Engendered Surgery: Women Surgeons Reveal their Experiences
— Patrizia Longo and Cliff J. Straehley
IN HER TALK at Harvard in April 2005, the feminist scientist Evelyn Fox Keller pointed to a distinction she was and is careful to make between garden variety discrimination and what she sees as the larger underlying issue: the way society constructs ideas of masculinity, femininity and science, and how these ideas overlap—or don't.
Today almost 50% of entering medical students are women, but when time comes to apply for residency appointments, suggestions are made to quite a number that family practice, internal medicine, pediatrics or psychiatry would be more suitable careers for them than surgery. Gender discrimination during residency years in surgical programs is widespread and sometimes flagrant—much more so than during medical school or later in practice.
We circulated a questionnaire to 100 women surgeons and surgical residents asking them to talk about their experiences as women in the field of surgery (in medical school, during their residency, and during their career as surgeons), and received in-depth responses from 80. Based on such responses, we note that sexual discrimination continues to be a pervasive problem. It seems, as Cassell notes, that "certain male-identified death-haunted pursuits, such as surgery, test piloting and race car driving, are embodied occupations, and that (to some) the body of a woman....seems bizarrely out of place to their martial masculine practitioners" (2000, 12-13).
Our study was primarily based on participant observations, interviews, and extensive surveys of women surgeons and residents, whose average age is below 45 years. All but two are currently professionally active. In their responses to our questionnaire, the participants describe their personal paths to a career in surgery and relate how they overcame the obstacles they encountered. A number of them said that voicing their concerns on the issues facing women in medicine was "therapeutic...although, admittedly, also a bit traumatic." Seventy-five percent experienced gender discrimination.
Nobody failed to observe in her responses that surgery is male dominated, but they put men's pre-eminence down to a variety of causes. Depending on which cause they stress, they are more or less likely to consider gender hierarchy something they could/can contest. One woman wrote:
I had two children in two years and this has impacted my academic and clinical productivity. I am on a time limited tenure track (7 years up or out). I had to take myself off the tenure track as I will be unable to meet requirements, because of the impact on my children....I fault my medical school for not having an option to freeze the tenure clock with childbirth (many/most top medical schools do.) I don't regret my decision to have children but feel the academic university could do much more to help someone like me who has lots to offer the academic environment.
In The Second Sex (1953), Simone de Beauvoir wrote that one of the main goals of human existence is the attempt to transcend the natural limits of being human—the inevitable bodily vulnerability to disease, injury, and death. Both men and women, as human beings, share this goal, but have different relationships to it.
Given women's biology—pregnancy, child birth and nursing are female "activities"—women seem to stand for what humanity is trying to transcend and escape. For de Beauvoir, this allows men to construct themselves as subjects vis-à-vis women as objects, as Selves vis-à-vis Others. Such logic constructs and justifies certain patriarchal arrangements.
Patriarchy is the structural and ideological system that perpetuates the privilege of masculinity. It functions to marginalize the feminine, infantilizing, ignoring, trivializing, or even actively casting scorn upon what is thought to be feminized. Many of the women surgeons we interviewed commented on these issues.
The battle is everywhere...I'm consigned to the nurses' locker room and our conditions there are much inferior to male counterparts. Equipment is sized for male hands, male heights. Golf is the second office—I hate golf. Sexism, racism, materialism prevail.
Another woman spoke eloquently to the dilemma faced by women in the field of medicine:
In trying to resolve these conflicts, the female physician has three options: (1) she can deny there is any difference between herself and her male colleagues and become "one of the boys," and the men will respond by treating her as a "neuter;" (2) she can adopt almost a caricature of the traditional female role with a seductive, helpless, and dependent posture, and the men will consider her a sex object; or (3) she may feel compelled to become "superwoman" with the goal of compulsive excellence in both career and family roles and a continued need to prove her competence in all areas.
This surgeon is describing what feminist social scientists call "doing or performing gender." Rather than accepting biological determinism or essentialism in describing differences between the sexes, several scholars see gender as produced through interaction; in other words, gender is not something someone has or possesses, but rather something one performs by behaving in gender-appropriate ways or challenging feminine and masculine constructs.
Ginsburg and Tsin explain what they mean by "gender": "the ways society organizes people into male and female categories and the ways meanings are produced around these categories...Gender is not seen as fixed or 'natural' but rather as a category subject to change and specifically to negotiation" (1990, 2; italics in the original).
Most respondents reported offensive remarks about women as women. One surgical resident said that a male professor told her that girls were just not as good as boys in physics. Another commented that "inappropriate remarks occur. I don't think many women in surgery have been able to avoid this." Still another reported being told that she belonged at home with her uterus occupied rather than in the OR with a scalpel in hand.
One resident filed a formal complaint when, during transplant surgery, an attending surgeon commented that "women are only useful as donors." However, she was told that her complaint resulted in his subsequent promotion.
Another stated that she experienced no more abuse than the men: "At the time I felt bullied but in retrospect it toughened me up to face the real world of hospital politics, patient demands..." (italics added) Is learning to be "tough" and behave in "masculine" ways a prerequisite to succeed as a surgeon? The qualities that are valued and praised in a surgeon are culturally masculine, and thus limiting for women given the traditional traits ascribed to females.
Once more, women face a dilemma. They may become "tough" and "masculine" and pay a price for going against gender stereotypes in being disliked by peers and superiors who feel more comfortable with "feminine" women. Alternatively, they may perform their gender and then not be seen as fully competent, as weak, and thus not respected as surgeons even though they may be liked "as women" (Cassell 2000, 81-99).
Feeling and reason are both human traits. Why parse them according to the genders? Why exclude feelings from science and reason from women's domain? These seem to be false dichotomies. As Conley suggests, "When it comes to academic medicine, emotion, and warmth, demonstrable humanity often are equated with weakness. Even though they are so-called feminine traits, should they not be used as criteria when choosing a leader in a masculine-dominated culture such as surgery?" (Conley 1998, 292).
Why should such "feminine" traits as compassion should be suppressed during surgical training? If senior staff members rewarded caring, trainees would learn to behave with kindness and compassion to the benefit of all, physicians and patients alike. "I see no reason why one must choose. Why not a brilliant and caring surgeon?" (Cassell 2000, 146; italics in the original).
Fear of Banishment
No patriarchy is composed only of men or just of the masculine. Patriarchies need the complex idea of femininity and enough women's acceptance or complicity to operate. Conley wrote that though "frequently offended, I dared not offend, for fear of banishment from the only professional camaraderie I had ever known. Not wanting to lose my quasi-membership in the surgeons' club, I had never done anything to stop behavior that was repulsive to me and ultimately damaging to my self-respect." She realized that "for years I had been an enabler, choosing to ignore sexist insults....not realizing that to endure meant to condone" (Conley 1998, 105, 136).
Conley supports her argument with examples of other women physicians who were similarly demeaned but played along. She documents how refusal to yield to a flagrant sexual overture destroyed one woman's aspiration to gain an ophthalmology residency, and then "found her life and career changed forever"(Ibid, 219).
Patriarchal attitudes spill over also into the behavior of subordinate women toward women in position of power. Respondents report that "men and women are treated differently by the nurses. Nurses are more willing to do things for them; are much nicer to them." They complain that nurses are often "jealous and competitive," and are "more respectful of the male than the female residents."
Conley has described what she considers to have been a pervasive undertone of male chauvinism and sexual discrimination at the university medical school where she was the first tenured full Professor of Neurosurgery in the country.
Sexist attitudes existed in several departments and in some cases were promulgated by individuals who wore the mantle of leadership. "The message heard by us women was that only a certain few disciplines were open to us....Dedicated career counselors steadfastly maneuvered us into pediatrics, psychiatry, pathology, general internal medicine and family practice....We (were told) that there are women who have finished surgical training but there are no women surgeons" (Ibid, 23-24).
Conley suggests that surgical training "reinforces the concept of male superiority." Most of the "abuse toward women in the medical school was verbal, subtle, ubiquitous, and probably unconscious. It was the additive nature of daily slights, confirming for all women our second-class citizenship on a regular basis that was most offensive, robbing us of self-esteem, dignity and respect" (Ibid, 111, 115).
At last, when faced with the promotion of an incorrigible sexist to the position of Chair of Neurosurgery at her university, Conley resigned her tenured professorship in protest. "My conflict was not about Professor 'S' and the chair position, but about a medical culture that condoned stereotypic thinking, outdated behavior, and an arrogant superiorist ideology coupled with stubborn resistance to change" (Ibid, 184).
"Good Mom or Good Surgeon"
A pervasive culture of misogyny thus seems to be one of the most persistent stumbling blocks; it can manifest itself in several ways, from subtle to overt. Here are a few responses:
- Most of my surgical attendings discouraged my wish to pursue a surgical career. ...A particularly difficult thing was to be ignored or minimized during small surgical group conferences.
- Several attending surgeons were demeaning/abusive and used sexual harassment to put 'us' in our places. Some gave away cases to male residents of lesser training. I was the 3rd female resident in our program to finish but it was a horrible experience! Many women behind me dropped out.
One respondent stated that an attending surgeon told her, "A woman could either be a good mom, good wife or good surgeon—pick one." At one hospital a senior attending surgeon told all women whom he encountered that women "do not belong in surgery." In another case, a respondent described how she was brushed off when she reported verbal abuse:
One attending in particular regularly abused all the female residents verbally. I told my program director and he said, "you're a tough woman—you can take it." This attending had multiple complaints against him from the nurses, yet nothing was ever done. After I complained, he called me at home to say, "F____ you for this." I also had a chief resident when I was an intern who abused me 100%—insulting me in front of patients. It was horrible.
Respondents reported also serious instances of sexual harassment. A cardiologist teaching a group of medical students how to examine the heart handled the women students by untying their gowns and exposing their breasts to the male students. "I complained to the dean in charge of academics but did not ever get a reply."
Another respondent reported that when she complained about sexual harassment by a senior attending during her residency and he admitted it, she was rotated to another hospital, but "this only made matters worse, because the male residents accused me of making this up for gain." A resident, who hoped to earn a residency appointment in cardiothoracic surgery at her university program, stated:
It was with one of our CT attendings who was known to be a womanizer. I was very interested in CT at the time and this attending let me do a lot of the cases as a junior resident. At times there were inappropriate comments that I just blew off. I was afraid though to really put a stop to his advances because I didn't want to hurt my chances at a CT fellowship. I ignored the times he put his arm around me, brushed up against me or made comments...I tried to stay away from him.
Many residents are afraid to complain because of their vulnerable position.
- A senior professor, the department chair, tried to feel me up at a cocktail party. I slammed my arm against my side to fend him off. I didn't dare complain.
- One well known surgeon used to come to the residents' parties, get drunk, and try to fondle and kiss the female residents. No one ever told on him, we were all too intimidated by the system (none of us were sorry when he was admitted to the hospital with pancreatitis)
One female resident surgeon was actually battered by an out-of-control cardiac surgeon prone to range and violent outbursts. She was thrown against the wall of the ICU cubicle while he shouted and spat at her, complaining that his patient wasn't doing well. Fortunately he was dismissed.
Curing and Unmaking Sexism
Obviously remedies to such behavior must be sought. Janet Bickel (2000) has offered several techniques for eliminating sexist behavior in medical schools and residency programs, such as inclusion of gender sensitivity training in the curriculum in medical schools. Furthermore, every medical school faculty and even residency training programs could have some disinterested senior person to serve as an ombudsman to whom medical students and residents could take complaints without fear of recrimination and with the expectation that abuses will be addressed and remedied.
We maintain, however, that so long as the demand for equality is based on the argument that women, if social arrangements allow them to be, are similar to men—instead of the possibility of men being similar to women—women are forced to adopt masculinist ways. Equality in this sense takes the life of men as its standard.
The entrance of women into medicine in critical mass is a necessary but not sufficient condition for gender equality. Increasing the number of women in surgery without altering the institutional arrangements and gendered organizational hierarchy does not substantially alter the rules of the game by developing inclusionary strategies which would allow combining work and family responsibilities.
The secondary status of women in society is a universal. Such universality of female subordination indicates that we are up against something deeply rooted and stubborn, something that cannot be eradicated by simply rearranging a few roles and tasks in the system or even by reordering the structure or hierarchy.
Various aspects of woman's situation (physical, social, psychological) contribute to her being seen as closer to nature, while the view of her being closer to nature is in turn embodied in institutional forms that reproduce the situation. The implications for change are equally circular: "a different cultural view can only grow out of a different social actuality; a different social actuality can only grow out of a different cultural view" (Ortner 1996, 41).
Efforts at changing the institution of medicine, and surgery in particular, through quotas for hiring, for example, woman-to woman mentoring, and guaranteed maternity leave, cannot be effective if cultural language and imagery continue to devalue women. At the same time, efforts to change cultural assumptions through gender-sensitivity training, for example, or through revision of educational material and courses, cannot succeed unless the institution is changed to support the changed cultural view.
The question is how we "enact," "resist" or "negotiate" the world as given, and in so doing "make" the world. This making may reproduce the same old social order, or it may produce something new. Human action is made and constrained by the given social structure, and at the same time always makes and potentially unmakes it. Ultimately both women and men must be involved in creating an environment that is friendly to the need of both and respects them equally.
- AAUW Report (2001) "Hostile Hallways: Bullying, Teasing, and Sexual Harassment in School" http://www.aauw.org/research/ girls_education/hostile.cfm.
- Bickel, J. (2000) Women in Medicine: Getting in, Growing, and Advancing. Sage Publications.
- Cassell, J. (2000) The Woman in the Surgeon's Body, Harvard University Press.
- Conley, F. T. (1998) Walking Out on the BoysFarrar, Straus and Giroux.
- De Beauvoir, S. (1989) The Second Sex. New York: Vintage Books.
- Ginsburg, F. and A. Lowenhaupt Tsin, ed. (1990) Uncertain Terms: Negotiating Gender in American Culture. Boston: Beacon Press.
- Ortner, S. B. (1996) Making Gender: The Politics and Erotics of Culture. Boston: Beacon Press.
- Report of National Women's Law Center concerning Discrimination against Women and Girls (2000) Obtained from NWLC, 11 Dupont Circle, N.W. #800, Washington D.C. 20036.
- Ross, M.M. (1992) "Women's Struggles to Enter Medicine," Pharos, 1 (Winter).
Patrizia Longo is Professor of Politics at Saint Mary's College of California. Cliff J. Straehley is Professor Emeritus of Surgery at the University of Hawaii and retired Clinical Associate Professor of Surgery at Stanford Medical School.
ATC 121, March-April 2006