Abstract
Background
Discriminatory practices against minority populations are prominent, especially in the workplace. In particular, lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) individuals experience several barriers and stressors more often than individuals who do not identify as LGBTQ+. Mistreatment is common among these individuals in their personal and professional lives. However, representation and perceptions of discrimination and bullying among attendings, residents, medical students, and other professionals who identify as LGBTQ+ and are “out” (openly acknowledging and expressing one’s sexual orientation or gender identity) is seldom studied in orthopaedic surgery.
Questions/purposes
(1) How often are orthopaedic trainees and professionals who identify as LGBTQ+ out in their workplaces? (2) What proportion of these individuals report experiencing discrimination, bullying, or differential treatment? (3) Is there regional variation in these reported experiences of bullying and discriminatory behaviors by orthopaedic trainees and professionals in the LGBTQ+ community?
Methods
Individuals registering for Pride Ortho, a community of LGBTQ+ individuals and their allies established in 2021 to provide mentorship, networking, and a sense of community among its members, completed an internet-based survey developed by organization leadership. A total of 156 individuals registering for the Pride Ortho community were eligible to participate in the internet-based survey. In all, 92% (144 of 156) fully completed the survey, 6% (10 of 156) partially completed it, and 1% (2 of 156) did not complete any part of the survey. Most respondents (64% [100 of 156]) identified as being LGBTQ+, with 77 members at the attending level of their careers. More than half of LGBTQ+ members (56% [56 of 100]) identified as cisgender women (individuals who identify as women and who were born female). Demographic information was privately collected and deidentified, and included sex assigned at birth, gender expression or identity (the social constructed role that an individual chooses to inhabit, regardless of that individual’s assigned sex at birth), sexual orientation, self-identified race, location, level of training, and orthopaedic subspecialty.
Results
Ninety-four percent (94 of 100) of LGBTQ+ respondents reported being out at their workplace, with nearly one-third of respondents indicating they were only partially out. Most (74% [74 of 100]) respondents reported either “yes” or “maybe” to perceived experiences of bullying, discrimination, or being treated differently. All individuals who partially completed the survey were straight or heterosexual and did not answer or answered “not applicable” to being out in their workplace. These individuals also all answered “no” to experiencing bullying, discrimination, or being treated differently. There was no geographic variation in reported experiences of bullying and discriminatory behaviors by orthopaedic trainees and professionals.
Conclusion
Most LGBTQ+ orthopaedic trainees and professionals are out in their workplaces, although they report experiencing discrimination and bullying more than do non-LGBTQ+ individuals. Bullying and discrimination can deter individuals from beginning and completing their training in orthopaedic surgery. We recommend that orthopaedic institutions not only enforce existing antidiscrimination legal mandates but also increase the visibility of LGBTQ+ faculty and residents. This effort should include the implementation of diversity and sensitivity training programs, strengthened by a structured process of monitoring, reporting, and integrating feedback from all members in the workplace to continuously refine policy adherence and identify the root cause of the reported perceptions of bullying and discrimination.
Clinical Relevance
To deepen our understanding of the experiences faced by sexual and gender minorities in orthopaedic surgery settings, it is crucial to quantify reports of perceived bullying and discrimination. Addressing these issues is key to creating a more diverse and empathetic workforce within orthopaedic institutions, which in turn can lead to improved patient care and a better work environment. Recognizing and understanding the specific contexts of these experiences is an essential starting point for developing a truly inclusive environment for both trainees and attending physicians.
Introduction
In the United States, it has been estimated that 7.2% of the population identifies as lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) [22]. However, sexual or gender minorities have had a longstanding history of experiencing discrimination. Individuals are often overlooked and stigmatized because of their sexual orientation (an individual’s identity in relation to which gender they are sexually or romantically attracted to) and gender identity (the social constructed role that an individual chooses to inhabit, regardless of that individual’s assigned sex at birth), leading to barriers and stressors. In the workplace, LGBTQ+ individuals experience discrimination, which impacts physical and mental health, job opportunities, and wage-earning potential [27, 35]. A 2008 General Social Survey found that only 25% of LGBTQ+ respondents reported being out (openly identifying as LGBTQ+) to their coworkers, 27% reported having experienced harassment, and 7% reported losing a job because of sexual orientation [20]. Such experiences create environments where members of the LGBTQ+ community do not feel safe to express their sexual or gender identities.
Societal bias and discrimination also occur in the healthcare setting, which negatively impacts LGBTQ+ patients and healthcare providers [25]. In 1994, Schatz and O’Hanlan [34] surveyed 711 physician members of an LGBTQ+ medical organization and identified that many respondents had witnessed discrimination against LGBTQ+ patients or personally experienced discriminatory behaviors. In a 2011 survey of 427 LGBTQ+ physicians, the distribution of respondents spanned various specialties, with internal medicine representing 22%, family medicine representing 21%, and an additional 10% each from a range of 50 other specialties [9]. The surveys found that 10% of the participants reported being denied referrals, 15% reported experiencing harassment by colleagues, 22% reported feeling socially ostracized, and 65% reported overhearing derogatory comments about LGBTQ+ individuals [9]. More recently, a 2014 national climate survey of general surgery residents reported that 57% of LGBTQ+ residents concealed their sexual orientation from fellow residents and physicians because of fear of rejection or poor evaluations [25]. These findings show that LGBTQ+ physicians often choose not to disclose their sexual orientation because of concerns about harassment, isolation, and depression [6]. Chu et al.’s [6] review of evidence about LGBTQ+ experiences in orthopaedic healthcare revealed notable challenges that affected patients and providers. That study underscored the need for mentorship and inclusivity initiatives, particularly for orthopaedic trainees and providers. Pride Ortho, founded in 2021, is one such initiative, which aims to build a supportive network for LGBTQ+ orthopaedic surgeons and allies, focusing on mentorship, networking, and education and increasing community visibility [3]. The limited research on LGBTQ+ individuals in orthopaedic surgery, especially among physicians and trainees, highlights the need for a study such as ours to explore their reported experiences and representation in this specialty.
In this study, we asked: (1) How often are orthopaedic trainees and professionals who identify as LGBTQ+ out in their workplaces? (2) What proportion of these individuals report experiencing discrimination, bullying, or differential treatment? (3) Is there regional variation in these reported experiences of bullying and discriminatory behaviors by orthopaedic trainees and professionals in the LGBTQ+ community?
Patients and Methods
Survey and Study Design
Individuals registering for the Pride Ortho community completed a 16-question, internet-based survey (Supplemental Digital Content 1; http://links.lww.com/CORR/B276). The survey questions were integrated into the online membership registration process on the Pride Ortho website, ensuring that all new members had the opportunity to participate in the voluntary survey as part of their signup procedure. Participation in any of the 16 survey questions was optional for respondents.
The survey was designed by the Pride Ortho board of directors using the Delphi method, which is an accepted tool used to gain consensus where scientific data are lacking [36]. The board members participated in multiple rounds of survey question creation, providing their professional opinion, garnering feedback, and aiming to reach consensus [11, 26, 36].
Once the data were entered, only board members had access to the information. A password-protected Excel sheet was created to ensure data protection. Although individual data were collected at the time of the application process for each member, cross-sectional data were compiled on July 25, 2023.
Demographic data including sex assigned at birth, gender expression or identity, sexual orientation, race, location (state or country), level of training, and area of specialty were analyzed. Additional questions determined whether individuals were public regarding their sexuality, the members’ status of being out at work, and whether they perceived experiencing bullying, harassment, or discrimination. In our study, we focused on self-reported perceptions of bullying, harassment, and discrimination. This approach acknowledges that the impact of such experiences on an individual’s well-being and professional life is great, regardless of external validation. By capturing these perceptions, we aimed to gain a deeper understanding of the challenges faced by LGBTQ+ individuals in orthopaedics.
Participants
One hundred fifty-six individuals registered for membership and were eligible to participate in the voluntary survey. In total, 92% (144 of 156) fully completed the survey, 6% (10 of 156) partially completed the survey (answered some of the questions, but not all), and 1% (2 of 156) did not complete any portion of the survey. Most member respondents were assigned female sex at birth (58% [89 of 154]), were White (74% [114 of 154]), used she/her/hers pronouns (53% [82 of 154]), and were located in the United States (88% [136 of 154]), with an approximately even regional spread (approximately 20%) (Table 1).
Table 1.
Respondent demographics and reported frequencies
| Entire membership (n = 154) | LGBTQ+ (n = 100) | Straight or heterosexual (n = 51) | |
| Sexual orientation | |||
| LGBTQ+ | 65 (100) | ||
| Straight or heterosexual | 33 (51) | ||
| Did not respond | 2 (3) | ||
| Gender identity | |||
| Agender | < 1 (1) | 1 (1) | |
| Cisgender man | 36 (56) | 31 (31) | 45 (23) |
| Cisgender woman | 50 (77) | 56 (56) | 39 (20) |
| Nonbinary | 3 (4) | 4 (4) | |
| Transgender man | 2 (3) | 2 (2) | 2 (1) |
| Did not respond | 8 (13) | 6 (6) | 14 (7) |
| Sex assigned at birth | |||
| Female | 58 (89) | 63 (63) | 49 (25) |
| Male | 42 (65) | 37 (37) | 51 (26) |
| Pronouns used | |||
| He/him/his | 42 (65) | 37 (37) | 53 (27) |
| She/her/hers | 53 (82) | 57 (57) | 47 (24) |
| They/them/theirs | 1 (2) | 2 (2) | |
| Multiple | 3 (4) | 4 (4) | |
| Did not respond | < 1 (1) | ||
| Location | |||
| United States | 88 (136) | 87 (87) | 92 (47) |
| Northeast | 21 (32) | 20 (20) | 22 (11) |
| Midwest | 21 (32) | 20 (20) | 22 (11) |
| Pacific | 1 (2) | 1 (1) | 2 (1) |
| South | 23 (36) | 26 (26) | 20 (10) |
| West | 20 (31) | 17 (17) | 27 (14) |
| Not specified | 2 (3) | 3 (3) | |
| Other | 12 (18) | 13 (13) | 8 (4) |
| Africa | < 1 (1) | 1 (1) | |
| Asia | < 1 (2) | 1 (1) | |
| Australia | < 1 (1) | 1 (1) | |
| Canada | 5 (7) | 6 (6) | < 1 (1) |
| Europe | 3 (4) | 1 (1) | 6 (3) |
| Central/South America | 1 (2) | 2 (2) | |
| Did not respond | < 1 (1) | 1 (1) | |
| Career or training status | |||
| Attending | 50 (77) | 39 (39) | 73 (37) |
| Fellow | 5 (7) | 4 (4) | 4 (2) |
| Resident | 12 (19) | 16 (16) | 6 (3) |
| Medical student | 27 (41) | 36 (36) | 8 (4) |
| Other (retired, researcher, sales representative) | 4 (6) | 4 (4) | 4 (2) |
| Did not respond | 3 (4) | 1 (1) | 6 (3) |
| Race | |||
| Black, African, or African American | 3 (4) | 3 (3) | 2 (1) |
| East Asian or Southeast Asian | 6 (10) | 7 (7) | 4 (2) |
| Hispanic, Spanish | 3 (5) | 5 (5) | |
| Indian or South Asian | 1 (2) | 4 (2) | |
| Middle Eastern | < 1 (1) | 2 (1) | |
| Multiracial | 9 (14) | 11 (11) | 6 (3) |
| White | 74 (114) | 71 (71) | 82 (42) |
| Did not respond | 3 (4) | 3 (3) | |
Data presented as % (n); LGBTQ+ = lesbian, gay, bisexual, transgender, and queer or questioning individuals; straight or heterosexual = being sexually or romantically attracted to individuals of the opposite gender; sexual orientation = an individual’s identity in relation to which gender they are sexually or romantically attracted to; gender identity = the social constructed role that an individual chooses to inhabit, regardless of that individual’s assigned sex at birth; agender = an individual who does not identify as having a gender; cisgender man = individuals who identify as male and who were born male; cisgender woman = individuals who identify as female and who were born female; nonbinary = gender identity that is not solely male or female; transgender man = individuals with male gender identity who were born as female; pronouns used = the way an individual prefers to be called when others refer to them.
Demographics
Most respondents identified as being LGBTQ+ (65% [100 of 154]), with half being at the attending stage of their careers (50% [77 of 154]). A large portion of the cohort were medical students (27% [41 of 154]) or residents (12% [19 of 154]). Major subspecialties of the respondents included pediatrics (14% [26 of 183]), trauma (12% [22 of 183]), and hand and upper extremity (11% [20 of 183]) (Table 2). Nearly half of the respondents reported their gender identity as cisgender women (individuals who identify as women and who were born female) (50% [77 of 154]). Of the LGBTQ+ cohort, more than half the responders were cisgender women (56% [56 of 100]), 31% (31 of 100) were cisgender men (individuals who identify as men and who were born male), 2% (2 of 100) identified as transgender men (individuals whose gender identity is that of men who were born female), 4% (4 of 100) identified as nonbinary (gender identity that is not solely that of a man or a woman), and 1% (1 of 100) identified as agender (an individual who does not identify as having a gender). Of the straight and heterosexual cohort, 39% (20 of 51) identified as cisgender women and 45% (23 of 51) identified as cisgender men, and one individual identified as a transgender man. Three individuals did not report their identity or orientation (Table 1). The 92% (144 of 156) response proportion and 65% (100 of 154) identifying as LGBTQ+ suggest this sample reflects the perspectives of LGBTQ+ and non-LGBTQ+ individuals at all career levels in orthopaedic surgery.
Table 2.
Subspecialties represented (n = 183)
| Adult reconstruction | 8 (14) |
| General | 6 (11) |
| Hand or upper extremity | 11 (20) |
| Oncology | 4 (7) |
| Pediatrics | 14 (26) |
| Research | 5 (9) |
| Spine | 3 (6) |
| Sports | 9 (17) |
| Trauma | 12 (22) |
| Did not respond | 28 (51) |
Data presented as % (n).
Ethical Approval
The current study was exempt from institutional review board approval because it was deemed not to be human-subject research.
Statistical Analysis
Frequencies were recorded for categorical variables. Data were analyzed using IBM SPSS Statistics for Windows (version 28.0). This study was designed as a descriptive analysis to capture a broad range of experiences among LGBTQ+ individuals in orthopaedics. The focus was on qualitative insights rather than statistical relationships, making statistical comparisons unnecessary for our exploratory objectives.
Results
How Often Are Orthopaedic Trainees and Professionals in the LGBTQ+ Community Out in Their Workplaces?
Of the LGBTQ+ respondents, 94% (94 of 100) reported being out at their workplace. Career status of these respondents consisted of 39% (39 of 100) attendings, 16% (16 of 100) residents, and 36% (36 of 100) medical students. Of these individuals, 31% (31 of 100) indicated that they were only partially out (that is, not out to all coworkers). Of the LGBTQ+ respondents, a larger percentage of cisgender men (74% [23 of 31]) reported being out compared with cisgender women (57% [32 of 56]). Of the two transgender men respondents, both individuals reported only being partially out at work. Nonbinary individuals reported either being out (75% [3 of 4]) or only partially out (25% [1 of 4]) at work (Table 3). Only 6% (6 of 100) of LGBTQ+ respondents reported not being out in the workplace; these individuals included four early-career trainees and two late-career attendings. The respondents who partially completed the survey (6% [10 of 156]) were all straight or heterosexual, and either did not respond or marked “not applicable” regarding being out at work.
Table 3.
Proportion of being out at work among LGBTQ+ individuals in Pride Ortho
| Yes | Partially | No | Not applicable | |
| All LGBTQ+ survey respondents (n = 100) | 63 (63) | 31 (31) | 4 (4) | 2 (2) |
| Responders by gender | ||||
| Cisgender woman (n = 56) | 57 (32) | 36 (20) | 4 (2) | 4 (2) |
| Cisgender man (n = 31) | 74 (23) | 23 (7) | 3 (1) | |
| Transgender man (n = 2) | 100 (2) | |||
| Nonbinary (n = 4) | 75 (3) | 25 (1) |
Data presented as % (n); LGBTQ+ = lesbian, gay, bisexual, transgender, and queer or questioning individuals; cisgender man = individuals who identify as male and were born male; cisgender woman = individuals who identify as female and were born female; nonbinary = gender identity that is not solely male or female; transgender man = individuals with male gender identity who were born female; being out = openly identifying as LGBTQ+ to others.
Based on geography, the percentage of those answering “yes” to being out at work showed an even distribution among the various United States regions. The Pacific region, including Hawaii and Alaska, was the least-represented region among respondents (Table 4).
Table 4.
Percentage of being out at work based on US region
| Yes | Partially | No | Not applicable | |
| All LGBTQ+ survey respondents (n = 100) | 63 (63) | 31 (31) | 4 (4) | 2 (2) |
| Responders by region | ||||
| Northeast (n = 20) | 45 (9) | 55 (11) | ||
| Midwest (n = 20) | 60 (12) | 30 (6) | 5 (1) | 5 (1) |
| Pacific (n = 1) | 100 (1) | |||
| South (n = 26) | 69 (18) | 27 (7) | 4 (1) | |
| West (n = 17) | 59 (10) | 35 (6) | 6 (1) |
Data presented as % (n); LGBTQ+ = lesbian, gay, bisexual, transgender, and queer or questioning individuals; cisgender man = individuals who identify as male and were born male; cisgender woman = individuals who identify as female and were born female; nonbinary = gender identity that is not solely male or female; transgender man = individuals with male gender identity who were born female; being out = openly identifying as LGBTQ+ to others.
Discrimination, Bullying, or Differential Treatment
Of the LGBTQ+ survey respondents, 74% (74 of 100) responded “yes” or “maybe” to reporting experiences of bullying, discrimination, or being treated differently. Of the straight or heterosexual respondents 92% (47 of 51) answered “no” to experiencing any sort of bullying, discrimination, or being treated differently (Table 5). Of the respondents who partially completed the survey (6% [10 of 156]), all individuals responded “no” to reporting experiences of bullying, discrimination, or differential treatment.
Table 5.
Proportion of bullying, discrimination, or being treated differently based on sexual orientation among LGBTQ+ and straight and heterosexual individuals in Pride Ortho
| Yes | Maybe | No | Prefer not to say | |
| LGBTQ+ (n = 100) | 50 (50) | 24 (24) | 22 (22) | 4 (4) |
| Straight or heterosexual (n = 51) | 4 (2) | 92 (47) | 4 (2) |
Data presented as % (n); LGBTQ+ = lesbian, gay, bisexual, transgender, and queer or questioning individuals; straight and heterosexual = being sexually or romantically attracted to individuals of the opposite gender.
Regional Variation in Perceived Bullying and Discriminatory Behaviors
We observed no differences among regions in terms of orthopaedic trainees and professionals being out in their workplace or perceptions of experiencing discrimination, bullying, or differential treatment (Table 6).
Table 6.
Proportion of people reporting experiences of bullying, discrimination, or being treated differently based on sexual orientation among LGBTQ+ individuals based on region (n = 100)
| Yes | Maybe | No | Prefer not to say | |
| All LGBTQ+ survey respondents (n = 100) | 50 (50) | 24 (24) | 22 (22) | 4 (4) |
| Responders by region | ||||
| Northeast (n = 20) | 35 (7) | 25 (5) | 30 (6) | 10 (2) |
| Midwest (n = 20) | 55 (11) | 20 (4) | 20 (4) | 5 (1) |
| Pacific (n = 1) | 100 (1) | |||
| South (n = 26) | 54 (14) | 23 (6) | 19 (5) | 4 (1) |
| West (n = 17) | 41 (7) | 35 (6) | 24 (4) |
Data presented as % (n); LGBTQ+ = lesbian, gay, bisexual, transgender, and queer or questioning individuals.
Discussion
In the United States, LGBTQ+ individuals often encounter discrimination and stigmatization because of their sexual orientation and gender identity, impacting their workplace experiences and overall well-being [24, 30, 31, 35]. Knowledge of LGBTQ+ practitioners’ experiences in orthopaedics, particularly in terms of workplace openness about sexual and gender orientation and perceived experiences of bullying, discrimination, or differential treatment, remains limited despite acknowledged diversity gaps in our profession [6, 15, 20]. We aimed to gather demographic information and assess reported experiences of bullying, discrimination, and differential treatment toward LGBTQ+ individuals in orthopaedic surgery. We found that although most LGBTQ+ orthopaedic trainees and professionals openly identified their orientation at work, many still reported experiencing bullying, discrimination, or differential treatment in their workplaces. This juxtaposition of increased visibility and persistent discrimination highlights the need for continued efforts toward creating a more supportive environment in orthopaedic surgery.
Limitations
Our study has several limitations. First, this survey was not validated; it was developed through the Delphi method by members of the Pride Ortho LGBTQ+ community [18]. In light of the absence of a validated questionnaire aimed to assess LGBTQ+ experiences in the workplace, our survey followed guidelines proposed by Hughes et al. [19] to design survey questions regarding sexual orientation, gender identity, and perceived LGBTQ+ experiences. These guidelines were employed in a previous study conducted by Harless et al. [14] to assess health experiences of LGBTQ+ in southern states within the United States. Based on our incorporation of these strategies and their previous use, we believe that the trends and perspectives gathered in our survey should be interpreted as indicative and serve as a preliminary step to inform the development of validated methodologies tailored to assess LGBTQ+ experiences in the workplace. Second, the survey was conducted among individuals who are members of Pride Ortho, an organization dedicated to providing empowerment, support, and mentorship for the LGBTQ+ community in orthopaedics. Although the targeted nature of this group could be seen as limiting the survey’s generalizability to the general public, focused groups such as this provide insights into perceived experiences of orthopaedic trainees and attendings. Due to the relative small percentage of the population that identifies as LGBTQ+ in the United States, Hughes et al. [19] highlighted the importance of accessing these “hidden” populations by leveraging community partners. As a result, we believe our survey was able to effectively sample the diverse perspectives and experiences of LGBTQ+ individuals in orthopaedics that broader surveys might overlook.
It is particularly challenging to distinguish whether such experiences, especially among LGBTQ+ women, are because of gender or sexual orientation. For example, it has been shown that 81% of women have experienced discrimination, bullying, sexual harassment, and harassment in orthopaedics [2]. Although our study provides valuable insights into the experiences of the LGBTQ+ community in orthopaedics, it does not fully address the intersectionality of gender and sexual orientation. It has been shown that patterns of discrimination can be multiplicative, such that when different identities coalesce, it can lead to disproportionately high levels of discrimination [16]. For example, an African American gay woman in orthopaedics may have several “strikes” against her in a field that is dominated by cisgender White men. The multifaceted nature of discrimination is complex and merits further exploration. Nonetheless, our study provides a baseline of understanding from which to start.
Despite robust engagement in our survey, 8% (12 of 156) of Pride Ortho registrants did not fully participate in it. Nonresponse bias might arise if individuals with negative experiences felt less inclined to participate because of discomfort or skepticism about the impact of their input. This could lead to an underestimation of negative experiences in the overall results. However, the involvement of community partners in designing our questionnaire, a key aspect of the Delphi method, likely enhanced response rates. Such involvement is known to improve participation as it adds legitimacy to the research in the eyes of the LBGTQ+ population [19]. Additionally, it should be noted that all partial respondents (10 of 156) were straight or heterosexual. Therefore, we believe that our survey was able to mitigate the influence of these biases to an extent and provide detailed insights into perceived LGBTQ+ experiences of bullying and discrimination.
The potential for recall bias and the subjective nature of self-reported experiences are an additional limitation in our study. Respondents may overreport or underreport their experiences because of the emotional impact of traumatic events or the subtlety of discriminatory behaviors, which may have contributed to hypervigilance in their perceived experience [5]. Nonetheless, perceived experiences are lived experiences, and they should be understood and minimized.
Additionally, we included medical students in the study (they represented 27% [41 of 154] of the sample). These individuals may not ultimately choose orthopaedic surgery as their specialty. Consequently, their responses regarding experiences of bullying or harassment may not specifically reflect the orthopaedic surgery environment but rather their broader experiences while training in medical settings. However, their inclusion in the study is justified because their membership in Pride Ortho suggests a serious interest in our profession, and their responses provide valuable insights into the broader medical training environment’s impact on LGBTQ+ individuals.
How Often Are Orthopaedic Trainees and Professionals in the LGBTQ+ Community Out in Their Workplace?
Our survey indicates that 94% (94 of 100) of LGBTQ+ respondents were open or partially open about their sexual or gender identities at work. However, 6% (6 of 100) either concealed their identities or chose not to disclose their status. This suggests a general comfort among orthopaedic trainees and professionals in expressing their identity, a crucial factor for incoming trainees. The presence of minority mentors is vital for attracting diverse candidates to orthopaedics because underrepresentation and stereotypes can deter potential applicants [31]. Gerull et al. [10] found that a lack of identity alignment can diminish interest in orthopaedics, and a survey by Lee et al. [25] observed that 80% of LGBTQ+ surgery residency applicants were more inclined toward applying to programs with visible LGBTQ+ faculty or residents. Our findings diverge from both Lee et al.’s [25] study on general surgery residents and the 2008 General Social Survey [20], because 57% of their general surgery residents surveyed chose to conceal their sexual orientation and 25% of workers were openly out to their coworkers, respectively [27, 31]. The variance in our results compared with other studies might be because orthopaedic trainees and professionals feel more comfortable expressing their sexual and gender orientations in their workplaces. This notion is supported by a more recent 2023 Indeed survey, which reported that 69% of LGBTQ+ workers in a sample of 491 full-time employees are openly out at their workplaces, suggesting that supportive environments in corporate settings increase LGBTQ+ individuals’ willingness to disclose their identities at work [23]. The concealment of LGBTQ+ identity in the workplace, often because of a lack of safety and support, can cause psychologic stress, underscoring the importance of enhancing LGBTQ+ visibility in orthopaedics to foster a welcoming environment for potential candidates [15, 24, 30]. Based on our findings, we suggest that orthopaedic residency programs implement mentorship programs and increase LGBTQ+ faculty and resident visibility. These measures can provide a supportive network and role models for LGBTQ+ trainees, improving their sense of belonging and engagement in orthopaedics. Future research should focus on evaluating the effectiveness of these recruitment programs with the goal of increasing LGBTQ+ representation in orthopaedic surgery.
Discrimination, Bullying, or Differential Treatment
In our survey, among LGBTQ+ respondents, 74% (74 of 100) reported experiencing or potentially experiencing bullying or discrimination, with 50% (50 of 100) answering “yes” and 24% (24 of 100) answering “maybe,” in contrast to 92% (47 of 51) of non-LGBTQ+ individuals who denied such experiences. These results suggest that despite a general openness about their identity at work, many LGBTQ+ individuals perceive experiencing discrimination, bullying, or differential treatment more than their non-LGBTQ+ colleagues. Similar experiences reported by trainees and physicians from minority groups have been shown to negatively impact overall individual well-being and lead to burnout and poor health outcomes [1, 24, 32, 34, 38]. To create a fairer orthopaedic profession, it is essential to recognize and address the experiences of our LGBTQ+ colleagues. Our study observed a lower percentage of individuals reporting discrimination, bullying, and differential treatment among LGBTQ+ orthopaedic professionals than in other medical specialties. Heiderscheit et al. [15] found that 60% (161 of 272) of LGBTQ+ general surgery residents reported these experiences, whereas Lall et al. [23] found that 56% (73 of 130) of LGBTQ+ emergency medicine residents reported harassment. Newsom et al. [29] observed that 97% (42 of 43) of LGBTQ+ plastic surgery attendings reported encountering microaggressions, with 37% (16 of 43) reported experiencing discrimination from colleagues. Although the proportion of individuals reporting experiencing bullying in orthopaedics appears to be lower than has been reported in other specialties, DiFiori et al.’s [7] study on United States orthopaedic trainees and surgeons highlights the issue of underreporting bullying behaviors because of fear of retaliation, damage to reputation, perceived inaction, and career impact. Similar to our results, they found that 43% of LGBTQ+ respondents reported experienced bullying; however, they found that experiences of bullying continued even after reporting incidents to the institution [2, 7]. Despite antidiscrimination legal mandates within the United States, results of these studies suggest that reports of experiencing continued mistreatment may be exacerbated because of inadequate policy enforcement. However, institutions focusing purely on punitive measures for discriminatory behavior has been shown to be ineffective in addressing the root problem in the workplace [8]. To be most effective in remediating mistreatment, we suggest orthopaedic institutions adopt proactive measures such as feedback loops to continuously collect data on worker perspectives and perceptions of the environment and current policies [8]. These can assist in identifying the context and cause of the reports of experiencing bullying and discrimination for all members in the orthopaedic workplace.
Building on our findings and corroborating studies, it is imperative for orthopaedic leaders and educators to actively combat mistreatment of LGBTQ+ individuals [1]. Key strategies currently employed by healthcare institutions include implementing competency training at all career levels, establishing protective reporting policies, and providing bystander intervention training [15]. Chu et al. [6] emphasized how little formal continuing education regarding LGBTQ+ issues exists for established providers in orthopaedic surgery and called for methods to educate the current workforce on reducing implicit bias against LGBTQ+ individuals. Faculty can leverage tools such as the Implicit Association Test, already integrated into the University of Pittsburgh’s internal medicine residency curriculum, to uncover and address their own implicit biases toward diverse populations, including LGBTQ+ individuals [12]. This approach has demonstrated effectiveness in enhancing resident knowledge and confidence in delivering comprehensive care to LGBTQ+ patients, illustrating its potential as a valuable resource in reducing biases [39]. However, implementation of this test should be carefully considered as it has been faced with several critiques including the concern of the test’s reliability and validity in consistently measuring implicit biases [4]. At Albany Medical Center in New York, a workshop series was conducted for residents in pediatrics, emergency medicine, family medicine, and general surgery, focusing on allyship (supportive association with marginalized or mistreated groups to which one does not belong). Assessments after the workshop showed an increase in understanding and application of allyship concepts [28]. We suggest implementation of a similar curriculum for residents and attendings. Additionally, promoting a culture of inclusivity through diversity training, clear enforcement of antidiscrimination policies, and increased LGBTQ+ leadership representation is crucial. These measures will foster a respectful, supportive workplace, mirroring the care provided to patients.
Regional Variation in Perceived Bullying and Discriminatory Behaviors
The absence of regional variation in reported experiences of bullying or discrimination among LGBTQ+ individuals in orthopaedics, as indicated by our survey, contrasts with previous studies suggesting heightened discrimination in certain regions, particularly in the southern United States [33, 37]. This finding suggests that challenges faced by LGBTQ+ individuals in orthopaedics may be uniformly distributed across various geographic areas, rather than being concentrated in specific regions. Consequently, we suggest that the strategies and policies previously described should be applied nationally in the orthopaedic community. Many organizations are attempting to tackle health disparities in the LGBTQ+ community. For example, the Joint Commission and United States Department of Health have highlighted the importance of education in sexual and gender minority health [21], and the WHO created an agenda focusing on the health of LGBTQ+ patients [20]. The Association of American Medical Colleges offered best-practice recommendations for medical education curriculum focused on LGBTQ+ patient care [17], and a 2015 National Institutes of Health and American College of Surgeons Summit proposed a research agenda to improve the delivery of culturally competent care [13]. These efforts should be uniformly applied across all regions to create a fairer and more supportive environment for all orthopaedic professionals, regardless of their geographic locations.
Conclusion
Our study revealed several key findings about the experiences of LGBTQ+ individuals in the orthopaedic community. Although a high proportion of LGBTQ+ orthopaedic professionals and trainees are open about their sexual and gender identities in the workplace, many still reported experiences of bullying, discrimination, or differential treatment. We found no regional variation in these reported experiences. This dichotomy emphasizes the persistent challenges faced by LGBTQ+ individuals in orthopaedics, despite apparent openness. In addition to the key findings, our study underscores the importance of organizations such as Pride Ortho in empowering and mentoring the LGBTQ+ community in orthopaedics and highlights the need for institutional efforts such as promoting LGBTQ+ surgeons into leadership roles and enforcing no-tolerance policies against bullying and discrimination, to create a safer and more inclusive environment that supports orthopaedic professionals and patients. For orthopaedic institutional leaders and policymakers, these findings emphasize the need for specific measures such as establishing continuous feedback loops in which all members of the workplace can provide insight on the environment and policies and implementing curricula for residents and physicians. Ultimately, we believe these would create a supportive environment for all individuals in the orthopaedic workplace. Future research should aim to quantify the impact of these inclusive practices on both the recruitment and retention of LGBTQ+ individuals in orthopaedics. Studies should use longitudinal designs to track changes over time, providing a clearer understanding of how specific interventions influence the experiences and career trajectories of orthopaedic professionals. Additionally, expanding the scope to include a more diverse range of institutions and geographic locations would offer a more comprehensive view of the global orthopaedic community.
Supplementary Material
Footnotes
Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Ethical approval for this study was waived by the institutional review board of Nationwide Children’s Hospital, Columbus, OH, USA.
This work was performed at Nationwide Children’s Hospital, Columbus, OH, USA.
Contributor Information
Yogesh Kumaran, Email: yogesh.kumaran@rockets.utoledo.edu.
Jaime Bellamy, Email: jaime.bellamy@gmail.com.
Ryann Maciejewski, Email: rscarberry@tulane.edu.
Kirsten Tulchin-Francis, Email: kirsten.tulchin-francis@nationwidechildrens.org.
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