LONDON: A new study by the Aga Khan University Hospital (AKUH) has found that significant cultural barriers prevent women from pursuing a surgical career in Pakistan, amid calls for policymakers to address underrepresentation.

The study titled “Cultural barriers for women in surgery: How thick is the glass ceiling?” was published after peer review by the World Journal of Surgery this week as an analysis from a low middle-income country.

The publication detailed the findings of a cross-sectional survey in which questions were put to 100 full-time faculty members and trainees in the Department of Surgery at AKUH from July 2019 to November 2019. The respondent breakdown was 32 per cent female and 68pc male.

Results revealed that nearly 72pc of female surgeons said cultural barriers to a surgical career existed for their gender, as compared to 25pc of male surgeons. Around 40pc women reported having been discouraged by family or close friends from pursuing surgery, as compared to only 9pc of males.

It also found that a greater percentage of female surgeons were responsible for household cooking, cleaning and laundry, as compared to male surgeons. Nearly 71pc of female surgeons felt that having children had hindered their surgical career, as compared to 5pc of males.

Survey carried out at AKUH found that 47pc of female surgeons were told they could not become a surgeon

At the time of the study, a total of 194 surgeons were working or in training at the university hospital, of which only 47 were female. The surgical specialties at AKUH with the lowest percentage of female surgeons were vascular surgery (0pc), orthopaedic surgery (6.06pc) and otolaryngology (11.1pc). However, all breast surgeons were female.

Majority (47pc) of female surgeons reported having been told that they could not become a surgeon, as compared to 22pc male surgeons. A higher percentage (86pc) of females felt the “culture” perceived surgery as a field suited for males, as compared to male surgeons (54pc). A large percentage of the respondents (40pc) felt that a surgical career was not conducive to raising a family, with this opinion being more common in females as compared to males.

A significantly higher percentage (76pc) of male surgeons were married, as compared to female surgeons (44pc). While all married female surgeons had a spouse who was currently employed, 38pc of male surgeons reported having stay-at-home spouses.

The majority (86pc) of surgeon mothers felt that their motherhood was perceived negatively at work. Moreover, most women (71pc) worried that their hectic work schedule and duties might compromise their health or the health of their children.

Dr Mahim Malik, the head of cardiothoracic surgery at AKUH and Pakistan’s only paediatric cardiac surgeon, was among the lead authors of the study, which was presented at the 15th Annual Academic Surgical Congress in Orlando this February. She said the idea of the study came about when her peers decided to form a female surgeons association which would help women network and access mentors.

“The issue of low female representation in surgery is not unique to Pakistan, as it reflects a trend prevalent in the United States as well,” said Dr Malik, who received her training in the US and returned to Pakistan two years ago.

“The challenge here is that we don’t recognise this as a problem and are not doing anything to address it.”

She added that women who become doctors are often confronted with the challenge of balancing demands of professional duties with pressures of family life, which keeps them out of a demanding field like surgery. “Women are often viewed just through the lens of ‘mother’ and boxed into paediatrics or OB GYN which are seen as more ‘feminine’.”

Institutional change

Dr Malik felt that the culture today reflected the stereotypes of the 50s and 60s, when surgery was growing in the world and was dominated by men. “Men are perceived as more intelligent. You often hear things like ‘women can’t do this’ or ‘don’t have the temperament’, which creates a toxic atmosphere.”

While she considers herself lucky for having a supportive family, she is cognisant that the experience of many women is starkly different. “I am definitely an outlier in that sense, because during the survey I saw exactly what women have to face.”

To increase female representation in a field like surgery, Dr Malik said Pakistan needed a change in the work environment. “It is lagging behind and can only change at the institutional level. It is not up to one person.”

She said the environment was still “fairly toxic” and that women had to face taunts from their colleagues. Questions such as ‘how will you work if you are married?’ or ‘your career is over now that you have a baby’ are thrown at women quite commonly.

“This implicit bias is normalised here. People saying these things have to be held accountable, but still this is challenging because the hierarchical structure is also male-dominated.”

She emphasised the need for an approach of “equity over equality”, as policies like flexible hours and flexible pay structures must be enacted to support women. “Right now, women know that if they take time off to have a baby, they will be sidelined for a promotion. This needs to change.”

Published in Dawn, May 9th, 2020