Diversity and equity are timely and essential topics in all of medicine, including urology. Regarding lesbian, gay, bisexual, transgender, and other allied (LGBT+) urologists, our representation is difficult to quantify. While there is a small cadre of out LGBT+ urologists, even an estimate of the total number is impossible. From our anecdotal experience, we estimate that this number is low. According to a 2017 Gallup poll, 4.5% of Americans identify as LGBT+,¹ leading one to assume that there are similar numbers within urology. Using this figure, we could estimate that of the 23,000 AUA members globally, a little over 1,000 may identify as LGBT+. However, the issue of calculating this number is complicated since there are likely urologists who identify as LGBT+ but do not feel comfortable making this information known personally or professionally for various reasons.

There are reasons for a urologist to feel uncomfortable being out professionally. Many LGBT+ physicians have experienced discrimination or mistreatment based on sexual orientation or gender identity perpetrated by mentors, colleagues or even patients.² The fear of this treatment continues to encourage some to remain in the closet. Additionally, since urology involves working with patients on sensitive issues, including sexual health (topics around which LGBT+ urologists already face stigma), unique professional challenges are posed that are rarely discussed and deserve attention.

Nonetheless, some providers use their LGBT+ identities as assets instead of a liability and market their services to other LGBT+ people. As patients, LGBT+ people may have specific health issues to consider, especially in urology,³ that may not be familiar to nonLGBT+ physicians. Additionally, many patients feel more comfortable talking about these issues with providers with whom they can identify. Increasing the diversity of the urological workforce will only improve the quality of care these patients receive.

The number of out LGBT+ students and trainees is increasing in medicine overall and likely also within urology. There is also some evidence that the number of practicing out LGBT+ physicians is rising. The American Medical Association added sexual orientation and gender identity to their census in 2018, and in that year 4% of 15,000 members self-identified as LGBT+. This is similar to the general population. In 2019, 15% of Harvard’s entering class of medical students identified as LGBT+.⁴ This speaks to the value schools have placed in diversity, equity and inclusion in recent years.

However, as these numbers increase it is essential to recognize that LGBT+ students and trainees within urology have unique challenges that we must address. One study has shown that stigma prevents LGBT+ students from forming close relationships with faculty members and educators.⁵ Given this and the fact that there are few out LGBT+ urologists, young urology trainees and students often struggle to find mentors or role models with whom they identify. Additionally, many students are still actively encouraged to hide their LGBT+ identity to improve chances of matching, and some continue to feel uncomfortable coming out during residency.

For more than 25 years, there has been an annual gathering of LGBT+ urologists at the yearly AUA meeting. Now known as the “Pink Trigones,” the group initially came together as an idea by Dr. Mark Litwin, now Chair of Urology at UCLA. In 1994, after completing a fellowship, he was interested in fostering social and professional connections between community members. As he noted in a recent discussion, this was before the time of email/internet and still at the height of the AIDS crisis. He decided to organize an informal social gathering at the 1994 AUA meeting in San Francisco, and about 8 or 10 people gathered at a local urologist’s home for that first meeting.

The name of the group evolved organically and represented essential concepts in our community heritage. The trigone’s shape and color evoke the pink triangle, a sign that was used as a mark against gay and bisexual men and transgender women in concentration camps during WWII. The community has since reclaimed the symbol as a symbol of LGBT+ pride. The group’s purpose is still social but has helped many people realize they are not alone as LGBT+ in urology. The gatherings now include increasing numbers of practicing urologists, trainees and medical students. Dr. Timothy Tseng, urology faculty member at the University of Texas at San Antonio, who is now the group organizer, notes that there are 118 people on the most recent invitation list. Anyone interested to join is welcome.

So what do we do now? We have a long way to go before we will have true sexuality and gender minority (SGM) equity in urology where every LGBT+ urologist is comfortable being out. However, until we have some data we will not know the scope of the issue and the extent of the work needed. To help attain these data, the AUA census will be adding questions regarding members’ gender identity, sexual orientation and other essential data points. This is a crucial first piece of the puzzle. For now, it is crucial to make LGBT+ colleagues feel comfortable and accepted at work. Besides benefiting LGBT+ practitioners, having a more open dialogue about these issues will help the entire urological community. Contact with LGBT+ faculty, residents, students and patients has been demonstrated to reduce implicit and explicit bias among medical students⁶ and other professionals.⁷

Reducing bias improves diversity, which is in line with the AUA’s recently developed Diversity and Inclusion Task Force goals. It’s also vital to keep LGBT+ urologists in academia to serve as role models for medical students and residents interested in urology. With some work, we can vastly improve the diversity of our field and the well-being of our colleagues and our patients.