency for LGBTQ members, yet we have limited data on LGBTQ members. The available data indicates that only 3.2% of AAFP members identify as gay, bisexual or uncertain. This is well below the 4.5% LGBTQ figure reported in the Gallup poll and could indicate underrepresentation in AAFP membership and/or a reluctance to self-identify. With 8% of AAFP member respondents declining to answer the SOGI questions, we are far from acquiring the comprehensive data needed to make changes. (Members can easily update their demographic information online. We are only as good as our data.)

The numerous pipeline programs that directly address racial, ethnic and socioeconomic diversity in the physician workforce have amassed data to track their progress. I have been told by some physician leaders that similar data isn't collected on SOGI because of the need to protect individuals who identify as LGBTQ. I am not naïve. There are real reasons why students, residents, practicing physicians and physician leaders are afraid to self-identify as LGBTQ.

I recently saw two of my favorite patients -- a wife and husband with a complicated medical history who I have been following since residency. During the visit, the husband made a homophobic joke about his effeminate psychiatrist, who is openly gay. The joke didn't seem hateful or ill-intentioned, but it still stung me deeply. In that moment, I realized that this couple had no idea that I was an LGBTQ physician.

I want my diversity to count and be counted. I am open about being LGBTQ in my department and residency program, but it is sometimes difficult to convey this identity to others in the same way that racial and ethnic identity is conveyed. Despite never hiding my sexual identity from patients, most of them, if not all, likely assume I am heterosexual.

It would have been easier to let my patient's joke go and continue with my clinic, but that's not what I did. Instead, I took the opportunity to have a brief discussion with my patient; I hope it was a formative moment for us both.

I recognize that I am in a relatively safe situation. I live in one of the 21 states that protect employees from discrimination based on sexual identity. I am a physician in a department that values diversity, including LGBTQ identity, and I have a group of colleagues, friends and a husband who support me. Not everyone is so lucky.

Discrimination, and even violence, based on sexual or gender identity is real, and indicates that this impacts medical students' desire to self-identify. A 2015 study examined survey results from 2009-2010 regarding the LGBTQ status of graduating U.S. and Canadian medical students. Of the 920 LGBTQ medical students who responded, 44% feared discrimination in medical school, and 61% said their sexual identity was "nobody's business." More than 30% of respondents stated that they concealed their sexual identity in medical school.

I want to respect individual physicians and their unique situations, but that respect must be balanced with the need to develop the LGBTQ physician workforce that our patients deserve. Building the Next Generation of Academic Physicians is one of the organizations that is working on this development, and the AAFP, in its policy on workforce diversity, states that it will "position itself in a leadership role in creating a medical workforce reflective of the patient populations family physicians serve."

Diversity strengthens family medicine, and that diversity includes our LGBTQ physicians. I hope that someday in the near future we have the data needed to align ourselves fully behind that goal and continue advocating for a diverse workforce that serves our communities.

Kyle Leggott, M.D., is a family physician doing a fellowship in health politics and policy at the University of Colorado. You can follow him on Twitter @KyleLeggott.

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