Sara E. Burke

Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People among Heterosexual First-Year Medical Students? A Report from the Medical Student CHANGE Study

Purpose A recent Institute of Medicine report concluded that lesbian and gay individuals face discrimination from health care providers and called for research on provider attitudes. Medical school is a critical juncture for improving future providers’ treatment of sexual minorities. This study examined both explicit bias and implicit bias against lesbian women and gay men among first-year medical students, focusing on two predictors of such bias, contact and empathy. Method This study included the 4,441 heterosexual first-year medical students who participated in the baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, which employed a stratified random sample of 49 U.S. medical schools in fall 2010. The researchers measured explicit attitudes toward gay and lesbian people using feeling thermometer self-assessments, implicit attitudes using the Implicit Association Test, amount and favorability of contact using self-report items, and empathy using subscales of the Interpersonal Reactivity Index. Results Nearly half (45.79%; 956/2,088) of respondents with complete data on both bias measures expressed at least some explicit bias, and most (81.51%; 1,702/2,088) exhibited at least some implicit bias against gay and lesbian individuals. Both amount and favorability of contact predicted positive implicit and explicit attitudes. Both cognitive and emotional empathy predicted positive explicit attitudes, but not implicit attitudes. Conclusions The prevalence of negative attitudes presents an important challenge for medical education, highlighting the need for more research on possible causes of bias. Findings on contact and empathy point to possible curriculum-based interventions aimed at ensuring high-quality care for sexual minorities.

The mixed impact of medical school on medical students’ implicit and explicit weight bias

Health care trainees demonstrate implicit (automatic, unconscious) and explicit (conscious) bias against people from stigmatised and marginalised social groups, which can negatively influence communication and decision making. Medical schools are well positioned to intervene and reduce bias in new physicians.

Internalized HIV and Drug Stigmas: Interacting Forces Threatening Health Status and Health Service Utilization Among People with HIV Who Inject Drugs in St. Petersburg, Russia

Marked overlap between the HIV and injection drug use epidemics in St. Petersburg, Russia, puts many people in need of health services at risk for stigmatization based on both characteristics simultaneously. The current study examined the independent and interactive effects of internalized HIV and drug stigmas on health status and health service utilization among 383 people with HIV who inject drugs in St. Petersburg. Participants self-reported internalized HIV stigma, internalized drug stigma, health status (subjective rating and symptom count), health service utilization (HIV care and drug treatment), sociodemographic characteristics, and health/behavioral history. For both forms of internalized stigma, greater stigma was correlated with poorer health and lower likelihood of service utilization. HIV and drug stigmas interacted to predict symptom count, HIV care, and drug treatment such that individuals internalizing high levels of both stigmas were at elevated risk for experiencing poor health and less likely to access health services.ResumenLa frecuente simultaneidad entre el VIH y el consumo de drogas inyectables en San Petersburgo, Rusia, sitúa a muchas personas en la necesidad de disponer de servicios de salud, bajo el riesgo de estigmatización basado en la ocurrencia de ambas características simultáneamente. El presente estudio examinó los efectos independientes y de interacción entre los estigmas internalizados hacia el VIH y hacia las drogas, sobre el estado de salud y la utilización de servicios de salud en 383 personas con VIH que se inyectan drogas en San Petersburgo. Los participantes realizaron autoinformes sobre el estigma internalizado hacia el VIH, el estigma internalizado hacia la droga, el estado de salud (valoración subjetiva y enumeración de síntomas), la utilización de servicios de salud (atención de VIH y tratamiento de drogas), las características sociodemográficas y la historia de salud/conductual. Para ambas formas de estigma internalizado, los niveles altos de estigma se correlacionaron con una salud más pobre y con una menor probabilidad de utilización de servicios. El VIH y el estigma hacia las drogas interactuaron para predecir la enumeración de síntomas, la atención del VIH y el tratamiento de drogas, de manera que los individuos que internalizan altos niveles de ambos estigmas se encontraban en riesgo elevado de experimentar problemas de salud y con menos probabilidades de acceder a servicios de salud.

A Comparison of the Mental Health and Well-Being of Sexual Minority and Heterosexual First-Year Medical Students: A Report From the Medical Student CHANGE Study.

Purpose Research is lacking on psychological distress and disorder among sexual minority medical students (students who identify as nonheterosexual). If left unaddressed, distress may result in academic and professional difficulties and undermine workforce diversity goals. The authors compared depression, anxiety, and self-rated health among sexual minority and heterosexual medical students. Method This study included 4,673 first-year students who self-reported sexual orientation in the fall 2010 baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, a national longitudinal cohort study. The authors used items from published scales to measure depression, anxiety, self-rated health, and social stressors. They conducted bivariate and multivariate analyses to estimate the association between sexual identity and depression, anxiety, and self-rated health. Results Of 4,673 students, 232 (5.0%) identified as a sexual minority. Compared with heterosexual students, after adjusting for relevant covariates, sexual minority students had greater risk of depressive symptoms (adjusted relative risk [ARR] = 1.59 [95% confidence interval, 1.24–2.04]), anxiety symptoms (ARR = 1.64 [1.08–2.49]), and low self-rated health (ARR = 1.77 [1.15–2.60]). Sexual minority students were more likely to report social stressors, including harassment (22.7% versus 12.7%, P < .001) and isolation (53.7% versus 42.8%, P = .001). Exposure to social stressors attenuated but did not eliminate the observed associations between minority sexual identity and mental and self-reported health measures. Conclusions First-year sexual minority students experience significantly greater risk of depression, anxiety, and low self-rated health than heterosexual students. Targeted interventions are needed to improve mental health and well-being.

A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Järve, Estonia

Experiences of stigma are often associated with negative mental and physical health outcomes. The present work tested the associations between stigma and health-related outcomes among people with HIV who inject drugs in Kohtla-Järve, Estonia and St. Petersburg, Russia. These two cities share some of the highest rates of HIV outside of sub-Saharan Africa, largely driven by injection drug use, but Estonia has implemented harm reduction services more comprehensively. People who inject drugs were recruited using respondent-driven sampling; those who indicated being HIV-positive were included in the present sample (n = 381 in St. Petersburg; n = 288 in Kohtla-Järve). Participants reported their health information and completed measures of internalized HIV stigma, anticipated HIV stigma, internalized drug stigma, and anticipated drug stigma. Participants in both locations indicated similarly high levels of all four forms of stigma. However, stigma variables were more strongly associated with health outcomes in Russia than in Estonia. The St. Petersburg results were consistent with prior work linking stigma and health. Lower barriers to care in Kohtla-Järve may help explain why social stigma was not closely tied to negative health outcomes there. Implications for interventions and health policy are discussed.

The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey

ABSTRACTBACKGROUNDThe stigma of obesity is a common and overt social bias. Negative attitudes and derogatory humor about overweight/obese individuals are commonplace among health care providers and medical students. As such, medical school may be particularly threatening for students who are overweight or obese.OBJECTIVEThe purpose of our study was to assess the frequency that obese/overweight students report being stigmatized, the degree to which stigma is internalized, and the impact of these factors on their well-being.DESIGNWe performed cross-sectional analysis of data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) survey.PARTICIPANTSA total of 4,687 first-year medical students (1,146 overweight/obese) from a stratified random sample of 49 medical schools participated in the study.MAIN MEASURESImplicit and explicit self-stigma were measured with the Implicit Association Test and Anti-Fat Attitudes Questionnaire. Overall health, anxiety, depression, fatigue, self-esteem, sense of mastery, social support, loneliness, and use of alcohol/drugs to cope with stress were measured using previously validated scales.KEY RESULTSAmong obese and overweight students, perceived stigma was associated with each measured component of well-being, including anxiety (beta coefficient [b] = 0.18; standard error [SE] = 0.03; p < 0.001) and depression (b = 0.20; SE = 0.03; p < 0.001). Among the subscales of the explicit self-stigma measure, dislike of obese people was associated with several factors, including depression (b = 0.07; SE = 0.01; p < 0.001), a lower sense of mastery (b = −0.10; SE = 0.02; p < 0.001), and greater likelihood of using drugs or alcohol to cope with stress (b = 0.05; SE = 0.01; p < 0.001). Fear of becoming fat was associated with each measured component of well-being, including lower body esteem (b = −0.25; SE = 0.01; p < 0.001) and less social support (b = −0.06; SE = 0.01; p < 0.001). Implicit self-stigma was not consistently associated with well-being factors. Compared to normal-weight/underweight peers, overweight/obese medical students had worse overall health (b = −0.33; SE = 0.03; p < 0.001) and body esteem (b = −0.70; SE = 0.02; p < 0.001), and overweight/obese female students reported less social support (b = −0.12; SE = 0.03; p < 0.001) and more loneliness (b = 0.22; SE = 0.04; p < 0.001).CONCLUSIONSPerceived and internalized weight stigma may contribute to worse well-being among overweight/obese medical students.

Beliefs about the causes of obesity in a national sample of 4th year medical students.

OBJECTIVE Physician knowledge of the complex contributors to obesity varies. We do not know whether todays medical students are graduating with deep understanding of the causes of obesity. Our objective was to assess beliefs about causes of obesity in a national sample of 4th year medical students. METHOD We randomly selected 2000 4th year students from a random sample of 50 U.S. medical schools and asked them to rate the importance of several factors as causes of obesity. Of those invited, 1244 (62%) responded. We conducted latent class analysis to identify groups with similar response patterns. RESULTS Most students demonstrated knowledge that obesity has multiple contributors. Students fell into 1 of 4 classes: (1) more likely to endorse all contributors (28%), (2) more likely to endorse physiological contributors (27%), (3) more likely to endorse behavioral or social contributors (24%), and (4) unlikely to endorse contributors outside of overeating and physical activity (22%). CONCLUSION Though students were generally aware of multiple causes, there were 4 distinct patterns of beliefs, with implications for patient care. PRACTICE IMPLICATIONS Targeted interventions may help to improve depth of knowledge about the causes of obesity and lead to more effective care for obese patients.

Avoidant attachment style predicts less positive evaluations of warm (but not cold) social groups

Two studies investigated the hypothesis that because individuals who are high on attachment avoidance tend to be disinterested in warmth in interpersonal relationships, they may respond less favorably to groups perceived as warm, attenuating the generally positive association between perceived warmth and favorable evaluation of a group. In Study 1, participants responded to groups representing the four quadrants based on warmth and competence identified by the stereotype content model (e.g., White people, homeless people). On average, people evaluated groups higher in stereotypical warmth more positively. However, as predicted, this effect was significantly weaker among participants higher in attachment avoidance. No effect was found for attachment anxiety. Study 2, in which the perceived warmth of a fictitious group was experimentally manipulated, conceptually replicated the effect for attachment avoidance. Understanding how attachment avoidance may attenuate favorable attitudes toward socially warm groups can help illuminate broader processes of intergroup relations.

Informal Training Experiences and Explicit Bias against African Americans among Medical Students

Despite the widespread inclusion of diversity-related curricula in U.S. medical training, racial disparities in the quality of care and physician bias in medical treatment persist. The present study examined the effects of both formal and informal experiences on non-African American medical students’ (N = 2,922) attitudes toward African Americans in a longitudinal study of 49 randomly selected U.S. medical schools. We assessed the effects of experiences related to medical training, accounting for prior experiences and attitudes. Contact with African Americans predicted positive attitudes toward African Americans relative to white people, even beyond the effects of prior attitudes. Furthermore, students who reported having witnessed instructors make negative racial comments or jokes were significantly more willing to express racial bias themselves, even after accounting for the effects of contact. Examining the effects of informal experiences on racial attitudes may help develop a more effective medical training environment and reduce racial disparities in healthcare.

Beyond generalized sexual prejudice: Need for closure predicts negative attitudes toward bisexual people relative to gay/lesbian people

Increasing evidence suggests that bisexual people are sometimes evaluated more negatively than heterosexual and gay/lesbian people. A common theoretical account for this discrepancy argues that bisexuality is perceived by some as introducing ambiguity into a binary model of sexuality. The present brief report tests a single key prediction of this theory, that evaluations of bisexual people have a unique relationship with Need for Closure (NFC), a dispositional preference for simple ways of structuring information. Participants (n=3406) were heterosexual medical students from a stratified random sample of 49 U.S. medical schools. As in prior research, bisexual targets were evaluated slightly more negatively than gay/lesbian targets overall. More importantly for the present investigation, higher levels of NFC predicted negative evaluations of bisexual people after accounting for negative evaluations of gay/lesbian people, and higher levels of NFC also predicted an explicit evaluative preference for gay/lesbian people over bisexual people. These results suggest that differences in evaluations of sexual minority groups partially reflect different psychological processes, and that NFC may have a special relevance for bisexual targets even beyond its general association with prejudice. The practical value of testing this theory on new physicians is also discussed.