For much of the 20th century, the work of medicine in the U.S. was performed by predominantly male physicians. As women began entering medical schools in larger numbers during the 1970s, some specialties were welcoming to women, others weren’t.
Surgical specialties were particularly resistant to the inclusion of women, with the exception of obstetrics and gynecology. After decades of increasing percentages of women entering gynecology, the field became the first majority women surgical specialty in 2012. This should have been embraced as evidence of the legitimate role for women in surgery. Instead, it led to a devaluation of gynecology as a specialty.
Despite the advancement of women in medicine, traditional gender roles persist. Men and women physicians are still expected to pursue “male” and “female” jobs, where women opt into caring and nurturing positions and men select technical or managerial roles. A surgical field composed mostly of women surgeons defies this conventional separation of physician specialties by gender.
Occupational segregation, the unequal distribution of workers across and within professions by gender, defines and drives professional status. When the percentage of women in a traditionally male field increases, the work begins to be viewed as “women’s work,” which leads to a decline in wages, respect, and status.
The subsequent collective abandonment by men of now female-dominated fields is, at least in part, because of the gender-specific stigma and wage penalty associated with working within a “feminine” occupation. A tipping point, when approximately one-third of a field becomes women, leads to a precipitous decline in men employed in the field. In gynecology, this point has passed: Women comprise 58% of practicing OB-GYNs and 84% of trainees.
Gender segregation across occupations drives much of the gender wage gap. As the share of women in a field increases, wages go down, even when controlling for education and skill. A documented negative correlation exists between the percentage of women working within a specialty and the mean salary. For OB-GYNs, salaries are currently lower than for any other procedural specialty. Similar work on women’s reproductive tracts is reimbursed at lower rates than on men’s reproductive tracts. For example, a surgeon is paid 45% more for a biopsy of a penis than of the vagina.
The attrition of men has resulted in lack of attention to the traditionally masculine, surgical side of the specialty. Obstetrics and gynecology is a unique specialty, the only field where medical and surgical care of an organ system are combined. Obstetrics is care related to pregnancy; gynecology is the surgical care of female reproductive organs. Today, academic obstetrics and gynecology departments are disproportionately led by nonsurgeons who tend to have expertise in obstetrics. These departments center around the labor and delivery units and maternity care, not the operating room.
Within health care systems, the bias and discrimination commonly experienced by individual women surgeons now extends to the group of surgeons who care exclusively for women patients. Gynecologists are no longer viewed as possessing the stereotypical masculine traits of surgeons — bold, decisive, and analytical. This categorization leads to preferential allocation of vital resources such as staff, operating room time, and equipment toward surgical specialties such as orthopedics or cardiothoracic surgery, where practitioners still fit the established perception of what a surgeon looks like. Regardless of revenue generated, increasingly gynecologists get the scraps.
More than 20 years ago, during my medical education, the conspicuous absence of women in surgery factored prominently in my decision to pursue a surgical career through gynecology. In retrospect, I assume there was ambient messaging from faculty and classmates that gynecology was more appropriate for a woman. A generation of women like me have now been trained in pelvic surgery for women as gynecologists.
As women physicians increasingly speak up about gender equity, their voices have arisen predominantly from non-gynecologic realms. The social media phenomenon #ILookLikeASurgeon highlights the widespread experiences of women going unrecognized as surgeons. #Time’sUp efforts now extend to health care. Zero-tolerance policies on sexual harassment are being adopted by health care organizations. Yet women in gynecology have remained remarkably quiet, despite being part of the first majority women surgical specialty.
To retain the value of our field, we must acknowledge that “women’s work” or not, medicine is medicine and surgery is surgery.
Sarah M. Temkin, M.D., is a gynecologic oncologist who works in Maryland.