Rhode Island Hospital’s origins extend to the early 19th century. Like many medical centers, it’s campus is cobbled together, and embodies the history of hospitals and progress of medicine in its very strata. The Nursing Arts Building was one such layer, historically the home of the nursing school, but for me it was the lab of my mentor, the surgeon-scientist Jorge Albina. Fourteen years ago, as a second-year med student, I was returning to the lab, a short walk across a courtyard from the cafeteria. I walked down the stairs to our basement lab and returned to my desk. Bill, the sixty-something affable research associate, looked up at me with some surprise.
“That was fast!”
“They wouldn’t let me donate,” I replied, feeling a tingling in my palms and a surge in my gut. We’d both committed to donating at the hospital blood drive that day. Bill looked puzzled, but then smiled and joked,
“Why not, too many tattoos?” I took a deep breath.
“They don’t let gay men give blood.”
This was how I first came out in surgery. This was where I decided that I could step across a threshold which to that point I’d debated endlessly. Since coming out to my parents, most of my family, my friends several years prior, I’d worried that being ‘out’ as a surgeon would be an impossibility. Even as a student, I knew closeted surgeons. Men and women who did their best to conform to the scrubbed and typified ideal: those who they thought–who they were told–‘looked like a surgeon’. Those surgeon ‘ideals’ were frequently described by residents and attendings as “a surgeon’s surgeon” echoing another more common and exclusionary veneration of being a “man’s man”. I worried that my dreams of becoming a surgeon and my own personal truths were at odds, and the conflict drove a constant fear.
Fourteen years later, this memory still evokes feelings of pride and sadness. It was a moment that catalyzed my resolve to live openly and honestly. I deeply recognize the privilege associated with being a cis-gendered, white male, and being able to be ‘out’ safely and confidently. My purpose in relating this story is, in part, for those who cannot be out, and conversely for those individuals and institutions who make being out an impossibility. October 11th is National Coming Out Day. Being ‘out’ in surgery has changed dramatically over my education, training, and career: we now have national mobilization with the Association of Out Surgeons and Allies, a robust group of individuals committed to opening the doors of the ‘house of surgery’ wide to all, regardless of who they are or how they love. This diversification and growth is critical to the future of our profession, and I am encouraged to see this progress and can only imagine the surgeons who might-have-been had the field been more welcoming.
The sadness I feel from this memory is not from coming out to Bill, but rather the moments before when I was being interviewed by the phlebotomist and answered “yes” to ever having had sexual contact with another man. I knew this would be disqualifying, but I’d donated gallons of blood prior to this moment—given my very self to the benefit of someone unknown. And now, I was being told that because I was gay, because of who I loved, that this was not good enough. No cookies, no juice for me.
What may come as a surprise to some of you is that fourteen years later, in the midst of what the Red Cross calls “the worst blood shortage in more than a decade”, I am still prevented from donating blood. Restrictions on what kind of person might donate blood came from fear of transmitting HIV in the early 1980s, and the lack of large-scale, rapid and reliable nucleotide testing for these viruses. Thirty nine years ago, the US Public Health Service recommended a lifetime ban for blood donation from men who have ever had sex with a man. These recommendations were adopted by the FDA as policy in 1992.
But we now live in an era where rapid molecular testing has enabled all blood products to be tested for hepatitis B and C, as well as HIV. While the federal government relaxed this lifetime ban in 2015 to a one year period of abstinence–and more recently to three months in early 2020 due to the extraordinary pressures of the COVID-19 pandemic–the practice still lags far behind other countries and continues to discriminate against specific populations without scientific merit. The majority of European and South American countries, as well as Australia, South Africa, Ukraine, and Russia do not restrict MSM blood donation. This practice is supported by literature comparing HIV detection rates in the US donor pool pre- and post-indefinite deferral. A 2020 paper presented at the Conference on Retroviruses and Opportunistic Infections showed no change in the prevalence of HIV in the first time donor blood pool (historically a higher risk cohort than repeat donors) since reducing lifetime bans to one year.
Removing donation bans in the US would generate an estimated 615,000 additional annual units of packed red blood cells, which are currently utilized at an average rate of 29,000 per day. Blood shortages are responsible for delays in surgical care in particular, as the need for transfusion plays into the pandemic-weakened balance of staffing, beds, and resources. This shortage nearly cancelled a liver resection I was about to do a few Fridays ago when a heavy night of trauma had exhausted the hospitals O-negative red cells. The anesthesiologist I was working with that day was O-negative and offered to donate blood if the FDA would let him—he also happens to be gay.
In January of this year, a group of twenty-two senators urged the HHS Secretary to re-examine donation restriction practices—it remains to be seen whether the seeming ebbtide of the pandemic will slow the momentum on this cause. Currently, three major blood centers are conducting a study into changes in policy and the donor questionnaire (ADVANCE Study), but whether this will effect change in FDA policy is questionable, and the ongoing toll of discriminatory donation practices will only worsen the blood crisis.
Given the lack of awareness of donation restrictions by progressive and well-informed members of my own Department, I have made raising awareness around this issue a passion project. Sharing one of my coming out stories with a direct link to an ongoing discriminatory practice that affects surgeons and their patients felt like a fitting way to commemorate National Coming Out Day and LGBTQ+ History Month, as a call to allyship and action for your colleagues and your patients; to celebrate those who are able to be out, and to encourage and support those who can not. This Coming Out Day, I write for you to understand that I look like a surgeon; you look like a surgeon; we look like surgeons.
Patrick J. Worth, MD, FACS, FSSO
The Value of Dedicated Research Time