Time to Shine the Light

Not long ago I received an e-mail from PTJ Editor-in-Chief Alan Jette, asking me to write a guest editorial on the paper titled “An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, or Professional Roles” by Ross et al.1 My first thought was: “Alan, why me?” As I thought more about the invitation, however, I concluded that this was an opportunity—perhaps even an obligation—to provide comment and reflective insights on the value of research that shines a light on an area that for too long has been in darkness. In 2020, Dr. Jette wrote a powerful editorial advocating for the importance of collecting data on sexual orientation and gender identity in rehabilitation research.2 That editorial examined the need to collect data that currently are missing about the LGBT population, from both the patient and the population perspective. The research by Ross and colleagues, published in this issue, demonstrates that there is an important gap in the literature and data about the experience of the LGBTQIA+ community in practice and education. Dr. Jette and PTJ continue to widen the profession’s lens to engage us in important and sometimes uncomfortable dialogue. It is time for the physical therapy profession to be more authentic in recognizing the lived experience of many of our colleagues—past, present, and future. As a lesbian and a physical therapist, my career journey resonates with several of the themes described in this research. This editorial gives me the opportunity to reflect more deeply on my own career journey, to offer additional validity to and triangulation of the authors’ findings, and to bring my lived experiences to light for a broader audience. When Ross and colleagues say that there is a dearth of knowledge about physical therapists who identify as LGBTQIA+, that is an understatement. Although the legal status of same-sex marriage has been transformative in some countries, including the United States, that does not necessarily translate into acceptance in daily life as we live and work in our environments. The cultural norms and traditions in our workplace are often tightly aligned with our Western values, where there is the assumption that heterosexuality is the dominant sexual orientation and gender identity aligns with biological sex. Let me begin my comments in the safe place of the methodology used in this study. This study is an exemplar for the role of narratives and discourse analysis in exploring participants’ stories and lived experiences in relation to sensitive topics such as gender identity and sexual orientation. The work is theoretically grounded in a social constructionist framework. Notably, the research team is international, the sample represents therapists from 4 countries (Australia, Canada, United Kingdom, and the United States), and the 22 participants include a range of LGBTQIA+ identities, ages, experiences, countries, and ethnic backgrounds. The 3 main concepts of normativity, stress and labor, and professionalism are conceptually sound and well supported by evidence, and they also facilitate a critical, reflective look at what the profession can learn from this research. The first construct, normativity, allows us to explore the language that frames LGBTQIA+ issues. What do we mean by normativity, heteronormativity, cis-normative, and intersectionality? The authors share a glossary of terms that are important in understanding these perspectives. You might ask yourself, why do I need to know these terms? Understanding the term heteronormativity is foundational to gaining insight into the lived experiences of our community. As a doctoral student at Stanford University, still navigating how to publicly be my authentic self, I remember hearing Adrienne Rich give a lecture on compulsory heterosexuality. She argued that compulsory heterosexuality—the assumption that women in every culture have an innate preference for relationships with men—is enforced on women by a patriarchal and heteronormative society. Women in turn are socialized to identify with men and subscribe to social, political, and intellectual allegiances with them.3 This assumption has the potential to dehumanize people who may be perceived as outside the “norms” (homosexual, asexual, or transexual). Rich said: To take the step of questioning heterosexuality as a “preference” or “choice” for women…will call for a special quality of courage…I think the rewards will be great: a freeing up of thinking, the exploring of new paths, the shattering of another great silence, new clarity in personal relationships.”3(p648) Forty years later, reading the compelling and often painful narratives from our physical therapy colleagues, who represent multiple countries and career paths, gives me pause. The phrase “turning my light down,” shared as part of the physical therapy discourses of normativity, is particularly powerful in expressing the cost and impact of hiding one’s real, authentic self. I am reminded of Harvey Milk’s The Hope Speech. In 1977, in his position on the San Francisco Board of Supervisors, he was the first openly gay elected official in the United States.4 In the speech, he made the claim for being authentic with self and others; to come out from the shadows, shine the light, and be visible: Like every other group, we must be judged by our leaders and by those who are themselves gay, those who are visible. For invisible, we remain in limbo—a myth, a person with no parents, no brothers, no sisters, no friends who are straight, no important positions in employment.4 My lived experience is that being authentic (thanks to my friends in California for questioning norms and traditions and giving me strength to question as well) has reaped many benefits and loving support from family, friends, and colleagues, regardless of where I have lived (West Coast, East Coast, the South, and now the Midwest). The second construct, stress and labor, highlights our work environment. Ross and colleagues found that, for the physical therapist colleagues in their study, there is a toll arising from the fear they experience when they consider sharing their true identity. The risk of possible discrimination, the fear of repercussions, and the reality of working in an environment that requires some level of invisibility all contribute to increased stress. This inner conflict and need to “do the safety math” have an emotional cost. The concept of psychological safety described in Edmondson’s research on teams may have application here.5 Fearless organizations create workplaces where human capacities can flourish in an environment that provides psychological safety. These environments facilitate a sense of trust and respect as all members of the team are free to speak up without the fear of embarrassment or rejection. In what ways do workplaces support a psychologically safe environment for physical therapists and physical therapist assistants? What can we do to facilitate learning and workplace environments in which there is psychological safety for every and each person to celebrate all aspects of their identity? Another component of the workplace experienced by therapists in this study was the additional labor and added stress of having to hide their sexual orientation or gender from patients. At times, this hiding was coupled with therapists feeling that they were responsible for finding ways to educate colleagues and patients. The Josiah Macy Jr. Foundation’s Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments6 included a discussion highlighting the tension that may occur if there is bias and discrimination in the patient-clinician relationship. There is the expectation that (1) we care for all patients, regardless of their behavior, and (2) this caring overrides everything; however, …clinicians also have the right to work without fear of being abused and the right to be treated with dignity and respect. Today there is little explicit support for balancing the rights of patients and clinicians when they are in conflict.6(p4) The burden of stress and labor that therapists experienced has a cumulative and layered effect that may contribute to therapist burnout. Perhaps the underlying concept here is not burnout per se, but recognition of the moral distress and possible moral injury7 that therapists may experience with feelings of powerlessness, discrimination, and invisibility. This is a complex area that has received little study. Ross et al argue that the third construct, professionalism, is the pervasiveness of cis/heteronormativity, along with other white middle-class norms that can lead to the perception of being “deviant” and not conforming to what is perceived as professional. This pressure to conform to the image of “ideal professional” leads to a “dulling down” as therapists who are LGBTQIA+ need to be vigilant in separating their personal life from their professional life. Just what is professionalism? What does it mean to be a professional? Who defines these concepts? Our profession would be well served by understanding the role of critical theory in thinking more deeply and broadly about our physical therapy community. Critical theory has an established history in education research, questioning the potential for dehumanization that can occur from constraints that stem from race, class, and gender. By looking through the lens of critical theory, we can question the narrow interpretations that stem from social structures and cultural assumptions that have long dominated our conception of what a profession is.8 For far too long, we have assumed that the conceptions of a profession—developed and shaped by how we see traditional (historically white, male-dominated) professions—are not to be questioned or shaped by other professions, including female-dominated professions. Traditional conceptions of what it means to be a professional (white, middle-class norms) can then become the standards through which those with the power and privilege can oppress those who might not comply. Articles such as that by Ross et al can inspire us to reconceptualize what is meant by profession and professionalism, recognizing the limits of the current conceptualization.9 The ability of our colleagues to bring their diverse characteristics into the workplace is important in connecting better with patients and fostering inclusive workplaces for others. Respondent Emma’s quote says it all: “when I talk to students, I bring that up too. Being your whole self in a space, it always empowers other people, even if you don’t know or expect that.” Most health care professions have developed resources for educating and training colleagues for providing equitable, respectful care to our patients who are LBGTQIA+. Some health care professions have also made great strides in developing resources to support students and colleagues. The resources available through the American Association of Medical Colleges are good examples.10 One of our colleagues, Karla Bell, PT, DPT, OCS, GCS, adapted and modified several of the American Association of Medical Colleges curricular recommendations for physical therapy.11 The findings of Ross and colleagues demonstrate the need for a critical, reflective inward look at our profession in how we promote and support inclusion and belonging for colleagues who are LGBTQIA+. My observation over 4 decades as a physical therapist is that we have a robust community of colleagues who identify as LBGTQIA+; however, for many of the reasons identified in this research, they still struggle to be fully authentic in our professional community. I am curious as to what factors contribute to our profession’s hesitancy to be explicit and intentional in visibly celebrating and supporting all diversity. Is it because of our history as a profession founded by women (strong women) with connections to physical education and the military, who needed to suppress their sexual identities to succeed? Is it because of our gender demographic profile? Is it because our profession embraces a dominant emphasis on the biological and physical sciences with less integration of the behavioral sciences and the humanities that could facilitate a deeper understanding of justice in all forms and mutual respect for all? Do we lack the moral courage to have challenging conversations in a political climate that is often polarized? Sexual orientation and gender identity need to be reconceptualized in our physical therapy communities, paving the way for reimagined workplaces and continued research on this important topic. When a physical therapist identifies as a member of a marginalized community, are there patient reactions and behaviors that cause concern, and, if so, what are they? What actions, if any, should be taken in such situations? Is the physical therapist’s identity always secondary in the provision of patient-centered care? Should a therapist suppress their sexual identity and gender in the interest of serving the patient? What does it mean to be a professional? What gains are there for the profession and for patient care when workplaces are welcoming to diverse practitioners? These questions, and many more, need to be addressed. The paper by Ross et al provides us with an opportunity to move forward and address an important and long overdue challenge—to turn our light up, not down. My dear colleagues and friends, Laurie Hack, DPT, PhD, MBA, FAPTA, and Terrence Nordstrom, PT, EdD, FAPTA, provided me with critically reflective feedback and insight, for which I am grateful. Writing this editorial was not an easy task, and their feedback, along with the support of my partner/wife of 37 years, Judy Gale, DPT, MPH, OCS, made all the difference.

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