How to Define and Address Gender Discrimination and Sexual Harassment in Surgical Training

Gender discrimination (GD) is defined as behaviors, policies, and practices that lead to disparate treatment secondary to an individual’s gender. When these behaviors occur or impact an individual’s employment experiences and opportunities, it is termed workplace GD.^1,2 Sexual harassment (SH) is defined by unwelcome verbal or physical conduct of a sexual nature and is an explicit and illegal form of GD.^3,4

Discrimination and harassment exploit inequities in power and are often directed against vulnerable populations. Residents and medical students represent a vulnerable population, as they are dependent upon superiors for letters of recommendation, training opportunities, awards, and career advancement. This power differential engenders an environment in which GD is not only more likely to occur, but also less likely to be reported.⁵

GD is perpetrated and experienced by both men and women and impacts the direct victim of the abuse as well as witnesses and other individuals adversely affected by the misconduct.⁶ GD creates a hostile work environment for practitioners and trainees and may ultimately negatively impact patient care.^7,8 While GD may take the form of overt intimidation, disparaging comments, or blatant sexual misconduct, it also presents more subversively in the form of subtle inequities, double standards, and bias. Though many institutions have policies prohibiting explicit bias and discrimination, implicit bias—or unconscious attitudes and opinions—more insidiously subverts workplace equity.⁹ Implicit bias is often unrecognized by the individual, yet powerfully and prevalently influences actions through stereotyped belief systems.⁹

The Council on Graduate Medical Education concluded in a 1995 report that “Gender bias, a reflection of society's value system, remains the single greatest deterrent to women achieving their full potential in every aspect of the medical profession and is a barrier throughout the professional life cycle.”¹⁰ Yet, more than 20 years later, GD is reported by 87 percent of female medical students, 88 percent of female residents, and 91 percent of female surgeons.¹¹ GD is overwhelmingly directed towards female trainees, with female residents reporting SH at rates that are more than four times the rates reported by male residents.¹²

The experience of workplace GD begins well before residency. The vast majority of students (93 percent of females and 83 percent of males) have personally experienced, witnessed, or heard about at least one episode of GD in medical school.¹⁰ Sources of GD include residents, faculty, patients, nurses, and classmates.¹³ Although the preponderance of GD stems from male sources, approximately 40 percent of GD comes from women.¹¹ The most frequently reported form of GD is inappropriate verbal exchange, followed by lack of respect, and SH.¹¹ GD is most prevalent during core clerkships, with rates of unwanted sexual advances and exclusion based upon gender more than doubling between preclinical and clerkship years.^13–15 Notably, general surgery has the highest perceived incidence of GD of all specialties by both female and male students.^14,15

Although this discussion focuses on gender bias and discrimination broadly, most studies demonstrate that rates of GD are higher for individuals, particularly women, of color.¹ Additionally, lesbian, gay, bisexual, or transgendered (LGBT) individuals are disproportionately targeted by GD and SH, with nearly half of medical students reporting anti-LGBT jokes, rumors, and bullying by classmates and other members of the healthcare team.¹⁶

GD experienced during medical school and residency selection directly translates into reduced recruitment of women into the surgical profession.¹⁰ Fourth year medical students indicate that GD influenced their choice of specialty; women were more than twice as likely as men to report being influenced by GD concerns in their residency selection.¹⁰ Although women represent half of medical school matriculants, only 38 percent of general surgery residents are female, and women represent only 19 percent of practicing general surgeons in the United States.^17,18 Even fewer female surgeons are seen in specialties such as vascular surgery (89 percent male) and orthopedic surgery (95 percent male).¹⁷

For women who do pursue a career in surgery, GD negatively impacts professional achievement. The vast majority of women report that GD negatively affects their sense of professional self-confidence and negatively impacts career advancement.^11,19 One-third of female surgical residents and early-career female surgeons report that attitudes about their gender create current barriers to their career aspirations and advancement, and attrition rates for female residents and surgeons remain significantly higher than for males.^11,20 In a study evaluating student, resident, and surgeon experience of GD, 16 percent of respondents who personally experienced GD requested position reassignment or relocation, 45 percent considered leaving or declining a position, and 24 percent ultimately left a position due to GD.¹¹ The psychological sequelae of GD may be profound and include poor self-esteem, emotional exhaustion, depersonalization, depression, and posttraumatic stress disorder.^10,12,21

The consequences of GD may extend beyond medical training to negatively affect the diversifying of academic medical faculty. Women are far outnumbered by men as faculty and full-time professors at medical schools and in practice as chairs of clinical departments.²² Career advancement for women at academic health centers proceeds at a slower pace, and female physicians receive lesser remuneration and experience harsher peer review as compared to male colleagues.^20,22,23 More than half of female faculty have experienced SH by a superior or colleague as compared to only 5 percent of male faculty, which is significantly associated with lower career satisfaction.¹ Projections using data from the AAMC estimate that it is not until the year 2096 that females will be represented in equal numbers to males in terms of surgical professorship.²⁴

There are many efforts underway to both understand and mitigate GD within the medical system. Programs have developed initiatives that aim to alter the experience for medical students and residents. These efforts should focus on reporting mechanisms, a zero-tolerance policy, educational interventions, and mentorship (Table 1).

Reporting Mechanisms

Although GD significantly impacts trainee well-being and achievement, the vast majority of incidences of GD remain unreported.^5,11,12 Cited reasons for lack of reporting include fear of reprisal, perception that nothing will be done, uncertainty for how to report GD, and feeling that GD constitutes a part of standard medical culture.^5,25 Institutions are mandated to have venues for reporting SH, but more importantly, there must be reliable mechanisms to protect victims from retribution and to ensure that appropriate action is taken with clear, transparent policies. Essential features of a reporting system include confidentiality, accessibility, timely investigations of reports, and a supportive environment that ensures that uncertainty and fear do not deter victims from reporting abuse.²⁶ Medical schools and hospitals must commit to addressing reports of GD and must outline concrete actions to investigate and address claims and protect the privacy of the individual who files the report. Additionally, an institution-wide GD policy should clearly state a single code of conduct with a zero tolerance policy toward GD to promote a cultural norm of gender equity.^2,26

Educational Interventions

The aim of GD interventions should be not only to report and address incidences of abuse, but to prevent further occurrences. As GD occurs across training in a variety of contexts, it is necessary to increase awareness of this issue and direct appropriate interventions towards faculty, medical students, and residents. Institutional advocacy groups should be organized to raise awareness of the prevalence and impact of GD.² Educational seminars directed toward faculty have been shown to decrease trainees’ reported experiences of sexual harassment.^27,28 Implicit bias training should be conducted for both males and females across medical training levels.^9,29 A randomized controlled trial conducted by the University of Wisconsin-Madison demonstrated that when at least 25 percent of a department's faculty attended a series of workshops to address gender bias, there was a significant increase in specific gender-equity-promoting actions.²⁹

Since up to 40 percent of GD comes from women, it is important that trainings be conducted with clinical support staff including nurses, advanced care professionals, and medical technologists.^9,29 Female residents may encounter reduced trust and respect from female nurses, colleagues, attendings, and patients. Gender-normative expectations and implicit bias from both men and women result in female physicians being referred to by their first names, being mistaken for nurses, and being rated as less confident in professional evaluations.⁹ Unconscious inequity in how female residents are evaluated by patients, colleagues, and support staff translates into tangible disparities in pay and promotions. Providing education through collaborative efforts between residency programs and all medical team members regarding the impact of implicit bias is a step toward dismantling barriers to workplace equity for female surgeons.

Mentorship

Mentorship constitutes a powerful source of support for trainees through surgical training.^11,20,30 Early exposure to female role models and leaders within the surgical field encourages students to pursue careers in surgery.¹¹ Instituting formalized mentorship programs between medical students, residents, and faculty is instrumental in creating a culture of mentorship as seen in the Association of Women Surgeons Coaching Project.^31–33

GD is a rampant problem that affects all medical trainees with significant consequences. Preventing and addressing GD is important for promoting workplace security and satisfaction. Moreover, workplace diversity has been demonstrated to increase industry productivity, innovation, and financial performance.^34,35 Companies in the top quartile of gender diversity are 15 percent more likely to demonstrate financial returns above the national industry median, and it is estimated that $12 trillion could be added to the global GDP by 2025 by advancing women’s equality and increasing female leadership.³⁴ Advancing female equity and leadership by addressing GD within a medical context has the potential for both social and economic gains.

Ultimately, further research is needed regarding the prevalence, prevention, and remediation of GD. Confronting GD head-on from a multimodal approach is essential for creating an equitable, productive, empowering, and safe workplace for future generations of surgeons.

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34. McKinsey & Company. Diversity Matters. November 2014.
35. Misercola M. Higher Returns with Women in Decision-Making Positions. Credit Suisse. https://www.credit-suisse.com/corporate/en/articles/news-and-expertise/higher-returns-with-women-in-decision-making-positions-201610.html. Accessed October 26, 2018.

Anna Alaska Pendleton, MD, is a resident in the department of vascular and endovascular surgery at Massachusetts General Hospital, Boston, MA.

Taylor M. Coe, MD, is a resident in the department of surgery at Massachusetts General Hospital, Boston, MA.

Noelle N. Saillant, MD, FACS, is a surgeon at Massachusetts General Hospital, Boston, MA.