Are LGBTQ+ Allyship Symbols Associated With Patient Trust in the Orthopaedic Surgeon? A Dual Cohort Survey.

Abstract

Background: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients often face barriers to trust in healthcare settings because of historical and ongoing discrimination. In orthopaedic surgery-a specialty sometimes perceived as less inclusive-visible symbols of allyship such as rainbow flags may influence patient perceptions, yet this remains unstudied.

Questions/purposes: (1) Is the display of LGBTQ+ allyship symbols (rainbow flags) associated with patient trust in an orthopaedic surgeon? (2) Which demographic factors are associated with positive or negative responses to these symbols? (3) What opinions do patients have regarding LGBTQ+ surgeons or displaying these symbols in an orthopaedic setting?

Methods: We conducted two randomized, blinded surveys; the first recruited from a tertiary urban and academic orthopaedic clinic (362 of 477 patients contacted) and the second cohort recruited nationally via the online Amazon Mechanical Turk (MTurk) platform (439 of 1258 patients contacted). Clinic participants had a mean ± SD age of 48 ± 17 years, with 62% (223) women, while online participants had a mean ± SD age of 45 ± 17 years, with 49% (215) women. Online participants were more frequently White, men, urban dwelling, and highly educated, with 82% (358 of 439) holding a bachelor's degree or higher. Prior reported experience with orthopaedic care was common in both groups: 77% (280 of 362) in-clinic, 69% (303 of 439) online. Participants viewed an image of a hypothetical orthopaedic surgeon presented as a Black man wearing a white coat either with a rainbow pride lapel pin or without a pin; they then completed the Trust in Physician Scale (TIPS), a previously validated measure of patient trust, with higher scores indicating more trust (range 0 to 100). Scores were then compared between the group that viewed the image with the pin and the group that viewed the image without a pin using a minimum clinically important difference of 14 points. Participants were blinded to the purpose of the study and could not go back to change the TIPS scores. Demographic factors including US Census region, urban versus rural location, age, race or ethnicity, education, income, degree of religiousness, political ideology, reported gender, and sexual orientation were assessed for association with position toward allyship symbols. Explicit attitudes toward LGBTQ+ allyship symbols and LGBTQ+ surgeons were then assessed via direct questioning using a 10-point Likert scale (10 indicating more positive response) and ordinal categorical responses about hypothetical surgeons or scenarios. Free response answers were also collected and qualitatively categorized.

Results: Among all responders, we found no important difference in trustworthiness between surgeons wearing allyship symbols and those not wearing them in clinic (mean ± SD 76 ± 16 versus 71 ± 15, mean difference 5 [95% confidence interval (CI) -8 to -1]; p = 0.005) and online (64 ± 13 versus 64 ± 13, mean difference 0.7 [95% CI -2 to 3]; p = 0.6). Democrat-leaning participants reported higher trust in both cohorts (in clinic: OR 10.00 [95% CI 5.56 to 20.00]; p < 0.001 and online: OR 3.45 [95% CI 2.33 to 5.00]; p < 0.001), with women and less religious individuals in the clinic cohort showing greater trust (OR 2.27 [95% CI 1.52 to 3.45]; p < 0.001 and OR 1.80 [95% CI 1.18 to 2.75]; p = 0.006, respectively) and nonheterosexual participants in the online cohort (OR 2.43 [95% CI 1.56 to 3.85]; p < 0.001). Conversely, Republican-leaning participants in both groups reported lower trust (in clinic: OR 0.1 [95% CI 0.05 to 0.18]; p < 0.001 and online: OR 0.29 [95% CI 0.20 to 0.43]; p < 0.001), with lower positivity among men and more religious clinic participants (OR 0.44 [95% CI 0.29 to 0.66]; p < 0.001 and OR 0.56 [95% CI 0.36 to 0.85]; p = 0.006, respectively) and among heterosexual respondents online (OR 0.41 [95% CI 0.26 to 0.64]; p < 0.001). When asked, most respondents expressed neutral or positive views toward LGBTQ+ symbols: rainbow pins (clinic group versus online group 6 ± 3 versus 7 ± 3, mean difference 0.3 [95% CI -0.07 to 0.7]; p = 0.1) and flags (6 ± 3 versus 6 ± 3, mean difference 0.3 [95% CI -0.01 to 0.8]; p = 0.06). Confidence in the surgical skills of LGBTQ+ surgeons was high across cohorts (> 90% in both groups). A minority reported that they would be more likely to switch surgeons (clinic 12% [41 of 350], online 11% [50 of 439]) or less likely (clinic 11% [38 of 350], online 28% [124 of 439]). Free responses were largely neutral, with a number of patients responding to individual displays of allyship positively, while institutional displays were interpreted as unprofessional. Respondents emphasized the importance of surgical skills above all. Mean differences within this paragraph appear incorrect due to rounding of means ± SDs.

Conclusion: We found no perceptible difference in the degree to which a surgeon would be trusted based on whether (s)he did or did not display LGBTQ+ allyship symbols. However, among some subgroups of patients, displaying these symbols was associated with greater or less trust.

Clinical relevance: Displaying LGBTQ+ allyship symbols is unlikely to meaningfully shape trust in orthopaedic settings but may foster trust or distrust among certain patient populations. Individual surgeons should consider context and patient demographics when choosing whether to display such symbols, but they are unlikely to alienate most patients who prioritize surgical competence. Institutions may achieve greater benefit by prioritizing structural inclusion efforts-such as nondiscrimination policies, staff training, and outreach-rather than relying on symbolic displays.