For Michael A. Puente Jr., MD, being open about himself and advocating for an overlooked community hasn’t always been as easy as it is today. Progress has been incremental, but he is optimistic about the state of ophthalmology for LGBTQ+ physicians and patients.
Pursuing a career in ophthalmology is a rewarding path that opens many doors for those who successfully clear all of the hurdles through medical school and residency. Now, imagine having to clear an extra hurdle that is completely out of your control and that few of your peers have to deal with.
That is what happens to medical students who are a part of the LGBTQ+ community as they travel the long and winding road through medical school toward residencies.
For Michael A. Puente Jr., MD, now an assistant professor of ophthalmology and director of Medical Student Education in Ophthalmology at the University of Colorado School of Medicine and Children's Hospital Colorado, it meant hiding a major part of his life.
“I didn't come out professionally until graduation day from residency,” Puente said in a conversation with Ophthalmology Times. “I was scared that if I was out publicly during my training that it would hurt me, that some of my more conservative attendings might treat me differently, might teach me differently, might deprive me of some educational opportunities. I felt safer just hiding. I didn't come out of the closet to my department until graduation day.”
As Puente moved on to his fellowship, he initially hid his sexuality, deciding not to come out to his peers.
“I didn't come out at first,” he recounted. “I had to put out some feelers to make sure that it was a place that I'd be safe. And I was thrilled to find that it was a place where I was very safe and supported, where I was encouraged to advocate for LGBTQ+ issues.”
Puente notes that there has been a lack of attention to ophthalmic issues important to the LGBTQ+ community. Today, he can be open and also pursue the issues that are important to him with the support of the University of Colorado.
“I think that's a common experience that we all are scared that our identity could potentially hurt us in certain settings,” he added. “I think a lot of us aren't sure if we can be open about our LGBTQ+ status with patients, families, our coworkers. And that's a daily small challenge that our heterosexual ophthalmology peers don't have to face every day of their careers.”
However, even selecting ophthalmology as a career path can prove to be a challenge for LGBTQ+ medical students, and Puente cited a study that found ophthalmology coming in second to last in the percentage of matched residents who identify as LGBTQ+.
“I think that an obstacle that LGBTQ+ ophthalmologists face is that historically, there hasn't been a lot of visibility for LGBTQ+ people within our profession,” Puente said, “and so a lot of people feel like they may not be welcome and may not feel comfortable being out within the ophthalmology community and may feel like they may not be welcome in certain job settings or practices.”
Moreover, LGBT residents may feel the need to remain closeted during their training and worry that perceptions could adversely impact them.
“That stigma can really impact our psyches and ability to thrive in ophthalmology,” Puente recounted. “I think that's probably the biggest concern.”
While concerns about being out can be one concern, finding a mentor can prove to be another issue.
“I think it's very difficult for a lot of LGBTQ+ trainees to find mentors in ophthalmology,” Puente noted. “When people are trying to decide on a specialty, they want to make sure it's a specialty where they'll fit in and be able to thrive. If they have never met an LGBTQ+ ophthalmologist before and have never seen LGBTQ+ issues discussed within the field of ophthalmology, it can be a deterrent to those students. If students perceive other specialties as more LGBTQ+ accepting, it can drive a lot of great potential ophthalmologists away from our specialty.”
However, the paradigm may be shifting, as groups like the American Academy of Ophthalmology are stepping up to provide support for LGBTQ+ ophthalmologists, and Puente was involved in the formation of an LGBTQ+ interest group within the Academy.
“We have received support from AAO leadership. They're very excited to support us and have offered us all the resources that we've been asking for,” he said. “We've created a network of more than 130 LGBTQ+ ophthalmologists, residents, fellows, and medical students interested in ophthalmology. It's been great having a support network where we can talk about shared obstacles and shared issues and talk about ways that we can support each other and our LGBTQ+ patients.”
To make ophthalmology more attractive to LGBTQ+ medical students could mean an open discussion of issues important to the LGBTQ+ community.
“These LGBTQ+ trainees are often going to be interested in research about LGBTQ+ patients and health disparities,” Puente explained. “They want to see that the issues affecting LGBTQ+ patients and professionals are considered important topics for discussion and valid topics for discussion within ophthalmology.”
On open dialogue of those issues and increased visibility for LGBTQ+ issues in ophthalmology will ultimately help attract a lot of those great candidates into the field, Puente added.It also has driven him to take an active role on issues, including an existing FDA regulation banning corneal donation by any man who has had sex with another man (MSM) in the preceding five years, a policy in place since May 20, 1994, amid concerns at the time that men who have sex with men have a higher rate of HIV than the population at large.
“In 1994, there was no reliable way to screen corneal donors for HIV,” Puente said. “Soout of fear that corneal transplants from gay men could potentially spread HIV to corneal tissue recipients, the federal government instituted essentially a categorical ban on corneal donation by gay men.”
Today, nearly three decades later, there are more accurate HIV tests that are performed on anyone donating corneas.
“Three HIV tests are required to be performed on everyone who donates a cornea in the United States,” Puente said. “Those tests are extremely accurate within just about a week of someone having been exposed to HIV.”
The FDA policy hasn’t been updated since its inception 29 years ago, and the policy being followed by eye banks today dates back to 1994 and is based on science from that era, rather than current scientific evidence.
“I've been advocating for the last four years for the FDA to look at the decades of advances in HIV science since 1994,” Puente said. “So that we can have a policy that's based on current evidence and not 1994 evidence.”
The FDA recently made a recommendation that eases restrictions on blood donations by MSM, and the hope is it will lead to changes on the separate restrictions on MSM cornea donations.
“The FDA has loosened its restrictions on MSM blood donors three times in just the last 10 years, but they haven't changed the policy for MSM corneal donors a single time since 1994,” Puente said. “So I'm optimistic that the FDA will go through that same process, look at that same evidence that led them to end their ban on MSM blood donation altogether, and that evidence and logic will lead them to the same conclusions for corneas.”
The FDA did announce on Jan. 30, 2023, it intended to change the corneal donation policy sometime this year, Puente added, but that has yet to occur.
Amid the changes, Puente said he is optimistic about the future of ophthalmology with regard to LGBTQ+ physicians and the issues that matter to them as well as LGBTQ+ patients.
“I'm very optimistic,” he said. “I think in the past, ophthalmology didn't pay enough attention to the unique needs of its LGBTQ+ patients and ophthalmologists. But that's really changed a lot in the last few years.”
In 2020, Puente called attention to the FDA ban on gay corneal donors in a paper published by JAMA Ophthalmology.
“As far as I know, that was the first time that any ophthalmologist had ever raised that issue in the literature or through advocacy since the FDA policy was put in place in 1994,” he said.
“That's evidence to me that LGBTQ+ issues were being ignored by our specialty for decades.”
In recent years, progress has been made and Puente is now optimistic that LGBTQ+ issues will never be ignored as happened over previous decades. From a patient perspective, more attention is needed to research on the eyecare needs of the LGBTQ+ community.
“Studies all throughout medicine have consistently found health care disparities that are faced by the LGBTQ+ community,” he said, “but I'm aware of no research looking into LGBTQ+ health disparities in ophthalmology. Everywhere we've looked in other specialties we found disparities facing LGBTQ+ patients, so I have no doubt that there are also health disparities affecting LGBTQ+ patients in ophthalmology. We just have to start looking.”
Ophthalmology has come up short when it comes to understanding those disparities, or identifying where resources could be directed to improve the health of LGBTQ+ patients, fueling the need for research.
There also are some key issues still lingering for LGBTQ+ ophthalmologists like Puente and others.
“For our LGBTQ+ ophthalmologists, I think that the biggest issues we face are issues of acceptance,” he said. “I think that many of our more senior LGBTQ+ ophthalmologists have had to live their whole careers closeted, and I think that that's a tragedy that they couldn't be fully themselves during their professional lives.”
And with the increased attention given to LGBTQ+ issues in recent years, Puente said he remains optimistic that younger ophthalmologists and future ophthalmologists will feel more comfortable fully being themselves and that we'll be able to attract a more diverse ophthalmology workforce by helping to ensure LGBTQ+ trainees can have successful careers on the same level as their straight colleagues.
“Last year at the American Academy of Ophthalmology annual meeting, we were accepted to present an instructional course on LGBTQ+ issues in the field of ophthalmology,” Puente said. “As far as I know, that was the first time any programming had ever been dedicated to LGBTQ+ issues in the history of the AAO annual meeting.”
Puente’s group has been accepted to present the program again at the AAO annual meeting this fall.
“That course had great attendance and great reviews,” he said. “I think that people were really appreciative to see attention being paid to those unaddressed issues for the first time in the history of the annual meeting.”