Striving for LGBTQI+ Health Equity in Arthroplasty

Healthcare equity is a core principle of modern medicine, yet disparities persist for marginalized communities. LGBTQI + individuals continue to encounter barriers in accessing orthopaedic care, particularly in the field of arthroplasty. These barriers are multifactorial, encompassing systemic discrimination, implicit bias, and cultural incompetence, which contribute to healthcare avoidance and poor patient outcomes. It is important to recognize and overcome the challenges that LGBTQI + patients face to affect an inclusive and compassionate healthcare environment.

Systemic discrimination and implicit bias

Discrimination against marginalized communities is one of the most pervasive barriers to accessing healthcare. Factors such as race, ethnicity, gender, and socioeconomic status continue to influence who receives care. Racial and ethnic minorities have been shown to undergo joint arthroplasty at lower rates compared to White individuals [1,2]. They are also more likely to experience provider bias, lower referral rates, and discharge to institutional facilities rather than home, all of which are associated with a poorer overall recovery [[3], [4], [5]]. In both the United States and United Kingdom, individuals from lower socioeconomic backgrounds experience surgical delays [1], poorer postoperative outcomes, and decreased access to joint arthroplasty surgery [6]. While awaiting arthroplasty surgery, more deprived patients have also been found to have poorer health-related quality of life and increased opioid use [7]. In the wider healthcare setting, systemic discrimination has perpetuated a gender health gap. Across specialties, women are more likely to experience delayed diagnosis/misdiagnosis [8], symptom dismissal, [[9], [10], [11]] and discrepancies in pain management [[12], [13], [14]]. In arthroplasty surgery specifically, data from the UK National Joint Registry 2024 Annual report [15] highlight that women more commonly undergo joint replacement surgery. Previous studies have also identified higher prevalence rates of osteoarthritis in female patients [16]. However, female patients continue to present with more severe symptoms and greater disability [17,18]. Although multifactorial in nature, historical evidence of unconscious gender bias in surgical recommendations for total joint arthroplasty [19] may persist.

Clinical research investigating disparities in access to joint replacement surgery for LGBTQI + individuals is limited. However, there is definite evidence to support that LGBTQI + patients experience overt prejudice or subtle biases in medical settings. A study by the Center for American Progress in 2017 highlighted that 8% of lesbian, gay, bisexual, and queer patients had been refused care due to their sexual orientation, with 29% of transgender individuals reporting that they had been denied care based on their gender identity [20]. A subsequent report in 2024 highlights that this discrimination persists, with 37% of LGBTQI+, 21% of transgender, and 45% of intersex adults postponing or avoiding medical treatment due to anticipated discrimination [21]. Kcomt et al proffered similar rates of healthcare avoidance in transgender adults [22], with Rusow et al. identifying that these biases extend to transgender and gender-diverse youth of color [23]. Furthermore, Boddu et al [24] found that nonheterosexual orientation was associated with a higher likelihood of delayed care in patients with knee osteoarthritis. This suggests that, despite increased generational awareness of the importance of diversity and inclusivity, discrimination remains a notable barrier to accessing healthcare.

Discrimination alongside the anticipation of bias and mistreatment may outweigh the perceived benefits of seeking care thus creating a cycle of medical mistrust and healthcare avoidance. This has been shown to correlate with poorer general and mental health outcomes among transgender adults [25] and has the potential to increase the burden of musculoskeletal disorders among LGBTQI + individuals. In the context of arthroplasty, this could cause significant delays in the diagnosis and treatment of joint pathology, and patients may present with more severe joint degeneration on initial surgical consultation.

Standards of care, clinical guidelines, and gender affirming recommendations for LGBTQI + healthcare, in particular trans healthcare, have evolved dramatically over the last 10 years. This progress has been to safeguard LGBTQI + healthcare rights against the active discrimination observed in other areas of life. Government policies and discriminatory legislation that restrict access to gender affirming care contribute to existing stigmas and biases in medical settings. Imposing such restrictions limits the practice of evidenced-based care, autonomy in patient-clinician decision-making, and the provision of care that is in the patient’s best interests.

Cultural incompetence

Evidence-based medicine is a key component of clinical practice in the United Kingdom. It involves integrating clinical knowledge with scientific evidence to provide the highest standard of care and demands that practice must evolve as novel medical and surgical pathways are developed. As the percentage of the population who identify as LGBTQI+ is increasing, so too must our knowledge and training on how best to manage this community.

While cultural competence training has improved in the medical field, there is still lack of provider competency in LGBTQI + health. This issue stems, in part, from a lack of education and training in most medical schools and healthcare institutions [26]. Currently, only 1 in 8 medical students in the United Kingdom feel their knowledge and skills are sufficient for managing this population group [27]. Furthermore, orthopaedic surgery is viewed as one of the least diverse specialties, with inconsistent training regarding the healthcare needs and cultural issues affecting LGBTQI + patients [28].

Harper et al [29] outline the unique considerations for transgender patients undergoing total joint arthroplasty surgery, acknowledging the paucity of research in this field. These include the correct documentation of gender identity and respectful communication to prevent misgendering patients. The study also highlights key points for preoperative planning and postoperative care such as stabilization on hormonal therapy, patient positioning intraoperatively, anesthetic considerations, increased venous thromboembolism, and osteoporosis risk, highlighting specific knowledge gaps in this area. This emphasizes the importance of a multidisciplinary approach and individualized care plans for transgender patients undergoing total joint arthroplasty. Training programs must incorporate this into their curricula to improve outcomes for this cohort of patients.

There is also a lack of representation of the LGBTQI + community in clinical trials [29,30], which means they are excluded from research outcomes which inform surgical pathways. This lack of representation stems from inadequate data collection methods, exemplified by the fact that many major joint arthroplasty registries record legal sex and offer binary sex categories (Table 1), and do not currently capture sexual orientation or gender identity data [39]. A systematic review of gender and sex terminology in arthroplasty research by Bellamy et al [40] found that these terms were often used interchangeably, with limited information regarding how this was measured. This will not reflect the diverse gender identities within the LGBTQI + population. Incorporating specific fields for sexual orientation and gender identity would enable more inclusive research. It would also allow the utilization of large registry datasets, leading to evidence-based practices that accurately reflect this community’s outcomes following arthroplasty surgery.

Table 1.

How gender is recorded in international joint registries.

Registry	Country	How sex/gender is recorded	Recording method and source
Swedish Arthroplasty Register [31]	Sweden	Binary (male/female) Based on annual report	Information is automatically derived from the patient’s personal identity number, which is based on the national population register’s record of legal sex.
National Joint Registry (NJR) [32]	United Kingdom	Male/female/indeterminate	Entered by the hospital. “Indeterminate” may be used where sex cannot be clearly assigned or is missing. Patients must give consent to have their personal details, including sex, recorded.
Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) [33]	Australia	Binary (male/female)	Recorded as binary based on what is entered by the hospital.
American Joint Replacement Registry (AJRR) [34]	United States	Binary (male/female)	Recorded as binary based on what is entered by the hospital.
Canadian Joint Replacement Registry (CJRR) [35]	Canada	Male/female/other	The registry collects data on both sex and gender and provides for categories including “other.”
New Zealand Joint Registry (NZJR) [36]	New Zealand	Binary (male/female)	2024 report only showed male/female categories.
Danish Hip Arthroplasty Register (DHR) [37]	Denmark	Binary (male/female)	Derived from civil registration number and reflects legal sex.
Norwegian Arthroplasty Register (NAR) [38]	Norway	Binary (male/female)	Date is obtained from the national ID number, reflecting the patient’s legal sex. Annual reports categorize patients as male or female.

Without the necessary training, education, and scientific background, we cannot demonstrate evidence-based medicine or develop inclusive medical practices.

Knowledge gaps

The effects of gender-affirming hormone treatment on musculoskeletal health are not fully understood. Studies have reported compromised bone health in transgender patients, and inconsistent results due to variations in hormonal treatments and follow-up durations [41,42]. In arthroplasty surgery, sparsity of literature creates knowledge gaps leading to uncertainty in surgical decision-making. This affects our ability to create targeted treatment plans, manage patient expectations, and communicate longer-term surgical outcomes. The LGBTQI + community represents a heterogeneous group of patients for whom standard practices cannot be broadly applied. They require personalized, specialist care reinforced by clinical competence and robust scientific evidence.

LGBTQI + individuals have higher rates of chronic pain conditions [43], including arthritis [44], which may be exacerbated by chronic stress and past trauma. They are at least 1.5 times more likely to suffer a mental health disorder [25,45], with LGBTQI + youth 2 to 3 times more likely to attempt suicide [30]. Mental health disorders are acknowledged to correlate with higher pain perception [46,47]. Given the aforementioned implicit bias in pain management for other marginalized groups, LGBTQI + patients may also face similar disparities in postoperative pain control, the fear of which may further limit their engagement. Additionally, LGBTQI + patients report higher rates of obesity [48,49], smoking [50], risk for cardiovascular disease [51], and HIV, [41] of which many are associated with increased postoperative complications following joint arthroplasty [52].

This evidence indicates that LGBTQI + patients have a higher risk of additional comorbidities, resource needs, and complications when undergoing arthroplasty surgery. Increased awareness and understanding of these factors can aid surgical planning and optimize perioperative support to reduce the rate of complications. Anticipating that these patients may present with chronic pain and psychiatric comorbidities could proffer the use of combined clinics with multidisciplinary team members and psychosocial support teams. Modifiable risk factors like obesity and smoking could be targeted early with easy access to weight management and smoking cessation services. Early detection and risk factor management is essential for these patients.

Structural and financial barriers

Beyond interpersonal challenges, structural and financial barriers can limit access to arthroplasty care for LGBTQI + individuals. The Center for American Progress 2024 report [21] showed that 33 percent of LGBTQI + adults and 45% of transgender adults, postponed care because of affordability. There are also higher rates of unemployment and job discrimination within the LGBTQI + community [53,54], which can lead to lower rates of employer-provided health insurance. The Affordable Care Act and Equality Act 2010 contain provisions to help and support LGBTQI + individuals, but many health insurance companies still restrict access to gender affirming care. The financial instability that accompanies funding gender alignment surgery can indirectly affect access to other elective procedures such as arthroplasty. Even for insured patients, the costs associated with surgery, rehabilitation, postoperative care, and transport can be prohibitive, particularly for those who lack traditional family or social support networks. LGBTQI + elders, for example, are more likely to live alone and less likely to have children, leading to reduced social support for recovery and heightened feelings of loneliness [55].

Barriers within the healthcare environment

Representation

The issue of patient-clinician concordance has received increasing attention in medical literature. Various studies have shown improved health outcomes with shared gender identity between patient and clinician [46,[56], [57], [58], [59]]. This is due to improved communication, trust, and a greater sense of being heard. While these findings largely stem from research in chronic disease management or specialties requiring prolonged interactive care, a recent study by Ikesu et al [60] found that female patients undergoing elective surgery had lower readmission and complications rates when operated on by a female surgeon. Furthermore, a large registry-based study from Sweden [61] of 11,993 primary total hip arthroplasties found that, overall, patient-surgeon sex discordance was associated with a modest reduction in adverse events. However, subgroup analyses showed that female patients operated on by a female surgeon had the lowest complication and readmission rates. While this study appears to be the only arthroplasty-specific study to date, it reflects findings in the wider medical literature and highlights the complexity of gender dynamics. Furthermore, dedicated, arthroplasty-based studies are therefore vital to determine whether gender dynamics influence access to joint replacement surgery, perioperative communication, decision-making, and outcomes.

Despite the acknowledged benefits of patient-clinician concordance, women and LGBTQI + individuals are still noticeably underrepresented in orthopaedic surgery [62]. In the United Kingdom, just 4% of surgeons contributing to the National Joint Registry of England, Wales and Northern Ireland in 2023 were female [39]. Similarly, in 2021, only 7% of orthopaedic consultants in the United Kingdom were female [62], confirming that gender inequality persists [63]. In 2022, the American Academy of Orthopaedic Surgeons (AAOS) reported that only 3% of AAOS members openly identify as LGBTQI+ [64].

While specific data on LGBTQI + patients in arthroplasty are limited, it is reasonable to infer that the presence of openly LGBTQI + surgeons would foster a similar sense of safety and trust [62], allowing patients to engage more openly in consultations and absorb information more effectively. Furthermore, being able to bring a partner to appointments without the fear of judgment can positively impact shared decision-making and advocacy. Professional respect in surgery is grounded in skill and competence, but having visible LGBTQI + representation would also facilitate mentorship opportunities for medical students and trainees and promote greater inclusivity within the specialty.

The AAOS and British Orthopaedic Association recognize the importance of diversity and inclusivity within orthopaedic surgery and have demonstrated their support through multiple social media campaigns. Pride Ortho is another organization that advocates for LGBTQI + representation in the field of orthopaedic surgery. It welcomes all members of the orthopaedic community, regardless of gender identity or sexual orientation, who share their ethos of inclusivity and health equity. Visible efforts like these that challenge inherent biases are invaluable for patients and surgeons alike, encouraging better engagement and mentorship within the specialty.

Visible allyship

Promoting diversity and inclusion practices in the immediate healthcare environment can help further support the LGBTQI + community. Many LGBTQI + patients report anxiety in clinical settings, particularly when their identities are invalidated or when they are forced to navigate gendered spaces that do not align with their identity [65]. The presence of visible signs of allyship, such as rainbow badges or LGBTQI + affirming posters, can help create a more welcoming atmosphere and signal to LGBTQI + patients that their identities and experiences are respected.

Addressing barriers to LGBTQI + access in arthroplasty

While there is still a distinct health inequity for LGBTQI + patients in accessing arthroplasty care, there are actionable solutions that can help create an inclusive and affirming orthopaedic healthcare system.

Medical schools and residency programs should incorporate LGBTQI + health into their curricula to ensure that new generations of orthopaedic surgeons are adequately prepared to meet the needs of diverse patient populations. Such initiatives have been shown to improve attitude and knowledge, leading to more equitable, respectful, and effective care, ultimately improving patient outcomes [[66], [67], [68]]. Cultural competency training programs that educate providers on LGBTQI + health issues, cultural sensitivities, and inclusive communication practices should be initiated by healthcare institutions. Mentorship programs, scholarships, and inclusive hiring practices should be encouraged to increase the representation of LGBTQI + individuals among healthcare providers, fostering an environment where LGBTQI + patients feel safe, heard and understood.

Policy reforms at both institutional and governmental levels can help protect LGBTQI + individuals from bias in healthcare settings. Enforcing nondiscrimination policies and supporting legal initiatives that protect LGBTQI + rights in medical care must continue to be a driving force in eliminating disparities in healthcare access for these patients. Addressing financial barriers such as including gender-affirming procedures and related healthcare needs in insurance coverage, offering sliding scale payment options, and providing financial counseling services can help alleviate the economic burdens that disproportionately affect LGBTQI + individuals.

Endeavors to facilitate access to care and promote advocacy should be a priority. Partnering with LGBTQI + organizations to promote outreach programs, health education workshops, and support groups can improve communication and trust and can encourage timely review of joint pathologies. Simple modifications comprising inclusive language on clinical documents, providing gender-neutral facilities, and displaying symbols of support can help to create a more inclusive environment.

There is a significant research gap regarding LGBTQI + patients and arthroplasty outcomes. Consequently, surgical recommendations are often based on heteronormative and cisgender-centric data, which may not be fully applicable to LGBTQI + patients. Inclusive research into LGBTQI + health issues, access to care, potential disparities, and outcomes should be expanded to facilitate targeted interventions and structural changes that promote healthcare equality.

Conclusions

LGBTQI + individuals continue to face considerable challenges in accessing arthroplasty care. These barriers are systemic and multifactorial, but not insurmountable. Addressing them requires a concerted effort from healthcare institutions, professional societies, and individual care providers. A combination of education, policy reform, representation, allyship, and advocacy is necessary to create a truly inclusive healthcare system. The orthopaedic community must actively work to uphold the principle that every patient deserves access to compassionate and competent surgical care. The time for change is now.

CRediT authorship contribution statement

Lauren A. Ross: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Jaime L. Bellamy: Writing – review & editing, Supervision, Conceptualization. Chloe EH. Scott: Writing – review & editing, Supervision, Methodology, Conceptualization.

Conflicts of interest

C. EH. Scott is in the speakers’ bureau/paid presentations for DePuy Synthes; is a paid consultant for Stryker, Smith & Nephew, Osstec, and Pfizer; and is an editor for Bone and Joint Research Journal; all other authors declare no potential conflicts of interest.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2025.101916.

This article is part of a supplement entitled 'Achieving the Vision – Striving for Health Equity in Arthroplasty' supported by Zimmer Biomet.