As a child, I was not aware of the many limitations of the adult world. I believed I could do and be anything with enough hard work. Sunday, I wanted to be a princess and by Wednesday, I was going to be a lawyer. Fast forward several hundred Wednesdays and now I am becoming a doctor, drawing a particular joy and excitement from surgery. However, being older, wiser and ever so slightly more jaded, I now know there are things other than hard work to consider: how long do I want to be training? What kind of lifestyle do I want? And, though difficult to ask, would I feel welcomed in this space? Based on my identity and the body into which I was born, could I get there?
It is no secret that those with privileged identities are more likely to see themselves represented in surgery compared to those from racialized groups, women, those from a lower socioeconomic status and especially for those with intersectional identities. This results in vast differences between surgeons and the populations they serve. While there have been many efforts to acknowledge and address these gaps across surgical specialties, including general surgery and gynecology, there is still a significant lack of representation of non-privileged identities in surgical specialties across Canada. Women and gender diverse persons only account for 30.3% of all surgeons, and these numbers can be as low as 8.7%, depending on the surgical specialty.
Through the Surgical Skills and Technology Elective Program (SSTEP), incoming third-year medical students can train in and explore a variety of surgical and procedural skills prior to their clinical clerkship. An original survey was designed as part of the SSTEP academic enrichment program to identify potential barriers to entering surgery for women and gender-diverse persons. From the 40 student participants in the 2023 program, 12 completed this survey (83.3% female-identifying). Through analysis of short semi-structured interviews, several themes emerged. These interactions identified perceived boundaries to entering surgery at levels varying from the individual to broader ideas of gender and gender roles throughout society.
“The time-honoured tradition of misogyny” – Discrimination at Home and in the Workplace:
While most students surveyed reported they had positive experiences in the OR and surgical clinics, many were also subject to inappropriate comments/behaviours or perceptions based on their gender. One student reported a male preceptor saying, “As a surgeon, I barely have a life – I am glad I am not a woman.” Another received comments about women’s moods being inconsistent “probably due to their menstrual cycle.” No men surveyed reported experiencing discrimination based on gender, but all noted they had either seen or believed non-male gender identities would be discriminated against in surgical settings.
While approximately half of the women surveyed received some form of discrimination on observerships or in the hospital, approximately 80% reported they had been discouraged from pursuing surgical specialties by peers, friends, family and/or teachers. However, they indicated this did not have a substantial impact on their career aspirations. Participants were asked to rate the impact of discouragement from peers and family on a scale of 1-5, with 1 being no impact and 5 being maximum impact, and the average rating was 1.97. This highlights the significant impact that these attitudes may have on aspiring surgical applicants.
Whether they had experienced it directly or not, the sample of SSTEP participants surveyed indicated there was an overwhelming perception that women should not be surgeons. Additionally, there were beliefs that balancing life and family with a career in surgery is much more difficult for women than for men. Some of the beliefs mentioned from the participants and their communities included, “perceptions of women being physically weaker than men, women do not make for good surgeons and the OR is an ‘old boys club.’” Having these beliefs about the atmosphere in surgery – whether or not they accurately reflect the profession – could discourage female and gender diverse medical students from pursuing these specialties.
Lack of Mentorship/Representation:
Many participants identified that they did not personally have a mentor in their specialty of choice with the same gender identity as them and that this impacted their desire to pursue a surgical specialty. Several noted that, despite this, seeing women surgeons through academic courses, clubs and observerships “was inspiring” and made them more comfortable considering surgery as a potential specialty of choice. For those who did find female-identifying mentors, they felt more capable of realizing careers in surgical fields, for example:
I’ve had 2 female mentors who really supported me and shaped my interest in surgery… there is a culture in [surgery] that it is not for women in terms of the demands and lifestyle it requires, but having people the same gender as me encourages me to pursue it more than if I only had male mentors. (Participant A)
Family as a Maternal Responsibility:
The participants explained that having a family was the most commonly identified barrier for women pursuing surgical careers. Other common facets identified included managing pregnancy and family planning during residency training (as well as negative perceptions of this by male co-residents and preceptors), wanting to choose a specialty where they felt they were able to prioritize family and a limited reproductive timeframe that could conflict with a long surgical residency. Interestingly, most female-identifying participants also mentioned that they felt a lot of responsibility for having a family that relied on them, as opposed to male medical students facing the same decisions. Male participants also shared a perceived pressure to conform to traditional gender roles, stating they felt pressured to provide and take on the role of the financial provider and spending more time away from family. This is perceived as a “valiant sacrifice” but means men in heterosexual relationships feel pressure to take on careers that might not give them the family time they desire.
Despite ongoing efforts and changing perspectives, gender equity in surgical specialties has not yet been achieved and is not simply a problem of the past. Only in addressing deep-seated gender roles and actively creating opportunities for the representation of women and gender-diverse persons in surgery can surgeons in Canada accurately reflect the populations they serve. And while hard work may not be the only factor to consider as I strive to realize my dreams, it can be a powerful motivator for meaningful change – and I don’t think my childhood self would be disappointed.