Volume 47, Issue 6 p. 538-540
Commentaries
Free Access

It's all about gender, or is it?

Carol-anne Moulton

Carol-anne Moulton

Toronto, Ontario, Canada

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Natashia Seemann

Natashia Seemann

Toronto, Ontario, Canada

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Fiona Webster

Fiona Webster

Toronto, Ontario, Canada

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First published: 12 May 2013
Citations: 11
Correspondence: Carol-anne Moulton, The Wilson Centre for Research in Education, University Health Network, Toronto, Ontario, Canada. Tel: 416-340-4800 x8819; E-mail: [email protected]

It is well known that women are under-represented in surgery. In addition, as the number of women in surgery increases, there has not been a corresponding rise in women holding leadership roles.1 For the most part, this has been explained by women having assumed greater responsibility in the home compared with their male colleagues. However, even when time for maternity leave and childcare responsibilities are considered, women in surgery are still less likely to be successful in their academic careers compared with men.2 This, plus lower numbers of women in surgery in general, leads to fewer women being ‘seen’ by medical students. In an interesting paper published in this issue of Medical Education, Hill and Vaughan3 use the ‘paradigmatic trajectories’ concept from the theory of communities of practice to examine the underlying processes that cause female medical students to opt out of a surgical career. They argue that the things female medical students ‘see, hear and do’ (or do not see, hear and do) during their surgical rotations make it difficult to ‘imagine’ themselves pursuing careers in surgery. According to this view, these underlying processes might contribute to women ‘self-selecting’ out of a surgical career and include gendered experiences, lack of access to role models, dis-identification and subtle sexism.4

Underlying processes may contribute to women ‘self-selecting’ out of a surgical career and include gendered experiences

Gender is a highly complex concept and probably contributes substantively to issues of recruitment into surgery, as well as issues of training, promotion and performance in ways that are both direct and nuanced. Feminist theorists have long distinguished between sex (defined by anatomy – male or female) and gender (socially constructed –masculine or feminine traits). We learn to ‘do gender’ and these learned behaviours and beliefs affect how we act, how we speak, the verbal and non-verbal gestures we portray and the levels of confidence and self-efficacy we may attain.5 What is considered appropriate gender behaviour differs historically and geographically and is modified by other social influences, such as socio-economic status and cultural affiliation.6 In Western culture, women have been constructed as a ‘negative reference group’ in binary opposition from men, who are viewed as possessing the most socially desirable traits. For example, men are seen as independent and women as dependent; men are seen as stoic and women as emotional. Through this lens, surgical identity is arguably constructed from a group of traits that are traditionally considered masculine, such as ‘boldness of action’ and a ‘take-charge machismo’.7

As more women have entered surgery, it is reasonable to assume that the tendency to favour traits of masculinity has changed or is changing. However, some evidence suggests that a tendency still exists for women to take on these qualities in order to fit in as they undertake surgical training.8 This is in keeping with theories of social identity and intergroup behaviours that describe how, through constant interaction and the powerful process of socialisation, individuals learn the attitudes, values and behaviours that are esteemed by the group they wish to join.9

Given that the surgical standard is historically based on a gendered notion of masculinity, more women than men will probably sense this ‘otherness’ of not fitting in.10 This is a different issue than being the ‘only girl in the room’ and suggests that the participation of women in surgical careers may have more to do with gender in surgical professional roles than with sex (anatomic) in surgery. Through this lens, it becomes possible for a woman medical student to feel ‘othered’, even when surrounded by other female surgeons. As long as these masculine characteristics are valued and promoted, a ‘simple’ increase in the numbers of women joining the profession will probably be insufficient to counter the effects of the long standing processes of gender identification.11

An important aspect of the gender issue within surgery lies in the link between self-efficacy (the belief in one's own ability to succeed in a particular task) and performance.12 Self-efficacy is a vital component of the mental training necessary for surgical performance. It is not unusual for surgeons to feel uncertainty in the operating room13or anxiety about whether they can complete an operation safely. In training, we recognise this, and the system of ‘graded responsibility’ probably builds (but perhaps occasionally hinders) the confidence and self-efficacy necessary to operate independently.14 Individuals with higher levels of self-efficacy tend to pursue higher levels of performance and will persevere when problems are encountered, leading to increased success.15 Gender differences in levels of self-efficacy, as well as self-reported levels of confidence, have been documented, particularly when they are studied in what is commonly understood to be masculine-dominated tasks or performances.16 Men tend to be more ‘self-congratulatory’ in their responses, expressing confidence in skills they might not possess and overconfidence in skills they do possess; women tend to be more modest.17 These are probably gendered processes. Men are also more likely to ‘act’ confident and certain even when they are not, whereas women are more likely to ‘act’ uncertain.5, 18 Perhaps this provides an alternative explanation of why male medical students in Hill and Vaughan's study3 recounted being in the abdomen ‘up to their elbows’, whereas female medical students recalled not having participated in a meaningful way.

As we attract more women into surgery, the role of gender and the effect of gendered behaviours must be further studied. It probably affects not only the recruitment of women, but also their training, their selection of a subspecialty, their performance and their eventual promotion into leadership. As this conversation unfolds, it is best to consider the qualities that are necessary for surgical expertise and to explore ways that gender helps or hinders in this training process. Perhaps moving towards a ‘personalised training’ programme where individual needs are matched with specific training requirements.18 A man who is struggling with self-doubt in the operating room can engage in specific training steps, as athletes do, to improve levels of self-efficacy.19 A women who is overconfident and quick in her approach to diagnosis can undergo mindfulness training to learn the perils of overconfidence in diagnosis and decision making.20, 21 There is reason to be optimistic that these issues can be successfully addressed, particularly with increased awareness of the socialisation process,22 hidden curriculum23 and social construction of the surgical identity22 (rather than considering them as static and innate traits). Certainly the field of surgery would do well to attract the best and brightest medical students regardless of their sex or gender and encourage them to reach their full potential.