Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery

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Said El Hage,^1,2,3 Elias Wakim,¹ Georgio Sayde,¹ Dany Akiki1 and Pascale Salameh^1,3,4,5

¹Department of Medicine, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon (Correspondence to: D. Akiki: This email address is being protected from spambots. You need JavaScript enabled to view it.). ²Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon. ³Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Sector of Public Health and Epidemiology, Department of Public Health, Beirut, Lebanon. ⁴Department of Basic Science, Faculty of Pharmacy, Lebanese University, Beirut, Lebanon. ⁵Department of Primary Care and Population Health, Medical School, University of Nicosia, Nicosia, Cyprus.

Abstract

Background:  Little is known about gender disparity in the surgery specialty in Lebanon.

Aims: To assess the status of female surgeons and possible gender gaps in surgery specialty in Lebanon.

Methods: The study was conducted in May 2021. Data were retrieved from the Lebanese Order of Physicians website, indicating the number of physicians in the different specialties, their gender, hospitals, and locations. The c2 test of homogeneity was used to establish whether the gender distribution was equal.

Results: Women only accounted for 21.84% (3,370) of physicians in Lebanon, with surgery having the lowest number of female physicians in (n = 65; 2.30%). Women accounted for 1.63% of all surgeons in Lebanese hospitals, there were more female plastic and reconstructive surgeons (n = 12; 7.14%), while neurosurgery, oncological surgery and vascular surgery had no females. There was no significant difference in gender between academic and non-academic institutions (χ2 = 2.164, P = 0.149), or between public and private hospitals (χ2 = 1.277, P = 0.234). 

Conclusion: The surgical specialty had the widest gender gap among all the medical fields in Lebanon. Therefore, the healthcare systems, including public and private hospitals, have a long and difficult road in narrowing the gender gap. Different strategies to incorporate women into surgery should be explored to assure equitable opportunities for all physicians, based on competency rather than gender.

Keywords: women, physicians, gender gap, surgery, Lebanon.

Citation: El Hage S; Wakim E; Sayde G; Akiki D; Pascale Salameh. Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery. East Mediterr Health J. 2022;28(10):743–750. https://doi.org/10.26719/emhj.22.077 Received: 09/08/21; accepted: 29/05/22

Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

In the last century, the implementation of gender equality has faced several obstacles. Gender disparity manifests as social, educational, financial, and workplace discrimination. Numerous crucial milestones were achieved in the last 200 years, such as the ratification of the Nineteenth Amendment of the American Constitution in 1920 and the Equal Pay Act signed by President Kennedy in 1963 (1). Despite much progress in closing the gender gap, the patriarchal mindset is still a serious impediment to ensuring gender fairness in the workplace.

Medicine has long been a male-dominated field. Fortunately, over the last 30 years, the number of female physicians and medical students has witnessed a remarkable increase (2). In 2019, for the first time in the United States of America (USA), women represented the majority of medical students (50.5%). However, some specialties remain tenaciously male-oriented, with surgical specialties being the most affected by gender disparity. Despite an increase in the number of female surgical residents, the total number of female surgeons remains low (3). Although discrimination and harassment are common among both male and female general surgery residents, rates are markedly higher among women (4). Gender-based discrimination is perceived at different stages of medical careers, from medical school to surgical practice (5).

Arab countries in particular have long had gender inequality, and have the lowest female participation in the labour force worldwide, with female unemployment rate 3 times higher than the global average (6). Patricentric standards and stereotypes, harassment, and legal restraints are among the problems encountered daily by women in Arab countries (6). The medical field is no exception, and female physicians in Arab countries suffer from discrimination on the cultural, social and structural levels (7). Surgical specialties in particular are male dominated with a limited place for female surgeons (8).

Lebanon has long been known as one of the most liberal Arab countries (9), and women and men have the same opportunities to choose any career path. However, Lebanon ranks 132 out of 156 countries in the Global Gender Index (10). According to the United Nations, only 29% of women participate in the Lebanese employment market, compared to 76% of men (11). To date, no study has described the status of female physicians in Lebanon and the possible gender gap in surgery. Our objective was to show the gender gap in surgery in Lebanon.

Methods

Data collection and cleaning

This was an epidemiological cross-sectional study. Data were retrieved from the Lebanese Order of Physicians website (https://lopbeirut.org/en/homepage-en/) in January 2019. Two authors independently reviewed 15 429 physicians for inconsistencies, duplications, hospitals, and assigned gender. Specialties were grouped into 7 domains: general medicine, internal medicine, obstetrics–gynaecology, paediatrics, psychiatry, surgery, and others. The latter included specialties that did not fit into the classical domains of medicine. The surgical domain included the following specialties: general surgery, neurosurgery, oncological surgery, orthopaedic surgery, otorhinolaryngology, plastic and reconstructive surgery, thoracic and cardiovascular surgery, urological surgery, and vascular surgery. The numbers of physicians in the different specialties, as well as physicians’ specialties, gender and hospitals, were retrieved. Each hospital was assigned its appropriate location in Lebanon (Beirut, Metn-Baabda, North Region, Keserwan-Jbeil, Chouf-Aley, South and Nabatiyeh, and Beqaa Region). Hospitals were also divided into academic and nonacademic centres/hospitals. Academic hospitals included the Al Makassed, Al Sahel and Al Zahraa Hospitals, American University of Beirut Medical Center, Baabda Governmental Hospital, the Lebanese American University Medical Center, Hotel-Dieu de France, Libanais-Geitaoui, Notre Dame de Secours Hospital, President Martyr Rafic Baha eddin Hariri Hospital, and Saint George Orthodox Hospital.

Ethical clearance

The data were available publicly on the Lebanese Order of Physicians website; therefore, no ethical clearance was needed. In addition, physicians’ names or IDs were blinded during the study and are not mentioned in the manuscript.

Statistical analysis

Univariate analysis was conducted for all the variables. SPSS for Windows version 23.0 was used to collect data, calculate P values, and analyse the data. Physician gender distribution in each surgical specialty, hospitals, regions, academic centres, and nonacademic centres were retrieved. A χ2 test of homogeneity was used to test whether gender distribution was equal. A χ2 test was used to assess whether gender distribution among academic hospitals was equal to that of nonacademic centres. It should be noted that when assessing physician distribution in hospitals, a single physician could occur in several hospitals and each post in the hospital was taken individually, even if there was a duplicate in another hospital.

Results

Gender distribution of Lebanese physicians in the different domains in Lebanon is shown in Table 1. Most physicians in Lebanon were male (12 059; 78.2%) and only 21.8% (3370) were female. Women accounted for 39.3% (n = 558) of physicians in paediatrics; the domain with the highest frequency of female physicians. The lowest frequency of female physicians was in surgery, with only 2.30% (n = 65). In all of these results, test of homogeneity revealed unequal gender distribution skewed towards male physicians (P < 0.001).

Among all the surgical specialties, the highest frequency of female physicians was in plastic surgery

(n = 12; 7.1%) followed by otolaryngological surgery (n=19; 4.7%) and general surgery (n = 19; 2.1%). The same pattern was reported in the USA, Canada, Brazil, and Argentina, where female surgeons were most involved in plastic, otolaryngological and general surgery (Table 2). There were no female physicians in neurosurgery, vascular surgery or oncological surgery.

Regarding the gender distribution of surgeons between hospitals, there were 46 female surgeons in 37 of 157 hospitals in Lebanon (Table 3). Al Zahraa hospital had 4 female surgeons, which was the highest number among all the hospitals. Six hospitals had 2 female surgeons and 30 had only 1. The highest percentage of female surgeons was in Beydoun (20.0%) and Hasbaya Governmental Hospital (18.2%). This high percentage was because of the low number of surgeons overall in the investigated hospital. The total percentage of female surgeons in all Lebanese hospitals was 1.6%, which was significantly lower than the percentage of male surgeons (P < 0.001).

Academic centres had 14 (2.3%) females surgeons, while nonacademic centres had 32 (1.4%) (Table 4). The χ2 test showed no significant gender difference between the 2 types of centres (χ2 = 2.164, P = 0.149). Public hospitals had only 5 (2.6%) female surgeons, whereas private hospitals had 41 (1.5%). The χ2 test showed equal distribution of male and female surgeons in public and private hospitals (χ2 = 1.277, P = 0.234).

Bekaa, Keserwan, and Beirut Regions had the highest percentage of female surgeons at 2.33%, 2%, and 1.8%, respectively (Table 5). In contrast, Chouf-Aley and the North Region had no female surgeons. However, the χ2 test revealed no significant difference between males and females in the different regions of Lebanon (χ2 = 4.17, P = 0.394).

Discussion

In summary, 21.8% (n = 3370) of physicians and 2.3% (n = 65) of surgeons in Lebanon were women. Among the surgical specialties, the highest frequencies of women were in otolaryngological surgery with 4.7% (n = 19) and general surgery with 2.1% (n = 19). Female surgeons were present in 37 of 157 hospitals in Lebanon. The highest number was at Al Zahraa Hospital (n = 4), while the highest frequency was at Hasbaya Governmental Hospital (18.2%). Distribution of female surgeons did not differ significantly between academic (n = 14; 2.3%) and nonacademic (n = 32; 1.4%), and public (n = 5; 2.6%) and private (n = 41; 1.5%) hospitals. Bekaa Region had the highest percentage of female surgeons (2.33%).

In agreement with our results, several studies have shown that obstetrics and gynaecology, and paediatrics have the highest rates of female physicians, while surgical specialties are more male-oriented (12,13). However, the gender gap observed in surgical specialties is less obvious in more developed countries. Among the surgical specialties, orthopaedic, cardiothoracic and urological surgery had the lowest proportions of female surgeons in Lebanon. Remarkably, there were no female physicians in neurosurgery and vascular surgery. Compared with other countries, orthopaedics, urological surgery and cardiothoracic surgery were largely male-dominated specialties in Lebanon. The highest percentage of female surgeons in Lebanon was in plastic surgery and otorhinolaryngological surgery, with 7.1% and 4.7%, respectively. The trends in other countries show that the highest female ratio is also in plastic surgery and otorhinolaryngological surgery, in addition to general surgery. The domains with the highest rates of female physicians in Lebanon hardly exceeded the rates of female physicians in the most male-oriented specialties in the USA, Canada, Brazil, Argentina, Germany, and Sweden.

There is an erroneous misconception that women cannot balance between career and sociomarital life. It is seen particularly in the residency years, which coincide with the prime childbearing age; thus, female physicians tend to avoid a surgical specialty to establish a healthy sociomarital life (14). Although the number of female surgical residents and physicians is increasing, gender disparity is still obvious in healthcare leadership positions in the most advanced countries (15). In the countries where the gap is at its narrowest, women are rarely in chief executive positions. Healthcare systems in Lebanon still have a long way to go in assisting women to climb the leadership ladder and break the glass ceiling.

Many studies have discussed the impact of gender on the choice of medical students’ specialties. A systemic review of 751 studies suggested that women opt for specialties that require more social skills, whereas men favour more technical disciplines, notably surgery (16). A possible reason for this choice could be the difference in work–life balance and salary between surgical and nonsurgical specialties. Students for whom work–life balance is the most important parameter avoid surgical specialties, whereas students that focus most on financial compensation choose surgery (17).

It is important to discuss reasons why women focus on the quality of life when choosing their future specialty. Hamid et al. found that female students favoured minimum working hours and convenient on-call schedules over higher salaries (18). Stability at work and less-strict hours mean that women focus more on psychological well-being and having more family or personal time. Men focus more on being well remunerated for choosing their career path.

Another motivating factor for women to opt for nonsurgical specialties is the extensive patient contact and opportunities for private practice. Nonsurgical differ from surgical specialties because of the loss of patient contact and an exclusively hospital-based career (19). This idea suggests that women generally opt for jobs that require more social skills like nursing and teaching, while men prefer more technically inclined jobs such as engineering and software development.

Beirut is the capital and largest city in Lebanon and the most cosmopolitan and culturally diverse in the country (20). Most female civil societies are located in Beirut and the largest female-led movements and protests take place in the city (21). Surprisingly, only 16 of 913 (1.8%) surgeons located in Beirut were female, which merely reflected the numbers found in the country as a whole. The North and Chouf-Aley Regions did not have any female surgeons, which may have been caused by poverty, disparity in gender education or career orientation, and illiteracy. Tripoli, the northern capital and the second largest city in Lebanon is the poorest in the country and hosts a large number of refugees (22,23). Poverty is a major obstacle to gender equality in surgery because lower-income countries perceive female surgeons as being less capable than their male counterparts, compared with higher-income countries (24). However, compared with male physicians, female physicians provide better quality of care and have a lower patient mortality rate (25, 26). The countries with the best healthcare are predominantly rich, and have the highest number of female physicians (27).

Another aspect that could explain this gender disparity in surgery is the influence of society and culture. Stereotypes, patriarchy, and the impact of religion, notably Islam, belittle the role of women in society (28). In a country where religion, customs and tradition play a big role in framing society, female participation could be limited to domestic chores and maternal duties. Thus, women are seen as incapable of balancing between a highly demanding job such as surgery and their everyday life. The idea of a work–life imbalance associated with familial, cultural and peer pressure may lead the most determined and skilled female medical students away from surgical specialties. Women have more restraints and barriers than their male counterparts when climbing the social ladder. Discrimination and sexual harassment are other obstacles that women face at work and in everyday life. Another barrier to the inclusion of women in surgery is the lack of role models, and ineffective mentorship (24). The lack of female senior surgeons discourages aspiring female students and may influence their choice in residency. Thus, there is a lot of missed opportunities to defy these social norms.

The number of female surgeons did not vary between academic and nonacademic centres. There is no strategy to encourage more female surgeons in academic hospitals, which are centres for research and education. Thus, they need to set a good example for their residents, students and researchers, especially in lowering the gender gap to keep up with larger institutions.

Private hospitals boasting nongovernmental funding sources should have a plan to attract and recruit more women into surgery to assure equitable opportunities to all competent physicians. Thus, they can optimize the quality of care for their patients. Half of Lebanese adults have no gender preference when choosing their surgeon, and the surgeon’s skills and competence are of greater importance (29). Lebanese society welcomes female surgeons, hence the pivotal role of private institutions in integrating women into surgical specialties. Therefore, it is necessary for academic hospitals in Lebanon to set an example in breaking the glass ceiling and delivering a suitable workplace.

We should follow a multitier approach to involve women in surgery. We need cooperation between academic hospitals, governmental and nongovernmental institutions, and researchers to reduce inequality. It is important to increase female interest in surgery by assuring better working conditions and increasing the number of role models (24). There is a need to make the patriarchal society aware of the importance of defying cultural and religious boundaries. More research and data are needed in Arab countries about gender inequality to narrow the gap. Future research should focus on the role and importance of women in medicine, particularly in surgical specialties.

The Arab world consists of 22 countries that are members of the League of Arab States located in the Middle East and North Africa (MENA) Region. Bahrain, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syrian Arab Republic, United Arab Emirates (UAE), and Yemen are located in the Middle East. Algeria, Comoros, Djibouti, Libya, Mauritania, Morocco, Sudan, Somalia, and Tunisia are located in North Africa. According to the 2021 Global Gender Gap ranking, Arab countries had the highest gender disparity. Out of 156 countries, Syrian Arab Republic, Iraq and Yemen ranked 152, 153 and 155, respectively. The only Arab country in the upper half of the list was UAE, ranking 72 (10). The healthcare systems in Arab countries are among the worst worldwide. Part of the problem is due to the limited investment in public health. Arab countries spend only 5% of their gross domestic product on health, which is lower than the average for low-income countries (30). In this region, starvation, infant and maternal mortality, and mental illness are above average, along with military expenditure (30). The leading cause of illness for women in the region is depression (31). The highest rate for female depression globally is in Arab countries.

Gender inequality in surgical fields seems to be narrowing in some Arab countries, notably Gulf countries. In Oman, Bahrain and Saudi Arabia, 63%, 39% and 27% of surgical residents are female, respectively (32). Moreover, Kuwait established the first female surgical group in the Gulf Region in 2018 – the “Women Surgeons of Kuwait”. Regrettably, the same is not the case in less-fortunate Arab countries; notably those in conflict, war and crisis, such as the Syrian Arab Republic, Iraq and Yemen. It is not uncommon to encounter gender disparity in a region constantly at war. Emergencies, conflicts and wars widen the gender gap. Yemen is currently facing the worst humanitarian crisis in the world. Women suffer from gender inequality in a patriarchal society with strict gender roles. In terms of education, sending girls to school is considered shameful in some regions, and finding a female teacher is a challenge (33). In the Syrian Arab Republic, for example, 75% of girls living in camps do not attend school, and more than a third of Syrian women suffer domestic violence (34). Child and forced marriages are increasing at an alarming rate; thus, female illiteracy increases. As a result, the role of women is limited to marital duties. There is no involvement of women in social and economic life. In the long-term, an increase in gender-based violence and a decrease in female literacy and social participation will further deprive women of their rights. In these countries in crisis, we need to facilitate transport and access to schools for both genders, notably for girls. We need educational campaigns that focus on the role of women in the community in these patriarchal societies. 

One limitation of our study was that it did not investigate the cause of the gender disparity. Thus, we could not assess the reasons for female physicians’ preference in their choice of specialty.

Conclusion

Among all medical domains in Lebanon, surgery had the widest gender gap, with only 2.3% of surgeons being female. Some specialties, such as neurosurgery and vascular surgery, had no female surgeons. A total absence of female surgeons was also noted in some locations, particularly North and Chouf-Aley Regions. Poverty, lack of gender education, influence of a patriarchal society, and erroneous misconceptions about women’s capacity to balance their professional career and sociomarital life were the major causes of the low female participation in surgical specialties. No significant gender gap could be noticed between academic and nonacademic hospitals, or between private and public hospitals. Healthcare systems in Lebanon must elaborate strategies to incorporate more women into surgical specialties to assure an equitable opportunity to all competent physicians, and to optimize the quality of care.

Funding: None

Competing interests: None declared.

Évaluation des inégalités fondées sur le genre dans les spécialités chirurgicales parmi le personnel médical libanais : la nécessité d'impliquer les femmes dans le domaine de la chirurgie

Résumé

Contexte : Il existe peu d'informations sur la disparité entre les genres dans les spécialités chirurgicales au Liban.

Objectifs : Évaluer le statut des chirurgiennes et les éventuelles disparités entre les genres dans la spécialité chirurgicale au Liban.

Méthodes : L'étude a été menée en mai 2021. Des données ont été extraites du site de l'Ordre des Médecins du Liban, indiquant le nombre de médecins dans les différentes spécialités, leur genre, les hôpitaux dans lesquels ils travaillent et leur emplacement. Le test du khi-deux d'homogénéité a été utilisé pour déterminer si la répartition entre les genres était à égalité.

Résultats : Les femmes ne représentaient que 21,84 % (3 370) des médecins au Liban, le domaine de la chirurgie étant celui qui comptait le moins de femmes médecins (n = 65 ; 2,30 %). Les femmes représentaient 1,63 % de l'ensemble des chirurgiens dans les hôpitaux libanais, le nombre de femmes spécialisées en chirurgie plastique et reconstructive était plus élevé (n = 12 ; 7, 14 %), tandis que la neurochirurgie, la chirurgie oncologique et la chirurgie vasculaire ne comptaient aucune femme. Aucune différence significative relative au genre n'a été constatée entre les établissements universitaires et non universitaires (χ2 = 2,164, p = 0,149), ou entre les hôpitaux publics et privés (χ2 = 1,277, p = 0,234). 

Conclusion : Les spécialités chirurgicales présentaient les plus importantes inégalités fondées sur le genre parmi tous les domaines médicaux au Liban. Par conséquent, les systèmes de soins de santé, y compris les hôpitaux publics et privés, ont encore un chemin long et difficile à parcourir pour réduire ces inégalités. Différentes stratégies visant à intégrer les femmes dans le domaine de la chirurgie devraient être envisagées pour garantir des opportunités équitables à tous les médecins, sur la base des compétences plutôt que du genre.

تقييم الفجوة الجنسانية في التخصُّصات الجراحية بين العاملين الطبِّيين اللبنانيين: الحاجة إلى إشراك المرأة في الجراحة

سعيد الحاج، إلياس واكيم، جورجيو سيدي، داني عقيقي، باسكال سلامة

الخلاصة

الخلفية: لا يُعرف الكثير عن التفاوت بين الجنسين في تخصُّص الجراحة في لبنان.

الأهداف: هدفت هذه الدراسة الى تقييم وضع الإناث الجرَّاحات والفجوات الجنسانية المحتملة في تخصُّص الجراحة في لبنان.

طرق البحث: أُجريت هذه الدراسة في مايو/ أيار 2021. واستُخلصت البيانات من الموقع الإلكتروني لنقابة أطباء لبنان، وتشير تلك البيانات إلى عدد الأطباء في مختلف التخصُّصات وجنسهم ومستشفياتهم ومواقعهم. واستُخدم اختبار مربع كاي (χ2) للتجانس لتقرير ما إذا كان ثمة تساوٍ في التوزيع بحسب الجنس أم لا.

النتائج: لم تتجاوز نسبة النساء (21.84% (3370 من الأطباء في لبنان، وكانت أقل نسبة للطبيبات في تخصُّص الجراحة (عددهن = 65؛ بنسبة 2.30%). ومثَّلت النساء 1.63% من مجموع الجرَّاحين في المستشفيات اللبنانية، وحظيت الجِراحات التجميلية والترميمية بالنسبة الكبرى (عددهن = 12، بنسبة 7.14%)، في حين لم توجد إناث في تخصُّصات جراحة الأعصاب والأورام وجراحة الأوعية الدموية. ولم يوجد اختلاف كبير بين المؤسسات الأكاديمية وغير الأكاديمية (اختبار مربع كاي = 2.164، القيمة الاحتمالية = 0.149)، أو بين المستشفيات العامة والخاصة (اختبار مربع كاي = 1.277، القيمة الاحتمالية = 0.234). 

الاستنتاجات: يشهد تخصُّص الجراحة أوسع فجوة جنسانية مقارنةً بجميع المجالات الطبية في لبنان. لذا فإن ثمة طريق طويل ً وصعب أمام نُظُم الرعاية الصحية، ومن ذلك المستشفيات العامة والخاصة، لتضييق الفجوة الجنسانية. وينبغي البحث والتقصِّي عن استراتيجيات مختلفة لإدماج المرأة في تخصُّص الجراحة، لضمان تكافؤ الفرص لجميع الأطباء، وأن يكون ذلك على أساس الكفاءة لا الجنس.

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