The experiences of female surgeons around the world: a scoping review

This review was led by the question, ‘What are the experiences of female surgeons around the world and how to do they differ based on geography, country income level, and cultural beliefs of gender equity?’ The female surgical experience was defined as any difference in attitude, treatment, behavior or career outcome that results from a surgeon’s female gender.

Included were original, peer-reviewed, full-text articles published in English that studied female surgeons, female surgical residents, and female medical students considering surgery. Topics required for inclusion were work–life balance, salary, health, job titles, career factors and barriers, training, skills, pregnancy, childrearing, domestic work, volunteerism, interpersonal interactions and discrimination/harassment. All study types were included, such as cross-sectional analysis, questionnaires, longitudinal analysis, and controlled trials. Editorials, case reports and personal anecdotes were excluded due to potential bias. No restriction was placed on the year of publication to assess the complete literature on female surgeons.

A search of PubMed, Web of Science, and MEDLINE (Ovid) was conducted on April 2, 2020 and included six search constructs (Table 1). One author (M.X.) conducted the initial review and excluded articles that did not meet inclusion criteria according to title. Two authors (M.X. and N.M.) reviewed the remaining study abstracts and excluded articles that did not meet inclusion criteria. The remaining articles were summarized in a chart in Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA). Full-text articles were individually reviewed by two authors (M.X. and N.M.) to extract study characteristics including study design, publication year, study population countries and gender distribution, the category of the female surgical experience, funding source, and the study’s main findings. Studies that did not meet the inclusion criteria were excluded. Any inclusion discrepancies between authors was resolved through discussion. Data from included studies was compiled into a single spreadsheet for analysis independently.

Studies were sorted into four key categories based on main focus: careers challenges, residency and training, family and work–life balance, and other. The World Bank Income Level Group and GGGI ranking of included countries were recorded. The World Bank classifies countries into four categories according to gross national income per capita: low-income country (LIC), lower-middle income country (LMIC), upper-middle income country (UMIC), and high-income country (HIC) [13]. These income-level groupings indicate a country’s economic capabilities, associated resources, and opportunities that may be available to the population within. The Global Gender Gap Index is a weighted rating comprising of scores for economic participation and opportunity, educational attainment, health and survival, and political empowerment. GGGI ratings contextualize the experiences of women around the world in a social and professional capacity. Lower scores and rankings correspond to less equality for women [14]. Summary and descriptive statistics were calculated using Microsoft Excel 2013.

Fifteen studies examined populations from multiple countries (Table 2). Most study populations originated from the North America (n = 103, 62.4%) and Europe (n = 31, 18.8%). Remaining study populations originated from Asia (n = 13, 7.9%), Oceania (n = 10, 6.1%), and Africa (n = 8, 4.8%) (Table 3). No studies evaluated female surgeons in Central or South America (Fig. 2, Table 3). Ninety-one percent (n = 127) of the studies exclusively examined populations from HICs (Table 2). Six studies (4%) exclusively examined populations from lower income countries (UMIC, LMIC, or LIC), whereas five studies (4%) evaluated populations from at least one HIC and one lower income country (Table 2). The country origins of the population in one study (1%) could not be determined [15]. Populations from HICs were represented in 95.0% of the studies (n = 132). Of the 26 countries represented, half (n = 13) were within the top 25% countries in the world for GGGI, and 73% (n = 19) fell within the top 50% of the 153 countries ranked by the index. One hundred and twenty-five (90%) studies exclusively examined populations from the top 50% of all GGGI ranked countries. Of the lower 50% of all countries rated by the GGGI, only 9% (n = 7) have study populations included in the current literature (Fig. 2, Table 4). Two countries, Japan, and Saudi Arabia were high-income economies with GGGI rankings in the bottom 50% of countries. One country, Rwanda, was a LIC ranked in the top 10 of GGGI ranked countries.

Fifty-one percent (n = 19) of the articles reviewing residency and training, highlighted female surgical trainees’ challenges with gender-based discrimination [28‐46]. Gender-based discrimination was described as negative stereotyping, exclusion from networking, and physical, emotional and sexual harassment. Male colleagues were the perpetrators of 98% of reported harassment by female surgical residents in the US and 72% of these cases were from attending physicians [41]. In Canada, 25% of female medical students reported gender-based discrimination during their surgical clerkship, versus 3% of men; this discrimination was from surgeons (35%), surgical residents (25%), and nurses (17%) [33]. In the UK, 15% of female medical students were told by senior healthcare professionals that women should not be surgeons and 34% witnessed negative comments made about women as surgeons [44]. In Australia and New Zealand, the attrition of female surgical trainees was caused in part by bullying, sexual harassment, sexism, fear of repercussion, poor mental health, and a lack of support pathways [46]. In South Africa, an UMIC, 34% of female surgeons experienced physical threats, 40% experienced emotional threats, and 50% reported bullying [28]. Female surgical trainees in Turkey (an UMIC) were more likely to report gender-based discrimination if they were training in departments without female faculty (p < 0.006) [29]. Discrimination against female surgical trainees in Turkey was perpetrated by their seniors (68%), colleagues (25%), patients (6%) and hospital staff (1%) [29].

Three studies compared the surgical skills of male and female trainees in six HICs [47‐49]. Two studies examining technical capabilities in bowel anastomoses and physical strength found no significant difference in male and female surgical residents’ capabilities [47, 48]. In Rwanda, 66.7% of male and 50% of female surgeons believed that women were physically and mentally weaker than men and therefore less able to perform surgeries [30]. One female surgeon reported that there was a biological basis for the gender disparity in surgery, stating that the difference was “testosterone. Men do not fear and female do fear” [30].

The impact and lack of mentorship in training were discussed in six articles from HICs [32, 36, 46, 50‐52], one article from an UMIC (South Africa) [28], and one article from a LIC (Rwanda) [30]. One study from the US found that a significantly higher proportion of female medical students pursued surgery when their school had more female surgical role models (p < 0.0001) [50]. However, a qualitative survey in the US reported that 44% of female general surgery residents felt they lacked mentorship and that more mentorship for female surgeons is needed [36]. Similarly, in Canada, 80% of the female members of the Royal College of Physicians and Surgeons reported needing a female mentor [32]. The absence of interactions with other women in surgery was a noted reason why female trainees left surgical training in Australia and New Zealand [46]. Female surgeons in Japan had 3.6 mentors each on average, with 2.8 being male and 0.8 being female [52]. In South Africa, 75% of the female surgeons reported having a mentor, with 33.3% of their mentors being female [28]. In 22% (n = 7) of cases, respondents believed that the gender of their mentor made a difference in their training quality [28]. Rwanda had two female surgeons in the country as of 2018; role models for female surgical trainees in Rwanda were male surgeons and female peers [30].

Nineteen studies reported on the pregnancies of female surgeons [19, 53‐70]. In the US, 27.5% of female surgeons had children during residency, compared with 62.4% after residency [70]. In Canada, 29.4% of female surgeons had children during residency, 7.7% prior to residency, and 55.2% after residency [62]. Female surgeons in the US who were pregnant during training reported feeling poorly judged (73.1%), pressured to schedule their pregnancies around training (55.1%), and that their work schedule negatively impacted their or their child’s health (63.3%) [65]. US female surgical trainees without children reported sadness when thinking about children (p = 0.047) and worry that they will never have children compared to male trainees (p < 0.0001) [67]. In contrast, female surgeons in Nigeria who had children gave birth more often during training (78.8%); 37.5% felt their pregnancy negatively impacted their training by increasing training time, straining relationships with instructors, or creating difficulty with scheduling outside rotations [53].

Ten studies evaluated access to childcare and maternity leave policies for female surgeons from only HICs [54, 55, 57, 61‐63, 66, 69‐71]. A study by Walsh et al. included populations from the US, Canada, the UK, China, Sweden, Australia, Nigeria, and South Africa [19]. In this study, Chinese female surgeons were the least likely to reduce their workload while pregnant [19]. All Nigerian female surgeons reported their spouses could not receive paid paternity leave and 86% reported that their spouses were unlikely to get unpaid paternity leave [19].

Nine studies exclusively from HICs [57, 64, 70‐76] found that women had a higher proportion of household and childcare responsibilities. Female surgeons from the US reported one to ten more hours of housework per week versus male surgeons [72]. In Germany, female surgeons spent 7.4% of their week running the household compared to 5.9% for male surgeons [70]. Female surgeons from Canada reported more hours of childcare per week compared to male surgeons (p < 0.0003) [74]. Twenty-seven percent of female surgeons in Switzerland completed all housework themselves [75]. In Hong Kong, more female surgeons reported having less time to rest than male surgeons (p = 0.038) [71]. Japanese female surgeons were more likely to report sacrificing career success or advancement for childbearing (p < 0.01); they had less family support for their careers than female surgeons from other countries (p < 0.01) [76]. Japanese female surgeons also had the least amount of personal time [76]. In Hong Kong, female surgeons reported less time for community participation and rest compared to male counterparts [71].

Different geographic regions along with cultural and societal norms influence gender equity and the experiences of women in surgery. Universally, women from all regions reported a lack of mentorship as a barrier to advancement. An overwhelming majority of studies originated in high-income, high GGGI countries in Europe and North America. In HICs, surgical trainee abilities are seen as equal between men and women, but women endure discrimination from male co-workers and reported more child-related barriers to their careers than their male counterparts. While female surgeon abilities were seen as inferior in some lower income countries, limited studies suggest that women may have more child rearing support and be less likely to delay childbearing. The effects of income and GGGI are complex, as neither independently predict gender equity in surgery. More studies in lower income and lower GGGI countries are needed to understand this relationship and how to improve the female surgical experience to increase surgical capacity worldwide.