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Milieu in Dental Schools and Practice |
Dr. More is Professor, Department of Epidemiology & Health Promotion, College of Dentistry, New York University; Dr. Whitehead is Assistant Professor, Department of Family Medicine, College of Osteopathic Medicine and Assistant Professor, Department of Oral Health Science, College of Dental Medicine, Nova Southeastern University; and Mr. Gonthier is Associate Dean, Student Affairs and Admissions, School of Dental Medicine, Tufts University. Direct correspondence and requests for reprints to Dr. Frederick G. More, New York University, 433 First Avenue, Room 114, New York, NY 10010-9416; 212-998-9981 phone; 212-995-4317 fax; fgm1{at}nyu.edu.
Key words: gay men, lesbians, bisexual, transgender, multicultural, GLBT patients, support services
Submitted for publication 01/13/04; accepted 03/31/04
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Events beginning with the 1969 Stonewall Riots in New York City and continuing since then have facilitated GLBT persons becoming more open and visible about their sexuality. The self-disclosure or "coming out" of persons who hold political office and others who are recognizable figures in politics, the arts, and academe, as well as the increasing visibility of GLBT through the media, has encouraged many people, formerly closeted, to redefine being open about their sexuality. The openness of personalities in the media, sports, and elsewhere has brought gay men and women from invisibility to visibility. The recent decision by the U.S. Supreme Court ruling3 that sodomy laws were unconstitutional was another step in opening doors for even more homosexuals to emerge from their silence. In a more accepting environment, adolescents and young adults have accepted their sexuality and gained appropriate support during their adolescence and early adulthood. They expect to be recognized and accepted as GLBT persons and regard their sexuality as a core part of their identity.
Based on the experiences of a group of GLBT students currently enrolled in dental schools, it is our position that, from the first introduction that applicants have with prospective dental schools, there is an assumption that the applicant is heterosexual. The application process is only one example of heterosexism in the process: "Heterosexism is a belief in the superiority of heterosexuals or heterosexuality evidenced in the exclusion, by omission or design, of non-heterosexual persons in policies, procedures, events, or activities."4
During the application process, at interviews, and during informal discussions, it is assumed that the applicant is heterosexual rather than approaching the process with neutrality. Social activities, faculty interviewers, and opportunities on the main campus of the university reflect mainstream heterosexual experiences and values. The GLBT applicant is forced to make a choice immediately about being "out," or to network under the surface, with respect to his or her sexuality and ultimately answer the question "are gay people a part of dentistry?" Contrast this with an application process where visibility for GLBT students is similar to other minority groups. Racial and ethnic minority applicants are identified early, and there is an active process to promote the spirit of inclusion that may exist at the institution. The minority applicant is introduced to students already enrolled and faculty members at the college from similar backgrounds in order to increase the level of comfort for the applicant. In publications that promote the institution that are distributed to applicants and entering students, editors rigorously work to make their publications portray the "multicultural" nature of the institution.
The issue of human sexuality has been extensively investigated, and it is accepted that one’s sexuality is not a matter of choice.5–8 Given this information, it follows that GLBT persons in society have gained acceptance. Newsweek9 reported the results of a survey of adults conducted in association with a special report on "Gay and Lesbian Issues." It showed that 82 percent of adults polled reported that gay men and lesbians should not be subjected to discrimination in the workplace and 62 percent supported providing benefits for the same-sex partners of employees where benefits existed for married employees. Colleges and universities have nondiscrimination policies that recognize sexual orientation as a protected group. In recruitment and retention efforts, a few prestigious institutions have worked to gain employment for the same-sex partner of a faculty member that the institution wants to hire in a manner similar to efforts with spouses of straight couples.10 The American Academy of Pediatrics has endorsed adoption by same-sex couples as an acceptable means to provide a loving nurturing family for children.11 Considering the number of same-sex couples who have adopted, dentists will undoubtedly have young patients with same-sex parents.
In one study, reported by a task force at the University of Michigan, a survey of GLBT persons showed that they remained "closeted"—that is, secretive about their sexuality.12 They can repress or deny their "gayness" and pretend to be heterosexual. In conversation, they avoid referring to personal items and choose to talk in generalities about their personal life. They may live the same way or have a life that is divided between their gay life and their other life. They encounter hostility overtly and covertly in their life. Examples include classmates and other persons using terms such as "queer," "fag," "fairy," "butch," "dyke," and "queen" in a derogatory manner. An angry comment may result in one person calling another "fag." In a national survey conducted in 2001 of students in the K-12 system, reported by the Gay, Lesbian, Straight, Education Network (GLSEN), 84.3 percent of 904 students reported that they hear derogatory comments about GLBT frequently or often at school, and 81.8 percent said that teachers overhearing the comments do not act.13 Negative self-image and low self-esteem result when a person’s feelings about his or her sexuality are continually labeled as wrong or bad. That plus the absence of GLBT role models makes the task of being open or admitting their sexuality (being "out") difficult if not impossible. The suicide rate for gay youth is estimated to be three times that of heterosexual youth.14
The Gay Lesbian Medical Association (GLMA) was coauthor of a study on the health of GLBT persons. This study is found as an addendum to "Healthy People 2010." The GLMA study showed that GLBT person have diminished health and health outcomes and are marginalized in the health care community because of their sexuality. The study also shows that GLBT patients find it difficult to identify health care providers with whom they are comfortable and report "filtering" information they are asked to provide because they lack safety in the health care setting.15
There is no information about the environment in U.S. dental schools and dental education institutions for GLBT students. The purpose of this study was to assess the present situation with respect to nondiscrimination policies, etc., in these schools, review the literature about other health professions, and generate recommendations for strategies to support GLBT students.
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Student affairs administrators were selected because they are assumed to be very knowledgeable about the school, students, and faculty. The data collected was public information contained in university and dental school publications and readily available for the administrator. No confidential sources or information that personally identified participants or subjects in incidents was included in the survey. The completed survey was returned to one person, any identifiers inadvertently included were removed, and the survey form was sent to another person who analyzed the results to maintain anonymity and ensure confidentiality.
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and outlined here.
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Dental schools do not collect data on personal information such as sexuality. However, ten of the responding schools provided estimates of the numbers of GLBT students and faculty ranging from at least one to more than ten. Each of these ten schools reported higher numbers of GLBT students and faculty compared to 1997.
When asked to assess the "climate of their dental school" for GLBT students/faculty, 61 percent of the respondents rated their institution as "somewhat tolerant" or "very tolerant." Sixteen administrators were not willing or unable to assess the climate at their institution. Eight of forty-five responding schools were not aware of any dental school or campus support groups for GLBT students. Of those who were knowledgeable about their school and campus resources, only two (7 percent) said their school had a support group for GLBT students. However, thirty-two dental school student affairs officers reported that their campus had such a support group.
When asked to report the occurrence of incidents within the dental school based on sexuality, five out of thirty-six respondents completing this item reported that incidents had occurred in their school compared with eight who did not know about incidents in the dental school and thirty-one who claimed no incidents had occurred. When asked about occurrences reported on the main campus of their parent institution, twenty-eight of forty-five respondents did not know of incidents on their main campus. Of those sixteen who responded having specific information about incidents, seven respondents were aware of incidents occurring on their main campus, and eight respondents confirmed there were no incidents on their campus that had been reported.
Administrators were asked questions about patients in the college clinics. Forty-five percent (21 responding dental schools) were aware of GLBT patients being treated in their schools. Twenty percent said that students had not reported treating GLBT patients, and 33 percent (sixteen dental school student affairs administrators) reported that they did not know if GLBT patients were not treated in their school.
An effort was made to ascertain to what extent GLBT issues occupied curriculum time in the dental school. Twenty-two of forty-five schools responding to these questions said that zero to two hours were spent on GLBT issues. Eighteen dental schools reported spending more than two hours on these issues.
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In part, this article stemmed from work done over the past seven years during which a Gay-Straight Alliance Special Interest Group (GSA-SIG) was formed within the American Dental Education Association. A thorough review of the health sciences, education, and social sciences literature, as well as the popular press, revealed a high level of support for inclusion of GLBT persons in all aspects of their personal and professional lives. While some geographical areas have historically been more hospitable than others for GLBT persons, there is a growing level of support for GLBT persons to enjoy the same protections and freedom from nondiscrimination as others enjoy in this country.
The Climate and Culture of U.S. Medical and Dental Schools
Issues of climate and culture in dental and medical education have been a matter of discussion over the years. These issues include matters related to the health and well-being of patients and the climate and culture of the profession itself. Our survey attempted to identify if issues of sexuality are addressed in any manner with respect to dentists forming doctor-patient relationships. In the survey (Figure 1), Question #17 asked about patient case histories that included sexuality. It was assumed that if sexuality was included in a patient case history, faculty would be more inclined to elaborate on this element of the patient’s life experience. What is the ethical obligation of dentists with regard to the acceptance of subgroups that seek oral health care? Anecdotal evidence of the public’s expectation that the profession is open to all patients is available in at least one case where the New Hampshire Board of Dental Examiners removed the license of a dentist who discriminated against patients because of their sexuality.16 Cultural blindness in a health care practice is not appropriate in an era in which cultural diversity is valued. It should be considered as part of the normal process of developing a productive relationship with patients to promote health and working toward optimal treatment outcomes.
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Other professions have sought to gain information about the climate and culture in that profession. In 1991, Townsend et al.17 reported that GLB medical students perceived that there were unmet needs in the social environment of medical school and in the medical school curriculum with respect to their needs and the needs of GLB patients. Tinmouth and Hamwi18 received survey responses from eighty-two U.S. medical schools and learned that schools devoted an average of 3.5 hours of curriculum time to education about GLBT topics under the heading of human sexuality. This situation is in contrast to information provided by dental schools in this survey that indicates that little or no time is spent on this topic. In nursing, Eliason and Raheim19 report that nursing students experience negative emotional reactions and social disproval about GLB persons and claim that lack of knowledge and inexperience are the root causes.
The dental profession has taken a positive position with respect to the obligation of dentists in a multicultural society. In 2002, the American Dental Association published its report on the Future of Dentistry.20 One of the values reported and recommended for adoption related to "diversity." Specifically, it spoke to the primary goal of the profession to improve the health of the public in a culturally competent manner. The mission and values statements of dental schools often contain language supporting "diversity" and "multiculturalism." Accepting this goal at face value stimulates educators—who are charged with educating the entry-level practitioner—to define the full range of diversity and ensure that students are at least minimally competent to meet the needs of the subgroup. It follows that schools will provide an environment for students, faculty, administrators, and patients that fosters skill and experience in building trusting relationships and therapeutic alliances among all members of the community.
In this survey, respondents did not know why GLBT students were not out and visible, but speculated on several causes. "Fear" and "prejudice" were reported as the major reasons suspected for these students choosing to remain invisible. Most GLBT students are unfamiliar with GLBT faculty who may be around them. One illustration of the experience of GLBT persons can be found in a response to an open-ended question in a survey about campus life at the University of Michigan in 1990, where a lesbian administrator wrote, "When people I know find out I’m a lesbian, they change what they think about lesbians. When people I don’t know find out I’m a lesbian, they change what they think about ME."12
In a letter to the editor of the American Student Dental Association, a student from one west coast dental school protested the inhospitable environment for gays and lesbians she witnessed at an annual meeting of ASDA and shared a disturbing anecdote about an experience with a transgender patient. She called upon ASDA leadership to become sensitive to their stated mission that encourages openness to diversity in every respect.21
There is a dichotomy between the altruistic values in health care that seek to promote inclusion and respect for diversity and the present climate and culture in health professions schools. Providing foundation knowledge and experiences that result in multiculturalism competence—or the understanding and acceptance of personal differences—would result in academic and student affairs administrators knowing characteristics of their community. If this were so, students would witness others demonstrating respect for persons who are different from themselves and see faculty modeling behaviors that show respect for everyone within the environment. In fact, Townsend et al.22 showed that medical students who had access to school or community support were more likely to disclose their sexuality and know faculty with whom to discuss issues.
Self-Disclosure
Knowledge about the sexuality of a person or "coming out" is a major event for a lesbian or gay man. For the transgender person, knowing which gender-identity is an essential issue. This reluctance to self-disclose their sexuality is usually based on their sensitivity to the openness and safety of their present environment and whether this environment can be trusted. The risk for the GLBT person is once they are out they cannot retreat to their former anonymity.23 This survey showed that student affairs administrators, who by virtue of their position should be most familiar with the student body, appeared to be largely unaware of this aspect of student life. Because of this, GLBT students may not trust the school environment because they do not perceive themselves as being known or understood by student affairs administrators. A proactive student affairs administrator role model may be able to prevent this self-fulfilling prophecy from occurring.
The search for sexual identity, along with adjusting to college life, adds a special challenge for gay, lesbian, and bisexual students. Homosexuality should be recognized as only one aspect of a student’s identity. When you team the search for sexual identity with the changes typically associated with student life, many GLBT students have a unique and difficult transition in higher education.
Unfortunately, when students are recognized on campuses as being GLBT, they often live with, and fear, verbal harassment and/or physical violence from others not part of the gay community. D’Augelli and Rose studied the attitude of 218 first-year students at Pennsylvania State University toward GLB persons. These students, predominantly Caucasian and middle-class, had negative views regarding GLB students on campus. In particular, the male respondents were more homophobic than the female respondents and reported making homophobic comments.24 These same researchers in another study at Pennsylvania State University collected data from 121 self-reported GLB students. They found that 99 percent of the GLB students had heard derogatory remarks related to gay men, lesbians, and bisexuals from other students on campus. Only 3 percent of the respondents felt "totally comfortable" in revealing their sexual identity to others.8
Hogan and Rentz25 studied homophobia among faculty members and student service personnel at two midwestern state-related institutions. Student service personnel were surveyed about their attitudes about homosexual students. Their findings concluded that faculty members were more homophobic than student service personnel and that the male respondents were more homophobic than female respondents.
Most students regard their professors as positive role models. Finding homophobia among faculty members is detrimental to GLBT students. Referring to gay and lesbian students as the "Invisible Minority," Lopez and Chism26 investigated concerns that this population has regarding faculty and curriculum issues. Emphasis was placed on the role a professor has in the classroom to make the learning experience positive for gay and lesbian students. The researchers make recommendations for professors to overcome their homophobia (that is, overcome their difficulty interacting with GLBT students or talking about GLBT issues) based upon surveys and interviews they conducted with gay and lesbian students.
Within the gay community of professionals, there has been ongoing dialogue about the wisdom of professors "outing themselves" in the classroom. In her article in the periodical Change, Catharine Stimson writes, "One reason the tension is so dynamic [for educators who resist coming out in the classroom] is the ferocity and pervasiveness of the prejudice against gays and lesbians."27 She explains that the roots of the tension are social and psychological. She concludes that heterosexuals cannot be solely the members of a single block that is "normal" and homosexuals cannot be part of a block that is hateful. Others view that coming out in the classroom is a positive action. The faculty member being out relieves the tension felt by the faculty member because of the effort and secrecy of trying to "pass" as heterosexual and it precludes students learning a "secret" about the faculty member that becomes a "dirty little secret." Faculty being out challenges the dominant thinking of the institution about sexuality, plus coming out provides a role model for gay and straight students alike.28
Supporting GLBT Students
This survey found many inconsistencies. First was the general lack of information about a significant subgroup within their dental school in spite of the vast majority of dental schools being in an institution with a nondiscrimination policy that includes sexual orientation as a protected group. In addition, more than half of U.S. dental schools are part of a campus with GLBT support groups. Based on anecdotes provided by GLBT students at seven U.S. dental schools in their self-reported experiences presented at ADEA Annual Sessions between 1998 and 2004, they found support in the form of a dental school group or a faculty member who is out and open. They report that classmates choose not to be out because of fear of reprisals and discrimination from other students and faculty. In 2000, at one dental school, a class officer risked coming out to his class to quell rumors and innuendos being spread by another student who was a candidate for the same class office.
Supporting students during their education takes many forms such as advisement, counseling, and advocacy, as well as specific support of cultural and ethnic subgroups in the school. The Commission on Dental Accreditation defines "personal, academic, and career counseling" as services that institutions must provide to students. During one testimonial about his experience given at the GSA-SIG program at the 2002 ADEA Annual Session, a gay student said that he had rejected dentistry as a career choice based on his conviction that there were "no gay dentists." Then after making contacts with professional organizations on the Internet, the student found an ally in the form of an out faculty member at another dental school.
In their description of the coming out process, Rosario et al.29 identify four dimensions in a multidimensional process: 1) sexual identity as GLB, 2) self-identification as GLB, 3) attitudes toward homosexuality, and 4) disclosure of sexual identity to others. Further, they link this orderly process as part of the student’s overall well-being. Given this clear description, support services for GLBT students should attempt to facilitate the realization of these dimensions and provide support during the student’s matriculation.
To provide these services, dental schools must demonstrate their acceptance of the students who are enrolled as well as to recognize that all students have individual needs that must be met during the time they are enrolled. On the diversity issue, faculty and administration have the responsibility to define "diversity" and provide the foundation knowledge, define competence, and demonstrate that they value the presence of each subgroup within the college community.
GLBT students face the same challenges as other students, as well as the additional somewhat unique burden and responsibility of defining their place with themselves and their families, society, and profession. Given the level of acceptance articulated as a goal by the profession, it is inappropriate to exclude subgroups.
Several dental schools have made initial attempts to provide services for GLBT students. The University of Pittsburgh School of Dental Medicine publishes a brochure titled "Gay and Straight Alliance" designed to demonstrate inclusion of GLBT students and faculty. The University of the Pacific School of Dentistry began a Commission on Equity and Diversity that seeks to provide a forum to promote equality throughout the institution. New York University provides a student-sponsored program called "Safe Zone" designed to train GLBT persons and their allies to promote openness and to make the environment sensitive to the needs of GLBT students. Tufts University provides a website for prospective students who have questions about GLBT persons on campus and programs that are available.
There are models for promoting inclusion available on the main undergraduate campuses of many health professions schools. A core feature of each model is the goal of promoting openness and inclusion. These programs recognize the struggle of a group of students who have unresolved issues related to their sexuality and need support during a vulnerable time of self-discovery. Access to mental health professionals, coming out groups, and support services are essential resources that are found on college campuses but not within any U.S. dental school at this point in time.
Based on the survey results reported in this article and review of the literature, we recommend that dental education institutions should provide the following support services for GLBT students:
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As we work to overcome homophobia in academia across all lines, the expected outcome is to have a better understanding of this distinct population and a heightened awareness of what GLBT individuals face living in a society that is less intolerant than in previous years, but can remain hostile to gay men, lesbians, bisexuals, and transgender persons. If universities, including dental schools, are the supposed bastions of freethinking and liberalism, it is ironic that academic settings are also the place where GLBT individuals meet with adversity or silence. As members and leaders in dental education, what we choose to do or not to do to serve this population will not only have some bearing on their accomplishments and persistence at our institutions, but also contribute greatly to their self-esteem.
Additionally, health professions schools like dentistry can play an important role by providing the kind of supportive developmental environment for students that has been emphasized in this article. Schools also educate the entry-level practitioner to reach multicultural competence. The goal embodied in this latter effort is to reduce disparities in health outcomes. The extent to which we adopt a model that foster inclusion, acceptance, and understanding is the extent to which we can erode disparities.
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