Since its inception, the AUA Census has sought to characterize the current state of urology in North America. Census results have been used to guide policy making and identify areas of improvement within the urological and broader communities. In line with its diversity, equity, and inclusion initiatives, the AUA has taken steps to broaden the scope of questions within the Census. Most recently, this push has included demographic and discrimination questions related to gender identity and sexuality. As the AUA seeks to evolve into a more inclusive organization that reflects American society, focus has turned to how the Census and advocacy arms of the AUA can be used to improve representation in the LGBTQ+ urological workforce.

The history of AUA Census questions pertaining to sexuality and gender identity is brief: prior to the 2021 Census, demographic questions were limited to a male-female gender binary, race/ethnicity, and relationship status. Thus, the 2021 Census was the first to inquire about sexual orientation and gender identity. Of the 13,790 urologists who took the 2021 Census, 208 (1.5%) identified as gay or lesbian; 164 (1.2%) used a term other than straight, gay, or lesbian; and 48 (0.3%) identified as transgender, nonbinary, or gender nonconforming (see Figure).¹ This small number of gay, lesbian, or gender-nonconforming practicing urologists stands in contrast to recent data on LGBTQ+ demographics in the United States. Perhaps the most prominent recent estimation is the U.S. Census Bureau’s 2021 Household Pulse Survey, which estimates the gay/lesbian population at 3.3%, the transgender population at 0.6%, and the nonbinary population at 1.7%.²

Interestingly, 5.6% of urologists who took the AUA Census preferred not to answer demographic questions related to sexuality. This may be because LGBTQ+ physicians experience stigma and discrimination within the workplace.³ The 2021 AUA Census data corroborate this and show that 1.4% of urologists experienced discrimination based on sexual identity and 1.8% experienced discrimination based on gender expression. Due to this discrimination and potential fear of being stigmatized, some LGBTQ+ urologists may not feel comfortable being “out” in the AUA Census, professionally, or to their patients.

The AUA Census is not without limitations. The AUA Census recognizes some of these when it states that, due to small sample sizes, some of these “estimated value[s] should be used with caution.” Another limitation is that these are self-reported data, which may underestimate real numbers. And perhaps most unfortunately, the most recent AUA Resident Census (Urologists in Training: Residents and Fellows in the United States) limited gender identity questions to a male-female binary and did not inquire about sexual orientation. In this way, the AUA Census fails to shed some light on the future of the urological community.

Urologists are uniquely positioned to provide care for people of various sexual and gender identities because our wide scope of practice includes care for patients with disorders of sexual differentiation, transgender individuals seeking gender-affirming surgery, and a range of people with sexual dysfunction. Further, meta-analyses have repeatedly shown that diverse health care teams lead to better patient outcomes; improved innovation, communication, financial performance, and risk assessment; and greater ability to avoid the friction associated with change.⁴ Thus, it behooves the urological community to continuously assess the state of diversity and equity, and to include differing viewpoints when setting policy and advocating for patients and providers.

Through this lens, the AUA Census can be wielded as a force to better serve providers and communities, and to decrease the disparity between the LGBTQ+ urological providers and the general population. One way that the Census can achieve this is through outreach: if urologists better understand the advocacy role(s) the AUA Census can serve, then they may be more willing to answer questions pertaining to sexuality. Another way to achieve this is by stressing confidentiality and privacy of Census data. Efforts to assuage fears of discrimination or release of private information, and to maintain data security should be paramount for AUA Census administrators. While the landing page for the Census states that the data are de-identified, we propose that this be reinforced prior to asking potentially sensitive questions such as gender identity, sexual orientation, and experiences of stigma and discrimination. A third way to bridge the LGBTQ+ urologist-to-population gap is to increase recruitment of LGBTQ+ students, historically underrepresented in medicine, into urology. And a final way is to give LGBTQ+ urologists positions within the AUA policy-making groups to ensure their involvement in decision-making for the organization.

The stated mission of the AUA is to advance urology through education, research, and advocacy. The AUA Census works to achieve this mission by better understanding its constituents for the purpose of advocating for their needs, interests, and patients. We recommend that the AUA continue and expand upon these efforts to ensure accurate and confidential data collection, ensure LGBTQ+ representation in policy decision-making processes, and promote a more diverse workforce to improve quality care for all our patients.