Fostering an inclusive workplace for LGBTQIA+ people in radiology and radiation oncology

The inclusion and celebration of LGBTQIA+ staff in radiology and radiation oncology departments is crucial in developing a diverse and thriving workplace. Despite the substantial social change in Australia, LGBTQIA+ people still experience harassment and exclusion, negatively impacting their well‐being and workplace productivity. We need to be proactive in creating policies that are properly implemented and translate to a safe and inclusive space for marginalised groups. In this work, we outline the role we all can play in creating inclusive environments, for both individuals and leaders working in radiology and radiation oncology. We can learn how to avoid normative assumptions about gender and sexuality, respect people's identities and speak out against witnessed discrimination or slights. Robust policies are needed to protect LGBTQIA+ members from discrimination and provide equal access across other pertinent parts of work life such as leave entitlements, representation in data collection and safe bathroom access. We all deserve to feel safe and respected at work and further effort is needed to ensure this extends to LGBTQIA+ staff in the radiology and radiation oncology workforces.


Introduction
There has been a clear and strong move towards acceptance and celebration of lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA+) people in Australia and Aotearoa (the M aori language name for the New Zealand continent). Many rigorous policies and guidelines exist in the healthcare space to minimise marginalisation and ensure equality. However, there is scope for more specific recommendations for radiology and radiation oncology departments to develop a more welcoming and respectful workplace for LGBTQIA+ staff. An organisation committed to workplace inclusion may better attract and retain staff, improve workplace productivity and better serve patients.
LGBTQIA+-led medical organisations have championed this effort to provide safe spaces for marginalised groups and to advocate for their members (e.g. GLADD, Diversity Works NZ, ALMA). Medical organisations have been increasingly vocal in their support by issuing public statements and updating their policies (e.g. The Australian Medical Students Association, The Royal Australian and New Zealand College of Radiology). There have also been efforts to better understand the workplace conditions for LGBTQIA+ people in Australia and Aotearoa in workplaces through data collection. The Australian Workplace Equality Index is considered the national benchmark for assessing workplace inclusion. It surveys employees on their experiences in the workplace to measure equality across hundreds of organisations, but few medical services have yet participated. 1 While general workplace data are somewhat informative, there is a paucity of data collected regarding gender and sexuality for medical students and doctors in Australia and Aotearoa. No data are collected regarding the sexuality or transgender status of medical students, junior doctors or radiology/radiation oncology trainees or fellows in the surveys done in Australia or Aotearoa. In 2017, a third gender option was added to graduating medical student surveys (non-binary or unspecified) in both countries, but no further information about gender diversity was gathered. Data gaps regarding demographics and workplace experiences hinder progress in achieving equity.
There are strong indications that a dedicated effort is required to translate these efforts into radiology and radiation oncology workplaces in order to protect and advance LGBTQIA+ members. Among Australian employees, 78% still feel it is necessary to conceal their identity at work 2 due to fear of being discriminated against and losing connections with their co-workers. 3 In Aotearoa, 40% of LGBTQIA+ employees did not feel confident in support from their manager and team. Transgender and gender diverse people often reported even more negative experiences with 31% considering leaving their workplace due to bullying and harassment. 4 The experiences of LGBTQIA+ people in the workplace and their exclusion in data collection highlight the need for careful consideration of how to create more inclusive workplaces. Engaged leadership, dedicated resources, training and continual monitoring and feedback have been identified as key to effecting change. 5 The radiology and radiation oncology literature on LGBTQIA+ inclusion has largely focused on the needs of patients, while guidance for workplaces is sparse. Further, it is crucial in countries like Australia and Aotearoa to recognise the role oppressive systems of colonisation have had in imposing heteronormativity on Indigenous peoples and attempting to deny their inherent diversity. 6 Additionally, intersectionality frameworks emphasise the way in which multiple marginalised identities can result in distinct and multiplicative experiences of marginalisation. 7 In this work, we describe a number of key ways in which radiology and radiation oncology workplaces can be made more inclusive to members of the LGBTQIA+ community. We cover concepts broadly applicable to workplaces as well as specific to radiology and radiation oncology, to serve as reasonably complete resources for departments. It is worth noting that the LGBTQIA+ community is broadly diverse by its very nature and that the needs of one segment of the community may not be the same as another. The term LGTBQIA+, standing for lesbian, gay, transgender, bisexual, queer, intersex and asexual, is used throughout this paper. While terms such as sexual orientation and gender identity (SOGI) are often used in research and policy discussions, we have chosen to use the initialism LGBTQIA+ as a label that is more commonly embraced in the communities of the people it refers to and is inclusive of identities that are often marginalised even within queer spaces. Additionally, the term 'queer', once uniformly considered a slur, has since been reclaimed by some of those who were once stigmatised by such usage. Now queer is often used as a banner term for various identities but is still felt to be derogatory by some due to its historical use. We include the plus to indicate that this list is not exhaustive, and people whose identities are not named are still included under this banner. We acknowledge that there is no one term to perfectly encapsulate the diversity of the community, and terminology will likely further evolve with time.

For individuals
Every employee in a radiology or radiation oncology department is responsible for developing a positive and welcoming workplace culture. Inclusivity does not mean merely tolerating differences within the workplace but must comprise a concerted effort from all parties to be achieved. The marginalisation LGBTQIA+ staff face can often stem from unconscious biases, which require intentional self-reflection and effort to combat. We must inspect and unpack our biases, actively educate ourselves and strive to prevent harms that are currently culturally accepted.

Normative environments
The underpinning factor for exclusion and discrimination is heteronormative and gender-normative environments, where it is assumed that everyone is cisgender, heterosexual, endosex and allosexual. Cisgender describes a person whose gender aligns with their sex assigned at birth (the opposite of transgender), endosex describes a person whose natal sex characteristics fit normative ideas of male and female (the opposite of intersex) and allosexual refers to people who experience sexual attraction (the opposite of asexual) 8 (see Table 1 for further definitions). For example, asking a woman if they have a boyfriend rather than if they have a partner/significant other, assuming someone's gender identity, or assuming the sexuality of someone in a straight passing (heterosexual) relationship are all behaviours that reinforce normative environments. These assumptions may be inaccurate, and individuals should avoid heteronormative language, even when it is believed that those affected are not present.
Normative behaviours exclude and erase people and contribute to the additional labour often required of LGBTQIA+ people, where they feel they must regularly speak up and correct those making assumptions.
LGBTQIA+ staff are often expected to advocate for themselves and explain concepts to their colleagues, who in normative environments are not expected to have educated themselves. This can be a significant burden of emotional labour if marginalised people repeatedly need to justify their life and existence to an indifferent or hostile audience. There is also labour in navigating a system that is exclusionary, such as the challenge of onerous policies, forms and surveys that do not take sex and gender diversity into account. Such encounters can reinforce notions to LGBTQIA+ staff members that they do not belong in these spaces. These factors contribute to what has been termed 'minority stress', whereby this accumulation of discrimination, additional labour and stressful environments can result in mental illness 9 and professional burnout. 10

Gendered language
Gendered language is pervasive in everyday conversation, and the assumptions we often make about the gender/s of individuals or groups can be harmful. How we use gendered language particularly impacts transgender and gender diverse people, who may choose to change their name and/or pronouns to better align with their gender. There can be adjustments when changing the way of referring to someone, but it is vital to call someone by their chosen name and pronouns, and a concerted effort is always appreciated.
For example, transgender people may be told 'this is too difficult, I'll just keep calling you by your old name'. This is called deadnaming, when one is called by the name they were given at birth rather than their chosen name. 11 Misgendering is a similar idea whereby a person is referred to as the wrong gender, which could include incorrect gender descriptors, titles or pronouns. Pronouns, such as he, she or they, are words used to refer to someone when not using their name. People may also choose to use neopronouns (newly created terms) that may better reflect their identity, for example xe/xim/xirs.
Beyond simply using the correct pronouns and names for colleagues, there are several ways individuals can demonstrate their commitment to inclusion. Introductions with one's name and pronouns are a good approach so others do not have to make assumptions and can help to normalise this practice. Figure 1 shows an example of pins that can be worn in the workplace to communicate your pronouns with others. Nonetheless, we should not demand others share their pronouns with us as it can force people to misgender themselves if they are not yet open about their gender identity. In situations where a person's gender is uncertain, the use of gender-neutral pronouns such as 'they/them' is a good default as these pronouns are already used when the gender of a person is not known (e.g. 'I'm going to see my specialist next week, I hope they give me good news'). It is impossible to determine someone's gender or pronouns just by looking at them, so it is best not to assume.
Finally, recognition and acknowledgement of mistakes with a brief apology and quick correction are key. In depth, overcompensating apologies only draw attention to the error and contribute to the othering of marginalised groups. Othering refers to social exclusion by highlighting an individual's differences from the societal norm. Although it is natural to feel bad about a mistake, it is vital to not centre these feelings in the interaction. It would be inappropriate to expect a transgender person to console the offender's feelings when they are the one who has been wronged. Honest attempts to respectfully address someone as they wish, even with the occasional error, go far in creating a welcoming culture.

Medical language
Imprecisely gendered language is also pervasive in clinical environments. Terms like 'women's health' and 'men's health' are widely used even in the naming of radiology and radiation oncology subspecialties. 12 This language does not accurately reflect the patient population who use these services, excluding non-binary people and forcing binary transgender people to be misgendered (e.g. a transgender man who requires mammograms would be expected to attend a 'women's imaging' service).
In radiology and radiation oncology, it should be standard practice to use more specific terminology rather than these unclear gendered terms. For example, if discussing people who need prostate cancer screening, it would be more accurate to say 'people with prostates' rather than men. Using the phrase 'people with prostates' includes non-binary people and transgender women with prostates, and appropriately excludes transgender men who do not have prostates and do not need the service. Similarly, when talking about pregnancy, we should not assume that everyone who gets pregnant is a woman but instead use terms like 'pregnant person' or 'birthing parent' until we can clarify the terminology that a specific patient prefers to use for themselves. 13 A 2022 paper found that out of a random sample of 500 recent articles discussing pregnancy, only 1.2% used genderinclusive language. Of course, if a cisgender woman wishes to be identified as a mother instead of a birthing parent, then respecting their identity is just as important as respecting the identities of any patient.
In the research setting, accurate reporting of sex and gender has often been overlooked. The 'Sex and Gender Equity in Research' guidelines, published in 2016, was developed to address the historical under-representation of women in research as well as the frequent conflation of sex and gender. The guidelines advocate for the disaggregation of data by gender and sex and to hypothesise about the expected influence of these variables on the outcome of interest. 14 Additional resources such as from the Australian Bureau of Statistics and the National Institute of Health offer invaluable guidance for inclusive data collection. 15,16 Better measurement is key to better understanding and addressing the challenges faced by marginalised groups.

Microaggressions
Microaggressions are subtle forms of hostility that can be intentionally or unintentionally harmful to LGBTQIA+ people. The term was coined by Pierce et al. 17 in relation to racial microaggressions and defined by DW Sue in his 2010 book as 'brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership'. 18 For example, a gay, bisexual or lesbian person might be told 'do what you want but just keep it to yourself', when they are simply talking about where they went on the weekend with their partner. In a 2018 study, the Human Rights Campaign found that 59% of non-LGBTQIA+ workers thought that it was unprofessional to mention one's sexual orientation or gender identity in the workplace. 3 Such sentiments presume that there is something 'inappropriate' about gender or sexual diversity and is a double standard not applied to cisgender or heterosexual people. Conversely, a transgender staff member may be asked invasive questions about their medical history that would never be usually considered appropriate otherwise, such as 'what surgeries have you had?' The impacts of microaggressions are often dismissed due to their subtlety and thus these behaviours are allowed to continue, further oppressing marginalised groups. 19 Addressing microaggressions in the workplace is inherently complicated and a source of stress for those affected. The victim of a microaggression may worry they have misinterpreted the interaction and bystanders may further minimise it by saying 'they didn't mean it like that'. The victim has to weigh up the power dynamics to determine whether it is safe to address the perpetrator, and often risks being read as over-sensitive or rude. If the offence goes unaddressed, it can set the tone that such behaviours in the workplace are acceptable, amplifying such harms, but if the offence is addressed it can still ultimately reflect poorly on the victim, rather than the perpetrator. As individuals, staff members should recognise their lack of understanding of what constitutes a microaggression, and by default believe LGBTQIA+ staff members when they say they have been wronged. Bystanders in these situations can play a key role in supporting their colleagues by employing 'microinterventions' such as highlighting the underlying prejudice or expressing disagreement with the perpetrator. 20

For leaders
While the following section is directed towards leaders in radiology and radiation oncology, anyone can raise these issues with their leadership teams and promote action within the department. Support from the employee body is invaluable to translate leadership decisions into changes in workplace culture.

Policy
All radiology and radiation oncology workplaces need policies that protect LGBTQIA+ people from harassment and discrimination. It is unlawful in Australia and Aotearoa for a workplace to treat people differently based on sexual orientation, gender identity or intersex status. Governments in both countries have invested in developing updated policies in recent years. These policies have committed to provide strengthened legal protections, healthcare access, improved data collection, better governmental representation and expanded awareness campaigns. However, discrimination may still be experienced as a result of misjudged or poorly implemented policies. 21 A policy may be vague and thus offer insufficient protections, it may neglect affirmative action or it may not be appropriately executed. While the following policy suggestions are not exhaustive, they provide a starting point to consider more proactive approaches.
Policies should use language that is inclusive of people with diverse sexualities and gender identities. Assumptions in the way policy are written can result in indirect discrimination, whereby a practice or policy that applies to everyone unintentionally impacts a certain group of people negatively. Parental leave provisions may assume a monogamous, heterosexual relationship in which a woman gives birth and takes on the primary caring duties. There are innumerable situations where this assumption does not apply. For example, a policy which grants mothers or birth parents particular leave provisions may give a cisgender, gay male couple very minimal leave to care for their new baby. The national policies in Australia and Aotearoa largely allow for the many variations in the way people parent and are a good example for guiding local policies.
Workplaces can also provide support to people undergoing gender affirmation by providing paid leave, including leave to support the social, medical and legal aspects of gender affirmation. 22 Additionally, coming out as transgender in the workplace often involves a substantial amount of labour, such as navigating complex bureaucratic systems regarding name and gender marker changes as well as communicating changes to other staff members. Departmental guidelines on gender affirmation outline the processes for 'coming out' and transitioning and are valuable in easing the burden on transgender staff. 23 This can include guidance on updating personal details, how to access gender affirmation leave entitlements, examples of communicating changes to colleagues and details of key support people in the workplace.
Finally, gendered dress codes written in policy often reinforce gender normativity (as well as white, patriarchal, ableist ideals) rather than achieving the stated purpose of maintaining professionalism and infection control standards. Forms of non-normative presentation such as brightly dyed hair, piercings and more diverse clothing choices are common in the LGBTQIA+ and other marginalised communities, and department leaders should consider whether their standards of professionalism simply reflect societal norms. Visible diversity in the workplace is likely beneficial for patients as well as perceived personal similarities in values between clinicians and patients has been shown to engender trust and increase satisfaction in a medical consultation, particularly for members of marginalised groups. 24

Physical environment
The physical environment is an important component of healthcare space for LGBTQIA+ staff to feel safe. Gendered bathrooms and changing rooms can be especially stressful. Gendered spaces reinforce the notion that people who do not align with traditional normative standards of gender do not belong in such spaces. While this is often considered an issue that affects transgender people alone, it has long been recognised as a problem affecting cisgender people with non-normative presentations as well. For example, butch lesbians call this 'the bathroom problem', 25 and there are numerous examples of gender non-conforming cisgender women being verbally and physically attacked for using spaces intended for them.
All-gendered facilities, for example single-occupant bathrooms, are the best solution where possible. Requiring gender diverse people to use an accessible toilet is not an adequate solution, as this can prevent access to people who need such specially designed facilities. Where all-gendered facilities are not available, policy should at least explicitly permit individuals to use the gendered facilities they feel most comfortable with. Educational posters within these spaces can be used to communicate this policy to staff and patients.

Complaints
Complaints regarding breaches of workplace policies are important to identify in order to prevent further discrimination or harassment. LGBTQIA+ individuals may not feel confident raising concerns due to fear of being dismissed or not having their confidentiality respected. Despite being more likely to experience workplace discrimination, complaints are often not raised, with one study in the UK finding that 24% of lesbian, gay and bisexual people reporting they 'did nothing' when discriminated against, and only 20% reported making a formal complaint. 26 The process needs to take issues seriously, even when they seem 'small' as is often the case with microaggressions. As stated above, the default of believing LGBTQIA+ staff should also apply to complaints processes. Properly addressing complaints is an important step to provide a clear pathway for breaches in policy to be addressed.

Education
Providing training to staff regarding diversity, equity and inclusion is a proactive way to establish and reinforce organisational policy and expectations. While there is a push to include such training in the medical school curriculum, this still tends to be under-taught with 47% describing the teaching of LGBTQIA+ content as poor or very poor in universities in Australia and Aotearoa. 27 Almost all education on LGBTQIA+ content throughout radiology and radiation oncology training is ad hoc and relies on the efforts of local champions. This is an everevolving subject that involves people of all workforce backgrounds and deserves to be formally revisited regularly to ensure all have updated training. There are many groups who provide LGBTQIA+ inclusive workplace training and it should be a departmental priority to provide this.

Affirmative action
Departments can also include marginalised groups through affirmative action, whereby groups previously discriminated against are instead favoured. It is becoming increasingly common to establish 'Ally Networks' that staff can join to express their commitment to allyship. There may be a mandatory training session before joining to ensure a minimum level of understanding to be a part of the network. Affirmative action could also include uplifting local LGBTQIA+ role models and elevating their visibility in the workplace. Individuals within the leadership team may also be identified as diversity champions who may have LGBTQIA+ membership themselves or have shown commitment to advancing the cause. Departments can also celebrate events throughout the year to acknowledge LGBTQIA+ history and celebrate diverse identities (see Table 2 for relevant dates in Australia and Aotearoa).

Conclusion
Organisational practices and individual allyship can play a key role in developing inclusive workplaces in radiology and radiation oncology. In this work, we provide suggestions for how staff members and departmental leaders can improve workplace culture and create more welcoming environments. Using inclusive language, combating microaggressions and abandoning normative assumptions are important steps for individuals. Leaders are tasked with developing robust policies to support their LGBTQIA+ staff and ensuring these policies translate into tangible changes in the workplace. People create culture, and ultimately, we are all responsible for developing departments that celebrate diversity and promote inclusivity.

Acknowledgement
The authors have received no funding for this work. Open access publishing facilitated by The University of Adelaide, as part of the Wiley -The University of Adelaide agreement via the Council of Australian University Librarians.

Data availability statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.