Impact of Gender Inequity on Women Surgeons in the Professional Setting

Abstract

The concept of equity ensures that each individual is given the environment, treatment, and resources needed to reach an equal outcome to those around them. Equity is central to initiatives for advancing diversity and inclusion among physicians. This article will identify key barriers to equity that women surgeons face within the professional setting. More specifically, inadequate female representation, discrimination in the form of unconscious gender bias and microaggressions, and sexual harassment will be explored regarding their continued threats to gender equity, as well as constructive ways to mitigate these effects.

Equality versus Equity

When we look at our historical efforts to increase representation and opportunities for marginalized persons and minorities, the goal had been to establish equality between the differing groups and demographics. In times and environments where certain rights were not guaranteed, the hope was that at the very least you would be given the same treatment and basic resources as everyone around you. However, with the new societal push toward diversity and inclusion, we have begun to realize that basic equality is not enough. With more nuanced retrospection and development of respect for people's individual needs, equity has become a more appropriate and inclusive goal when we look toward improving representation and success among all groups. Equity involves recognizing that no two people (or groups) are the same, which means that they have unique experiences, strengths, and difficulties when pursuing a goal. Equity ensures that each person is outfitted with the resources they need to reach an equivalent outcome. ¹

The concept of equity is immeasurably important and can be applied to many different aspects of society and life, such as education, health, and career advancement. Its role within the medical field at large has become increasingly important as we continue to see large disparities between men and women within different facets of medicine. These disparities continue despite the number of women and men entering medicine has equalized, with women now making up the majority of trainees. ^{2 3} These disparities become more glaring when looking at a specialty such as surgery. It forces us to ask how our experiences differ from those of our male colleagues moving along the same career path, and why we still see these barriers to advancement in our field for women.

In this review, we identify some key reasons for the continued inequity that women surgeons face within the professional setting. Barriers such as inadequate women representation, discrimination in the form of unconscious gender bias and microaggressions, and sexual harassment will be explored. We offer suggestions on how to continue to move forward toward equity while also understanding this is a multifaceted issue, and its complexity is only further compounded when discussing the intersectionality of these issues with those faced by women surgeons of color and those who identify as LGBTQIA + .

Inadequate Representation in the Professional Setting

Recent data from the Association of American Medical Colleges (AAMC) Physician Specialty Data Report have shown that women now comprise more than half of medical school enrollees, and the proportion of women entering general surgery residency has steadily increased to 43.1% in 2019, up substantially from 32% in 2008. As there is no longer a substantial “pipeline issue” of insufficient numbers of women entering the surgical field, this suggests other, more insidious, and complex factors exist to perpetuate underrepresentation of women surgeons in so many domains within the professional setting. These factors will be explored in this article, as well as others in this issue.

Despite the encouraging trend of women entering the surgical field in nearly equal numbers compared with their male peers, currently only 22% of attending surgeons in the United States are women, which reflects the longstanding history of severe underrepresentation of women in surgery until very recently. ³ With more women pursuing postgraduate training in general surgery, more are considering subspecialty training, and some interesting trends in representation have emerged across different fields. Between 1994 and 2014, subspecialities such as critical care surgery and colorectal surgery have dramatically increased their proportion of women trainees from 14.8 to 42.7% and 5.7 to 40.7%, respectively, and thus have nearly achieved equal representation. ² In that same time interval, vascular and thoracic surgery have also had dramatic increases in the proportion of women, although both are farther from achieving parity, with increases from 8.3 to 29.9% and 4.7 to 19.6%, respectively. ² By stark contrast, neurosurgery and orthopaedics have a persistent large gender gap within their fields at only 5 to 6.5% women. ⁴

To some extent, these trends may be perpetuated by the guidance given by mentors. A 2020 survey-based study of 663 practicing surgeons (71% male) asked participants to identify subspecialties that were most conducive to men or women, and how they would advise surgical trainees of both genders on pursuing a surgical specialty. Notably, only 8% of all respondents had a female mentor. The study found that women were advised more toward breast surgery, obstetrics and gynecology, plastic surgery, ophthalmology, and general surgery. ⁵ This suggests that there are gender biases toward certain specialties that have the perceived benefits of a better lifestyle and fit for women.

A striking consequence of there being fewer midcareer and senior women in surgery is that a significant disparity exists in terms of academic rank achieved by women surgeons compared with their male peers, with lower proportions of women observed with increases in academic rank. Specifically, a 2018 study revealed that 29% of assistant professors of surgery were women, compared with 21% of associate, and only 12% of full professors, with little change from 2015 (19% associate, 10% full professor). ⁴ These numbers make it even less surprising to note that less than 10% of the 364 academic chairs of surgery throughout the country are women. There are 27 in total as of 2022, 11 of which identify as a person of color, which is an improvement from previous years. ^{6 7}

One might assume that naturally, as more women enter the surgical field, this disparity will automatically correct over time. However, a study reporting binomial and linear trend lines by utilizing all available data from the AAMC's Women in Medicine Annual Reports until 2012 demonstrate that, with the current trajectory, parity with respect to academic rank will not be achieved until the year 2096. ^{4 8} This affirms the need for deliberate, conscious efforts to identify and mitigate the pervasive, systemic inequities that contribute to this disturbing calculation.

The underrepresentation of women in leadership is also reflected within professional societies, although there has been recent progress. For example, since 1918, there have been only five women presidents of the American College of Surgeons (ACS), the first of which was recently appointed in 2005. ⁹ Although the proportion of practicing women surgeons within colorectal surgery has grown significantly, it fails to mirror that representation professionally at a higher level with only three women American Society of Colon and Rectal Surgery (ASCRS) presidents since its inception in 1899. ¹⁰ In response to this, recent deliberate and transparent efforts to improve representation within the ASCRS have resulted in a more diverse senior leadership, with a clear path for more women to be poised to assume key roles in the years to come.

The “queen bee” is an important concept related to representation that can subtly work to undermine the progress of women surgeons in leadership positions. Best known in the business world, this phenomenon also exists in medicine and can explain why counterintuitively, hiring only one woman among a team of senior leaders may hinder rather than help advance more women. More specifically, when only one woman is in a position of authority within a leadership group, she may feel a need to distance herself from her female colleagues to maintain a strong rapport with male peers. Whether consciously or unconsciously, it has been shown to manifest as mentorship refusal, discrimination, microaggressions, and even direct criticism or poor evaluation of their female colleague. This stems from a fear of getting “pushed out,” as some workplace dynamics will only allow for one successful woman to fill a quota, brewing unnecessary competition and resentment. ^{11 12} It is important to understand that this observed phenomenon is a consequence of the lack of female representation in leadership and not one of its causes and should be addressed accordingly. ¹²

This lack of gender diversity of leadership in nearly every type of professional setting in surgery can have detrimental effects on women looking to advance their career at any stage. The paucity of women in leadership creates an environment that can be daunting and discouraging to women seeking to advance their careers. It perpetuates and builds new barriers to advancement that only continues the cycle of inequity. Without female leadership readily available for mentorship, support, and advocacy for other women in their field, it will continue to make equity in surgery a perpetually difficult task.

Implicit Bias and Microaggressions

Implicit gender bias and microaggressions are two interrelated and ubiquitous forms of gender discrimination that undermine the advancement of women in the professional setting. Implicit bias refers to subconscious, unintentional, and pervasive stereotypes or beliefs that influence an individual's actions toward certain persons. ¹³ For example, women are often felt to intrinsically exhibit more “communal traits,” making them more kind, nurturing, and gentle-natured. This cultural stereotype inherently deems them to be lacking in “agentic traits” such as logic, independence, and strength. In the context of surgery, these biases tend to lean in favor of men and can help crystallize invalid assumptions, such as women not being as resilient, confident, or as “likable” as their male surgical counterparts. ^{4 14} Ultimately these societal biases toward women and other minoritized groups are pervasive and can unconsciously make women appear less fit for a career in surgery. ¹⁵

Cumulatively, implicit biases can have profound detrimental effects on professional advancement and leadership opportunities for women surgeons. These gender stereotypes have been shown to correlate with perceived overall poorer performance, leading to worse evaluations, lower position on rank lists, and male-led research being favored for publications and funding. ^{16 17} All of these critical factors are assessed when discussing tenure, faculty appointments, and awards, and thus have tangible negative consequences for women in terms of career advancement. ¹⁶

Microaggressions represent another subtle but damaging form of gender discrimination. Microaggressions are best understood as the outward manifestations of implicit bias. More concretely, while microaggressions can take many forms, they are often comments or actions that subtly and unconsciously express a prejudiced attitude toward a member of a marginalized group. ¹⁸ These verbal and nonverbal behaviors often are insidious and marginalize female colleagues, making them feel less skilled or qualified than their male peers. ¹⁶ Seemingly inconsequential gestures such as commonly being mistaken for nonmedical staff or assumptions about one's skill level or educational background, contrasting against the more consistent promotion of commonly represented groups within the field, can all have a detrimental effect over time. ¹⁸

Despite their subtle nature, microaggressions can be quantified, studied, and intervened upon to effect positive change. A study of video-archived internal medicine grand rounds found that male physicians were significantly more likely to introduce female physicians more informally, by their first name only, than other male physician speakers. ^{19 20} Similarly, in our own field, a study from the 2017 ASCRS Scientific and Tripartite Meeting found that women comprised approximately 28% of the 26 moderators on the formal program. Compared with male moderators, female moderators were more likely than male moderators to use formal speaker introductions overall (regardless of speaker gender), 68.7 versus 54.0%, respectively ( p  = 0.02). There was no statistical difference seen when women introduced speakers of either gender, 66.7% male versus 73.9% female ( p  = 0.52). ¹⁹ However, by contrast, male moderators were nearly twice as likely to formally introduce male speakers compared with female speakers, 59.2 versus 36.4% ( p  = 0.003). The findings of this study ultimately led to implementation of a new guideline for moderator introductions the following meetings. In the 2019 meeting, of the subset of 18 (32%) attended sessions and 78 directly observed introductions, male and female moderators introduced speakers formally with equal frequency, 77% for both. ²¹ Taken together, this example shows that even subtle forms of gender discrimination can be measured, and that simple interventions can help effect positive change toward equity.

Microaggressions chronically undermine the ability, competence, and potential to advance and are exhausting to combat. Consequently, microaggressions are a commonly reported major factor contributing to burnout by female faculty. Burnout and job dissatisfaction are experienced at higher rates by women, which only further negatively impacts their ability for advancement to leadership and maintaining representation. ^{4 16} Continued discrimination such as this and failure to recognize biases undermine the pillars of professionalism that many of our surgical societies and departments promote as their core values and competencies. ⁴ Despite these reported core values, the issue remains pervasive and ingrained in the culture. A survey-based study published in JAMA Surgery showed that among early-career surgery faculty, 50% of women reported experiencing some form of sex-based discrimination with 38.5% of them reporting their female gender as a main barrier to career advancement. ⁴ This only continues to marginalize women surgeons and further feed into the imposter syndrome felt by many in this field. ⁴ This can be detrimental to being able to advocate for oneself for promotion or positions on committees, and may dim the ambition of many trying to advance.

Sexual Harassment and Implications of the #MeToo Movement

Sexual harassment has been a longstanding burden for women physicians, including surgeons. Until recently, it was rarely discussed, having been considered an uncomfortable, taboo subject; however, data suggest high rates of sexual harassment directed toward surgeons. In a 2019 survey of over 1,000 members of the ACS and Association of Women Surgeons (AWS), with 744 respondents, of which 74% were women surgeons, 53% of these women had experienced sexual harassment in the workplace. “Unwanted sexual advances or physical contact” was the second most common experienced among these women with 23% of participants. A staggering 84% of these incidents were not reported to their institutions, with “fear of negative impact on my career,” “fear of retribution,” and “fear of being dismissed and/or inaction towards perpetrator” being the top three reasons for nonreporting. ²² Female trainees were more likely to be on the receiving end of sexual harassment than female faculty, with the majority of the abuse coming from attending surgeons and administrators, comprising 34 and 28% of perpetrators, respectively. ^{4 23} Together, the data demonstrate that sexual harassment is pervasive within the surgery and is especially prevalent among female trainees, greatly reflecting the already apparent issues with the hierarchical leadership structure seen in surgery. ⁴

As shown that sexual harassment is prevalent in medicine, it is important to address why this toxic culture is perpetuated. In 2018, the National Academies of Sciences, Engineering, and Medicine conducted a study that identified the main factors associated with continued sexual harassment in medicine to be: (1) perceived tolerance for sexual harassment, (2) male-dominated work settings, (3) hierarchical power structure, (4) symbolic compliance policies and procedures, and (5) uninformed leadership. ^{4 23} This study highlights important areas within the medical and surgical community that need ongoing attention and effort to help improve the work environment and opportunities for women physicians.

In the wake of the 2017 Harvey Weinstein and Bill Cosby sexual assault scandals in the mass media, a large platform for posting and amplifying transgressions has flourished with the recent Time's Up movement and #MeToo on social media. ²⁴ These movements not only have brought to light how pervasive a problem sexual harassment continues to be, but also have empowered women to speak up for themselves and others in an unprecedented way, with less fear of retribution. ^{25 26} These movements have bolstered the voice of women who stand in solidarity against sexual harassment, advocate for themselves and others, and feel heard and protected by their allies. ²⁶

An unfortunate but real consequence of this new age of transparency and public outcry at sexual harassment in the workplace has prompted some degree of backlash. More specifically, some men have responded by intentionally minimizing private workplace interactions with women and avoiding mentorship opportunities with women due to the new “fear of scrutiny.” ²⁵ Unfortunately, this only serves to further ostracize women in the professional setting and prevent the formation of crucial relationships with colleagues that are necessary for advancement. It also places undue burden and “minority tax” on more prominent women mentors to try to mentor all the women rising in the ranks, which is counterproductive. ²⁷ It is vital that we continue to further educate and discuss these interactions and relationships openly to come to a neutral ground where women can be seen and treated in a more equitable way that fosters career advancement rather than hinders it.

How Do We Move Forward toward Equity?

Gender inequity in surgery is a complex and longstanding issue, and as such will require a sensitive, intentional, multifaceted approach when making attempts to address it. First and foremost, we all must actively work toward creating a workplace that fosters an environment of diversity, inclusivity, belonging, and safety for women. It is essential to start by deliberately creating more robust representation within surgery at all levels, including influential leadership positions. It has been shown that when women are included on governing bodies, conference committees, and award panels, it is reflected by more evenly distributed representation in the selection of conference presenters and award recipients. ^{19 28}

It is also important to continue to work on acknowledging and recognizing the very real discrimination and microaggressions women surgeons face daily, and training men to be “upstanders,” and to point out this behavior in a sensitive, constructive manner. ²⁹ This will require honest discourse from female faculty and trainees as well as an open and compassionate audience within the surgical community. It is vital to remember that a work environment with a perceived tolerance for sexual harassment only further perpetuates this behavior. Consistent allyship and unambiguous policy against harassment is necessary to maintain a safe, collaborative, and productive work environment for all. ^{2 26}

It is important to note that with regard to implicit bias, we all harbor unconscious beliefs that impact our decisions and interactions with others, and that we each have the capacity to recognize these beliefs and work actively to work past them toward a culture of equity. Collectively recognizing that we are all vulnerable to our own preconceived thoughts can help bring about positive culture change in an institution or society. Tools such as the Harvard Implicit Association Test are readily available online to help provide objective insight into everyone's own implicit biases. ³⁰ Recognition of these biases is the crucial first step toward a well-rounded and effective education to bring about actionable and lasting culture change.

Practices such as blinded review of candidates for promotions, manuscript, and grant submissions, without mention of gender, race, or images available will allow the reviewer to impartially and judiciously evaluate without the potential risk of implicit gender bias. Beyond the institutional level, gender equity initiatives by national professional societies, such as the ASCRS, the ACS, and the AWS, all help support culture change and provide practical tools for implementation in a wide variety of professional settings. ^{31 32 33} All of these organizations have spoken out against gender discrimination and sexual harassment and have taken steps toward gender equity, such as the Group on Women in Medicine and Science from the AAMC and the Gender Equity Toolkit from AWS. ^{31 32} The Group on Women in Medicine has formed committees and provided tools for departments across specialties in medicine to help in working toward equity in recruitment and promotion. ³⁴ Directives such as these by large-scale entities are essential to help provide guidelines toward building equity to those in positions of power who have the ability to implement these changes at their respective institutions. It remains imperative for a higher standard to be set by these well-respected organizations to make this a common interest and goal for the surgical community to strive toward.

The implementation of task forces and initiatives at an institutional level has been shown to lead to positive change in representation and environment for women physicians in professional settings. Successful programs should lay out detailed step-by-step initiatives to help combat gender inequity through extensive training of staff to recognize and address unconscious biases, provide transparent policies and metrics regarding promotion and compensation, and create an environment that encourages reporting of and zero tolerance toward harassment. ¹⁶ In 2000, the University of California Davis School of Medicine established a program called the Women in Medicine and Health Science to establish effective interventions to support women professionally in medicine. They found that their interventions were enthusiastically embraced and implemented. During this time, there was a significant increase in the number of female faculty hired, retained, and promoted. ³⁵

Conclusion

The barriers to gender equity for women in surgery can seem obscure and subtle, yet also daunting and insurmountable. In recent years, there is a new momentum within society and our surgical community promoting this momentum for positive change. Research has shown time and again that the benefits of a diverse and inclusive workforce are many. It is time now to create an environment in which women can thrive, succeed, and contribute equally to men in surgery at all levels, including senior leadership. If a real commitment is made to this end, it will only seek to benefit our community and future generations of surgeons and, importantly, improve patient outcomes.