Reducing gender bias in surgery

The first female British surgeon, Margaret Ann Bulkley (1795–1865), spent her entire career pretending to be a man named James Barry. Although surgery has come a long way in the past two centuries – female surgeons no longer disguise themselves as men – most people still think of a typical surgeon as a confident man, and implicit and explicit gender biases continue to limit women's careers. Female surgeons earn significantly less and are less likely to attain full professorship than equally qualified male physicians. Women report less control of their work environment, which is a significant source of burnout.

A frequently proposed solution to such barriers is to wait patiently for gender bias to disappear, as more women choose a career in surgery. However, this strategy means that, for decades, the profession will tolerate lower wages, stunted career progress and reduced work satisfaction for women. More importantly, this approach will not work, because the pipeline leaks. In Canada, medical schools achieved gender parity in 1995, yet in 2018 Canada has only two female Deans of Medicine. Rather than relying on a passive approach, there are a number of areas where surgeons can lead change actively by using evidence-based actions to counteract known biases.

First, there must be equity in training. Female medical students are often encouraged to pursue non-surgical specialties, and tend to avoid surgery because of perceived gender-based discrimination and harassment. Among students interested in surgery, women are less likely to be considered exceptional candidates compared with men of equal calibre¹. Once in training, women receive less formative feedback² and less operating room autonomy than men³. To counteract these barriers, surgeons should begin by encouraging women to consider surgery. Standardized reference letters, highlighting ability rather than effort, appearance or family considerations, can also reduce gender bias in trainee selection⁴. Surgeons need to be aware of how they provide feedback, and ensure equal opportunities in the operating room, particularly as training programmes transition to competency-based frameworks.

Once in practice, gender bias continues to manifest itself daily in women's work environments. Women are less often introduced by their title⁵, and are commonly mistaken for non-physician members of the team. Public preconception is generally of a male surgeon, and this may affect the ability of female surgeons to gain their patients' trust and confidence. Despite having at least equivalent outcomes as men⁶, female surgeons can find their competence questioned and outcomes scrutinized, thus affecting referrals⁷. Mitigating the impact of societal perceptions on female surgeons requires everyone to work to effect change. Surgeons should use formal titles, refuse to participate in undermining gossip that questions the general competence of female surgeons, and consider whether they are referring less remunerative or more non-operative cases to women.

Female surgeons also face a motherhood penalty. For example, women with children are less likely to attain full professorship than equally qualified men with children⁸. This penalty is also applied to women without children, as female sex is itself often equated with a mandate for motherhood (compulsory maternity). This leads to constrained career opportunities irrespective of the desire or ability to have children. In reality, fewer female surgical trainees and surgeons have children compared with their male counterparts⁹. Assumptions about an individual's interest in training and career opportunities should not be based on the potential for parenthood. For surgeons who are parents, greater support should be provided by offering daycare services and spaces for breastfeeding in hospitals and at conferences. Paid parental leave should be offered and encouraged both for new mothers and fathers.

For female surgeons aspiring to leadership, gender bias can significantly limit their success. It is no coincidence that descriptors of great leaders – decisive, confident, firm – are commonly considered male traits. For women, exhibiting these leadership characteristics is discordant with the prevalent gender identity (societal generalization) of women as collegial and compassionate. This has social consequences: competent women are perceived as less likeable, and vice versa. Addressing such subconscious biases can be challenging, but is vital for change to occur. Terms such as emotional or abrasive should be avoided when describing women, particularly leaders. There should be a conscious aim for diversity in selection committee composition. Women should be considered actively for promotion, as they may not self-nominate, and the transparency of all application criteria should be improved.

An important manifestation of gender bias that carries lifetime implications is the sexual harassment of women in medicine. Sexual harassment affects women at every level, from medical student to senior surgeon. The incidence in surgery is unacceptably high^10,11, and underestimated owing to the adverse consequences of reporting it. Harassment affects mental health and job satisfaction, and has ended the careers of capable female surgeons. In the past, known offenders were not punished; in some cases, they were promoted to positions of power. Solving the issue of sexual harassment will not be easy, although the solution is straightforward: zero tolerance, with severe repercussions for offenders. Given the historical lack of consequences on the careers of perpetrators, these individuals are unlikely to stop of their own accord; therefore, everyone needs to take ownership of the workplace culture. The standard you walk past is the standard you accept.

One potential unintended consequence of the #MeToo movement is that men may be even less willing to mentor women in surgery¹². As men are over-represented in leadership positions, this exclusionary behaviour compounds the difficulties that women face in finding adequate mentorship and sponsorship¹³. The few female surgeons in leadership positions should not be expected to carry the burden of mentoring all other women in surgery because of unfounded fears of false accusations of harassment. Given the high cost of reporting harassment, under-reporting by women is a far greater issue than false reporting. Although female mentors can provide advice about the unique challenges that female surgeons face, mentorship around the shared experiences of all young surgeons aspiring to leadership positions and career advancement can be offered effectively by mentors of any gender.

Despite their increasing numbers in surgery, women's voices and presence can still easily be lost in the surgical culture. All-male panels at conferences, and awards given predominantly (sometimes exclusively) to men, reduce the visibility of female experts and role models. On social media, the voices of men are amplified¹⁴. In meetings, it is commonplace for vocal men to receive credit for the ideas of women. As individuals naturally gravitate towards those like themselves, the predominance of men in surgery can leave female surgeons unintentionally excluded. Fortunately, all surgeons can serve as allies. Rejecting invitations to participate in all-male panels would effectively end this practice. Nominating worthy female surgeons for awards can both acknowledge their contributions and encourage other women to apply. In meetings, women's ideas should be amplified to ensure credit is attributed correctly. Looking outside close circles when undertaking collaborative work will enable recruitment of a diverse network, that will enhance the creativity of the team's output. Finally, when moderating rounds or conference presentations, having a woman ask the first question encourages women to participate more actively¹⁵.

The future of the surgical profession depends on recruiting and promoting talented people, irrespective of gender. Although there is now increasing awareness of the impact of implicit and explicit biases on the careers of female surgeons, action on these issues is lagging. To see real change, surgery cannot wait for demographics or expect women to push the changes alone. There are numerous strategies that can reduce gender bias in surgery immediately, but require men and women, together, to take intentional, innovative action. To quote Julie Freischlag¹⁶: ‘Osmosis won't get us there – we need active transport.'

Disclosure

The authors declare no conflict of interest.

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