March 1, 2022
By Linda Duska, MD, FACS, ACS Board of Governors DEI Education/Advocacy Workgroup
The overall proportion of surgeons who are women increased from 15% in 2000 to 25% in 2013. Obstetrics and gynecology (OB/GYN) is the surgical field with the largest female workforce and the highest female-male ratio. In the same period (2000-2013) the female-male ratio in OB/GYN increased from 1:1.8 to 1:1. More recently, in 2018, more than 80% of residents matching in OB/GYN were women, and nearly 60% of OB/GYN physicians were women. If the theory that increasing numbers of women in surgery will result in gender equity is valid, then one might expect that OB/GYN is a specialty well on its way to achieving gender equity. Unfortunately, the published literature suggests otherwise.
Practicing women OB/GYNs still report high rates of gender-discrimination and sexual harassment, one of the largest gender wage gaps in medicine, and disproportionately low advancement and promotion. Notably, women in OB/GYN remain underrepresented in chairperson and full professor positions and are overrepresented in instructor and assistant professor ranks. When the gender of department-based leaders is considered based on the proportion of leadership roles held by women in 2013, divided by the proportion of residents in 1990 who were women, OB/GYN lags behind other specialties in the progression of women to departmental leadership roles.
Gynecologic oncology (GYO) is a surgical specialty of OB/GYN that requires a 3- or 4-year fellowship following residency focused on radical surgery. GYO surgeons perform complex pelvic surgery as well as bowel surgery, splenectomies, retroperitoneal node dissections, and other complex procedures. A study of academic rank in GYO described a similar lack of representation in leadership positions and full professor rank to OB/GYN, despite a 76% female representation in the specialty. In GYO, women tend to stall in advancement before becoming full professors, notwithstanding equivalent productivity in scholarly output measured by authorship trends.
Importantly, despite a high representation of women, the workplace environment remains challenging. In 2021, a survey study of GYOs was reported at the Society of Gynecologic Oncology (SGO) annual meeting. The authors’ objective was to determine whether leadership gender and practice infrastructure are associated with experiences of bullying and gender discrimination among women GYOs. Findings presented include: 53% of GYOs reported bullying (only 24% were formally reported), 57% reported gender discrimination (only 19% were formally reported), and 83% reported experiencing gender-related microaggression. These high rates of bullying, discrimination, and microaggressions are not dissimilar from reports in other surgical specialties and, notably, were not associated with division or department leadership gender or practice setting.
OB/GYN has a substantial percentage of women that is continuing to increase, given the ever-larger proportion of women trainees. Nonetheless, significant gender inequities persist. The findings described above suggest that the mere inclusion of women is insufficient to effect culture change. Instead, inclusion must be coupled with intentional changes to the system and the culture so that women can thrive. Suggested changes to the system include ensuring transparency and accountability to allow for the intentional promotion and advancement of women to leadership while avoiding the “glass cliff” phenomenon. Providing the support needed for women in leadership and ensuring pay parity/pay equity are critical to achieving success.