Editor’s Spotlight/Take 5: How Much Bullying and Discrimination Are Reported by Sexual and Gender Minorities in Orthopaedics?

Julie Balch Samora MD, PhD, MPH

Nobody likes a bully.

We’ve all heard that line many times. Among decent people, I think it’s true. And for that reason, the findings of this month’s Editor’s Spotlight article in CORR® [2] are dismaying: About three-quarters of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) members of Pride Ortho answered either “yes” or “maybe” to a survey question asking whether they’d perceived experiences of bullying, discrimination, or being treated differently because of their sexual orientation at work. Fully half answered “yes.”

Pride Ortho, as you may know, is a networking and mentorship community of LGBTQ+ individuals and their allies who are in orthopaedic surgery (or are students who are interested in our profession). The survey itself was straightforward, and over 90% of the 150-plus Pride Ortho members responded to it, so there’s every reason to trust that the survey’s troubling results apply broadly to the population of interest.

There are a few ways we can try to hide from these findings. We might say that these are perceptions, not documented occurrences of inappropriate workplace behavior. We could say that there’s a world of difference between bullying or discrimination (which may be fairly brutal) and differential treatment (which may not be). And certainly, bullying is a loosely defined term, though all definitions I could find involved either the desire to inflict intentional harm, or at least the willingness to do so in order to exert or project power.

But I suggest we not try to hide from such consistent, disturbing findings, and that instead, we confront them and try to mitigate them. We'll talk more about why and how in the Take 5 interview that follows with the article’s senior author, Julie Balch Samora MD, PhD, MPH.

As I sat down to write this essay, my thoughts went to a line from the eulogy I delivered at my father’s funeral: “He taught me to stand up to a bully, but not to imagine that it will go well. It’s still worth it.” Reading the article by Dr. Samora’s team made me wonder whether that line was too simplistic, and perhaps it’s advice from another time when the world was different. In the workplace, among people who have experienced what some of these Pride Ortho members have experienced, I am not so sure that standing up to a bully is possible or advisable. Read the Take 5 interview that follows with Dr. Balch Samora to see whether she thinks it is, along with her perspectives on a number of other pressing professional issues that affect all of us, not just those of us who are LGBTQ+.

Take 5 Interview with Julie Balch Samora MD, PhD, MPH, senior author of “How Much Bullying and Discrimination Are Reported by Sexual and Gender Minorities in Orthopaedics?”

Seth S. Leopold MD: Congratulations on this eye-opening study. My deepest hope is that this study (and others being published in this month’s symposium on diversity and disparities in CORR) will move our profession in the direction of greater fairness. But not everyone is going to agree with everything here, so let’s start by addressing the skeptic’s likely dismissal of your findings about bullying, discrimination, and differential treatment. Can you explain why the findings are important, even though they’re “just perceptions,” without resorting to the “perception is reality” defense? How much of these bad behaviors are “really” going on?

Julie Balch Samora MD, PhD, MPH: We are grateful to CORR for the opportunity to not only share, but also discuss our findings. Addressing the skepticism around perceptions of bullying, discrimination, and differential treatment among LGBTQ+ individuals in orthopaedics requires a thoughtful approach. It's essential to recognize that these perceptions are rooted in the lived experiences of LGBTQ+ members. Members of stigmatized groups’ perceptual sensitivity to social cues is not about being overly sensitive in a negative sense; rather, it reflects an increased awareness to nuances in behavior that might suggest bias or discrimination. This heightened vigilance is often developed through past experiences of acceptance or rejection, both within and outside professional settings [3].

When considering the actual occurrence of negative behaviors, it's important to recognize that what might be perceived as differential treatment could sometimes arise from well-intentioned efforts to be inclusive. However, these efforts can inadvertently be perceived as “othering” or exclusionary by LGBTQ+ individuals, especially if they result in any form of singling out, even with positive intent. This issue highlights the complexity of social dynamics in a professional setting and the need for a nuanced approach to interactions that respects individual identities while striving for genuine inclusiveness.

With regard to how much of these bad behaviors are “really” going on, it is difficult to quantify the precise extent of negative behaviors without context. Our study suggests that these types of behaviors are more prevalent than perhaps previously expected. Acknowledging the validity of LGBTQ+ individuals' perceptions and experiences is a critical step forward. It's about fostering a professional culture where every member, regardless of their sexual or gender identity, feels valued and respected. This approach doesn't necessarily rely on formal training programs or designated safe spaces, which might not resonate with all professional cultures, but rather on a collective commitment to understanding and respect that can be integrated into the everyday fabric of orthopaedic practice.

Dr. Leopold: The skeptic might also say that you lumped that which was better off split: Bullying and discrimination might actually be crimes (depending on what was done), while differential treatment may be something different altogether, and certainly can include a number of less-severe interactions. Can you convince the skeptical reader that the bundling of these different behaviors into a single question doesn’t inflate the percentages to make an advocacy point, or a splashy headline?

Dr. Samora: Bullying and discrimination indeed represent severe and potentially criminal behaviors that have no place in any professional setting. Differential treatment, on the other hand, encompasses a wider range of interactions that may not always be negative or harmful, but can still contribute to a sense of otherness or exclusion among LGBTQ+ individuals. The inclusion of these varied experiences in our survey was designed to provide a comprehensive snapshot of the environment that LGBTQ+ professionals navigate, rather than create a sensationalized narrative. We recognize that even subtle forms of differential treatment, while not necessarily malicious, can have cumulative effects on the morale and sense of belonging of LGBTQ+ individuals. The goal of our work was to illuminate the full spectrum of their experiences, encouraging a more nuanced understanding and fostering discussions on how to create a more supportive orthopaedic community.

Dr. Leopold: It seems clear enough to me that there ought to be a zero-tolerance approach taken for serious, overt, and purposeful bad behaviors. But do you think there’s any chance that the experiences reported by the survey-takers were unintentional, such that the people who committed the offenses would simply have apologized and tried to make amends if they were told that they’d made someone feel bullied or discriminated against? And if so, what suggestions do you have for all of us who may be guilty of that sort of offense?

Dr. Samora: It is likely that many of the infractions are unintentional, and I am guilty of such transgressions myself. Much of the original work on microaggressions was done by psychiatrist Chester Pierce in the 1970s. Derald Wing Sue furthered Pierce’s research over the past two decades, describing microaggressions as verbal, nonverbal, or environmental slights conveying negative messages that can be either intentional or unintentional, and can include subtle misunderstandings [5]. Oftentimes, perpetrators are unaware of the effect of their seemingly innocuous words or deeds, and because of the perceived innocence by the perpetrator and the subtleness of these “offenses,” the target can be seen as being overly sensitive or “overthinking” the situation. Taken one act at a time, they seem trivial, but the effects of microaggressions have been shown to be cumulative [1, 4, 6].

What all of us can do to minimize these types of interactions is to become more self-aware. Take an implicit association test (or two or three) to understand your implicit biases. Slow down; use more deliberate, “system two thinking,” rather than our fast “system one thinking” (instinctive, visceral, emotional) as described by psychologist Daniel Kahneman [7]. Be vulnerable and transparent on the learning journey. Step into someone else’s shoes (try to evaluate others’ perspectives), and practice and expect inclusion. For those who are witness to microaggressions, it is important not to become an enabler; silence communicates tacit approval. Serve as an ally to marginalized groups by promoting inclusiveness, challenging the status quo, and using your privilege to support and advocate for others.

I think the most important recommendation is to continually learn each day. Be open and curious. Ask questions. Be aware of how behaviors or comments may negatively impact others, and work to minimize or eliminate these microaggressions. Finally, an apology does go a long way.

Dr. Leopold: Another interesting and perhaps related finding from your study (and one about which there is much less ambiguity) is that more than one-third of the LGBTQ+ survey-takers were either not out or were only partially out—that is, they did not openly acknowledge their sexual orientation or gender identity to all coworkers, though 94% were at least partially out. This, perhaps more than the bullying and discrimination statistic, suggests that a lot of people do not feel comfortable being who they are at work. How can those of us who are straight and cisgender help solve this?

Dr. Samora: I enlisted the help of my coauthor, Jaime Bellamy DO, to help answer this question: “People in the LGBTQ+ community have a sixth sense of whether or not they belong in the spaces they are in. This means they listen to your language and how you act in the workplace. For example, do you question whether a person is a man or a woman? Do you make comments that are derogatory to that effect? Do you make fun of the way someone dresses because it may not fit the gender ‘norm’? Do you automatically assume a patient who is a woman has a husband? Do you use pronouns? Do you wear anything on your badge to show you are safe? Do you display LGBTQ+ patient materials and families in your office? People in the LGBTQ+ community notice all of these things that are said and done in the workplace. They also notice what is not said and done. If they feel a lack of safety, they will keep their true selves and personal lives private. In their minds, the internal stress of not being their true selves is more tolerable than the external stress they will probably endure by sharing. They stay invisible to protect themselves. They feel like they don’t belong enough to let you in.

“To get members of the LGBTQ+ community to let you in, use inclusive language and actions. Don’t assume everyone is straight and cisgender. Ask questions about their personal lives like you would anyone else. Read about the issues people in the LGBTQ+ community face. Talk about and participate in things and events that are important to the community. This will make it more likely that someone from the LGBTQ+ community will feel comfortable enough to let you in. Show the community is important by your actions: Hire, promote, and sponsor people in the LGBTQ+ community. The problem of lack of belonging will continue until inclusive, safe spaces are created that lead to more visibility. A culture of hiding and keeping things private is a way of the past. We at Pride Ortho are trying to change the old way of thinking and make safe spaces for all who feel they don’t belong.”

Dr. Leopold: Reaching back to the line in the Spotlight commentary about standing up to a bully: Is that ever sensible in this context? I wonder if the answer now is “no.” But I’m interested in your thoughts: What advice do you have for people who feel bullied at work?

Dr. Samora: Context is everything. Medicine remains very hierarchical. Someone in a position of authority can more easily call out inappropriate behavior and create a culture of inclusion and safety. However, when someone on the lower rungs of the ladder wishes to stand up to a supervisor, it can be challenging to navigate. Enlisting the help of colleagues, more senior trainees, program directors, or chairs can be a good first step if you are struggling with bullying and harassment. Keeping a record of consistent negative behaviors may be useful, particularly if others have similar grievances. Training programs are required to have safe ways that trainees can report bullying or harassment. These reporting mechanisms should be both anonymous and open so individuals can report in the way that they feel most comfortable. It is also critical that people have multiple ways to report incidents so that they can choose the way that is most comfortable for them. Even with “anonymous” reporting, retaliation is a legitimate concern, which can negatively impact someone’s daily life and ultimate career trajectory.

Taking on a bully, especially a bully with power, can be fraught with danger and negative repercussions. This very individual decision must be made on a personal level, taking into account all of the possible outcomes.