International Women’s Day:
insights from surgeons in training

International Women’s Day, held annually on 8 March, honours and celebrates the achievements of women. This year’s theme, “Accelerate Action”, draws on the fact that full gender parity is not expected to be achieved until 2158 if progress continues at its current pace¹. From the surgical training perspective, this day holds particular importance.

The proportion of female surgical consultants has increased over the past three decades. In 1991, 3.1% of all surgical consultants were women and this had increased to 16.3% in 2023². Now 64% of all UK undergraduate medical students are female yet this representation declines at core surgical training level (41%), specialty training (30%) and even further at consultant level (16.3%). Women surgeons are underrepresented in some surgical sub-specialties including neurosurgery, trauma/orthopaedics, vascular surgery and urology. Significant challenges persist, with few women progressing to leadership and academic roles, necessitating a collective commitment to understanding and addressing the imbalance. 

Career attrition

Applicants to surgical training programmes are often motivated, hard-working and enthusiastic individuals with a focus on patient care and positive outcomes. The process of training is rigorous, with high stakes and high rewards, and standards that must be upheld throughout. Surgical training demands long-term dedication and commitment in high-pressure environments. Research suggests that patients have positive long-term outcomes when treated by female surgeons^3,4. However, despite this, there is evidence of career attrition, which may be attributed to myriad factors. 

Studies have identified positive early experiences and mentorship at medical school and early residency in surgical specialties as a potential positive indicator to pursue surgery later⁵. Women surgeons have reported the demands of marriage and parenthood as some of the deterring factors to pursuing a career in surgery, with some opting to delay or not have children⁶. This disparity in representation is even more glaring in academic surgery, where establishing a family life and parenthood is often delayed so as not to impede progression⁷. Qualitative feedback also reported feelings of guilt, the perception of being a burden during pregnancy and returning to work after maternity leave as broad themes for barriers⁵. Less Than Full Time (LTFT) training provides an option to pursue craft specialties, such as surgery, but there remains a negative perception of trainees who pursue LTFT with some reporting undermining behaviours⁸. Other barriers identified by trainees include the rotational nature of training, long commutes and the costs associated with commuting, mandatory courses and childcare, although these are common to surgical trainees of all genders. 

Discrimination, sexism, bullying and negative work cultures also contribute to career attrition. The Association of Surgeons in Training (ASiT) conducted a survey in 2022 on bullying, discrimination and harassment in the workplace and found that 55.17% experienced bullying, 77.58% witnessed it and only 32.75% reported it. While 37.93% reported experiencing discrimination, 62.07% witnessed it but 68.97% did not report it⁹. These are often not singular events and have a cumulative negative impact on the wellbeing of the individuals affected, leading to reduced productivity and motivation, absenteeism, higher staff turnover, poor team dynamics and can even impact patient outcomes¹⁰. 

The snowball effect of disparity is reflected through lack of progression, withholding of further opportunities and a paucity of representation at public forums, including conferences¹⁰. 

Potential solutions

A concerted and proactive effort is required by all stakeholders to address these challenges. Achieving gender equity in surgery requires a multifaceted approach involving institutional policies, cultural shifts, and individual advocacy¹¹. There are some actionable strategies to tackle these challenges, as discussed below: 

• Mentorship and leadership opportunities. Surgery has historically been an apprentice-based craft specialty. The role of good mentorship is an underappreciated factor for career progression in surgery. Surgeons in training, who are in the process of transitioning to the next stage in their careers, can benefit from directed coaching, feedback and support to help them navigate the landscape of surgical training to help them to achieve their maximum potential¹². Mentorship can also be associated with lower burnout rates¹³. Positive mentorship among underrepresented and minority groups has also been associated with a higher likelihood of applying and pursuing a particular surgical sub-specialty¹³. 

There are many established sub-groups within professional surgical societies and institutions which focus on supporting women in surgical careers. However, gender equity is everyone’s responsibility. Senior colleagues and those in existing leadership roles can support trainees in their professional journeys.

• Equality, diversity and inclusion (EDI). The workforce has evolved over the preceding 20 years with more women in the national workforce than before. Recognising the needs of the diverse workforce, including minority and ethnic groups, is essential. It is about realising the need for flexible work patterns, reducing the stigma of LTFT, recognising differential attainment and how the playing field can be levelled. This also directs us to recognising the systematic barriers to EDI and incorporating strategies with active involvement from institutions and leaders to address these. Potential solutions include promoting diverse recruitment, training to mitigate unconscious bias, promoting data transparency and fostering an open and inclusive culture. 

Most individuals can flourish as leaders when given the tools, guidance and freedom to do so. The 2021 Kennedy report highlighted the ‘old boys club’ perception among women surgeons, which was a deterrent to applying for leadership positions¹⁴. 

This was also reflected by the mere 25% of female respondents who felt that the Royal College of Surgeons of England (RCSEng) ‘represented people like them’.

• Cultural transformation. Surgeons spend a significant amount of time in hospitals with long hours, shift work patterns and on-calls. This is offset by the demands of a high-stake and time-pressured work environment. Workplace culture has a significant impact. Negative environments can lead to burnout, compassion fatigue, poor decision-making and lower staff retention⁹. It is therefore imperative to foster and encourage mutual respect for all members of the team, encouraging inclusivity and open, honest and unbiased communication while also providing pathways to report negative, unacceptable behaviours¹⁵. It is also about providing timely constructive feedback or constructive critique, and empowering everyone to voice their ideas to enable a workplace to be holistically positive¹⁶.

The future: towards an inclusive surgical profession

Being a surgeon is a privilege and one that should not be underestimated. The responsibility conferred with the title is colossal and is earned over time through patience and perseverance. International Women’s Day reminds us that the progress made by women in surgery to date is not unlike that journey. Equity in surgery is not just a matter of fairness but a necessity for excellence in patient care and reflective of representation in surgery and society as a whole. A diverse and inclusive surgical workforce provides varied perspectives, enhances collaboration, teamwork and ultimately benefits patients. 

The late Dame Clare Marx, the first female President of RCSEng, said: “The pace of improvement in measurable parameters has not matched the urgency of the challenge.” We need to actively work on addressing challenges and promoting a culture of inclusion to ensure the next generation of surgeons practises in an environment that reflects the values of equity and excellence. 

As we look to the inclusive future, we must actively commit to celebrating achievements and fostering an environment where all surgeons, regardless of gender, can thrive. Let us renew our resolve to achieve gender parity in surgery.

References

1. International Women’s Day IWD 2025 campaign theme is ‘accelerate action’, International Women’s Day. Available at: https://www.internationalwomensday.com/Theme (Accessed: 29 January 2025).
2. The Royal College of Surgeons of England. Statistics: Women In Surgery. https://www.rcseng.ac.uk/careers-in-surgery/women-in-surgery/statistics. (Accessed January 2025).
3. Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. Bmj. 2017 Oct 10;359.
4. Wallis, C.J., Jerath, A., Aminoltejari, K., Kaneshwaran, K., Salles, A., Coburn, N., Wright, F.C., Conn, L.G., Klaassen, Z., Luckenbaugh, A.N. and Ranganathan, S., 2023. Surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries. JAMA surgery, 158(11), pp.1185-1194.
5. Singh C, Loseth C, Shoqirat N. Women in surgery: a systematic review of 25 years. BMJ Leader. 2020 Oct 20:leader-2019.
6. Cochran A, Hauschild T, Elder WB, Neumayer LA, Brasel KJ, Crandall ML. Perceived gender-based barriers to careers in academic surgery. The American Journal of Surgery. 2013 Aug 1;206(2):263-8.
7. Zhuge, Y., Kaufman, J., Simeone, D.M., Chen, H. and Velazquez, O.C., 2011. Is there still a glass ceiling for women in academic surgery?. Annals of surgery, 253(4), pp.637-643.
8. Harries RL, Gokani VJ, Smitham P, Fitzgerald JE. Less than full-time training in surgery: a cross-sectional study evaluating the accessibility and experiences of flexible training in the surgical trainee workforce. BMJ open. 2016 Apr 1;6(4):e010136.
9. El Boghdady, M., 2024. The development of anti-bullying, discrimination and harassment guidance: a survey among the Association of Surgeons in Training (ASiT) council members. The Annals of The Royal College of Surgeons of England, 106(4), pp.364-368.
10. El Boghdady M, Esmaeili A, Zargaran A, Brennan PA. Culture in surgery. The Bulletin of the Royal College of Surgeons of England. 2024 Sep;106(S1):38-41.
11. El Boghdady M. Equality and diversity in research: building an inclusive future. BMC Research Notes. 2025 Jan 14;18:14.
12. Stephens EH, Dearani JA. On becoming a master surgeon: role models, mentorship, coaching, and apprenticeship. The Annals of Thoracic Surgery. 2021 Jun 1;111(6):1746-53.
13. Enson J, Malik-Tabassum K, Faria A, Faria G, Gill K, Rogers B. The impact of mentoring in trauma and orthopaedic training: a systematic review. The Annals of The Royal College of Surgeons of England. 2022 Jun;104(6):400-8.
14. Kennedy H. The Royal College – Our Professional Home. An independent review on diversity and inclusion for the Royal College of Surgeons of England. An exciting call for radical change (available at https://diversity.rcseng.ac.uk/wp-content/uploads/2023/03/RCS-Diversity-report.pdf#page=2.06) Accessed 29 January 2025
15. El Boghdady M. Reporting unacceptable behaviour in the workplace and surgical leaders’ reflections on the new ASiT guidance. The Bulletin of the Royal College of Surgeons of England. 2024 Jan;106(1):26-30.
16. El Boghdady, M. (2024). Spreading positivity in the workplace: the trainees’ perspective. The Bulletin of the Royal College of Surgeons of England, 106(4), 176-177.