Structural Inclusion in Surgery: Above Visibility, Beyond Pride

David S. Shapiro, MD, MPH, CPHQ, MEd, FACS, FCCM

Chair, Connecticut Committee on Trauma;  Chair, ACS Stop the Bleed Program Chair

This is a special edition blog post presented in partnership with the Association of Out Surgeons & Allies (AOSA) in celebration of Pride Month.

Being a gay surgeon during Pride Month is no different than any other month. Surrounded by chaos is the ordinary, and let’s face it: the first “pride” was just as chaotic. It was a well-intentioned riot.

When inclusivity is treated as a seasonal calendar event, it becomes a cliché. True inclusion isn’t a mini-celebration or a morning email observing Pride, Juneteenth, or Eid al-Fitr just to make leadership feel compliant. It must be a permanent, structural component integrated into governance, workforce strategy, and daily culture; and this is not just in your hospitals, but in your departments, sections, and partnerships.

At our local American College of Surgeons (ACS) Chapter, groups like Association of Out Surgeons and Allies (AOSA), Association of Women Surgeons (AWS), the Latino Surgical Society (LSS), and the Society of Black Academic Surgeons (SBAS) each have an enduring seat at our table because they need to be there. Without this structural integration, compliance is merely symbolic.We must look to metrics like the Human Rights Campaign’s Healthcare Equality Index (HEI) to evaluate and promote truly equitable care and workplaces year-round, but this organization requires an application for hospitals or health systems, not individual departments or individual people. We all know the possibility of deviation from centralized standards while fringe efforts resist change. 

The Operational Imperative of a Workforce Crisis

The United States is entering a period of profound surgical workforce instability. National projections warn that retirements, the existing residency cap, fellowship specialization drain, and geographic maldistribution each combine with rising clinical demand to result in a critical shortage of surgeons. We cannot rely on traditional pipelines alone. To sustain capacity, the field must intentionally attract, retain, and promote talent from historically underrepresented groups including LGBT2SQI+ clinicians.

Currently, the profession is forfeiting much of this talent. Scoping reviews show that LGBTQ+ surgeons remain markedly underrepresented and essentially absent from leadership. Research on transgender and gender-diverse trainees highlights systemic barriers, lack of mentorship, and institutional cultures that fail to support identity safety and result in attrition rates higher than peers.

Surgery loses potential applicants when environments signal that only certain identities are welcome, but it loses even more when it fails to actively cultivate safety. Failing to create inclusive environments directly undermines our ability to maintain adequate staffing. Recruiting LGBTQ+ surgeons is not a symbolic gesture; diverse teams improve problem-solving, enhance patient trust, and enlarge the overall talent pool at the exact moment the pipeline is contracting.

If you don’t lead or participate in this work actively, it doesn’t mean you’re homophobic, transphobic, or otherwise being intentionally exclusive; but this said, you may indeed be complicit in your silence.

Stigma, Operational Risk, and “Being Enough”

As surgeons, we are the ultimate experts on the concept of risk: we operate on every component of the human form to correct disease, mend injuries, and affirm identities. This is our every day; why then does the profession often ignore the needs of particular segments of its own workforce?

Many of us have asked ourselves the same fear-driven question I once did: “If I become a leader, they’ll invite my family, see I’m a man with a partner/husband, and what will happen to my career?” “If I am promoted to the chair, they’ll have a dinner in my honor; will my spouse be welcome? Will they feel welcome?” 

If you are asking this of yourself, stop. You are beyond enough. You survived university, medical school, and a grueling surgical residency while carrying the hidden cognitive burden of feeling uninvited. You also survived the 80s, 90s, 00s, and beyond to become who you are with some reasonable comfort and affirmed identity.

Studies across surgical specialties including Hauch et al. in general surgery, Pang et al. in vascular surgery, and Dimant et al. on transgender physicians, demonstrate that LGBTQ+ clinicians experience higher rates of concealment, underrepresentation stress, and institutional exclusion. These are not abstract social issues, they are real operational risks. A workforce cannot remain stable if parts of it are forced to navigate additional emotional burdens simply to participate. As a mentor once told me: don’t get out of trouble, stay out of trouble. When I became the Chair of Surgery and then the Chief Medical Officer in a large, urban, Level-I trauma center, I could hide, but I didn’t feel it was right. I made sure the >95% Caucasian male representation in those who reported to me was remedied by looking at my community, my staff, and my options. Moving that 95% to having representation from women, gay, multiple ethnicities, and a trans member of my team wasn’t because I sought them out. I worked to create a safe space. I represented openness and transparency of inclusion, and a variety of diverse people applied because they wanted to be part of it. I’m not saying this to  toot my own horn. All of this didn’t happen overnight, it took a long time. It also took conviction and intentionality. No matter how much I felt alone embarking on this work, and though it was not my intention, even I felt more supported as a result. 

In my own written work on being a scarecrow, the phenomenon of being present, symbolically useful, yet structurally excluded is underrecognized. I argue that visibility without authority creates a paradox. LGBTQ+ surgeons are often invited to be visible, but not to shape the systems that determine if that visibility is safe, sustainable, or meaningful. This is about governance, not identity politics. Representation without influence is just being a scarecrow. Instead, become a beacon, a light to draw others in so that they can survive from your warmth and support. Initially they may simply follow, but this light helps to grow new, strong, intentional leaders who can become beacons of their own. Silence in surgical culture is frequently misinterpreted as neutrality. Do not be silent. In reality, silence is a professional adaptation to environments where speaking out about identity is penalized or labeled as a distraction, or even as unprofessional. We are pushed away from talking about families in interviews, tempting but verboten. Since  concealment correlates directly with burnout and attrition, requiring silence as a condition for belonging strips the institution and the individuals of cognitive bandwidth and psychological safety.

Inclusion as a Continuous Executive Function

Writing this post suggests that inclusion is still viewed as an initiative rather than infrastructure. If a topic is only discussed when prompted by the calendar, it is not embedded in society or in an institution’s operating system. Nevertheless, inclusion at this key time of year is beyond appreciated.

Effective inclusion requires:

• Leadership integration at all levels into the core strategic agenda.
• Continuous attention, not episodic celebration (think, “Am I being inclusive?” at every step.)
• Policy alignment, replacing symbolic gestures.
• Leadership accountability, rather than committee-level delegation.

The American College of Surgeons was the only organization to reply to my inquiry about this topic a few years ago, and welcomed the Association of Out Surgeons and Allies, into their Surgeon Well-Being Coalition. Advocacy for LGBTQIA2S+ inclusion is not only a personal project; but it is professional stewardship. A surgical workforce that reflects its trainees and patients is fundamentally more resilient and higher-performing. The future of surgery depends on building environments where all surgeons can contribute fully without navigating structural barriers. Inclusion and belonging are foundational to the survival and integrity of the surgical workforce. Fly that flag year round…it represents those folks who look for it.

David S. Shapiro, MD, MHCM, FACS, FCCM, is a trauma/critical care surgeon and Associate Professor of Surgery at both University of Connecticut and the Frank H. Netter School of Medicine at Quinnipiac University. He serves as the Program Area Chair for the American College of Surgeons Stop the Bleed Program, and the Connecticut Chair of the Committee on Trauma. He works clinically as a surgeon with Hartford Healthcare and has been a Chief Medical Officer, Chief Quality Officer, and Chair of Surgery during his career starting in 2008. He is a founding member of the Association of Out Surgeons and Allies, and advocates for those underrepresented, recognized or not. Dr. Shapiro conducts research on violence and injury prevention, hemorrhage management, and focuses on the continuum of trauma care along the chain of survival. David has board certification in Surgery, Critical Care, and Hospice & Palliative Care, and works as an ATLS and ATOM instructor. He has published on a multitude of topics including the book, After the ICU, describing the support of critical illness survivors.