The underrepresentation of women in academic surgery in China

China has the largest healthcare workforce in the world, yet it struggles with the persistent underrepresentation of women in the field of academic surgery. Although over half of medical students are women and 50 % of them express an interest in pursuing surgical careers, a 2019 report revealed that only 6.04 % of surgeons in China are women.^1,2 Several factors deter women from entering surgery; among them is the prevalent perception of male dominance in the field. While this phenomenon in China is widely acknowledged, it has never been extensively studied or quantified. Male dominance in the field can create informal groups that exclude women, making their rise in academic surgery more challenging. Therefore, it is essential to investigate the representation of women in academic surgery in China to both understand and address this disparity.

To explore the representation of women in academic surgery in China, we gathered data from publicly available online sources. This included lists of surgeons from the Chinese Academy of Engineering, the Board of Surgery, and the editorial boards of the top five Chinese surgical journals. Due to many Chinese hospitals not designating a specific chair of surgery, we measured leadership in academic surgery by examining the presidencies of the top 50 academic hospitals, as ranked by the Fudan edition of China Hospitals. To assess the gender distribution among faculty and residents, we analyzed the websites of the top 10 teaching hospitals and graduate schools. Surgeon genders were identified through personal profiles or photographs. Our study focused on 15 surgical specialties, excluding obstetrics and gynecology due to its historical pre-dominance of women surgeons.

Election to the Academy of Engineering represents the pinnacle of recognition for a Chinese academic surgeon. Of the 15 surgeon members, just one (6.7 %) was a woman. In the Chinese Board of Surgery, none of the 25 senior members were women, and only two (3.7 %) of the 54 junior members were women. While there was a chapter for women surgeons, no annual meetings specifically cater to women surgeons. From the top surgical journals, we found 1227 editors, with a mere 22 (1.8 %) being women. These women editors primarily specialized in breast and thyroid surgery (31.8 %), surgical oncology (27.3 %), hepatopancreatobiliary surgery (27.3 %), gastrointestinal surgery (9.1 %), and neurosurgery (4.5 %).

Among the top 50 teaching hospitals, 21 (42 %) had surgeons serving as presidents; however, none were women. In the top 10 teaching hospitals in China, we identified 2840 surgical attendings, with only 283 (10 %) being women. In comparison, a higher proportion of surgical residents were women, with 505 (27.2 %) out of 1854 residents (P < 0.001). The median percentage of women surgical attendings at institutions was 7.2 % (Interquartile range (IQR): 5.1 %–9.2 %), and the median percentage of women surgical residents was 26.9 % (IQR: 22.0 %–29.9 %). The specialties with the most women attendings were otolaryngology (36.9 %), breast and thyroid surgery (36.6 %), and plastic surgery (24.7 %). In contrast, orthopedics (1 %), urology (3.1 %), and transplant surgery (4.2 %) had the fewest. Among residents, trauma (75 %), otolaryngology (60.1 %), and breast and thyroid surgery (60 %) were the top specialties for women. Meanwhile, transplant (0 %), urology (14.9 %), and vascular surgery (16.7 %) had the lowest representation of women.

Our findings indicate that women are significantly underrepresented in China’s surgical field. Furthermore, women are rarely seen in academic and leadership roles in surgery, highlighting systemic barriers for women academic surgeons in China. While the dominance of men in the field is evident in hospital settings, there have been few studies on this topic. This suggests a lack of awareness and initiative to promote gender equality in China’s academic surgery.

Notably, only one third of women surgery residents go on to become faculty in top teaching hospitals. While no studies have followed their career paths post-residency, it is not uncommon for women surgeons to depart surgery for non-surgical specialties or leave medicine entirely due to family commitments or recruitment hurdles.³ For those remaining in surgery outside academia, their departure from academic surgery may often be a compromise rather than a preference for alternative practice settings. Compared to US, teaching hospitals are the most attractive career destinations for surgeons, given that community and private practices do not hold the same level of recognition and resources. Therefore, further exploration of the career trajectory of women surgeons in China is warranted.

One likely factor is the shortage of women mentors and role models. A study on women surgical leaders emphasized the importance of women mentorship for success, especially since women surgeons often face similar challenges.⁴ Our data supports this, showing higher numbers of women surgery residents in specialties with more women representation, such as breast and endocrine surgery. On the other hand, fewer women residents choose specialties dominated by men. We also observed fewer women surgeons in areas like orthopedics and transplant surgery, which are often associated with physical strength or long working hours. This could also suggest a potential role of gender bias in the recruitment for certain specialties.

Supporting academic women surgeons in China can be approached in several ways. First, increasing the visibility of women academic surgeons can encourage young women to choose surgical careers. This can be accomplished by promoting more women surgeons to leadership roles and by organizing conferences and networking events specifically for them.^5,6 Second, international collaboration offers an opportunity to share and learn from successful experiences. For instance, the Association of Women Surgeons accepts international members, but China currently has no chapters. Engaging with such international groups can provide Chinese women surgeons with practical insights and strategies to enhance their current standing.

This gender disparity is not unique to China, as similar trends have been seen in the US as well. Data from the Association of American Medical Colleges (AAMC) has shown that women make up over 50 % of medical schools matriculants and 43.8 % of surgery residents, but only 34.3 % of surgery faculty.^7,8 Asian females make up 12.4 % of medical school matriculants, but only 7.7 % of surgical residents and 6.4 % of US surgical faculty. In contrast, Asian males make up 10.5 % of medical school matriculants, but 9.3 % of residents and 11.3 % of residents. This indicates a clear attrition of Asian females from medical school to surgical residency, and even further in their career as attendings. A study of US general surgery residents has shown that men and women had similar interest in having academic careers and holding leadership positions, but women had lower salary expectations and believed that they would have more household responsibilities. This underscores how ingrained the bias and barriers are within academic surgical culture. Given this stark disparity, institutions have developed diversity, equity and inclusion (DEI) offices to promote the recruitment and retention of women residents and faculty members. These efforts, while new, have shown success in increasing the number of women applying to surgical fields.⁹ While the culture of academic surgery in the US and China differs, there are some similarities as well, and the establishment of DEI offices may be one potential solution to recruiting more women into academic surgery.

Given our study’s descriptive approach, we cannot delve into the organizational culture, gender discrimination, or work-family conflicts that women surgeons in China may encounter. However, identifying the problem is a vital first step towards addressing it. We aspire for our findings to catalyze change, ensuring that all women surgical trainees can freely pursue their passion for surgery in the future.