To the Editor,

Women and lesbian, gay, bisexual, transgender, queer, and two-spirited (LGBTQ2S+) physicians working in high-acuity environments disproportionately experience both individual and structural discrimination.1,2 Within anesthesiology, women occupy fewer leadership positions, receive fewer awards, and publish less frequently, indicating structural discrimination.1 Gender and sexuality-based individual discrimination among anesthesiologists has not been explored. We sought to investigate experiences of discrimination attributed to gender and/or sexuality among Canadian anesthesiologists.

With approval of the University Health Network Research Ethics Board (18 April 2019), and in accordance with the Checklist for Reporting Results of Internet E-Surveys, we distributed an internet-based cross-sectional survey to Canadian anesthesiology residents, fellows, and staff (see eAppendix; Electronic Supplementary Material [ESM]).3 The survey was e-mailed to a convenience sample of Canadian Anesthesiologists’ Society and University of Toronto Department of Anesthesiology and Pain Medicine members between June and December 2019 following the modified Dillman approach.4 Participation was anonymous, voluntary, and uncompensated.

Survey development was guided by previous methodology to intentionally characterize intersections between respondent gender or sexuality with experiences of discrimination in the workplace.5 Iterative revisions and validations were performed. The survey was pilot tested.

Multivariable logistic and ordinal logistic regressions predicted respondent likelihood of witnessing or experiencing discrimination, witnessing or experiencing career barriers, and likelihood of being made more uncomfortable. Each regression included the following predictor variables: gender, sexual orientation, age, and level of training. Model fit was assessed using the c-statistic, optimism-corrected Brier’s score, and calibration slope. Analyses were performed in R (version 4.0.1, Vienna, Austria) with a 5% two-sided level of significance.

From 2,313 e-mail recipients, the survey was viewed 1,134 times (view rate 49%), yielding 162 responses (response rate 7%). The majority of respondents were cisgender (159, 98%), heterosexual (130, 80%), and male (104, 64%). A power calculation determined that a minimum absolute difference of 25% could be detected by our sample size.Footnote 1 Being a woman (vs being a man) was associated with a higher likelihood of witnessing or experiencing discrimination (35/55 [64%] vs 40/104 [38%]; adjusted odds ratio [aOR], 3.7; 95% confidence interval [CI], 1.7 to 8.1; P = 0.004), reporting witnessed or experienced barriers to career advancement (38/55 [69%] vs 42/104 [40%]; aOR, 4.2; 95% CI, 1.9 to 9.2; P = 0.001), and being made uncomfortable more frequently by a colleague because of gender or sexuality (aOR, 5.2; 95% CI, 2.5 to 10.7; P < 0.001; Figure). Identifying as non-heterosexual (vs identifying as heterosexual) corresponded to a higher likelihood of witnessing or experiencing discrimination (20/30 [67%] vs 56/130 [43%]; aOR, 3.6; 95% CI, 1.3 to 9.5; P = 0.012) or being made uncomfortable more frequently by a colleague (aOR, 6.4; 95% CI, 2.6 to 15.4; P < 0.001). Data in tabular form can be found in the ESM (eTables 1-5).

Figure
figure 1

Multivariable logistic regression modelled the likelihood of respondents reporting witnessed or experienced discrimination and the likelihood of witnessed or experienced barriers to career advancement. Ordinal logistic regression modelled the likelihood of respondents witnessing or experiencing being made uncomfortable about gender or sexuality more frequently (i.e., often vs sometimes, rarely vs never). All models were adjusted for age and level of training. Adjusted odds ratios of the effect of sexual orientation (green) and gender (purple) are represented for each outcome. The adjusted odds ratio and 95% confidence interval is reported to the right of the Figure. The solid vertical line represents an odds ratio of 1; confidence intervals that cross this line are considered to indicate no effect

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We identified that gender and sexual orientation were significantly associated with witnessing or experiencing forms of individual discrimination. The broad definition of discrimination used in this survey (any behaviour or language towards another person that served to alienate, belittle, humiliate, or trouble) captures experiences of individual discrimination, previously termed as “micro-inequity”.2 To date, most studies of gender discrimination in academic anesthesiology have identified structural discrimination (“macro-inequity”) by identifying imbalances in promotion, leadership, or compensation between men and women.1,2 Structural discrimination has been suggested as a source of bias against LGBTQ2S+ early-career and trainee physicians.1,2 The impact of the “micro-inequities” we have identified may be less visible, but nevertheless damaging, and must be addressed.2 Implementing a departmental Code of Conduct and appointing a Diversity Officer can help address inequity, but individual discrimination must also be addressed individually and promptly.Footnote 2

Our survey limitations include a low response rate and possible selection bias as respondents with negative experiences may be more likely to respond. Conversely, these respondents may have avoided the survey for fear of “being outed.” Despite the low response rate, the sampled population resembles the most recently available Canadian anesthesiology workforce information, and the results highlight an emerging area of research that has not yet been addressed in anesthesiology. Further research by our group includes a qualitative examination of the responses received.

Women and non-heterosexual anesthesiologists are more likely to report witnessing or experiencing discrimination and these groups are more likely to report being made uncomfortable about their gender or sexual orientation. Perceived barriers to career advancement are reported more frequently by women.