The experiences of female surgeons around the world: a scoping review

Introduction The Lancet Commission for Global Surgery identified an adequate surgical workforce as one indicator of surgical care accessibility. Many countries where women in surgery are underrepresented struggle to meet the recommended 20 surgeons per 100,000 population. We evaluated female surgeons’ experiences globally to identify strategies to increase surgical capacity through women. Methods Three database searches identified original studies examining female surgeon experiences. Countries were grouped using the World Bank income level and Global Gender Gap Index (GGGI). Results Of 12,914 studies meeting search criteria, 139 studies were included and examined populations from 26 countries. Of the accepted studies, 132 (95%) included populations from high-income countries (HICs) and 125 (90%) exclusively examined populations from the upper 50% of GGGI ranked countries. Country income and GGGI ranking did not independently predict gender equity in surgery. Female surgeons in low GGGI HIC (Japan) were limited by familial support, while those in low income, but high GGGI countries (Rwanda) were constrained by cultural attitudes about female education. Across all populations, lack of mentorship was seen as a career barrier. HIC studies demonstrate that establishing a critical mass of women in surgery encourages female students to enter surgery. In HICs, trainee abilities are reported as equal between genders. Yet, HIC women experience discrimination from male co-workers, strain from pregnancy and childcare commitments, and may suffer more negative health consequences. Female surgeon abilities were seen as inferior in lower income countries, but more child rearing support led to fewer women delaying childbearing during training compared to North Americans and Europeans. Conclusion The relationship between country income and GGGI is complex and neither independently predict gender equity. Cultural norms between geographic regions influence the variability of female surgeons’ experiences. More research is needed in lower income and low GGGI ranked countries to understand female surgeons’ experiences and promote gender equity in increasing the number of surgical providers.


Introduction
In the modern era of medicine, Elizabeth Blackwell was the first reported woman to graduate from medical school in 1849 and pursue a career in surgery [1]. Women pursuing careers in medicine has steadily increased with women now representing 50% of current medical school matriculants in the United States (US) [2]. This shift is not reflected to the same extent in surgical specialties, where women have experienced much slower growth [1]. In the United Kingdom (UK) and the US, men are 73% and 61.6% of practicing surgeons, respectively [3,4]. The number of female surgeons in low-and middle-income countries rose disproportionately slower than female representation in other medical specialties Open Access *Correspondence: Naikhoba.munabi@med.usc.edu 2 Operation Smile Inc, Virginia Beach, Virginia Beach, VA, USA Full list of author information is available at the end of the article [5][6][7]. Concurrently, five-billion people lack access to safe, affordable surgical care globally and many countries need an increase in surgical providers to reach the recommended 20 per 100,000 population [6]. With the majority of low-and middle-income countries struggling to build an adequate surgical workforce, expanding the participation of women in surgery is a powerful way to help alleviate the global burden of surgery [6,7].
The experiences of women in medicine and how they differ from men is well documented. The majority of this work has focused on barriers such as discrimination, pay gaps, and promotion inequality [8][9][10][11]. Surgery continues to be a male-dominated field with the disparate experiences between genders not well documented worldwide. Understanding career experiences of women in surgery is essential to expand the female workforce, improve the professional surgical environment, and retain existing female surgeons.
This scoping review seeks to understand the experiences of female surgeons around the world and how they differ based on geography, national income (World Bank income level) and cultural beliefs of gender equity (Global Gender Gap Index (GGGI)). The experience of female surgeons is a very broad topic for which we hope to synthesize the current knowledge and identify where gaps in gender equity are evident globally. Our analysis can inform future training programs and professional, educational and institutional initiatives and policies. We hope to inspire new strategies to increase surgical capacity through empowering women globally.

Methods
A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for Scoping Reviews (PRISMA-ScR) [12] guidelines for reporting (Additional file 1). A detailed protocol has been provided as Additional file 2.

Research question
This review was led by the question, 'What are the experiences of female surgeons around the world and how to do they differ based on geography, country income level, and cultural beliefs of gender equity?' The female surgical experience was defined as any difference in attitude, treatment, behavior or career outcome that results from a surgeon's female gender.

Inclusion/exclusion criteria
Included were original, peer-reviewed, full-text articles published in English that studied female surgeons, female surgical residents, and female medical students considering surgery. Topics required for inclusion were work-life balance, salary, health, job titles, career factors and barriers, training, skills, pregnancy, childrearing, domestic work, volunteerism, interpersonal interactions and discrimination/harassment. All study types were included, such as cross-sectional analysis, questionnaires, longitudinal analysis, and controlled trials. Editorials, case reports and personal anecdotes were excluded due to potential bias. No restriction was placed on the year of publication to assess the complete literature on female surgeons.

Search strategy, study selection and data collection
A search of PubMed, Web of Science, and MEDLINE (Ovid) was conducted on April 2, 2020 and included six search constructs (Table 1). One author (M.X.) conducted the initial review and excluded articles that did not meet inclusion criteria according to title. Two authors (M.X. and N.M.) reviewed the remaining study abstracts and excluded articles that did not meet inclusion criteria. The remaining articles were summarized in a chart in Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA). Full-text articles were individually reviewed by two authors (M.X. and N.M.) to extract Total results 12,914 study characteristics including study design, publication year, study population countries and gender distribution, the category of the female surgical experience, funding source, and the study's main findings. Studies that did not meet the inclusion criteria were excluded. Any inclusion discrepancies between authors was resolved through discussion. Data from included studies was compiled into a single spreadsheet for analysis independently.

Synthesis of results
Studies were sorted into four key categories based on main focus: careers challenges, residency and training, family and work-life balance, and other. The World Bank Income Level Group and GGGI ranking of included countries were recorded. The World Bank classifies countries into four categories according to gross national income per capita: low-income country (LIC), lowermiddle income country (LMIC), upper-middle income country (UMIC), and high-income country (HIC) [13]. These income-level groupings indicate a country's economic capabilities, associated resources, and opportunities that may be available to the population within. The Global Gender Gap Index is a weighted rating comprising of scores for economic participation and opportunity, educational attainment, health and survival, and political empowerment. GGGI ratings contextualize the experiences of women around the world in a social and professional capacity. Lower scores and rankings correspond to less equality for women [14]. Summary and descriptive statistics were calculated using Microsoft Excel 2013.

Geography, World Bank income level and GGGI
Fifteen studies examined populations from multiple countries ( Table 2). Most study populations originated from the North America (n = 103, 62.4%) and Europe (n = 31, 18.8%). Remaining study populations originated from Asia (n = 13, 7.9%), Oceania (n = 10, 6.1%), and Africa (n = 8, 4.8%) ( Table 3). No studies evaluated female surgeons in Central or South America (Fig. 2, Table 3). Ninety-one percent (n = 127) of the studies exclusively examined populations from HICs (Table 2). Six studies (4%) exclusively examined populations from lower income countries (UMIC, LMIC, or LIC), whereas five studies (4%) evaluated populations from at least one HIC and one lower income country ( Table 2). The country origins of the population in one study (1%) could not be determined [15]. Populations from HICs were represented in 95.0% of the studies (n = 132). Of the 26 countries represented, half (n = 13) were within the top 25% countries in the world for GGGI, and 73% (n = 19) fell within the top 50% of the 153 countries ranked by the index. One hundred and twenty-five (90%) studies exclusively examined populations from the top 50% of all GGGI ranked countries. Of the lower 50% of all countries rated by the GGGI, only 9% (n = 7) have study populations included in the current literature (Fig. 2, Table 4). Two countries, Japan, and Saudi Arabia were high-income economies with GGGI rankings in the bottom 50% of countries. One country, Rwanda, was a LIC ranked in the top 10 of GGGI ranked countries.

Careers challenges
Eighty-nine percent of articles (42 of 47 articles) focusing on career challenges studied only populations from HICs (Tables 2 and 3). Three articles (7%) studied populations from HICs, UMICs, and LMICs, while two articles (4%) studied only populations from LMICs (Tables 2 and 3). Forty-two (89%) of these 47 studies exclusively examined women from the top 50% of GGGI rated countries (Tables 2, 3 and 4). Female surgeons from different countries had different perceptions of their career barriers. US surgeons attributed their career barriers to ineffective mentorship, gender stereotypes, unclear expectations, a perceived lack of belonging, and sexism in the workplace [21,22]. Barriers to career success in Europe were ineffective mentorship, gender stereotypes, a lack of parttime career availability, and work-family conflicts [23,24]. In Nigeria, female surgeons listed limited time with family, workload, physical effort, a lack of women in surgery, and a lack of role models as deterrents from surgical careers [25]. Two studies recommend steps to increase women in surgery. Kass et al. reported the most important factors for academic success by US female surgeons was the pursuit of mentorship (60% of respondents), setting career goals (50% of respondents) and honing writing skills and publishing (50% of respondents) [26]. To achieve better gender balance in surgery, female and male surgeons in Zimbabwe recommended better working conditions, increasing female interest in surgery, increasing the number of female role models, and changing cultural/ religious beliefs [27].

Residency and training
Thirty-seven studies focused on female surgeons in residency and training, with 86% (n = 32) of these articles exclusively describing HIC populations (Tables 2 and 3).                Included countries were indicated in a map in the article, therefore reliable data on exact countries could not be completely determined ∓ Only these 3 countries were listed: United States, Canada and Mexico. The rest of the study population was designated by continent only. A complete list could not be determined for this study as results did not analyze differences between countries° Respondents from 53 countries participated in this study, but the authors only reported countries with > 10 responses in their paper Thirty-three (89%) of the articles this category focused only on the upper half of all GGGI rated countries (Tables 2 and 4). Two articles studied UMICs exclusively (South Africa by Umoetok et al. [28] and Turkey by Eyigor et al. [29]) and one article focused on a LIC, Rwanda [30]. Two studies examined populations from multiple income levels [15,18].

Gender differences in surgical skill
Three studies compared the surgical skills of male and female trainees in six HICs [47][48][49]. Two studies examining technical capabilities in bowel anastomoses and physical strength found no significant difference in male and female surgical residents' capabilities [47,48]. In Rwanda, 66.7% of male and 50% of female surgeons believed that women were physically and mentally weaker than men and therefore less able to perform surgeries [30]. One female surgeon reported that there was a biological basis for the gender disparity in surgery, stating that the difference was "testosterone. Men do not fear and female do fear" [30].

Mentorship
The impact and lack of mentorship in training were discussed in six articles from HICs [32,36,46,[50][51][52], one article from an UMIC (South Africa) [28], and one article from a LIC (Rwanda) [30]. One study from the US found that a significantly higher proportion of female medical students pursued surgery when their school had more female surgical role models (p < 0.0001) [50]. However, a qualitative survey in the US reported that 44% of female general surgery residents felt they lacked mentorship and that more mentorship for female surgeons is needed [36]. Similarly, in Canada, 80% of the female members of the Royal College of Physicians and Surgeons reported needing a female mentor [32].
The absence of interactions with other women in surgery was a noted reason why female trainees left surgical training in Australia and New Zealand [46]. Female surgeons in Japan had 3.6 mentors each on average, with 2.8 being male and 0.8 being female [52]. In South Africa, 75% of the female surgeons reported having a mentor, with 33.3% of their mentors being female [28]. In 22% (n = 7) of cases, respondents believed that the gender of their mentor made a difference in their training quality [28]. Rwanda had two female surgeons in the country as of 2018; role models for female surgical trainees in Rwanda were male surgeons and female peers [30].

Family and work-life balance
Thirty-six studies focused on family and work-life balance with 34 articles (94%) exclusively evaluating populations from HICs. Of the 34 articles with GGGI ranked populations, 29 articles (85%) solely studied populations from the upper half of all GGGI rated countries (Tables 2, 3, and 4). One study (3%) by Abolarinwa et al. exclusively studied Nigeria, a LMIC [53]. Another study evaluated HICs, UMICs (China and South Africa) and a LMIC (Nigeria) [19].

Maternity leave
Ten studies evaluated access to childcare and maternity leave policies for female surgeons from only HICs [54, 55, 57, 61-63, 66, 69-71]. A study by Walsh et al. included populations from the US, Canada, the UK, China, Sweden, Australia, Nigeria, and South Africa [19]. In this study, Chinese female surgeons were the least likely to reduce their workload while pregnant [19]. All Nigerian female surgeons reported their spouses could not receive paid paternity leave and 86% reported that their spouses were unlikely to get unpaid paternity leave [19].

Childcare and housework
Nine studies exclusively from HICs [57,64,[70][71][72][73][74][75][76] found that women had a higher proportion of household and childcare responsibilities. Female surgeons from the US reported one to ten more hours of housework per week versus male surgeons [72]. In Germany, female surgeons spent 7.4% of their week running the household compared to 5.9% for male surgeons [70]. Female surgeons from Canada reported more hours of childcare per week compared to male surgeons (p < 0.0003) [74]. Twentyseven percent of female surgeons in Switzerland completed all housework themselves [75]. In Hong Kong, more female surgeons reported having less time to rest than male surgeons (p = 0.038) [71]. Japanese female surgeons were more likely to report sacrificing career success or advancement for childbearing (p < 0.01); they had less family support for their careers than female surgeons from other countries (p < 0.01) [76]. Japanese female surgeons also had the least amount of personal time [76]. In Hong Kong, female surgeons reported less time for community participation and rest compared to male counterparts [71].

Health and other topics
Nineteen studies, all from HICs and the upper half of GGGI countries, focused on other topics: interpersonal interactions (n = 3), payment (n = 8), physical health (n = 5), demographics (n = 2), and international volunteerism (n = 1) (Fig. 1, Table 2). Female surgeons in Poland had shorter life expectancies than the general female population (77.5 vs 86.6 years) [77]. Norwegian female surgeons drank large quantities of alcohol more frequently than non-surgeon female physicians (18% vs. 7.6%) [78]. Compared to the general population in the US, breast cancer prevalence was significantly greater in female orthopedic surgeons (p < 0.001) [79]. US female surgeons were more likely to receive treatment for issues relating to their hands than males (p = 0.028), citing instrument design (84%) and operating room table height (44%) as the cause of their symptoms [80]. In the US, female surgeons earned over $60,000 less per year than male surgeons after controlling for work hours, case volume, years in practice, practice setting and specialty (p < 0.001) [81].

Discussion
To the author's knowledge, this study reflects the only scoping review evaluating the experiences of female surgeons worldwide. The demographics of included studies alone provide unique insights into the literature on women in surgery. The majority of research on female surgeons was published in the past five years and focuses on women from the US or other HICs and high GGGI ranked countries. With only 26 countries in this review, we have demonstrated a large shortage of literature on female surgeons experiences compared to the reported 53 countries where female surgeons exist [19]. In particular, no literature on female surgeons was available from Central and South America, despite evidence of women working as surgeons in this region [82]. More importantly, this review has demonstrated that differences in culture, economic and educational opportunity, gender equity and women's empowerment affect the experiences of both female surgical trainees and current female surgeons [3,18,83].
The first step in training and retaining more women in surgery is to support the current cohort of female surgeons worldwide, as female surgeons in North America, Europe, Oceania, Asia, and Africa identified lack of mentorship, particularly female mentorship, as a barrier to career advancement and a reason for attrition in surgical training [23,27,28,30,32,36,46,52,75]. One possible solution for this barrier is to increase the mentorship and visibility of women in surgical specialties, which has been demonstrated in the US to positively influence young women to enter surgical specialties [50]. Increasing the number of female surgeons through mentorship is less feasible in some countries. Despite evidence that women and men have equivalent physical strength and skills, the limited number of female surgeons currently in countries like Rwanda, along with the societal belief that women are less suited for the demands of surgery, limits the availability of mentors for new female surgeons [30,[47][48][49].
A country's income and GGGI status can help frame the need to support their women in surgery. Rwanda is a LIC with a high ranking for global gender equality but very low ranking for educational attainment; negative attitudes towards female surgeons may stem from a deeper sociological mindset towards the educational achievements and career choices of women. Zimbabwe has a moderate GGGI ranking overall but a low ranking in educational attainment; there, both male and female surgeons believe that cultural and religious attitudes need to change in order to achieve gender equity in surgery [27]. In low-and-middle income countries with lower GGGI educational attainment rankings, working to change cultural attitudes about female education and stereotypical gender roles may be the first step towards increasing the prevalence of women in surgery.
Regardless of country income level, lower GGGI rankings can predict restrictive gender norms that limit female attainment in surgery. Populations from East Asia (Japan, Hong Kong, and China) had higher incomes (HIC and UMIC) and GGGI rankings in the lower 50%, particularly in economic participation. This dichotomy may highlight cultural structures less inclusive of female advancement. Unlike female surgeons from western countries, Japanese female surgeons reported less familial support for their careers and less leisure time. Seen as the responsibility primarily of women in countries with lower GGGI rankings and low female economic participation, domestic duties are in direct conflict with medical systems that rewards long hours and increased overtime work [76]. Therefore, the medical fields in countries with low GGGI rankings, regardless of income status, may be designed to favor the male workforce. Gender norms in these countries further strain female surgeons' work-life balance and career attainment. Future initiatives in these countries should target cultural attitudes about women's domestic roles and economic participation along with policies to increase flexible work schedules for female surgeons.
In HICs with high GGGI rankings, geographic and cultural differences affect surgeons' perceptions and barriers. Female surgeons did more household work than male counterparts. Child-related barriers were reported more by Europeans than Americans [21][22][23][24], which was surprising given the abundance of state and hospital sponsored childcare in Europe [84]. The ubiquity of childcare in Europe may have created an environment where small gaps in childcare services are a perceived barrier, while childcare in the US is completely privatized.
Countries with extended family support systems do not face the same childcare challenges. Nigeria has lower income and low GGGI, but most Nigerian female surgeons were able to have children during residency without barriers (79%), unlike women in the US and UK (28% and 47%, respectively) [53,61,70]. With older relatives living in the home, Nigerian women can rely on an extended family system to run households [53,85]. This extended family system is common in countries with similar cultural norms, allowing female surgeons from lower income and lower GGGI countries to achieve greater work-life balance at earlier stages of their careers.
Discrimination against female surgeons during their training, career, and pregnancy, was a common finding in high GGGI and higher income countries (HICs, UMICs) countries such as the US, UK and South Africa [28,[31][32][33][34][35][36][37][38][39][40][41][42]65]. Discrimination and harassment were perpetuated most commonly by male colleagues in positions of power, which increases work-related stress and burnout while decreasing retention rates among female surgeons [33,41]. High GGGI ranked countries may have more awareness towards discrimination against professional women. In lower ranked GGGI countries, the lack of studies on gender-based discrimination against female surgeons underrepresents the extent of the problem. A lack of awareness or minimal consequences for discrimination in low GGGI countries contributes to the absence of advocacy against discrimination. In a Turkish example, increasing the number of female surgeons in leadership is one way to reduced gender-based discrimination [29]; this model could be replicated in similar environments.
Female surgeons in HICs and high GGGI countries reported worse health outcomes compared to male surgeons and the general population. Studies from HICs reported that female surgeons had higher rates of cancer, alcohol consumption, and musculoskeletal ailment accompanied by lower life expectancies across European and North American countries [77][78][79][80]. As all the literature on female surgeons' health focused on HICs, this finding could not be compared to female surgeons in lower income countries. But, the difference between female surgeons and the general population may be less obvious in environments where average health and lifespan standards are lower [86]. It is also possible that a career as a surgeon may provide a higher standard of living in lower income countries, which can counteract some of the health detriments from the profession seen in HICs. However, further studies would be needed to validate these hypotheses.
This study is limited by its design as a scoping review, as such there was no formal evaluation of the quality of evidence or risk of bias in the studies. Additionally, the lack of reporting from Central and South America limits this study's generalizability to this region. The lack of studies from South or Central America likely has to do with our inclusion and exclusion criteria, specifically with regards to literature available in English. During the review many studies on South America emerged, one discussed the proportions of female surgeons in Brazil [82], but none specifically discussed the experiences of female surgeons from any country in this region. As 91% and 90% of studies exclusively examined HICs and high GGGI countries, respectively, the role of income level and GGGI ranking in female surgeons' experiences cannot be generalized without more diversity in the literature. The lack of reporting from lower income and lower GGGI countries limits the ability to provide definitive, context-specific recommendations to improve female surgeon experiences and participation.

Conclusions
Different geographic regions along with cultural and societal norms influence gender equity and the experiences of women in surgery. Universally, women from all regions reported a lack of mentorship as a barrier