I am honored to have been invited to serve as a member of the recently formed AUA Task Force on Diversity and Inclusion. This is an opportunity to provide serious analysis and work toward ongoing improvements on multiple fronts in our specialty. I also appreciate this opportunity to provide some brief personal reflections.

As an academic urologist who has focused much of my career on issues of aging and geriatrics in urology, I have seen the impact of ageism both from patients and colleagues. With a subspecialty in female pelvic medicine, reconstruction and neurourology, I have patients dismiss their symptoms as a normal or inevitable part of aging on a daily basis. Many assume surgery will be the only option offered or that other treatments won’t work. Conversely, I frequently see bias against surgery based on age alone when in reality, data from multiple studies clearly show chronological age is a poor predictor of surgical risk or treatment outcomes.

During my fellowship I established an outreach consultation service to regional skilled nursing and long-term care facilities in the Iowa City area. For two years, a urologic nurse practitioner and I made regular visits to 18 facilities covering more than 1,300 beds. We always had to get approval from the primary physician for each resident. I vividly remember reading one note in a chart that stated, “We will let the urology team see her, but doubt there is anything they can do for her incontinence because she is 87 years old.” Clearly we must continue our educational efforts to enlighten both patients and colleagues.¹

Ageism is also reflected in the proportional educational time devoted to general adult medicine and pediatrics compared to geriatrics. Many medical schools lack dedicated geriatrics educational experiences. Even in urology, it occupies a small portion of our textbooks, educational programs and overall curriculum despite the fact that care for patients over 65 will account for the vast majority of most general urologists’ practices.

I do think our specialty does a good job of avoiding professional ageism and honoring our history and senior colleagues. We have a growing cadre of distinguished leaders, and many of our most prestigious awards are named in their honor. We also have a thriving museum and annual historical display, and at least two of our major professional journals regularly devote space to articles on history.

The other diversity and inclusion topic of particular personal interest is sexual orientation and identity. Thirty years ago, there were few “out” role models, not just locally but in organized medicine. The American Medical Student Association (AMSA) was just starting to organize around this, but to my knowledge no students from my school participated and there was no local group for students or residents in training.

During my second year of medical school we had an entire section of our introductory clinical medicine course devoted to sexual medicine. Sexual orientation and identity were discussed, but perhaps because there was so much information to absorb it became just another part of coursework for me.

I remember one of my medical school classmates writing an eloquent opinion piece for our school newspaper discussing why they elected to conceal their sexual identity. She or he chose to remain anonymous because they had seen less than positive reactions from some of our other classmates about the topic during educational sessions. Although I never witnessed that overtly, I do remember sensing what would today be called micro aggressions by others. But the title of their editorial, ‘Sitting Among You’, spoke volumes about what they and many of us were feeling. Culturally it was a very different time, and when we had a session with members of the local LGBT+ community who came to help us learn about providing quality care for sexual minority patients, none of us revealed our own sexual identities. I remember it being a challenging small group discussion session after the large group presentations, and wanting to step forward about myself but feeling constrained by the prevailing social norms of that moment. Years later, it’s interesting to know a number of my medical school colleagues as out and proud lesbian and gay physicians and surgeons.

As an out gay man I am keenly aware how society, including organized medicine, has progressed recently. Everyone who identifies as a sexuality or gender minority is on their own personal path. I was not out during medical school, residency, or fellowship, but made a conscious decision to live openly when I became an attending urologic surgeon. It ushered in a new phase of my life both personally and professionally. Looking back, I realize it wouldn’t have mattered had I come out earlier given the strong support I received from my family, mentors, colleagues and friends. As an educator, I hope to provide similar support and guidance for people in training and others exploring their own personal and professional paths.²

My sexual orientation is only one facet of many parts that constitute my identity. It is not typically part of discussions with patients, but I have selectively offered this information when I knew someone was struggling with their own similar issues. I have received many referrals of LGBT+ patients over the years because they knew of someone who had previously received quality urologic care in our practice.

A true highlight of my career to date was being elected to serve as President of the AUA South Central Section for 2018–2019. Traditionally, the President and their spouse serve as co-hosts and organize large portions of the meeting. My husband, Michael Miklovic, and I took great pride in being able to fulfill this role together and the meeting was very successful.

As a society and as a specialty we have a long way to go to achieve true equity around topics of diversity and inclusion. But we have come a long way already in my lifetime, and will hopefully achieve more in our future. Although not gone, I see fewer barriers and more opportunities on the horizon.