Women in Surgery Italia: National Survey Assessing Gender-Related Challenges

Abstract

Background
In 2019, women accounted for 46% of surgical residents. Despite the international debate on gender disparities, no literature regarding the experience in Italy is available. The aim of this survey study was to assess satisfaction among female surgeons in Italy, and whether they encounter gender-based discrimination.

Study design
An anonymous 83-item web-based survey was distributed among female surgeons working in Italy, from November 18 to December 31st, 2020. Gender equity, satisfaction and factors associated with higher satisfaction and work-life balance were explored.

Results
There were 3,242 volunteer respondents, out of which 1,833 completed at least 50% of the specific questions and were included in the study. Approximately 54% of female Italian surgeons reported being satisfied with their job, but only 34% with their work-life balance. Among residents, 67% thought they were not adequately trained. The majority of respondents were responsible for most of the housekeeping (60%) and childcare duties (53%), regardless of their partner’s workload, and 62% reported that gender affects the way they are treated at work with most of them experiencing microaggressions. Sexual harassment was common (59%), but only 10% of women reported it.

Conclusions
Most Italian female surgeons are satisfied with their professional choice. However, they face gender discrimination, including incidents of sexual harassment and microaggressions. Due to the fact that half of surgeons working in Italian hospitals will be females in the next few years, actions are urgently required to build a culture that supports a gender-neutral environment.

Full text

ORIGINAL SCIENTIFIC ARTICLES
Women in Surgery Italia: National Survey
Assessing Gender-Related Challenges
Sara Parini, MD, Daniela Lucidi, MD, Danila Azzolina, PhD, Daunia Verdi, MD,
Isabella Frigerio, MD, PhD, FACS, Andrew A Gumbs, MD, FACS, Gaya Spolverato, MD
BACKGROUND: In 2019, women accounted for 46% of surgical residents. Despite the international debate on
gender disparities, no literature regarding the experience in Italy is available. The aim of this
survey study was to assess satisfaction among female surgeons in Italy, and determine whether
they encounter gender-based discrimination.
STUDY DESIGN: An anonymous, 83-item web-based survey was distributed among female surgeons working in
Italy, from November 18 to December 31, 2020. Gender equity, satisfaction, and factors
associated with higher satisfaction and work-life balance were explored.
RESULTS: There were 3,242 volunteer respondents, 1,833 of whom completed at least 50% of the spe-
cific questions and were included in the study. Approximately 54% of female Italian surgeons
reported being satisfied with their job, but only 34% with their work-life balance. Among
residents, 67% thought they were not adequately trained. The majority of respondents were
responsible for most of the housekeeping (60%) and childcare duties (53%), regardless of
their partner’s workload, and 62% reported that gender affects the way they are treated at
work, with most of them experiencing microaggressions. Sexual harassment was common
(59%), but only 10% of women reported it.
CONCLUSIONS: Most Italian female surgeons are satisfied with their professional choice. However, they face
gender discrimination, including incidents of sexual harassment and microaggression. Due to
the fact that half of surgeons working in Italian hospitals will be females in the next few years,
actions are urgently required to build a culture that supports a gender-neutral
environment. (J Am Coll Surg 2021;-:583e592. 2021 by the American College of
Surgeons. Published by Elsevier Inc. All rights reserved.)
In Italy, the number of women pursuing careers in surgery
has been steadily increasing for the past few years. In
2019, according to the Italian Ministry of Education,
University and Research (MIUR), women accounted for
46% of all trainees enrolled in surgical residencies.
1
Despite these apparently encouraging trends toward in-
clusion, male physicians continue to dominate many sur-
gical fields. In recent years, the growing number of
women surgeons, together with the increased sensitivity
toward gender equity, forced women to focus on the dis-
parities deeply ingrained in the field of surgery.
Surprisingly, or perhaps not, no Italian literature is
available. One might speculate that the condition of fe-
male surgeons in this country reflects the international sit-
uation; however, the reality is that female surgeons in Italy
are less satisfied than their counterparts working in neigh-
boring European countries.
2-5
The aim of this study was
to assess gender equity and satisfaction of female surgeons
in Italy. Factors associated with higher satisfaction and
work-life balance were also explored.
METHODS
An 83-item questionnaire was designed to acquire data on
the following issues: demographics, surgical training and
practice, satisfaction, mentorship, discrimination, and
Disclosure Information: Nothing to disclose.
Received July 11, 2021; Revised August 4, 2021; Accepted August 5, 2021.
From the Division of Thoracic Surgery, Ospedale Maggiore della Carita
`di
Novara, Novara, Italy (Parini); University of Turin, Turin, Italy (Parini);
Department of Otolaryngology - Head and Neck Surgery, University Hos-
pital of Modena, University of Modena and Reggio Emilia, Italy (Lucidi);
Department of Medical Sciences, University of Ferrara, Ferrara, Italy (Azzo-
lina); Department of Surgery, Mirano Hospital, Mirano, Italy (Verdi);
Pancreatic Surgical Unit, Pederzoli Hospital, Peschiera del Garda, Verona,
Italy (Frigerio); Department of Digestive Surgery, Centre Hospitalier Inter-
communal de Poissy/Saint-Germain-en-Laye, Poissy, France (Gumbs);
Department of Surgical, Oncological and Gastroenterological Sciences,
University of Padova, Padua, Italy (Spolverato).
Correspondence address: Sara Parini, MD, Division of Thoracic Surgery,
Ospedale Maggiore della Carita
`di Novara, 18, Corso Mazzini, 28100
Novara, Italy. email: sara.parini@gmail.com
583
ª2021 by the American College of Surgeons. Published by Elsevier Inc.
All rights reserved.
https://doi.org/10.1016/j.jamcollsurg.2021.08.675
ISSN 1072-7515/21

harassment. Pretest cognitive interviews were conducted
with surgeons from multiple institutions to assess clarity,
coherence, and balance of the survey. The first draft of the
questionnaire underwent iterative revisions and retesting
by the board members of Women in Surgery Italia
(WIS Italia). The survey was composed of multiple-
choice questions, and some items were scored using a 5-
point Likert scale. Questions judged as inquiring about
private or sensitive issues were optional. The final ques-
tionnaire was approved by the WIS Italia executive
committee.
The online survey was conducted from November
through December 2020, using REDCap electronic
data capture tools,
6,7
a secure, web-based software plat-
form designed to support data capture for research
studies. All responses were voluntary and anonymous.
An electronic informed consent was obtained from re-
sponders and stored through the REDCap e-Consent
Framework. A detailed information sheet explaining the
purpose of the study and data management was part of
the e-Consent.
Overall, 2,781 electronic mails of female surgeons were
collected from the WIS Italia membership database and
through a Google search on institutions of employment
and surgical department websites. Invitations to partici-
pate in the survey were sent to the contacts, with up to
3 reminders. Additional invitations were sent via e-mail
to the chairpersons of 310 surgical training programs,
1,887 surgical units, 98 surgical societies, and 107 medi-
cal boards. Moreover, the survey was shared on the
Women in Surgery Italia social media pages (Facebook,
LinkedIn, Twitter, and Instagram).
Statistical analysis
Data description
The respondents were placed into 2 groups based on their
level of training: trainee (residents) or fully trained (sur-
geons) and separately analyzed. Descriptive statistics
were reported for each variable. Categorical data were re-
ported as relative and absolute frequencies; continuous
data as median, I, and III quartiles. Wilcoxon-type tests
were performed for continuous variables and chi-square
test for categorical variables.
Cluster analysis
A cluster analysis was performed to characterize groups of
women according to their characteristics and attitudes to-
ward work. The Multiple Correspondence Analysis
(MCA) is a statistical method for analyzing multivariate
contingency tables, thereby not requiring definition of a
dependent variable. MCA aims to summarize associations
between variables in large, potentially complex, datasets.
8,9
To perform clustering analysis on categorical data, the
MCA results can be used to transform categorical variables
into a set of a few continuous variables (the latent dimen-
sion). The cluster analysis can then be applied to the results.
In this case, the MCA can be considered a pre-processing
step that allows for computational clustering of categorical
data.
10
A factorial agglomerative hierarchical clustering analysis
was then carried out on the MCA results. The distance be-
tween MCA loadings was computed via Manhattan mea-
surements using the Ward method to identify the
hierarchical partition. The data partition has been repre-
sented in a cluster dendrogram. The cluster membership,
together with the individual loading, has been represented
in a factor map with 95% confidence ellipses around cen-
troids. The features discriminating the clusters according
to the chi-square significance (alpha <0.05) were selected
and summarized in a descriptive table (eTable 1).
Women’s attitudes by cluster membership toward items
characterizing job satisfaction were investigated by calcu-
lating a logistic regression model for binary endpoints and
a proportional odds model for ordinal endpoints. A sig-
nificance level of 0.05 was used for the analyses. Compu-
tations have been performed with the R 3.6.2 system,
11
and the Factominer,
12
Matchit,
13
and Factoextra
packages.
14
RESULTS
In 2 months, 3,242 participants started the survey.
Female surgeons of all specialties who responded to at
least 50% of the specific questions totaled 1,833 (57%).
These 1,833 respondents were included in the following
analysis. Inclusion criteria are shown in Figure 1.
Demographics, professional status, and family
The cohort was composed of 1,215 (66%) specialist sur-
geons and 618 (34%) surgery residents. Details regarding
demographics, professional status, and training are sum-
marized in Table 1. The majority of responders were mar-
ried or cohabiting (60%). Most partners (57%) did not
work in healthcare. Of the remaining, 24% were sur-
geons, 12% internists, 4% other healthcare workers, and
only 3% were unemployed. Fifty percent of specialist sur-
geons and 9% of residents had at least 1 child. The me-
dian age for having a child was 33 years (interquartile
range [IQR] 31-37). Sixty-two percent of respondents
declared that they would have liked to have more chil-
dren, but 40% stated that the main reason that they did
not were mainly professional. The need to delay the first
pregnancy for professional reasons was reported by 59%
of respondents.
584 Parini et al Gender Discrimination and Female Surgeons J Am Coll Surg

Despite the fact that only 10% of their male partners
worked more than they did, the responsibility of the
house and of the children fell on the female surgeons.
In particular, 60% of the respondents took care of the
housework and 53% took care of childcare. Only 8% re-
ported that their partners took the lead in managing the
house and 17%, the children. Only 17% of surgeons
worked in a hospital that provides childcare for
employees.
Professional satisfaction and difficulties
Satisfaction was higher among surgeons compared with
residents, with 56% of surgeons saying that they were
often/always satisfied compared with only 47% of resi-
dents (p <0.001). The most satisfied were breast sur-
geons (82%), pediatric surgeons (68%), orthopaedic
surgeons (65%), and plastic surgeons (63%). In contrast,
only 33% of maxillofacial surgeons, 44% of urologists,
and 47% of general surgeons reported being satisfied
with their job. The majority of women (77% of all re-
spondents) reported that helping patients was their great-
est source of professional reward, followed by surgical
skills (75%), with no significant difference between the
2 groups (eFig. 1). The amount of administrative work
(62% overall) and inadequate training (67% of residents
and 38% of surgeons) were the most common sources
of dissatisfaction. The lack of work-life balance was the
second most common source of dissatisfaction for fully
trained surgeons (39%) and residents (53%). The lack
of mentorship was a source of frustration for 30% of sur-
geons and 50% of residents. The lack of tangible advance-
ment opportunities was cited as a source of job
unsatisfaction in 35% of surgeons (Fig. 2).
Difficulties experienced in the operating room are
depicted in Figure 3. Being poorly trained was the most
frequent complaint, especially for 53% of gynecologists
and 45% of thoracic surgeons. Of note, 21% of residents
and 12% of surgeons reported being ignored by the staff,
and only a minority perceived physical limitations. Career
advancement opportunities (61%), less administrative
work (55%), better training (52%), and higher salary
(47%) were identified as changes that could make surgery
more attractive. Interestingly, 84% of surgeons and 87%
of residents would still pursue a surgical career if they had
the opportunity.
Work-life balance
The majority of respondents (64% of residents and 50%
of surgeons) were poorly or not satisfied with their work
schedule, as well as with their work-life balance (60%
and 44%, respectively). Fifty-six percent of all respon-
dents reported that they prioritized work over their own
personal life, while only one-quarter prioritized their fam-
ily. Thirty-seven percent had to sacrifice sleep in order to
spend time with their family, while 49% did it to have
more free time for themselves.
Work environment and mentorship
Twenty-eight percent (IQR 18e43%) of respondents had
women in their surgical unit. The majority of specialists
(90%) and residents (86%) had encountered a role model
during their career, but in only 19% and 29%, respec-
tively, was it a female (p <0.001).
Self-assessment
When surgeons were asked about how they think co-
workers judge their professional performance, 52% of sur-
geons and 35% of residents thought they were judged as
above average or among the best, 41% of surgeons and
55% of residents as average, and only 4% of surgeons
Figure 1. Patients included in the study.
Vol. -, No. -, November 2021 Parini et al Gender Discrimination and Female Surgeons 585

Table 1. Self-Reported Demographic Characteristics, Professional Status, and Training of Respondents
Variable Evaluable responder Surgeon Resident Overall p Value
Total, n (%) e1,215 (66) 618 (34) 1,833 (100) e
Age, y, median (IQR) 1,819 39 (35e47) 30 (28e31) 35 (30e43) <0.001
Working years, median (IQR) 1,831 13 (8e22) 3 (2e5) 9 (4e18) <0.001
Area of practice, n (%) 1,833 0.179
Northern Italy e782 (64) 385 (62) 1167 (64)
Central Italy e228 (19) 138 (22) 366 (20)
Southern Italy e205 (17) 95 (15) 300 (16)
Surgical field, n (%) 1,833 <0.001
General surgery e386 (32) 276 (45) 662 (36)
Cardiac surgery e32 (3) 16 (3) 48 (3)
Thoracic surgery e43 (4) 20 (3) 63 (3)
Vascular surgery e73 (6) 42 (7) 115 (6)
Pediatric surgery e45 (4) 11 (2) 56 (3)
Plastic surgery e35 (3) 5 (1) 40 (2)
Obstetrics/gynecology e108 (9) 69 (11) 177 (10)
Orthopaedic/trauma surgery e157 (13) 65 (11) 222 (12)
Urology e33 (3) 22 (4) 55 (3)
Maxillofacial surgery e22 (2) 21 (3) 43 (2)
Neurosurgery e65 (5) 16 (3) 81 (4)
Ophthalmology e37 (3) 8 (1) 45 (2)
ENT surgery e119 (10) 36 (6) 155 (8)
Breast surgery e60 (5) 11 (2) 71 (4)
Academic position, n (%) 722 <0.001
PhD student e40 (38) 0 (0) 40 (6)
Research fellow e20 (19) 0 (0) 20 (3)
Assistant professor e21 (10) 0 (0) 21 (3)
Associate professor e19 (18) 0 (0) 19 (3)
Full professor e4 (4) 0 (0) 4 (1)
Resident e0 (0) 618 (100) 618 (86)
Nonacademic position, n (%) 1,164 <0.001
Attending surgeon e1,084 (93) 0 (0) 1,084 (93)
Chief of unit/department e80 (7) 0 (0) 80 (7)
Annual income, n (%) 1,676
<30,000 V(<w35,000 $) e76 (7) 532 (93) 608 (36) <0.001
30e45,000 V(w35,000e47,000 $) e282 (25) 24 (4) 306 (18)
45e60,000 V(w47,000e71,000 $) e334 (30) 7 (1) 341 (20)
60e80,000 V(w71,000e95,000 $) e253 (23) 5 (1) 258 (15)
80e100,000 V(w95,000e118,000 $) e93 (8) 1 (0) 94 (5)
100e150,000 V(w118,000e177,000 $) e52 (5) 1 (0) 53 (3)
>150,000 V(>w177,000 $) e16 (1) 0 (0) 16 (1)
Training outside Italy (>3 mo), n (%) 1,826 404 (33) 65 (11) 469 (26) <0.001
In Europe 1,833 1,141 (94) 607 (98) 1,748 (95) <0.001
Extra title (PhD, Master,
other higher level training title), n (%)
1,833 590 (49) 52 (8) 642 (35) <0.001
586 Parini et al Gender Discrimination and Female Surgeons J Am Coll Surg

and 6% of residents as worse than average. When they
were asked about how they judge themselves profession-
ally, 41% of surgeons and 32% of residents saw them-
selves as above average or among the best, 46% of
surgeons and 51% of residents as average, and 9% of sur-
geons and 12% of residents as worse than average.
Gender inequities, microaggressions and
harassment
Most respondents thought that they were treated differ-
ently because they were women (61% of surgeons and
64% of residents). Figure 4 describes their responses
when they were asked about inequalities. The most
Figure 2. Bar graph depicting the main sources of dissatisfaction at work, indicated as percentage of responders.
Figure 3. Bar graph depicting the difficulties faced in the operating room (OR), indicated as percentage of re-
sponders. Survey question, “What major difficulties have you experienced in the OR?”
Vol. -, No. -, November 2021 Parini et al Gender Discrimination and Female Surgeons 587

commonly reported answers highlighted negative, rather
than positive, gender influence. Regarding personal pref-
erence on gender diversity in the workplace, most respon-
dents stated that they did not care about the gender of
their coworkers (45%), or preferred a gender-balanced
environment (30%). However, for the 24% who did
have a gender preference, most women said that they
would rather work with men by a wide margin (21% vs
3%). When the results were broken down by position,
residents were less gender-neutral than surgeons, with
26% stating that they would rather work with men.
Despite these results, 37% of respondents thought that
they were supported by female colleagues, while only 21%
stated that male coworkers were a source of support.
Both groups reported hearing coworkers say, “surgery is
not a woman thing” frequently (57% of surgeons and
63% of residents) or occasionally (34% and 30%, respec-
tively). The majority of respondents were told that they
were “too aggressive” (58% of surgeons and 53% of
residents).
Most surgeons (57%) and residents (65%) reported
that they have been victims of unwelcome sexual ad-
vances, or verbal or physical conduct of a sexual nature.
Among these, only 10% reported it to a supervisor, while
38% did not, and 48% stated that they were able to
handle the situation alone. Within the minority who re-
ported it, 25% were listened to, but nothing happened
to the perpetrator, and 24% stated that their complaint
was ignored or undervalued, and only 18% stated that
their harasser received a formal or informal notice. The
prevalence of sexual harassment seems higher among
maxillofacial (79%), plastic (72%) and general surgeons
(67%).
Cluster description and satisfaction comparison
Two clusters (1 and 2) of fully trained surgeons have been
identified and compared, according to their characteris-
tics. When the 2 clusters were compared, cluster 2 showed
higher overall satisfaction (odds ratio [OR] 1.67, 95% CI
1.35e2.08, p <0.001), work-life balance (OR 1.69,
95% CI 1.37e2.12, p <0.001), and have less often
been the victims of harassment (OR 0.67, 95% CI
0.53e0.86, p <0.001). This cluster is made up of older
surgeons (median age 45 vs 35, p <0.001), who are mar-
ried or cohabiting (85% vs 52%, p <0.001), and have
kids (85% vs 13%, p <0.001). Surgeons in this cluster
practice more often in Northern and Central Italy,
compared to Southern Italy, 70% vs 59%, 21% vs
17%, and 10% vs 24%, respectively (p <0.001). They
work less frequently in academia (4% vs 9%, p <
0.001) or in a field of surgery that is considered “mascu-
line,” such as urology or orthopaedic surgery (55% vs
63%, p ¼0.004), and fewer were trained abroad (30%
vs 36%, p ¼0.024) (eTable 1 and eFig. 2).
Figure 4. Bar graph depicting respondent perception of different treatment related to gender, indicated as per-
centage of responders. Survey question, “In what ways do you think you are treated differently from a male
colleague?”
588 Parini et al Gender Discrimination and Female Surgeons J Am Coll Surg

Similarly, 2 clusters were identified among residents.
Those who are more satisfied with their work-life balance
(OR 2.08, 95% CI 1.52e2.84, p <0.001) and have less
frequently been the victims of harassment (OR 0.51, 95%
CI 0.35e0.72, p <0.001) belong to the cluster
composed of older residents (median age 30 vs 29 years),
who are more often married or cohabiting (100% vs 3%),
and are parents (22% vs 0%). They work more frequently
in Northern and Southern Italy and less in Central Italy,
66% vs 60%, 20% vs 12% and 14% vs 28%, respectively
(p <0.001). In addition, they work less frequently in a
field of surgery that is considered “masculine” (59% vs
72%, respectively).
DISCUSSION
Our results showed that most female surgeons in Italy are
satisfied with their professional lives and, aside from a few
critical issues, most of them would choose a career in sur-
gery again. The main sources of personal reward are help-
ing patients and performing surgical procedures. On the
contrary, the heavy administrative workload, poor surgical
training, and profound work-life imbalance are major
sources of frustration, suggesting that lifestyle, which clas-
sically makes surgery undesirable to medical students, is a
source of continued stress for working surgeons as well.
Tangible career advancement opportunities, a reduction
in the administrative workload, better training, and
improved salary were suggested as the most important
changes needed to make surgery more attractive.
When looking at gender-sensitive topics, many barriers
and critical issues have been highlighted. Most female sur-
geons feel like they are being treated differently because of
their sex, and their perception is that they receive less
consideration, fewer opportunities for promotion, less
training, and more thankless tasks than their male coun-
terparts, which is a disturbing trend already described
by Babcock and colleagues.
15
Interestingly, only a minor-
ity of respondents perceived the existence of physical lim-
itations in the operating room. This finding contradicts a
deep-rooted prejudice, claiming that the main limit in
pursuing a surgical career for women lies in their physical
inadequacies in facing long hours standing and physically
challenging maneuvers during surgery. The unstoppable
diffusion of minimally invasive surgery will most likely
end this prejudice, although research suggests that surgical
instruments and operating room design really do favor
surgeons who are taller and have larger hands, a trend
that has also been noted in minimally invasive surgery.
16,17
Regarding respondents’ self-evaluation, there are 2
points to be noted. First, as expected, older women
show more self-confidence than their younger
counterparts. Apparently, despite external evaluations of
their competence, a number of women think that they
are perceived by colleagues as more talented than they
perceive themselves to be. These results seem to match
with a psychological pattern referred to as “impostor syn-
drome,” which is typical of high-achieving women and
under-represented ethnic, racial, and religious
minorities.
18
Regarding personal lives, even though only a minority
of male partners have a more time-consuming job, the
vast majority of surveyed women take on most of the
housekeeping and child-rearing responsibilities. This indi-
cates that traditional gender roles continue to be rooted in
the household division of labor in Italy, and even when
women establish themselves as the main breadwinners
within the couple, an unequal distribution of labor in
the home is maintained. The additional amount of re-
sources women spend after formal work was described
as “the double burden” or “the second shift,”
19
and it af-
fects not only physical and mental well-being, but also
plays a critical role in leisure and the wage gap between
men and women.
20,21
This reality continues to go unno-
ticed, and despite the obvious need for adequate childcare
facilities, these are only available in less than 1 in 5
hospitals.
Regarding women’s inclusion and networking in the
workplace, although almost all surgeons had encountered
a role model, only a minority were females. On a positive
note, female role model percentage is rising among
younger surgeons in training, depicting an evolving situ-
ation. On the other hand, a discouraging quarter of re-
spondents deny having ever met a professionally
satisfied female surgeon. Literature shows that surgical
role models are important to all trainees,
22
however ac-
cording to Tambyraja and colleagues
23
and Lillemoe
and coworkers,
24
women place more importance on men-
tors than their male counterparts. As long as women who
consider pursuing surgery face a lack of same-sex role
models, a vicious cycle is generated, in which few female
mentors result in few female surgical trainees. Moreover, a
female mentor could educate male trainees to reach across
the gender divide and help close the gap once they are
fully trained surgeons.
Although female role models seem to have a positive in-
fluence on trainees, results on women’s working relation-
ship with other women are contradictory. Most
respondents think that female colleagues support other
women more than male colleagues do, and clustering
analysis revealed that women working in “masculine” sur-
gical fields show lower levels of satisfaction. Nevertheless,
it is striking that one-fifth to one-quarter of women would
prefer working with men rather than with women or in a
Vol. -, No. -, November 2021 Parini et al Gender Discrimination and Female Surgeons 589

gender-balanced environment, and this trend is even more
prominent among trainees. This paradox, wherein women
seem to avoid working with other women, might have a
number of explanations, but the most likely is the pres-
ence of a widely described phenomenon, the “Queen
Bee effect,” or “self-group distancing,” holding that
women who succeed in male-dominated fields distance
themselves from other women, as a form of self-
preservation. It was reported by Ellemers and associates,
25
among faculty members evaluating female students, and
the trend did not disappear with time.
26
As researchers
suggest, it is a consequence of the gender discrimination
they faced that made them show exceptional commitment
to succeed, making them less certain that other women
would be able to do the same.
Another important concern in female inclusion high-
lighted by this survey is the high prevalence of both
microaggressions (repeated gender-based negative com-
ments or acts) and sexual harassment. Even though micro-
aggressions may appear harmless to uninvolved observers,
they can be particularly stressful for people on the
receiving end.
27-29
Perpetrators typically defend their
behavior as a joke and blame recipients for being overly
sensitive. These dynamics, which undermine an individ-
ual’s self-esteem, are particularly dangerous for someone
who is in training.
30,31
Most respondents reported having been the subject of
sexual harassment, revealing that not only subtle dy-
namics are in action. Similar findings were also reported
in other countries.
3,32-34
The percentage of women who re-
ported the harassment to a supervisor is low, as recently
noted by Freedman-Weiss and colleagues.
34
We may as-
sume that cases that were reported were the most serious;
however, women may have avoided reporting when they
felt they were in an unsafe situation. In either case, data
showing that most complaints were ignored or underval-
ued are particularly worrisome and need to be addressed.
What happens in the other countries?
Most available literature on the subject is North American
and is focused on US physicians. On the contrary, Euro-
pean literature is scarce and does not provide a clear pic-
ture of the situation. Surprisingly, to our knowledge, no
such study has been published in the leading British
journals.
In broad terms, these results seem to be concordant
with previous surveys conducted in other countries. How-
ever, some of our data are quite alarming by comparison.
A 2013 survey among US general surgeons revealed that
54% of women had been, or anticipated being, treated
differently because of their gender,
35
while our survey
found a higher percentage of women (62%) stating that
they were treated differently. Consistently higher levels
of career satisfaction are shown by female general surgeons
in the US, as 80% declared being overall satisfied with
career
36
(compared to only 54% in our data). Work-life
balance is satisfactory for 56% of US surgeons,
36
vs only
34% of our respondents. In a survey conducted in
Switzerland, 12.2% of the surgeons reported the need
for better residency programs
3
vs 52% of our responders.
Sexual harassment seems a common experience among
surgeons and is reported by 67% of residents who
answered our survey. According to a survey study recently
conducted among US general surgery residents, the prev-
alence in the US seems consistently lower, with 42.5% of
females experiencing sexual harassment.
37
Strengths and limitations
This is the first study to assess the current status of women
in surgery in Italy. The distribution method hinders the
calculation of a response rate. The overall number of re-
spondents is higher than in most similar surveys conduct-
ed in other countries.
3,38
However, the population of
female surgeons is difficult to estimate because, to our
knowledge, there is no gender information collected on
Italian surgeons, and surgical societies cannot release
this information about their members. Moreover, another
limit to this study is the absence of comparison between
male and female surgeons.
The median age of respondents is low. This may hide a
selection bias, although the distribution method should
have ensured an extensive coverage of surgeons’ popula-
tion. Presumably, it may also represent the gradual in-
crease of female surgeons over the last few years. This
finding has a double downside: first, even when consid-
ering nonresidents, many women among our respondents
are young and, in a certain way, still in training. Second,
when analyzing an evolving situation through cross-
sectional data, it is very difficult to evaluate phenomena
such as a glass ceiling effect and barriers to career advance-
ment, due to the great imbalance between the few women
who entered the profession many years ago, and the many
more younger women who entered the profession more
recently.
CONCLUSIONS
Our study showed that most Italian women surgeons face
gender discrimination at work, including incidents of sex-
ual harassment and microaggressions. The heavy adminis-
trative workload, inadequate surgical training, and work-
life imbalance are major concerns among our respon-
dents. Despite these critical issues, they are satisfied with
their professional choice.
590 Parini et al Gender Discrimination and Female Surgeons J Am Coll Surg

In a few more years, half of surgeons working in Italian
hospitals will be female. A number of issues should be
addressed now; otherwise, increasing the number of
women at the expense of declining working conditions
may prove to be a Pyrrhic victory. According to our find-
ings, actions are required to build a culture that supports a
gender-neutral environment, such as supporting
parenting through affordable childcare and family-
friendly policies, ensuring sexual harassment policies
with clear reporting procedures, and provide training on
gender inclusion to hospital employees.
Author Contributions
Study conception and design: Parini, Lucidi, Azzolina,
Verdi, Frigerio, Spolverato
Acquisition of data: Parini, Lucidi, Verdi
Analysis and interpretation of data: Parini, Lucidi,
Azzolina, Verdi, Frigerio, Gumbs, Spolverato
Drafting of manuscript: Parini, Lucidi, Azzolina
Critical revision: Parini, Lucidi, Azzolina, Verdi, Frigerio,
Gumbs, Spolverato
Acknowledgements: This study could not have been
completed without the support and input of many people.
We wish to acknowledge valuable contributions from sur-
geons who supported the project in many ways: Ottavio
Rena, Giovanna Tacconi, Francesca Ratti, Eloisa Franchi,
Alice Gori, Maria Silvia Spinelli, Eleonora Trecca, Chiara
Dell’Utri, Viviana Cacioppo, Sara Negrello, Alba Scerrati,
Francesca Toia. We wish to extend our gratitude to all sur-
gical societies, medical boards, directors of training pro-
grams, and chiefs of surgical units, who distributed the
questionnaire, and especially, to all the Italian surgeons
who completed or shared the survey.
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eFigure 1. Bar graph depicting the main sources of satisfaction at work, indicated as percentage of responders.
eTable 1. Characteristics Discriminating the 2 Clusters (1 and 2) of Fully Trained Surgeons
Variable Evaluable responder Cluster 1 (n ¼591) Cluster 2 (n ¼624) Overall (n ¼1215) p Value
Age, median (IQR) 1,206 35 (33e39) 45 (39e55) 39 (35e47) <0.001
Area of practice, n (%) 1,215
Northern Italy 348 (59) 434 (70) 782 (64) <0.001
Central Italy 100 (17) 128 (21) 228 (19)
Southern Italy 143 (24) 62 (10) 205 (17)
Work in a field
considered masculine, n (%)
1,215 373 (63) 343 (55) 716 (59) 0.004
Years in practice, median (IQR) 1,213 9 (7e12) 20 (13e28) 13 (8e22) <0.001
Academic position, n (%) 1,215 54 (9) 22 (4) 76 (6) <0.001
Trained abroad, n (%) 1,213 215 (36) 189 (30) 404 (33) 0.024
Married or cohabiting, n (%) 401 112 (52) 158 (85) 270 (67) <0.001
Has child, n (%) 1,204 79 (13) 522 (85) 601 (50) <0.001
Vol. -, No. -, November 2021 Parini et al Gender Discrimination and Female Surgeons 592.e1

eFigure 2. Factor map depicting the 2 clusters (1 and 2) of fully trained surgeons identified
according to their characteristics, with the 95% confidence ellipses around centroids.
592.e2 Parini et al Gender Discrimination and Female Surgeons J Am Coll Surg