Journal of General Internal Medicine

, Volume 32, Issue 11, pp 1193–1201 | Cite as

Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students

  • Sean M. Phelan
  • Sara E. Burke
  • Rachel R. Hardeman
  • Richard O. White
  • Julia Przedworski
  • John F. Dovidio
  • Sylvia P. Perry
  • Michael Plankey
  • Brooke A. Cunningham
  • Deborah Finstad
  • Mark W. Yeazel
  • Michelle van Ryn
Original Research



Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students.


To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people.


Prospective cohort study.


A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014).

Main Measures

Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1.

Key Results

In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = −0.04 [−0.07, −0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004).


Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.


sexual minorities sexual orientation prejudice medical education longitudinal studies 



Dr. Phelan is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (award no. K01 DK095924). Other support for this research was provided by the National Heart, Lung, and Blood Institute of the National Institutes of Health (award no. R01 HL085631). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders played no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Sean M. Phelan
    • 1
  • Sara E. Burke
    • 2
  • Rachel R. Hardeman
    • 3
  • Richard O. White
    • 4
  • Julia Przedworski
    • 3
  • John F. Dovidio
    • 2
  • Sylvia P. Perry
    • 5
  • Michael Plankey
    • 6
  • Brooke A. Cunningham
    • 7
  • Deborah Finstad
    • 7
  • Mark W. Yeazel
    • 7
  • Michelle van Ryn
    • 1
  1. 1.Division of Healthcare Policy and ResearchMayo ClinicRochesterUSA
  2. 2.Department of PsychologyYale UniversityNew HavenUSA
  3. 3.Division of Health Policy and ManagementUniversity of MinnesotaMinneapolisUSA
  4. 4.Division of Community Internal MedicineMayo ClinicJacksonvilleUSA
  5. 5.Department of PsychologyNorthwestern UniversityEvanstonUSA
  6. 6.Division of Infectious Diseases, Department of MedicineGeorgetown University Medical SchoolWashingtonUSA
  7. 7.Department of Family Medicine and Community HealthUniversity of Minnesota Medical SchoolMinneapolisUSA

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