Gender in Society

In 2020, the United States (US) population was estimated to be 331 million people, of which 51.1% were women. (1) Although most Americans (72%) are white, the race and ethnicity of the US population is diversifying. The 2010 Census revealed the following racial demographics: 12.8% reported being Black; 5.7% Asian; 0.9% American Indian; 0.2% Native Hawaiian; 3.4% multiracial; and 18.4% Hispanic. (2) The modern role of women in the workforce first dramatically changed in the 1920s with two major events: new employment during World War I and the ratification of the Nineteenth Amendment to the US Constitution granting women the right to vote. (Reference Jones3; Reference Carnes, Morrissey and Geller4) Subsequently, social and cultural changes in the 1960s and 1970s prompted legal protections for women in education and the workplace, (Reference Carnes, Morrissey and Geller4) with women increasingly allowed to obtain post-secondary education. By 2018, women comprised 57% of college students and students, 49.5% of medical students, and 46.8% of the workforce. (5)

Cultural stereotypes continue to characterize women as ‘communal’ (e.g. kind, dependent, nurturing) while men are characterized as ‘agentic’ (e.g. logical, independent, strong). (Reference Heilman and Okimoto6) These stereotypes disadvantage women (and men) in domains such as science, medicine, and leadership, as competence can be viewed as a violation of a gender role. (Reference Carnes, Morrissey and Geller4; Reference Ashton-James, Tybur, Grießer and Costa7) Despite increased representation, women continue to be underrepresented in traditionally male-dominated professions, comprising 21.3% of protective service employees, 15.1% of architects and engineers, and 5% of CEO positions in S&P500 companies. Conversely, women remain clustered into ‘pink collar’ jobs, constituting 87.6% of health care support occupations, 94.5% of secretary and administrative assistant positions, and 95% of teaching assistants, kindergarten and elementary school teachers. (Reference Berdahl, Cooper, Glick, Livingston and Williams5) Occupational segregation, largely stemming from a continued cultural devaluation of work performed by women, contributes to a persistent gender wage gap. To enumerate, on average, women in the US earn 81.6% of what men earn, with the gap widening to 75% with increasing levels of education. (Reference Leisenring8) More concerning, gender-based discrimination, including sexual harassment, is reported by 50% of women in the US workforce, with few reporting the abuse to an authority. (Reference Das9) In 2017, the #MeToo movement brought awareness to sexual violence against women by advocating for survivors and encouraging them to speak out about their experiences. TIME’s UP Now, which had several industry-focused initiatives including TIME’s UP Healthcare, followed by bringing awareness of sexual harassment and discrimination in the workplace. TIME’s UP Foundation has expanded their mission to advocate for safe, fair, and dignified work for all women of all kinds, creating a society free of gender-based discrimination in the workplace and beyond. (Reference Kearl10; Reference O’Neil, Sojo, Fileborn, Scovelle and Milner11)

Figure 29.1

Infographic United States of America. Infographics were provided by CartoGIS Services, The Australian National University. Population: from World Bank https://databank.worldbank.org/source/population-estimates-and-projections. Sustainable Development Progress, global ranking and statistics on women in the workplace, women in management and intimate partner violence: from United Nations SDGs Data Portal https://unstats.un.org/sdgs/dataportal. Female doctor percentage: from Global health workforce statistics www.who.int/data/gho/data/themes/topics/health-workforce. Legislation and law statements: from the World Bank gender data portal 2023 https://genderdata.worldbank.org/en/indicators. Maternal mortality statistics: from the Global Health Observatory 2020 https://mmr2020.srhr.org. Infant mortality statistics: from United Nations International Children’s Fund (UNICEF) https://data.unicef.org/topic/child-survival/under-five-mortality.

Figure 29.1 Long description

The infographic provides information about the United States, with a population of 340 million and 35.6 doctors per 10,000 people. It highlights several gender-related statistics. 57 per cent of women participate in the workforce. 41.1 per cent of women are in managerial positions. 26 per cent of women have experienced intimate partner violence. Maternal mortality is 21.1 per 100,000. Infant mortality under 5 is 630 per 100,000. 34.8 per cent of doctors are women.

The infographic lists the presence or absence of law and policy on gender equality. In the United States:

• – a woman can get a job in the same way as a man.

• – there is legislation on sexual harassment in employment.

• – there is legislation specifically addressing domestic violence.

• – the law prohibits discrimination in employment based on gender.

• – criminal penalties or civil remedies exist for sexual harassment in employment.

• – there is no law mandating equal remuneration for females and males for work of equal value.

The S D G Gender Index global ranking is 38, and there has been some progress

Gender in Medicine

The Women’s Health and Feminist Movements of the 1960s and 1970s served as an inflection point for US women to embark on careers in medicine. (Reference Carnes, Morrissey and Geller4) With admissions restrictions removed by laws enacted at the end of this cultural movement, a surge of women graduating from medical school was observed, with 20,000 women matriculating from 1970 to 1980, compared to 14,000 from 1930 to 1970. (Reference Braslow and Heins12) By 2003, women in the US applied to, entered and graduated from medical school at similar rates as men. However, the percentage of full-time women faculty that identify as underrepresented by race or ethnicity (URiM) has been essentially unchanged from 12% in 2009 to 13% in 2018. (Reference Lautenberger and Dandar13) This is particularly true for most surgical specialties in the US, which remain predominantly occupied by men. In 2017, 20.6% of general surgeons in the US were women, (Reference Aziz, DuCoin, Welsh, Paramo, Andreone, Butsch, Smith, Pories and Baxter14) with Black women surgeons representing just 1% of the academic surgical workforce. (Reference Berry, Khabele, Johnson-Mann, Henry-Tillman, Joseph and Turner15; Reference Aggarwal, Rosen, Nehemiah, Maina, Kelz, Aarons and Roberts16)

Increased representation of women physicians has not correlated with workplace equity. Although the overall percentage of full-time women faculty in US medical schools continues to rise, the majority of women faculty held the rank of instructor. (Reference Lautenberger and Dandar13) Moreover, there has been no narrowing of the gender gap over time. Women physicians employed by academic centers are less likely than men to be promoted or appointed department chair. (Reference Richter, Clark, Wick, Cruvinel, Durham and Shaw17) Women physicians face a persistent wage gap that cannot be explained by hours worked, skill or experience. (Reference Jena, Khullar, Ho, Olenski and Blumenthal18) Furthermore, women physicians perceive gender-based discrimination 2.5 times more frequently than men, with reported rates of sexual harassment as high as 80%. (Reference Stephens, Heisler, Temkin and Miller19–Reference Heisler, Stephens, Temkin and Miller21) The structural acceptance of these abusive behaviors adversely impacts physicians, surgeons, and patients and contributes to burnout and voluntary and involuntary departure from the medical profession. (Reference Aggarwal, Rosen, Nehemiah, Maina, Kelz, Aarons and Roberts16; Reference Nunez-Smith, Pilgrim, Wynia, Desai, Bright, Krumholz and Bradley22; Reference Linzer and Harwood23) Tragically, 40% of women reduce their hours to part-time or leave medicine entirely within six years of finishing training. (Reference Paturel24) With this percentage of attrition and reduction in the workforce (see figure 29.2), Government and Academic Medical Centers, and the health care system as a whole must start viewing attrition as a sentinel event that has the potential to threaten public health and safety. (Reference Lautenberger and Dandar13)

Figure 29.2

Seven-year promotion outcomes for US full-time academic faculty, 2008–2009.

Figure 29.2 Long description

The horizontal axis represents promoted, not promoted, and left academic. The vertical axis ranges from 0 to 60 in increments of 10. The graph shows the following approximate data for: women assistant professor, n equals 3,588; men assistant professor, n equals 4,441; women associate professor, n equals 1,036; and men associate professor, n equals 1,977; respectively. 1. Promoted: 19, 24, 27, 32. 2. Not promoted: 44, 44, 52, 47. 3. Left academia: 39, 31.5, 21, 21.

(13)

Medical Regulation

Sexual misconduct in academic medicine is prevalent. A 2018 report of the National Academies of Sciences, Engineering, and Medicine (NASEM), entitled ‘Sexual harassment of women: climate, culture, and consequences in academic sciences, engineering, and medicine’, found that 45% of women in medicine experienced gender harassment before completing medical school and more than 50% of women faculty and staff have experienced gender harassment during employment. This rate for medical students is higher than for science or engineering students. (32)

In a study of early-investigator awardees, approximately 30% of women academic medical faculty in the US reported sexual harassment; among those reporting sexual harassment, 59% reported that it negatively impacted their professional confidence and 47% reported that it negatively impacted opportunities for career advancement. (Reference Jagsi, Griffith, Jones, Perumalswami, Ubel and Stewart33) Rates are even higher in some sub-specialties, as 67% of women vascular surgeons reported sexual harassment; only 7% of these incidents were reported to supervisors. (Reference Smeds and Aulivola34) Barriers to reporting, including fear of reprisal and retaliation, have been well-documented. (Reference Smeds and Aulivola34; Reference Binder, Garcia, Johnson and Fuentes-Afflick35)

Despite a high prevalence of sexual misconduct and significant negative outcomes for physicians and surgeons, most research on physician sexual misconduct focuses on acts against patients rather than between colleagues. (Reference AbuDagga, Carome and Wolfe36–Reference Gulrajani39) US state medical licensure boards and the Federation of State Medical Boards (FSMB) have the authority to investigate and discipline physicians who commit sexual misconduct by restricting, suspending, or revoking licensure to practice; (40) however, physician-on-physician sexual harassment is often investigated as a workplace misconduct issue. Furthermore, health care organizations have flexibility in reporting physicians accused of sexual misconduct to medical boards. (Reference AbuDagga, Carome and Wolfe36) Consequently, few academic medical faculty or physicians who are accused of sexual misconduct are sanctioned by medical boards. (Reference Espinoza and Hsiehchen41; Reference Liu and Hyman42) For example, an analysis of sexual misconduct-related reports indexed in the National Practitioner Data Bank from 2003 to 2013 revealed that a small number of physicians (N=1,039) were reported during that time period, and 70% of those reported were not disciplined by a medical board. (Reference AbuDagga, Wolfe, Carome and Oshel43) In the US, peers may be involved in reporting sexual misconduct but are rarely involved in disciplinary processes for physicians accused of sexual misconduct. Some US professional societies (e.g. American Association for the Advancement of Science) have created new policies and procedures for addressing sexual misconduct among their members, with those who violate these policies subject to removal from annual meetings and bans from attending future meetings. (Reference Bates, Jagsi, Gordon, Travis, Chatterjee and Gillis44) However, few professional societies provide publicly available statements or policies pertaining specifically to gender. (Reference Heisler, Miller, Stephens, Ton and Temkin45) Actions of individual organizations are unlikely to prompt significant, widespread change. To this end, recent publications emphasize a need for large-scale organizational and institutional change, (Reference Heisler, Miller, Stephens, Ton and Temkin45; Reference Fairchild, Holyfield and Byington46) as well as grass roots efforts to enforce codes of conduct, education, and training within academic institutions, health systems, professional societies, and private practices. (Reference von Gruenigen and Karlan47)

Prelude

As an intern covering minor surgical cases under direct supervision of my attending physician, I was fairly insulated from the egotistical behavior of this anesthesiologist. The stories and warnings from senior residents, nurses, scrub technologists and those same attendings were that he was difficult and could be hard on people. In truth, he was arrogant, condescending and rude. My encounters with him became more frequent and more inappropriate as I became more independent through residency and received a more substantial surgical caseload. He leaned into the power differential without overtly crossing a line into harassment. These interactions were not rare, nor specific to me. Rather, they were illustrative of an oppressor allowed to bully and intimidate anyone to maintain perception of power and an ineffectual organization that permitted it, unfettered.

After completing fellowship, I returned to my former residency program – now as an attending surgeon employed by a health care system. I would have the opportunity to train the residents in my surgical sub-specialty and to build the division which I now led. I was excited to work among the very talented attending surgeons who had trained me years ago. The only concern was that he was still there. As a member of the contracted group of anesthesiologists, this narcissist continued to reign the operating room (OR) suites, infecting the space with his arrogance and derision. His menacing presence continued without a specific direct incident. He was allowed to embed negativity throughout the surgical space without reprimand or consequence.

Assault

I had a major surgical case scheduled to start at 0730. I went to meet the patient in the pre-operative area, and he was behind a curtain talking with her and her family. He peered in my direction, informing me that he was talking with her and needed more time. I acknowledged his request, shut the curtain and stood by, waiting for my turn to talk with our patient. As his conversation turned from relevant medical history to social conversation and laughter, I again opened the curtain to signal I was ready to talk with the patient. He snapped at me, saying that he wasn’t done talking. I explained that I still needed time to talk with the patient before we proceeded to the OR, and he sharply and condescendingly replied that he would be done soon. I closed the curtain and stepped back a few feet. He finally emerged from the room and walked past me, indifferent. I met with the patient and her family to review our plan for surgery, the process of recovery and when she would see her family again.

I knew I needed to address the interaction in order to resolve the conflict. I approached him and asked to speak with him. I acknowledged the importance of his time to meet the patient and review the anesthesia plan for surgery, and noted that I did not appreciate his aggressive response nor his dismissive attitude about my time with the patient. He replied with a sharp tone that he was meeting the patient and developing a rapport with her and her family; my entering the space was disruptive to his time with her. I noted that his socializing with the patient continued, even after I specifically expressed my need to speak with her. I did not appreciate his blatant disregard of my time, nor his behavior in front of my patient, which was hostile and unprofessional. He rolled his eyes and told me to ‘Just calm down’. He reached behind me, patted me on the buttock and squeezed as he walked past me.

My instinct was to yell out or physically fight back at him for what he did to me. Instantaneously, I was reminded of my environment and my need to maintain professionalism, to control my emotions and my response. I was humiliated and embarrassed, left wondering if anyone saw this interaction or his action; yet I maintained integrity and continued on with the responsibilities that lay ahead.

In those subsequent few minutes as the patient was being wheeled from the pre-operative holding area to the OR, my mind was racing with the prior events. Eventually, I was in the OR with the team attempting to regain my focus on the case, but as my patient was prepped and draped, the harassment persisted. This anesthesiologist stood up behind the drapes, watching the surgical steps, and proceeded to comment on the case with nit-picking, criticism, condemnation, ridicule, and biting sarcasm. It was a totally inappropriate barrage of unnecessary negativity that did nothing but distract. My attempts to politely redirect him were futile. Finally, I sternly looked at him and requested that he stop his unprofessional behavior in front of the OR team. He then recoiled to his chair.

Limbo

I had no intention of reporting him. He was a prominent anesthesiologist in the institution and his reputation, though extremely despicable and reprehensible, was ingrained in the fabric of the OR and accepted by the institutional leadership.

I spoke with a male colleague later that day: ‘You won’t believe what happened to me …’ I blurted out the entire story. This colleague, a trusted confidant, was horrified to hear how I had been treated and unsurprisingly, immediately guessed the identity of the perpetrator. My colleague was unrelenting and said, ‘You have to report this. Dr Jarma crossed a line. He assaulted you!’ I explained that it wouldn’t matter. Nobody would believe me. It would be his word against mine. He offered to report on my behalf, to be my voice. I reluctantly agreed to allow him to report the event.

Shortly thereafter, I was called to a meeting with Human Resources, my department chair and two members of the Medical Staff Office. They requested details of the allegation, which I provided. Two profoundly imperative themes emerged from that meeting.

First, I was told that I had handled the situation incorrectly. I created a safety concern for my patient and my team by proceeding to the OR. I should have requested another anesthesiologist so I could focus on my job without additional distraction. Though there was no process available to guide me in this circumstance and the means of requesting another anesthesiologist would have resulted in questions and delay, my experience of being sexually harassed was distorted to imply that I was in the wrong by continuing with the case. In essence, I was potentially endangering my patient, my team, and my organization by doing the job: performing the scheduled operation. It was irrelevant that I had been sexually assaulted by a key member of the team.

More importantly, Dr Jarma was protected under the guise of ‘due process’. He would be allowed to work while they met with him and additional staff. As a physician, he shouldn’t suffer financial penalty just because I alleged inappropriate behavior. He would be treated fairly. In order to protect me, however, I was provided the option of paid leave. This would ensure I would not experience further interactions with him.

Exposure

I was bullied through the ongoing investigation process after the sexual harassment, which caused additional distress. Once, I was confronted by the Human Resources representative, who openly discussed my case in a busy cafeteria. She desired to update me as to the status of the investigation – Dr Jarma is aware, of course, and cooperating fully. Her attempt at timeliness was usurped by the lack of confidentiality. Worse, the rationale for this impromptu meeting was a request that I provide my story in writing.

While the investigation only took a few weeks, time seemed to stand still for me, as I was continually reminded of Dr Jarma’s presence. He was instructed to avoid direct contact or conversations with me, with which he complied. However, he was everywhere – the recovery room, the surgeon’s lounge, the hallways, and outside other operating rooms. He demonstrated complete lack of regard for my discomfort, and in fact seemed to revel in the awareness that he was abiding by the rules without being constrained by them.

At the final meeting with the investigation team, I was informed that, despite this assault occurring in a populated place during the busiest time of day, nobody could corroborate my claim. However, they learned through staff interviews that Dr Jarma had a pattern of unprofessional behavior including sexual harassment that violated organizational standards and was unlawful. As a result, the anesthesia group and hospital leadership agreed to reassign Dr Jarma to another hospital where he already worked, but now on a full-time basis. The final decision did not include any sort of serious punishment: revocation of hospital privileges, termination, suspension of medical licensure, or legal action.

Removing him from the OR environment resulted in excessive gossip occurring around me. ‘Did you hear what happened to Dr Jarma?’ ‘Yeah, I heard he was just being himself and it upset a sensitive surgeon.’ Occasionally, I was confronted with direct questions like ‘Did something happen between Dr Jarma and you?’ ‘Are you really the reason Dr Jarma was reassigned?’ ‘Are you doing okay? I heard about Dr Jarma and you.’ I maintained a professional demeanor and politely played dumb, or deflected the questions, acknowledging that these conversations were inappropriate, regardless of whomever they involved. Though the outcome removed this perpetrator from my hospital, he was allowed to work in another environment, thereby subjecting others to his abusive behavior. I didn’t feel like the outcome was satisfactory. I wanted to disclose everything – the indignities, the hostility, the abuse. This anesthesiologist sexually assaulted me in public in the presence of witnesses but was protected by this institution and allowed to maintain his professional standing and financial security. On the other hand, I suffered from threats, ridicule, disbelief, exposure, antagonizing behavior and revictimization.

Aftermath

Ideally, this sexual assault would have ended with vindication and institutional support; however, that was not the case. Eventually, I resigned from that health care institution; this incident and the institutional culture were the basis of my resignation. The resentment I carried from that situation, and how it was handled by hospital administration, still lingers, though it does lessen with the passage of time.

This experience is unfortunately not unique to attending surgeons, nor is it situationally rooted in one health care system. Through my educational and other leadership roles, I continue to help others navigate these emotional, professionally challenging, and unlawful situations. I have the great fortune to have developed a network of strong women colleagues that are similarly focused on creating an equitable, safe and dignified workplace environment for everyone in health care. Through our collaboration and collective passion for this cause, we strive to make this the new culture in medicine and surgery for future clinicians.