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.

A recent Institute of Medicine (IOM) report noted that gay and lesbian individuals “face discrimination in the health care system that can lead to an outright denial of care or to the delivery of inadequate care.”1(p62) Biases among health care providers may help explain a number of observed health disparities faced by these sexual minority groups, such as possible higher risks for cancer, HIV/AIDS, and eating disorders as well as less use of preventive health services.1,2 As a result, the IOM report called for more research on provider attitudes toward gay and lesbian individuals as a next step toward addressing unequal treatment. Given that medical schools represent a critical context in which lay people become providers, understanding the attitudes of heterosexual students entering the medical profession is an important aspect of building a medical school curriculum that can effectively address biases and help ensure future physicians will provide high quality care for sexual minorities. In this study, we aimed to assess the amount of bias against gay and lesbian people (i.e., less favorable attitudes toward gay and lesbian people relative to heterosexual people) among heterosexual first-year medical students and to investigate factors that may predict such bias. We examined both explicit and implicit attitudes. Explicit attitudes are consciously controlled and are traditionally assessed using self-report measures such as feeling thermometers.3,4 Implicit attitudes are automatic responses that often occur outside conscious awareness5,6 and are commonly measured using response-latency tasks such as the Implicit Association Test (IAT).7 Implicit attitudes help explain behavioral outcomes that cannot be predicted from explicit attitudes alone.6 For example, implicit racial bias has been shown to predict provider decisions and demeanor that result in lower quality of care for black patients.8–12 Explicit attitudes are susceptible to social desirability concerns, so they often appear more favorable than implicit attitudes.5,13 Explicit negative attitudes toward homosexuality have declined (but have not disappeared) in recent years,14 particularly among well-educated individuals.15 However, even when explicit bias becomes socially unacceptable, implicit bias tends to remain prevalent.16–18 We therefore predicted that implicit bias against gay and lesbian individuals would be pervasive among heterosexual first-year medical students, even those who avoid expressing explicit bias. We focused on two characteristics that may predict bias among medical students—prior contact with sexual minorities (contact) and self-reported empathic tendencies (empathy).19,20 One of the most robust predictors of lower levels of bias is previous experience with members of the group in question.21 Both greater frequency of contact (quantity or amount) and more positive contact (quality or favorability) predict more positive intergroup attitudes.22,23 Even brief contact can mitigate bias against sexual minorities.19,22 In one study at a single medical school, encouraging direct contact by bringing gay and lesbian speakers into the classroom resulted in reduced levels of explicit anti-homosexual attitudes.24 Research with other groups also suggests that intergroup contact can mitigate implicit biases.25 In line with past work, we hypothesized that both amount and favorability of prior contact would be associated with lower levels of explicit and implicit bias. Empathy is a second consistent predictor of positive attitudes toward a range of groups.26 There are two types of empathy—cognitive and emotional.27,28 Cognitive empathy involves trying to think about things from another’s perspective (perspective-taking); emotional empathy reflects having compassionate and sympathetic feelings (empathic concern).29 Both cognitive and emotional empathy can be measured as traits or states and relate to positive intergroup attitudes in general.26,30,31 More specifically, there is correlational evidence from college student samples that both cognitive and emotional empathy predict positive attitudes toward gay and lesbian targets.20 Therefore, we hypothesized that higher scores on trait measures of perspective-taking and empathic concern would predict lower levels of bias, both explicit and implicit, in heterosexual first-year medical students.