This survey study explores how practicing male and female surgeons’ experiences with gender compare across career aspirations, gender-based discrimination, mentor-mentee relationships, perceived barriers, and recommendations for change.
Key Points
Question
How do practicing male and female surgeons’ experiences with gender compare across 5 qualitative/quantitative domains?
Findings
In this national concurrent mixed-method survey of Fellows of the American College of Surgeons and female Association of Women Surgeons members, important differences were seen in career aspirations, gender-based discrimination, mentor-mentee relationships, perceived barriers, and recommendations for change. Despite differences, surgeons of both genders acknowledged positive and negative aspects of dealing with gender in a professional setting.
Meaning
The results emphasize the importance of recognizing the voices of all stakeholders involved when striving to promote workforce diversity and the related need to develop quality improvement/surgical education initiatives that enhance inclusion through open, honest discourse.
Abstract
Importance
A growing body of literature has been developed with the goal of attempting to understand the experiences of female surgeons. While it has helped to address inequities and promote important programmatic improvements, work remains to be done.
Objective
To explore how practicing male and female surgeons’ experiences with gender compare across 5 qualitative/quantitative domains: career aspirations, gender-based discrimination, mentor-mentee relationships, perceived barriers, and recommendations for change.
Design, Setting, and Participants
This national concurrent mixed-methods survey of Fellows of the American College of Surgeons (FACS) compared differences between male and female FACS. Differences between female FACS and female members of the Association of Women Surgeons (AWS) were also explored. A randomly selected 3:1 sample of US-based male and female FACS was surveyed between January and June 2020. Female AWS members were surveyed in May 2020.
Exposure
Self-reported gender.
Main Outcomes and Measures
Self-reported experiences with career aspirations (quantitative), gender-based discrimination (quantitative), mentor-mentee relationships (quantitative), perceived barriers (qualitative), and recommendations for change (qualitative).
Results
A total of 2860 male FACS (response rate: 38.1% [2860 of 7500]) and 1070 female FACS (response rate: 42.8% [1070 of 2500]) were included, in addition to 536 female AWS members. Demographic characteristics were similar between randomly selected male and female FACS, with the notable exception that female FACS were less likely to be married (720 [67.3%] vs 2561 [89.5%]; nonresponse-weighted P < .001) and have children (660 [61.7%] vs 2600 [90.9%]; P < .001). Compared with female FACS, female AWS members were more likely to be younger and hold additional graduate degrees (320 [59.7%] were married; 238 [44.4%] had children). FACS of both genders acknowledged positive and negative aspects of dealing with gender in a professional setting, including shared experiences of gender-based harassment, discrimination, and blame. Female FACS were less likely to have had gender-concordant mentors. They were more likely to emphasize the importance of gender when determining career aspirations and prioritizing future mentor-mentee relationships. Moving forward, female FACS emphasized the importance of avoiding competition among female surgeons. They encouraged male surgeons to acknowledge gender bias and admit their potential role. Male FACS encouraged male and female surgeons to treat everyone the same.
Conclusions and Relevance
Experiences with gender are not limited to supportive female surgeons. The results of this study emphasize the importance of recognizing the voices of all stakeholders involved when striving to promote workforce diversity and the related need to develop quality improvement/surgical education initiatives that enhance inclusion through open, honest discourse.
Introduction
The World Health Organization defines gender as a complex social construct that combines elements of cultural, behavioral, and social factors into a person’s outward perception of self. In recent years, the term has become the subject of increased scrutiny and, at times, heated debate as efforts within medicine at all levels of training grapple with what it means to promote greater gender inclusion and equity. Statistics tell us that in surgery, there remains a predominance of more female medical students expressing hesitance about pursuing surgical careers; more male medical students and residents matching into more competitive surgical specialties; and more male surgeons attaining the traditional hallmarks of academic success, including R01 grant funding, promotion to full professor and successful appointment as a department chair.
Recognizing the challenges that gender inequities can pose, a growing body of literature has been developed with the goal of attempting to understand the experiences of female surgeons. The results have helped quantify disparities (eg, demonstrating that compared with male surgeons, female surgeons on average earn less and leave academia earlier in their careers), identify barriers (eg, lack of gender-concordant mentors), and illuminate instances of overt discrimination and harassment among female surgeons. Responses to it have led to important programmatic improvements (eg, more flexible family leave for both male and female surgeons, expanded institutional support for breastfeeding and childcare). They have promoted more equitable representation in professional societies and departments of surgery and, potentially, unintentionally contributed toward the emergence of a problematic anecdotal workplace culture of fear in which many male and female surgeons express concern about working closely alongside female peers.
Acknowledging that perceptions of gender are not limited to supportive female surgeons, the objective of this study was to take a step back and explore potential differences in practicing male and female surgeons’ experiences with gender across 5 qualitative/quantitative domains. Using a national concurrent mixed-methods survey, we sought to elicit and compare the perceptions of a diverse group of randomly selected male and female surgeons, represented by Fellows of the American College of Surgeons (FACS). Selected surgeons were asked about their experiences with career aspirations (quantitative), gender-based discrimination (quantitative), mentor-mentee relationships (quantitative), perceived barriers (qualitative), and recommendations for change (qualitative). As a secondary objective, differences between female FACS and female members of the Association of Women Surgeons (AWS), an international organization devoted to promoting greater “engagement, empowerment, and excellence” of female surgeons, were also compared.
Methods
Primary Population: FACS
Between January 1, 2020, and June 30, 2020, a randomly selected 3:1 sample of 7500 male and 2500 female FACS currently in practice in the US was identified in conjunction with the American College of Surgeons (ACS). Selected surgeons were required to have a publicly available email address. Given the nature of the research question covering multiple domains and presenting with uncertain gender-based differences in outcomes, power calculations were omitted. We instead opted to use a randomly selected representative sample of FACS with the overall goal of ensuring at least 750 responses from each gender. Prior FACS surveys have resulted in response rates of approximately 32%. We anticipated higher response rates from female surgeons and, for that reason, intentionally oversampled male surgeons. Completion of the survey required provision of written informed consent. Ethical approval was provided by the Human Investigation Committee of Yale University and the AWS National Executive Council. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Randomly selected FACS were emailed a link to an anonymous Qualtrics online survey hosted by AWS. They were contacted at their publicly available email address in January 2020. Of the 10 000 distributed emails, 361 (3.6%) were unable to be delivered. Qualtrics was used to keep track of which surveys were completed. Initial nonresponders were contacted again in February 2020 and April 2020 in an effort to increase completion. The survey was closed in June 2020. Known information on all randomly selected FACS, including self-reported gender, US state in which they practice, subspecialty, and year of graduation from medical school was abstracted from the ACS membership database. This information was used to account for potential differences between responders and nonresponders. When data for any of these variables were missing (<1.4%), it was supplemented using manual web-searching of the surgeon’s name and email.
Secondary Population: Female Members of AWS
Practicing female AWS members located in the US were emailed a link to the same survey in May 2020. It was distributed to eligible members directly by AWS. Given this distribution method, it was not possible to track which members responded or contact nonresponders with follow-up emails. Randomly selected female FACS who had previously completed the survey were asked not to fill it out again. Eligible AWS membership at the time of data collection was 1858.
Anonymous Electronic Survey
The anonymous concurrent mixed-methods survey was designed for this project by members of the study team. It was validated for content based on 3 rounds of predistribution pilot testing among medical student members of the AWS National Medical Student Committee, the AWS National Executive Council, and 5 male and 5 female FACS not affiliated with the study team and not included in the random study sample. Mean times taken to complete the survey in each round were recorded and used to modify the final version such that the final survey took a mean of less than 10 minutes to complete.
Included questions contained items addressing respondents’ demographic information (respondent age, year of graduation from medical school, year of completing training, additional graduate-level degrees, race and ethnicity, marital status, and whether they have children), career aspirations, personal experience with gender-based discrimination, mentor-mentee relationships, perceived barriers, and recommendations for change. A copy of the survey is included in the eMethods in the Supplement.
Quantitative Analysis
Descriptive statistics were used to summarize quantitative data: frequencies and percentages for categorical responses and means and SDs for continuous responses. Differences between male and female FACS were compared using nonresponse-weighted χ2 tests for categorical variables and 1-way analysis of variance for continuous variables. Nonresponse weights were calculated as the inverse of a randomly selected FACS’s probability of responding based on known differences in geographic location, specialty, and years in practice. They were incorporated in tests of statistical significance to attain P value results that best reflect the distribution of responses anticipated from the entire randomly selected study sample. Quantitative analyses were conducted using Stata version 17.0 (StataCorp). Two-sided P values less than .05 were considered significant.
Qualitative Analysis
A grounded theory approach was used to analyze FACS’ perceived barriers and recommendations for change. For each set of qualitative data for each gender, 2 team members (H.S.T. and M.A.S.) independently read all responses and compiled a list of emergent themes. Resultant themes were refined and collated in consultation with a third team member (C.K.Z.) formally trained in qualitative research. Results were reported as summary themes and corresponding exemplary quotes. Qualitative analyses were conducted using NVivo version 18 (QSR International).
Results
Demographics
A total of 3930 FACS completed the survey (response rate: 39.3%; Table 1). Of these, 2860 self-identified as men (response rate: 38.1% [2860 of 7500]) and 1070 self-identified as women (response rate: 42.8% [1070 of 2500]). Compared with male FACS, female FACS were more likely to be younger (mean [SD] age, 49.9 [9.5] vs 57.2 [12.2] years; P < .001) and newer to practice (Table 1). They held similar additional graduate degrees and represented similar races and ethnicities (female vs male: 850 [79.4%] vs 2392 [83.6%] White) but were notably less likely than male FACS to be married (female vs male: 720 [67.3%] vs 2561 [89.5%]; P < .001) and have children (female vs male: 660 [61.7%] vs 2600 [90.9%]; P < .001).
Table 1. Differences in Demographic Characteristics Between Male and Female Fellows of the American College of Surgeons (FACS) and for Female Members of the Association of Women Surgeons (AWS).
| Characteristic | FACS, No. (%) | P valuea | AWS member, No. (%) | |
|---|---|---|---|---|
| Male | Female | |||
| Respondents | 2860 (72.8) | 1070 (27.2) | NA | 536 |
| Total eligible | 7500 (75.0) | 2500 (25.0) | NA | 1858 |
| Response rate, % | 38.1 | 42.8 | NA | 28.8 |
| Age, mean (SD), y | 57.2 (12.2) | 49.9 (9.5) | <.001 | 44.4 (11.3) |
| Year of medical school graduation | ||||
| Before 1980 | 637 (22.3) | 82 (7.7) | <.001 | 32 (6.0) |
| 1980-1989 | 881 (30.8) | 210 (19.6) | 100 (18.7) | |
| 1990-1999 | 637 (22.3) | 307 (28.7) | 82 (15.3) | |
| 2000-2009 | 610 (21.3) | 420 (39.2) | 207 (38.7) | |
| 2010-2020 | 95 (3.3) | 51 (4.8) | 114 (21.3) | |
| Year of completing training | ||||
| Before 1980 | 275 (9.6) | 106 (9.9) | <.001 | 0 |
| 1980-1989 | 729 (25.5) | 85 (7.9) | 56 (10.4) | |
| 1990-1999 | 729 (25.5) | 275 (25.7) | 74 (13.9) | |
| 2000-2009 | 619 (21.6) | 339 (31.7) | 104 (19.4) | |
| 2010-2020 | 509 (17.8) | 360 (33.7) | 302 (56.3) | |
| Additional degrees | ||||
| MPH | 117 (4.1) | 60 (5.6) | .38 | 38 (7.1) |
| MS/MHS/MSPH/MSc | 143 (5.0) | 75 (7.0) | 84 (15.7) | |
| MPP | 10 (0.3) | 0 | 0 | |
| MBA | 182 (6.4) | 50 (4.7) | 6 (1.1) | |
| MHA | 42 (1.5) | 27 (2.5) | 4 (0.7) | |
| Other master’s | 195 (6.8) | 90 (8.4) | 33 (6.2) | |
| PhD/ScD/DPhil | 182 (6.4) | 20 (1.9) | 28 (5.2) | |
| Race and ethnicity (could choose >1) | ||||
| American Indian or Alaskan Native | 26 (0.9) | 10 (0.9) | .94 | 0 |
| Arab or Middle Eastern | 91 (3.2) | 10 (0.9) | <.001 | 8 (1.5) |
| Asian or Pacific Islander | 117 (4.1) | 90 (8.4) | <.001 | 74 (13.8) |
| Black or African American | 78 (2.7) | 40 (3.7) | .10 | 34 (6.3) |
| Hispanic or Latino/Latina | 130 (4.5) | 30 (2.8) | .01 | 32 (6.0) |
| South Asian or Southeast Asian | 117 (4.1) | 45 (4.2) | .87 | 24 (4.5) |
| White | 2392 (83.6) | 850 (79.4) | .002 | 398 (74.3) |
| Multiracial | 65 (2.3) | 20 (1.9) | .44 | 8 (1.5) |
| Otherb | 52 (1.8) | 15 (1.4) | .37 | 2 (0.4) |
| Marital status (could choose >1) | ||||
| Single | 52 (1.8) | 195 (18.2) | <.001 | 122 (22.8) |
| In a relationship | 65 (2.3) | 35 (3.3) | .08 | 64 (11.9) |
| Married | 2561 (89.5) | 720 (67.3) | <.001 | 320 (59.7) |
| Divorced/separated | 208 (7.3) | 100 (9.3) | .03 | 36 (6.7) |
| Widow/widower | 52 (1.8) | 20 (1.9) | .92 | 0 |
| Partnered | 0 | 15 (1.4) | <.001 | 8 (1.5) |
| Have children | 2600 (90.9) | 660 (61.7) | <.001 | 238 (44.4) |
Abbreviation: NA, not applicable.
Two-sided P values comparing male and female FACS were taken from nonresponse-weighted χ2 tests for categorical variables and 1-way analysis of variance for continuous variables. They accounted for potential differences in response rates based on known differences in geographic location (state), specialty, and year of graduation from medical school. P values comparing female AWS members were omitted given a lack of similar baseline information for the entire potentially eligible survey sample.
Respondents had the option of other race and ethnicity if they had an identity other than what was listed on the survey.
An additional 536 female AWS members completed the survey (response rate: 28.8% [536 of 1858]; Table 1). Responding female AWS members were, on average, younger than female FACS with a mean (SD) age of 44.4 (11.3) years (302 [56.3%] completed training between 2000-2020). Overall, 165 female AWS members (30.8%) held additional master’s degrees (vs 302 female FACS [28.2%]); 28 (5.2%) held additional doctoral degrees (vs 20 female FACS [1.9%]). A total of 320 AWS members (59.7%) were married, and 238 (44.4%) had children.
Career Aspirations and Extent of Gender Identity
Responding male and female FACS held similar current professional roles (Table 2). Female FACS were slightly less likely than male FACS to be involved in surgical/hospital administration (female vs male: 180 [16.8%] vs 585 [20.5%]; P = .01), less likely to be involved in education (90 [8.4%] vs 312 [10.9%]; P = .02), and more likely to be involved in nonacademic/private practice (490 [45.8%] vs 1027 [35.9%]; P < .001). However, female FACS were more interested than male FACS in pursuing medical school administration (range 0 [not interested] to 100 [completely interested], mean [SD]: 30.2 [29.9] vs 24.6 [28.2]; P < .001) and education (61.3 [30.9] vs 56.5 [31.8]; P < .001) at some point during their careers. Female AWS members’ current professional roles tended to reflect their earlier career status. Compared with female FACS, female AWS members expressed a stronger interest in pursuing surgical/hospital administration, academic practice, and education (Table 2).
Table 2. Differences in Career Aspirations and Their Association With Gender Between Male and Female Fellows of the American College of Surgeons (FACS) and for Female Members of the Association of Women Surgeons (AWS).
| Characteristic | Male FACS | Female FACS | P valuea | AWS Member |
|---|---|---|---|---|
| Current professional role (could choose >1), No. (%) | ||||
| Surgical/hospital administration | 585 (20.5) | 180 (16.8) | .01 | 52 (9.7) |
| Medical school administration | 26 (0.9) | 15 (1.4) | .18 | 12 (2.2) |
| Academic practice, clinical | 1287 (45.0) | 495 (46.3) | .48 | 204 (38.1) |
| Academic practice, research | 260 (9.1) | 120 (11.2) | .02 | 64 (11.9) |
| Education | 312 (10.9) | 90 (8.4) | .02 | 58 (10.8) |
| Nonacademic/private practice | 1027 (35.9) | 490 (45.8) | <.001 | 66 (12.3) |
| Industry | 65 (2.3) | 10 (0.9) | .006 | 2 (0.4) |
| Consulting | 65 (2.3) | 10 (0.9) | .006 | 10 (1.9) |
| Interest in pursuing professional roles, mean (SD)b | ||||
| Surgical/hospital administration | 52.5 (36.5) | 50.7 (34.8) | .21 | 62.1 (28.2) |
| Medical school administration | 24.6 (28.2) | 30.2 (29.9) | <.001 | 43.4 (31.1) |
| Academic practice, clinical | 64.7 (37.3) | 63.6 (36.2) | .45 | 79.5 (24.3) |
| Academic practice, research | 41.3 (35.7) | 42.0 (34.7) | .70 | 59.6 (32.1) |
| Education | 56.5 (31.8) | 61.3 (30.9) | <.001 | 67.9 (28.3) |
| Nonacademic/private practice | 61.4 (38.2) | 69.2 (34.0) | <.001 | 47.8 (30.1) |
| Industry | 29.8 (30.4) | 29.8 (28.8) | >.99 | 23.6 (25.4) |
| Consulting | 29.7 (29.8) | 36.6 (30.8) | <.001 | 34.5 (31.0) |
| Association with gender, mean (SD)c | ||||
| Gender is a part of how I define myself as a surgeon | 23.4 (29.7) | 50.8 (32.9) | <.001 | 63.4 (28.9) |
| Gender disparities exist among surgeons | 59.8 (33.5) | 84.6 (23.5) | <.001 | 90.8 (23.6) |
| Gender disparities exist among surgeons in my hospital | 44.3 (35.0) | 74.5 (31.4) | <.001 | 77.0 (26.8) |
| Gender disparities exist in how I conduct my personal practice with my colleagues | 18.3 (22.9) | 61.5 (35.3) | <.001 | 64.3 (32.3) |
| There is convincing evidence of gender disparities among physicians | 62.9 (32.6) | 84.3 (23.4) | <.001 | 88.8 (18.7) |
| There is convincing evidence of gender disparities among surgeons in particular | 60.9 (33.4) | 84.1 (23.7) | <.001 | 87.7 (20.3) |
| Existing strategies to address gender disparities in surgery are effective | 44.1 (24.6) | 31.2 (23.2) | <.001 | 36.6 (20.9) |
| My colleagues of a different gender influenced my…c | ||||
| Decision to pursue a career in surgery | 37.1 (32.3) | 76.8 (27.7) | <.001 | 76.4 (25.3) |
| Success in achieving my goals for a career in surgery | 42.0 (31.7) | 76.4 (23.1) | <.001 | 74.9 (23.2) |
| Satisfaction with my career in surgery | 50.1 (32.2) | 65.2 (29.6) | <.001 | 67.8 (25.9) |
| My colleagues of the same gender influenced my…c | ||||
| Decision to pursue a career in surgery | 70.6 (28.6) | 51.6 (35.2) | <.001 | 60.7 (32.8) |
| Success in achieving my goals for a career in surgery | 72.2 (26.2) | 55.3 (31.1) | <.001 | 65.0 (28.6) |
| Satisfaction with my career in surgery | 66.3 (28.6) | 60.1 (31.3) | <.001 | 68.3 (28.0) |
Two-sided P values comparing male and female FACS were taken from nonresponse-weighted χ2 tests for categorical variables and 1-way analysis of variance for continuous variables. They accounted for potential differences in response rates based on known differences in geographic location (state), specialty, and year of graduation from medical school. P values comparing female AWS members were omitted given a lack of similar baseline information for the entire potentially eligible survey sample.
0 Indicates not interested at all and 100, completely interested.
0 Indicates disagree completely and 100, completely agree.
The extent to which gender plays a role in how respondents define themselves as surgeons (Table 2) markedly increased when moving from male FACS (range, 0-100; mean [SD], 23.4 [29.7]) to female FACS (mean [SD], 50.8 [32.9]) to female AWS members (mean [SD], 63.4 [28.9]). While male FACS felt strongly that gender-based disparities among surgeons exist (range, 0-100; mean [SD], 59.8 [33.5]), they endorsed the statement at levels significantly lower than those reported by female FACS (mean [SD], 84.6 [23.5]) and female AWS members (mean [SD], 90.8 [23.6]). Male FACS similarly reported lower perceived levels of gender-based disparities in surgery compared with female FACS as the practice environment moved closer to their own (male vs female: mean [SD], 44.3 [35.0] vs 74.5 [31.4] within their hospital; 18.3 [22.9] vs 61.5 [35.3] within their personal interactions with colleagues; P < .001). Results were similar for female AWS members.
While female FACS and female AWS members reported strong involvement from colleagues of a different gender in their decision to pursue a career in surgery and their subsequent success and satisfaction with their surgical careers, the results were largely reversed for male FACS (Table 2). Most male FACS acknowledged strong involvement from predominantly male peers. Further stratified differences based on marital status (eTable 1 in the Supplement: married vs unmarried), race and ethnicity (eTable 2 in the Supplement: White vs non-White [ie, American Indian or Alaskan Native, Arab or Middle Eastern, Asian or Pacific Islander, Black or African American, Hispanic or Latino/Latina, and South Asian or Southeast Asian]), and age (eTable 3 in the Supplement: ≥50 vs <50 years) are included in the supplemental data.
Gender-Based Discrimination
A total of 1030 female FACS (96.3%) and 508 female AWS members (94.8%) reported having been treated differently because of gender in a professional setting compared with 1352 male FACS (47.3%) (Table 3). Among female FACS, issues arose from all types of colleagues but were most commonly reported as being caused by superiors (835 [78.0%]), hospital staff (eg, nurses, pharmacists, social workers; 820 [76.6%]), and patients (785 [73.4%]). Female FACS reported that both overt (665 [62.1%]) and unintentional (965 [90.2%]) discrimination affected their clinical work and emotional/psychological well-being to a greater extent than that reported by male FACS (Table 3). Among male FACS, rates of reported gender-based discrimination were similar between overt (676 [23.6%]) and unintentional (780 [27.3%]) forms. When issues occurred, they were most frequently caused by hospital staff (819 [28.6%]), superiors (806 [28.2%]), and patients (728 [25.5%]). A total of 1121 male FACS (39.2%) compared with 695 female FACS (65.0%) (314 female AWS members [58.6%]) admitted to treating someone differently because of gender (P < .001). A total of 1417 male FACS (49.5%) acknowledged having felt uncomfortable because of gender; 805 female FACS (75.2%) and 390 female AWS members (72.8%) endorsed the same (P < .001). Stratified results are presented in eTables 1 to 3 in the Supplement.
Table 3. Differences in Experiences With Gender-Based Discrimination Between Male and Female Fellows of the American College of Surgeons (FACS) and for Female Members of the Association of Women Surgeons (AWS).
| Characteristic | No. (%) | P valuea | AWS member, No. (%) | |
|---|---|---|---|---|
| Male FACS | Female FACS | |||
| Been treated differently because of gender in a professional setting | 1352 (47.3) | 1030 (96.3) | <.001 | 508 (94.8) |
| Frequency | ||||
| Once | 39 (1.4) | 0 | <.001 | 0 |
| Rarely but more than once | 507 (17.7) | 120 (11.2) | 32 (6.0) | |
| Sporadic occurrence | 481 (16.8) | 370 (34.6) | 170 (31.7) | |
| Regular | ||||
| Monthly | 39 (1.4) | 145 (13.6) | 34 (6.3) | |
| Weekly | 208 (7.3) | 185 (17.3) | 134 (25.0) | |
| Daily | 78 (2.7) | 210 (19.6) | 138 (25.7) | |
| Culprit (could choose >1) | ||||
| Hospital staff | 819 (28.6) | 820 (76.6) | <.001 | 446 (83.2) |
| Students/trainees | 312 (10.9) | 380 (35.5) | <.001 | 262 (48.9) |
| Peers | 468 (16.4) | 670 (62.6) | <.001 | 302 (56.3) |
| Superiors | 806 (28.2) | 835 (78.0) | <.001 | 430 (80.2) |
| Patients | 728 (25.5) | 785 (73.4) | <.001 | 452 (84.3) |
| Related to overt discrimination (range, 0-5), mean (SD) | 676 (23.6) | 665 (62.1) | <.001 | 288 (53.7) |
| Clinical work affected | 2.5 (1.9) | 2.9 (1.7) | <.001 | 2.7 (1.7) |
| Emotionally/psychologically affected | 2.2 (1.7) | 3.6 (1.3) | <.001 | 3.4 (1.4) |
| Related to nonovert discrimination (range, 0-5), mean (SD) | 780 (27.3) | 965 (90.2) | <.001 | 476 (88.8) |
| Clinical work affected | 1.2 (1.4) | 1.9 (1.6) | <.001 | 1.9 (1.4) |
| Emotionally/psychologically affected | 1.7 (1.2) | 2.6 (1.5) | <.001 | 2.7 (1.4) |
| Treated someone differently because of gender in a professional setting | 1121 (39.2) | 695 (65.0) | <.001 | 314 (58.6) |
| Frequency | ||||
| Once | 78 (2.7) | 20 (1.9) | <.001 | 16 (3.0) |
| Rarely but more than once | 689 (24.1) | 400 (37.4) | 100 (18.7) | |
| Sporadic occurrence | 221 (7.7) | 175 (16.4) | 92 (17.2) | |
| Regular | ||||
| Monthly | 26 (0.9) | 25 (2.3) | 4 (0.7) | |
| Weekly | 39 (1.4) | 40 (3.7) | 10 (1.9) | |
| Daily | 39 (1.4) | 25 (2.3) | 8 (1.5) | |
| Felt uncomfortable because of gender in a professional setting | 1417 (49.5) | 805 (75.2) | <.001 | 390 (72.8) |
| Inappropriate conversations, objectifying remarks, unwanted physical contact | ||||
| Frequency | ||||
| Once | 104 (3.6) | 15 (1.4) | <.001 | 12 (2.2) |
| Rarely but more than once | 757 (26.5) | 250 (23.4) | 154 (28.7) | |
| Sporadic occurrence | 390 (13.6) | 380 (35.5) | 158 (29.5) | |
| Regular | ||||
| Monthly | 0 | 15 (1.4) | 6 (1.1) | |
| Weekly | 78 (2.7) | 55 (5.1) | 32 (6.0) | |
| Daily | 39 (1.4) | 80 (7.5) | 20 (3.7) | |
| Culprit | ||||
| Happened to me | 468 (16.4) | 665 (62.1) | <.001 | 306 (57.1) |
| I have done this to others (worried that I might) | 455 (15.9) | 20 (1.9) | 14 (2.6) | |
| Happened to me and I have done this to others | 442 (15.5) | 105 (9.8) | 54 (10.1) | |
| Gender limited your opportunities for advancement/promotion | 559 (19.5) | 785 (73.4) | <.001 | 324 (60.4) |
Two-sided P values comparing male and female FACS were taken from nonresponse-weighted χ2 tests for categorical variables and 1-way analysis of variance for continuous variables. They accounted for potential differences in response rates based on known differences in geographic location (state), specialty, and year of graduation from medical school. P values comparing female AWS members were omitted given a lack of similar baseline information for the entire potentially eligible survey sample.
Mentor-Mentee Relationships
Compared with male FACS (eTable 4 in the Supplement), female FACS were less likely to have had a mentor of the same gender (615 [57.5%] vs 2639 [92.3%]; P < .001) and more likely to report that gender influenced their relationship with their mentor, whether the mentor was of the same gender (395 [36.9%] vs 286 [10.0%]; P < .001) or a different gender (235 [22.0%] vs 247 [8.6%]; P < .001). Gender also factored more heavily into female FACS’s decision to choose a mentor (range, 0-100; female FACS: mean [SD], 36.0 [26.9]; male FACS: 21.4 [27.4]; P < .001). Both male and female FACS reported having mentees of the same and different genders; however, when mentees were of the same gender, female FACS were much more likely than male FACS to report that gender influenced the mentor-mentee relationship (510 [47.7%] vs 195 [6.8%]; P < .001). Differences in mentorship results were more pronounced among female AWS members (eTable 4 in the Supplement). Stratified results are presented in eTables 1 to 3 in the Supplement.
Perceived Barriers
When asked about perceived barriers to overcoming gender disparities, female FACS identified the following 5 most important emergent themes: differences in salary, differences in task assignment, differences in clinical opportunities and referrals, discrimination related to pregnancy and childcare, and experiences of explicit discriminatory remarks. Exemplary quotes are presented in Table 4. Male FACS described their own experiences with differences in salary, double standards, explicit discriminatory remarks, fear of being misunderstood, and dismissal of gender-related concerns (Table 4).
Table 4. Perceived Barriers Reported by Male and Female Fellows of the American College of Surgeons (FACS).
| Female FACS | Barriers | Exemplary quote |
|---|---|---|
| 1 | Differences in salary | I was initially paid less than my male counterpart even though we had the exact same qualifications. It was only after I addressed the issue with my chair that it was fixed. |
| 2 | Differences in task assignment | I am consistently asked to do more time-consuming secretarial tasks as opposed to taking on leadership roles that would lead to promotion. |
| 3 | Differences in clinical opportunities, referrals | Referrals from both male and female medical colleagues preferentially go to male surgeons; breast referrals preferentially go to female surgeons. |
| 4 | Discrimination related to pregnancy, childcare | I was told that if I became pregnant during residency I would lose my spot. All my male colleagues had their families during their training, but I did not dare. I later had to do IVF [in vitro fertilization] due to infertility because I waited so long to have children. |
| 5 | Explicit discriminatory remarks | I was told not to unpack my bags at the beginning of an away plastic surgery residency because: “Girls shouldn't be surgeons, and it's my job to make you quit!”. |
| Male FACS | Barriers | Exemplary quote |
| 1 | Differences in salary | I was told that I cannot get a raise due to concern for the appearance of gender discrimination, ie, it is unfair to give me a raise because I am male, and it would look like males are being prioritized. |
| 2 | Double standards | Gender discrimination is often focused on men discriminating against women. While I would say that this is more institutionalized and common, the reverse is also true in my experience. Women surgeons are offended when men want to see a male surgeon for their hernia but find it completely normal when a woman prefers to see a female surgeon for breast cancer. |
| 3 | Explicit discriminatory remarks | I was in a university/hospital sponsored team-building meeting where one of those present said loudly, “We need to get rid of all the white men in this place.” There was stunned silence, but no response from the workshop leaders or participants. [...] If these comments were made about anyone else, notice would have been taken. |
| 4 | Fear of being misunderstood | As a white male, I no longer feel that I can talk openly or candidly about many issues, including gender, because of the possibility that I might be misunderstood. Changes made to promote mutual respect have had the unintended consequence of compartmentalizing diverse groups and genders. |
| 5 | Dismissal of gender-related concerns | I have been entirely ignored when I point out gender disparities. I have repeatedly been exposed to sexual jokes/innuendos [...] When I ask how such behavior would be perceived in a reverse situation, I am told, “Don't be a prude.” “Don't be a fragile male.” |
Recommendations for Change
The top 5 changes that male and female FACS recommended that surgeons of the same and different genders make to improve their experiences as surgeons are outlined in the Box. Female FACS emphasized the importance for other female surgeons to support each other, limit competition, and act as sponsors/mentors. They encouraged male surgeons to acknowledge gender bias and admit their potential role, ensure equal treatment and inclusion of all colleagues, and call out instances of gender bias when observed. Male FACS encouraged male surgeons to treat everyone the same, base decisions for advancement on merit, provide paternal family/childcare support, and work to avoid demeaning conversations and so-called locker room talk. They encouraged female surgeons to focus less on gender as (the only) determinant of treatment, be more available with their time, not expect special treatment, and not assume that all male surgeons discriminate or are biased.
Box. Recommendations for Change Suggested by Male and Female Fellows of the American College of Surgeons (FACS).
What, if anything, could your colleagues of the same gender do to make your experience better as a surgeon?
Female FACS (most frequent)
Support each other and stop creating competition
Do not ignore disparities or implicit bias
Be a mentor/sponsor to other female surgeons
Focus less on gender
Get involved in efforts to promote diversity/equity/inclusion
Male FACS (most frequent)
Treat everyone the same and be gender neutral
Do not equate poor performance/negativity to bias
Base decisions for advancement on merit
Provide support for paternal family/childcare
Avoid demeaning conversations, such as so-called locker room talk
What, if anything, could your colleagues of a different gender do to make your experience better as a surgeon?
Female FACS (most frequent)
Acknowledge gender bias and admit your potential role
Ensure equal treatment and inclusion of all colleagues
Call out bias when observed
Be a sponsor/mentor/advocate for female surgeons
Recognize that the issue is often the summation of repeated events
Male FACS (most frequent)
Focus less on gender as (the only) determinant of treatment
Be more available with your time, particularly call
Do not expect special treatment or use children as an excuse
Focus on being good surgeons/educators/researchers
Do not assume that all male surgeons discriminate or are biased
Discussion
This national concurrent mixed-methods survey of FACS and female AWS members demonstrates that experiences with gender were not limited to empowering stories from female surgeons. Building on a growing body of research, the results reveal that compared with male surgeons, female surgeons were less likely to be married and have children. They were less likely to be involved in academic leadership but were, overall, more interested in pursuing academic leadership as they advance through their careers. Female surgeons were more likely than male surgeons to identify themselves based on gender and acknowledge that gender disparities exist but were less likely to have ever had a gender-concordant mentor. Despite these differences, surgeons of both genders acknowledged positive and negative aspects of dealing with gender in a professional setting, including shared experiences of gender-based harassment, discrimination, and blame. Moving forward, female surgeons emphasized the importance of avoiding competition among female peers. They encouraged male surgeons to acknowledge gender bias and admit their potential role. Male surgeons encouraged male and female surgeons to treat everyone the same, base decisions for advancement on merit, and avoid noninclusive so-called locker room talk.
Implications for Understanding Gender Among Female Surgeons
Many of the findings for female surgeons’ experiences with gender mirror previous research, including struggles with bias and the added difficulty of navigating personal relationships, pregnancy, and work-life balance. Lack of access to gender-concordant mentors has been well-documented as a critical barrier to promoting female advancement, as have experiences of overt and unintentional discrimination among female surgeons. Where the results differ from what has previously been discussed comes the revelation that while more than 95% of female FACS and female AWS members reported having experienced gender-based discrimination, 65.0% admitted to treating someone differently because of gender. The same concern was echoed in qualitative results where the need for female surgeons to support each other, stop creating competition, and advocate for other female surgeons emerged as 2 of the 5 leading emergent themes.
There are several possible interpretations of this response. The first is that female surgeons treat other female surgeons poorly because of gender—a phenomenon known as female rivalry. This theory, largely derived from social psychology, suggests that in a male-dominated workplace like surgery, female surgeons could feel the need to compete to compensate for increased scrutiny and limited opportunities. Prior studies lend credence to this notion, citing instances of female seniors who had overcome gender-based challenges being disproportionately tough on female junior trainees. Such a theory, although often quoted in anecdotal reports of concerns about working with female peers, stands in stark contrast to most published literature on gender disparities, which has historically focused more on the positive aspects of female relationships and mentorship as a factor in encouraging women to pursue surgical careers. Positive relationships between female surgeons leads to the second possible interpretation: female surgeons could be treating other female surgeons more favorably because of gender. It is also possible that female surgeons treat male surgeons worse, resulting in a form of reverse discrimination stemming from a sense of exclusion working in historically male-dominated workspaces, perceived pressure to engage in/tolerate so-called locker room talk, and/or a response to a perceived need to outperform to be considered equal to their predominately male peers.
Compared with male and female FACS, female AWS members expressed a stronger interest in pursuing academic leadership roles. Such a difference could reflect differences in baseline demographics as AWS members were, on average, younger and more likely to have completed additional graduate degrees. It could also reflect the impact of positive female mentorship derived from membership in a professional society. Founded at ACS in 1981, AWS is an international organization geared toward uplifting women trainees and practicing female surgeons within the surgical community. It is possible that membership in such a group has an appreciable impact on the interests and career trajectories of younger female surgeons. For years, initiatives to promote gender diversity within the surgical workforce have centered around the idea of seeing female surgeons and having access to supportive female mentors as a positive force helpful in promoting change. It is also possible that female surgeons who choose to join AWS are more interested in having female mentors, have more ready access to junior/senior female peers, and/or are more interested in seeking out leadership roles and, for that reason, choose to join an organization like AWS dedicated to providing leadership opportunities for female surgeons.
Implications for Understanding Gender Among Male Surgeons
While less likely to have been treated differently because of gender, male FACS were not immune from experiences of gender-based discrimination. One in 4 reported experiencing overt or unintentional discrimination. Qualitative responses revealed concerns about double standards and explicit discriminatory remarks. Among male surgeons not reporting having experienced gender-based discrimination, the results point toward a frequently cited concern of being misunderstood and a tendency to not want to acknowledge disparities or talk about them by name, particularly in male surgeons’ personal interactions with colleagues. Male surgeons emphasized a repeated desire to treat everyone the same. Among recommendations for change, potentially inflammatory statements involving “not using children as an excuse” were frequently seen.
From these results, 2 critical conclusions emerge: (1) male surgeons can experience gender-based discrimination but are often less likely to voice their concerns or be recognized due to issues stemming from gender norms and apparent membership in the dominant nondiscriminated-against group and (2) lack of inclusion of male surgeons’ perspectives in efforts to promote more equitable workforce representation and discussions of gender disparities are likely to worsen disengagement (eg, lower reported perception that gender disparities exist, popular assertion that differences can be resolved by treating everyone the same) or address the concern about a mounting workplace culture of fear potentially leading to male surgeons being less willing to engage in discussions of gender disparities and/or work alongside female peers. In the surgical literature, few studies address the male perspective when discussing issues associated with gender disparities. Those that have limitedly acknowledge that among surgical trainees, both male and female surgeons can experience bias. Future research is needed to further explore these issues, identify the role that intersectional identities (eg, gender and race and ethnicity or gender and sexual orientation/gender identity) might play, and develop meaningful interventions capable of best supporting men who have experienced gender discrimination and creating safe spaces where all voices from all stakeholders expressing mixed positive and negative opinions can be heard.
Limitations
The study has limitations. The most important include its reliance on subjective data and the presence of an incomplete response rate. In looking to study surgeons’ experiences, we intentionally sought subjective perspectives. Doing so allowed us to garner a deeper understanding of respondents’ lived experience through a combination of qualitative and quantitative data. However, it should be recognized that subjective responses could vary between respondents, be affected by factors making individual respondents more or less likely to remember events, and differ from what actually occurred were results to be evaluated through some form of objective measure. Response rates among FACS (and female AWS members) were similar to those obtained in prior studies. Low response rates are a common limitation when surveying physicians. In an effort to help minimize potential response bias, FACS were randomly selected in conjunction with ACS. They were contacted up to 3 times to increase completion, and nonresponse weights were incorporated to account for potential differences based on known demographic factors. Despite these efforts and an overall good response rate for the population in question, it remains possible that the results could be influenced by disproportionately higher/lower responses from potential respondents who feel more or less strongly about the study topic.
Conclusions
Experiences with gender are not limited to supportive female surgeons. The results of this study build on a growing body of research, demonstrating that although important strides have been made in promoting greater workforce diversity and addressing gender disparities, work remains to be done, including a critical need to (1) bolster support for and among female surgeons, (2) provide space for open and honest discourse from all perspectives that addresses both positive and negative aspects of dealing with gender in a professional setting, and (3) recognize that experiences with gender-based discrimination can and do happen at all levels of training and among both male and female surgeons. Moving forward, future efforts to promote greater gender inclusion and limit gender-based discrimination are encouraged to emphasize the importance of recognizing the voices of all stakeholders involved and providing quality improvement/surgical education initiatives that enhance inclusion by creating safe spaces where diverse perspectives can come together to listen and learn.
eTable 1. Abbreviated differences in quantitative results stratified by marital status
eTable 2. Abbreviated differences in quantitative results stratified by race/ethnicity
eTable 3. Abbreviated differences in quantitative results stratified by age
eTable 4. Differences in mentor-mentee relationships between male and female Fellows of the American College of Surgeons (FACS), secondary analyses show results for female members of the Association of Women Surgeons (AWS)
eMethods.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Abbreviated differences in quantitative results stratified by marital status
eTable 2. Abbreviated differences in quantitative results stratified by race/ethnicity
eTable 3. Abbreviated differences in quantitative results stratified by age
eTable 4. Differences in mentor-mentee relationships between male and female Fellows of the American College of Surgeons (FACS), secondary analyses show results for female members of the Association of Women Surgeons (AWS)
eMethods.
