World J Surg (2021) 45:1409–1422

https://doi.org/10.1007/s00268-021-05974-z

SCIENTIFIC REVIEW

Gender-Based Microaggressions in Surgery: A Scoping Review

of the Global Literature
Holly N. Sprow1,9,11 • Nathaniel F. Hansen1,9 • Hannah E. Loeb1,9 • Caroline L. Wight1,9 •
Rolvix H. Patterson2,9 • Dominique Vervoort3,9 • Eliana E. Kim4,9 • Raphael Greving5,9 • Adelina Mazhiqi6,9 •

Kathryn Wall9 • Jacquelyn Corley8,9 • Emily Anderson10,9 • Kathryn Chu7

Accepted: 10 January 2021 / Published online: 11 February 2021

 Société Internationale de Chirurgie 2021

Abstract
Background In addition to systemic gender disparities, women in surgery encounter interpersonal microaggressions.
The objective of this study is to describe the most common forms of microaggressions reported by women in surgery.
Methods We conducted a scoping review using PubMed/MEDLINE, Ovid, and Web of Science to describe the
international, indexed English-language literature on gender-based microaggressions experienced by female sur-
geons, surgical trainees, and medical students in surgery. After screening by title, abstract, and full-text, 37 articles
were retained for data extraction and analysis. Microaggressions were analyzed using the Sexist Microaggression
Experience and Stress Scale (MESS) framework and stratified by country of origin.
Results Gender-based microaggression publications most commonly originated from the United States (n = 27
articles), Canada (n = 3), and India (n = 2). Gender-based microaggressions were classified into environmental
invalidations (n = 20), being treated like a second-class citizen (n = 18), assumptions of traditional gender roles
(n = 12), sexual objectification (n = 11), assumptions of inferiority (n = 10), being forced to leave gender at the door
(n = 8), and experiencing sexist language (n = 6). Additionally, attendings were more frequently reported to
experience microaggressions than surgical trainees and medical students, but more articles reported data on
attendings (n = 16) than surgical trainees (n = 10) or students (n = 4).
Conclusion While recent advancements have opened the field of surgery to women, there is still a lack of female
representation, and persistent microaggressions may perpetuate this gender disparity. Addressing microaggressions
against female surgeons is essential to achieving gender equity in surgical practice.

6
Ängelholm Hospital, Landshövdingevägen 7E,
& Holly N. Sprow
262 52 Ängelholm, Sweden
holly.sprow@tufts.edu
7
Centre for Global Surgery, Department of Global Health,
1
Tufts University School of Medicine, 145 Harrison Ave, Stellenbosch University, Tygerberg 7505, South Africa
Boston, MA, USA 8
Department of Neurosurgery, Duke University Medical
2
Department of Head and Neck Surgery & Communication Center, 2301 Erwin Rd, Durham, NC, USA
Sciences, Duke University Medical Center, 2301 Erwin Rd, 9
Gender Equity Initiative in Global Surgery, 641 Huntington
Durham, NC, USA
Avenue, Boston, MA, USA
3
Johns Hopkins Bloomberg School of Public Health, 615 N. 10
Department of Neurosurgery, Tufts Medical Center, 800
Wolfe St, Baltimore, MD, USA
Washington Street, Boston, MA, USA
4
University of California-San Francisco School of Medicine, 11
365 Washington St, Brighton, MA 02135, USA
533 Parnassus Ave, San Francisco, CA, USA
5
Gießen School of Medicine, Justus-Liebig-University,
Ludwigstraße 23, 35390 Gießen, Germany

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1410
Introduction
The number of women in medicine is increasing. In 2017,
women constituted 35% of the active physicians in the United
States (US), compared to 28% in 2007 [1, 2]. Additionally,
2019 was the first year that women comprised the majority
(50.5%) of US medical students [3]. Despite these advance-
ments, there remains a significant disparity in the number of
women who specialize in surgery. Studies have indicated that
females represent only 36% of general surgery trainees in the
US [4]. Strikingly, this percentage is even lower in US aca-
demic surgery, where women account for only 21.5% of
surgical faculty [5]. These disparities are reflected in US
surgical leadership, with only 22.7% of women surgical
faculty holding full professorship compared to 41.2% of men
[5]. Furthermore, women are half as likely to be academic
division leaders [5], and these gender disparities in surgery
are also pronounced in other countries. In 2012, only 19.7%
of physicians in Japan were female [6]; there were fewer
female physicians in senior academic positions, and they
were tenured less frequently. Additionally, there were no
females with the rank of ‘‘professor’’ within the fields of
gastrointestinal surgery, thoracic surgery, cardiovascular
surgery, and pediatric surgery [7]. Similar trends have also
been shown in both the U.K. and Australia, where less than
12% of surgical positions are occupied by women [8, 9].
Women may not pursue a surgical profession for several
reasons including being deterred by the perception of surgery
as a ‘‘boy’s club [10].’’ Gender role expectations and dis-
crimination, in both explicit and subtle forms, are pervasive
in the culture of surgical training and serve as major barriers
for women navigating their surgical careers. In many coun-
tries, there are processes to protect against gender discrimi-
nation on a systemic level; however, subtle forms of
interpersonal discrimination, or microaggressions, are still
commonplace [11]. Over the past decade, the volume of
literature on gender inequity in surgery has increased, but
there remains a limited understanding of gender-based
microaggressions in surgery. Therefore, the purpose of this
scoping review is to characterize the existing international
literature on gender-based microaggressions. Because sur-
gery remains a male-dominated profession in many coun-
tries, we hypothesize that gender-based microaggressions
are common across levels of training.
Materials and methods
Literature search
The overarching literature search queried PubMed/MED-
LINE, Ovid, and Web of Science through May 1, 2019
using the terms reported in Appendix. The search terms
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World J Surg (2021) 45:1409–1422
were determined with the assistance of a medical librarian.
This search produced 7382 articles regarding women
working or training in surgery, obstetric, and anesthesia
specialties as informed by the American College of Sur-
geons: general surgery, obstetrics and gynecology
(OBGYN), neurological surgery, ophthalmic surgery, oral
and maxillofacial surgery, orthopedic surgery, otolaryn-
gology, plastic surgery, urology, and anesthesia [12]. The
articles from this overarching literature search used a
search strategy that facilitated several scoping reviews on
gender equity in surgery. This study presented here was
limited to surgeons and did not include related profes-
sionals such as anesthetists or obstetricians.
Screening
Title and abstract screening (by RP, DV, EK, LM, RG,
AM, KW, CJ) narrowed the field to 798 articles. Using the
inclusion and exclusion criteria for the scoping review, 557
articles on gender bias, inequity, or disparities were
included after full-text review. A second round of screen-
ing focused on microaggressions, and 109 articles were
chosen that presented data on experiences of interpersonal,
micro-level discrimination such as mistreatment, sexual
harassment, and inequitable evaluations (Table 1). Subse-
quently, the additional inclusion and exclusion criteria
specifically related to microaggressions were applied
independently by at least two authors per article (by HS,
NH, HL, CW, RP) to further refine the search to ‘‘mi-
croaggressions’’ in surgery (excluding OB/GYN and
anesthesia), resulting in 37 total articles for extrac-
tion (Fig. 1) [10, 11, 13–48]. See Table 2 for a summary of
included studies.
Data extraction
Full-text extraction was performed on 37 articles. Extracted
data included stage of training of subjects, study countries,
corresponding World Bank Country and Lending Group
classifications [49], and all reported microaggression data
that satisfied the criteria described in the Sexist MESS
framework, a reliable and validated scale to measure
microaggressions among women (see Table 3) [50].
Extracted microaggression data were then categorized into
the seven Sexist MESS themes: being treated like a second-
class citizen, assumptions of inferiority, environmental
invalidations, sexual objectification, assumptions of tradi-
tional gender roles, being forced to leave gender at the
door, and experiencing sexist language. Being treated like a
second-class citizen refers to the idea that men and women
are equally capable, but men are given preferential treat-
ment. Assumptions of inferiority refers to the idea that
women are not as competent as men, both physically and
World J Surg (2021) 45:1409–1422 1411

Table 1 Inclusion and exclusion criteria for microaggressions scoping review

Inclusion Any region or country
Any time period
Pertaining to the field of surgery
Studies or reports with original data or analysis on gender inequality in surgery
Publications including raw data on gender in surgical workforce
Studies that report surgery-related outcomes pertaining to surgeons, trainees, or medical students
Review studies and meta-analyses
English-language articles
Articles that included original data on microaggressions as defined by the seven Sexist MESS thematic categories. See Table 3 for
these categories
Exclusion Case reports
Non-scientific news articles and opinion pieces
Studies that report patient outcomes based on surgeon or surgical trainee gender
Studies that report aggregate physician outcomes not stratified by subspecialty
Studies that report on surgical performance or decision-making by gender
Articles that do not include surgical disciplines
Abstracts without a full manuscript
No full text available
Articles that focus on obstetrics or anesthesia
Articles that do not stratify surgical data from obstetrics or anesthesia data

intellectually. Environmental invalidations are systemic,
macro-level aggressions. Sexual objectification refers to a
women being treated as a sexual object. Assumptions of
traditional gender roles refers to the idea that women
should maintain traditional gender roles. Being forced to
leave gender at the door refers to the idea that women
should leave feminine aspects of themselves outside of the
workplace. Experiencing sexist language is when women
are referred to in a way to is meant to degrade, dismiss, or
humiliate them [50]. Each extraction and categorization
were corroborated through review by a second author.
Discrepancies were resolved by group consensus. Each
article that contained at least one of the above themes was
included. Independently practicing surgeons were referred
to as attendings, consultant surgeons, faculty, or staff
physicians. Postgraduate surgical trainees were referred to
as interns, house officers, residents, registrars, medical
officers working in surgery, and fellows.
Results
Article characteristics
Thirty-seven publications were identified. Thirty-three
articles (89%) were from high-income countries (HICs) as
defined by the World Bank Country and Lending Groups,
and 4 (11%) were from low- and middle-income countries
(LMICs), including India (n = 2), Brazil (n = 1), and South
Africa (n = 1). The number of articles about microag-
gressions against women in surgery increased annually,
with a peak of six articles in 2018.
The Sexist MESS framework was used to categorize
gender-based microaggressions. Descriptions, examples,
and selected quotations to illustrate these microaggressions
are detailed in Table 3. Out of the 37 publications
reviewed, the most common type of microaggression was
environmental invalidations, which was present in 20
articles (n = 20). The other categories of microaggressions
included being treated like a second-class citizen (n = 18),
assumptions of traditional gender roles (n = 12), sexual
objectification (n = 11), assumptions of inferiority
(n = 10), leaving gender at the door (n = 8), and use of
sexist language (n = 6).
The publications were then further stratified by stage of
training. Sixteen (43%) articles described the experiences
of fully trained (consultant) surgeons, while 10 (27%)
focused on postgraduate surgical trainees, 4 (11%) focused
on medical students, and 7 (19%) related to more than one
level of training. Articles that only focused on only one
level of training were further categorized by types of
microaggression (Fig. 2). At the level of a fully trained
surgeon, the most commonly identified microaggressions
were being treated like a second-class citizen (n = 10) and
environmental invalidations (n = 8). For surgical trainees,
the most experienced microaggressions were

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Table 2 Included studies on gender-based microaggression in surgery

Author Research objective Methods Stage of Country Specialty
training

Capek et al. Identify gender-related differences within the field of Quantitative Consultant US Plastics
(1997) plastic surgery Surgeon
Kaur et al. Determine issues facing female private practice and Quantitative Consultant India Oral and Maxillofacial
(2019) academic oral and maxillofacial surgeons Surgeon Surgery
Furnas et al. Identify reproductive outcomes and disparities between Quantitative Mixed US Plastics
(2019) male and female plastic surgeons
Hessel et al. Determine if female residency applicants were asked Quantitative Medical US Medical students
(2017) more illegal questions about family status and student
childbearing than male applicants and compare this
data at community hospitals vs. academic centers,
surgical vs. nonsurgical specialties
Rangel et al. Learn about the experience of childbearing surgical Qualitative Postgraduate US Various surgical
(2018) trainees Surgical subspecialties
Trainee
Mundschenk Compare perceptions of pregnancy during residency Quantitative Postgraduate US Various surgical
et al. across specialties from 2008–2015 Surgical subspecialties
(2016) Trainee
Frohman Understand the issues facing nonwhite women in surgery Quantitative Consultant US Various surgical
et al. Surgeon subspecialties
(2015)
Salles et al. Assess female surgeon psychological well-being and its Quantitative Postgraduate US Surgery
(2016) association to negative gender stereotypes Surgical
Trainee
Thompson- Assess how faculty entrust male and female postgraduate Quantitative Postgraduate US Surgery
Burdine surgical trainees in the operating room Surgical
et al. Trainee
(2018)
Turner et al. Assess experiences of female general surgeons during Quantitative Consultant US Surgery
(2012) pregnancy and childbirth Surgeon
Sanfey et al. Determine sex differences in seeking help under stress Quantitative Consultant US Surgery/Education
(2015) Surgeon
Oancia et al. Determine attitudes towards reporting discriminatory and Quantitative Mixed Canada Education
(2000) abusive acts between different genders and specialties
Huntington Determine what factors are important to orthopedic Quantitative Medical US Orthopedic Surgery
et al. residency applicants, how these factors differ among student
(2014) men, women, and minorities, and the level of
importance placed on different information sources
when creating a match list
Myers et al. Identify gender-based differences in surgical training and Mixed Postgraduate US General Surgery
(2018) its effects on career development of general surgery Surgical
postgraduate surgical trainees Trainee
Kass (2006) Identify barriers to becoming a surgical leader as a Qualitative Consultant US Surgery
woman, key attributes of successful female leaders, Surgeon
and challenges faced by senior female leaders
Rogers Determine the impact of surgical training on lifestyle and Mixed Postgraduate Ireland Various surgical
(2019) parenthood and assess for workplace issues due to Surgical subspecialties, Non-
gender Trainee Surgical Specialties
Bohl et al. Determine the proportion of female orthopedic surgery Quantitative Medical US Orthopedic Surgery
(2018) applicants who are asked illegal questions over student
44 years
Cochran Determine whether or not female surgeons face different Quantitative Mixed US Academic Surgery
et al. barriers to academic careers than their male colleagues
(2013)

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World J Surg (2021) 45:1409–1422 1413

Table 2 continued
Author Research objective Methods Stage of Country Specialty
training

Colletti et al. Determine whether concerns of male and female surgeons Quantitative Consultant US Academic surgery
(2000) at a single academic institution are representative of the Surgeon
concerns faced by the greater population of academic
surgery and academic medicine
Bellodi Determine and characterize the stereotypes that Brazilian Mixed Postgraduate Brazil Surgery and General
(2004) postgraduate medical trainees have towards surgery Surgical Medicine
and general medicine Trainee
Saalwachter Identify the training needs and priorities of male and Quantitative Mixed US General Surgery
et al. female general surgery postgraduate surgical trainees
(2005)
Schroen et al. Showcase the different professional experiences of men Quantitative Consultant US Academic General
(2004) and women in academic general surgery, particularly Surgeon Surgery
academic productivity and leaving academia
Umoetok Determine how female registrars perceived the impact of Quantitative Postgraduate South Various surgical
et al. gender on surgical training and practice Surgical Africa subspecialties
(2017) Trainee
Fassiotto Explains how gender expectations affects evaluations of Quantitative Consultant US Various surgical
et al. surgical trainees Surgeon subspecialties
(2018)
Kawase et al. Determine how female surgeons maintain a work-life Quantitative Consultant US / Japan Various surgical
(2012) balance in different work environments and cultural Surgeon / Hong subspecialties
settings Kong
Seemann Explore career satisfaction and potential for advancement Quantitative Consultant Canada Various surgical
et al. for women in academic surgery Surgeon subspecialties
(2016)
Radunz et al. Investigate the career goals of female general surgeons as Quantitative Consultant Germany General surgery
(2017) well as their priorities for their lifestyle and family Surgeon
planning in a German liver transplant facility
Zutshi et al. Investigate gender differences of job perception in Quantitative Consultant US Colorectal surgery
(2010) general surgery by colorectal surgeons Surgeon
Bruce et al. Determine female perception of gender-based Quantitative Mixed US All surgical
(2015) discrimination in surgical training subspecialties
Saurabh et al. Determine work-family balance, personalities, and types Quantitative Consultant India Ophthalmology
(2015) of practice patterns of ophthalmologists in India Surgeon
Webster Determine the role of gender in advancing a woman’s Qualitative Consultant Canada Various surgical
et al. academic career Surgeon subspecialties
(2016)
Friedman Evaluate gender-based differences in recommendation Quantitative Medical US OHNS
et al. letters to otolaryngology-head and neck surgery student
(2017) residency programs
Rostami Determine whether there have been any changes in Quantitative Mixed US Oral and maxillofacial
et al. characteristics attracting women to the field of oral and surgery
(2010) maxillofacial surgery since 1994
Scully et al. Define how maternity leave affects physician-mothers Quantitative Consultant US Mixed physicians
(2017) personally, professionally, and financially and how Surgeon
maternity leave affects career satisfaction on a national
scale in both procedural and nonprocedural fields
Lerner et al. Determine satisfaction of timing of pregnancy among Quantitative Consultant US Urology
(2010) female urologists as well as characterize maternity Surgeon
leave and breastfeeding practices
Colvin et al. Determine the usefulness and reception of Quantitative Postgraduate US General surgery
(2018) professionalism and social competencies training Surgical
among first-year postgraduate surgical trainees Trainee

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Table 2 continued
Author Research objective
Hill et al. Explore the narratives of female surgeons and their
(2015) journey to accept themselves as surgeons
* ‘‘Consultant surgeon’’ refers to attendings, faculty, or staff physicians. ‘‘Postgraduate Surgical Trainee’’ refers to interns, house officers,
residents, registrars, medical officers working in surgery, or fellows
environmental invalidations (n = 5), assumptions of infe-
riority (n = 4), and assumptions of traditional gender roles
(n = 4). For the medical student, the most common
microaggression experienced was environmental invalida-
tions (n = 3).
Environmental invalidations
Across all publications, we found that 20 addressed envi-
ronmental invalidations, which were defined as systematic
or environmental-level aggressions that create a perception
that women do not belong in surgery [11, 13, 16, 18, 19,
22, 25, 26, 28, 29, 31, 35, 37, 38, 40, 41, 43, 44, 46, 48].
These environmental invalidations created barriers to entry
into surgical professions. One study found that 68% of US
female medical students applying to residency programs
eliminated prospective surgical training programs based on
the perception of gender bias, particularly if the program
was known not to accept females’ applicants [44]. Addi-
tionally, female students also experienced explicit bias,
where one study from the US reported that an applicant
was told that women were only interviewed to meet a quota
with no intention of actually hiring women [26]. Despite
knowing that systems to report bias in the interview pro-
cess were in place, US female medical students said that
they were unlikely to report negative experiences related to
gender bias for fear of being labeled a ‘‘whiner’’ and
jeopardizing their candidacy for a residency position [26].
Additionally, microaggressions around motherhood
were reported by female surgeons. Pregnant women and
mothers frequently experience environmental invalidation
through lack of guidance from mentors who have experi-
enced pregnancy [31], poor maternity leave policies [29,
35], or inadequate designated time and space for breast
pumping [35]. Women were forced to make up call days
that they missed during maternity leave, often having to
choose between their family or their career [31]. Further-
more, women often cited lack of female mentorship [11,
19, 31, 37, 38, 40, 46], unequal pay for equal work [18, 29,
41], and poor opportunities for career advancement [11, 13,
18, 19, 22, 28] as environmental invalidations for women
in surgery.
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World J Surg (2021) 45:1409–1422
Methods Stage of Country Specialty
training
Qualitative Mixed United Surgery
Kingdom
Being treated like second-class citizens
The experience of being treated like a second-class citizen,
or behavior suggesting preferential treatment to men, was
reported in 18 publications [11, 18, 21, 24, 26–29, 32,
34–38, 41, 45, 46, 48]. In the US, women described not
having their opinions as valued during executive decisions
compared to male colleagues [18]. Additionally, US female
surgical trainees reported having to outperform their male
colleagues to receive the same respect [38], and 56% of US
women reported that they were held to higher standards
than men to achieve academic promotion [18, 28].
Outside of the operating room, US female postgraduate
surgical trainees reported being introduced to patients by
their first name while men were referred to by professional
titles [11]. One female surgical trainee explained that this
‘‘automatically tells the patient that I am in a position of
less authority. It tells the patient not to trust me as much
and that I do not know as much [11].’’ US female surgeons
also reported that operating room nurses gave more respect
to male attending surgeons [18] and in the US, female
postgraduate surgical trainees were asked ‘‘when the doctor
will arrive,’’ even after introducing themselves as a doctor
[11].
Assumptions of traditional gender roles
Twelve studies described experiences with assumption of
traditional gender roles related to career plans, personality,
residency applications, and leadership by women in sur-
gery [11, 13–15, 19, 21, 23, 26, 31, 33, 41, 47]. Canadian
women fully trained surgeons reported that medical stu-
dents and postgraduate surgical trainees expected them to
be nurturing, and that speaking in a stern tone was per-
ceived as offensive [13, 26].
Assumptions of traditional gender roles were prevalent
in US postgraduate surgical training as well. During the
residency application process, women applying for US
orthopedic residency reported being told they should con-
sider a field more suited to women like obstetrics or family
medicine [26]. This does not seem to have improved over
time; publications from 1971 to 2015 reported identical
World J Surg (2021) 45:1409–1422
Fig. 1 Study selection process
rates (67%) of inappropriate questions asked during US
orthopedic surgery residency interviews [26]. Once in US
residency training, many male colleagues assumed that
females would only work part time after graduating to get
pregnant or raise a family [11]. One US resident reported
that the chair of the department negatively stigmatized
pregnancy and frequently made comments about buying
birth control for all the female residents [31].
Sexual objectification
Eleven studies documented sexual objectification which
was most commonly experienced as sexual harassment or
gender-based bullying [14, 26, 29, 30, 32, 36, 38, 40, 42,
45, 47]. In a study of Indian surgeons, 12.4% of females
(compared to 1.7% of their male counterparts) reported
1415
encountering physically uncomfortable situations or ges-
tures at work that were related to their gender [30]. Like-
wise, a study of US female surgical trainees reported that
36% of women were subjected to sexually inappropriate
comments or behavior compared to 15% of the men [42].
In studies from the United Kingdom, US, India, and
Canada, female surgeons and trainees reported feelings of
unease due to verbal innuendo, sexual gestures, and
physical touch, often from their male colleagues and
superiors [14, 30, 32, 38, 40, 42, 45, 47].
Assumptions of inferiority
Ten studies reported on assumptions of inferiority in terms
of strength and commitment [11, 17, 20, 26, 27, 31, 38, 39,
42, 44]. In studies from Germany and the US, colleagues
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1416
Fig. 2 Sexist MESS microaggression stratified by stage of training
and program leaders believed that female surgeons were
not physically strong or mentally resilient enough to be
effective surgeons [17, 38]. One female orthopedic surgeon
recalled being asked by a male interviewer during a post-
graduate interview in the US, ‘‘‘Are you strong
enough?…Women don’t belong in orthopedics’ while her
arm was squeezed [26].’’ Furthermore, US female surgeons
reported assumptions of inferiority related to their preg-
nancy, including the inability to ‘‘keep up’’ with expecta-
tions and a presumed lack of commitment [31].
Microaggressions were inflicted by patients as well.
Brazilian female surgeons reported that they were assumed
to be a nurse unless explicitly introduced as a surgeon [40].
Being forced to leave gender at the door
There were 9 studies that reported on leaving gender at the
door [11, 14, 19, 29, 31, 36, 38, 42, 47]. This included
reports that women were told they would not fit into the
‘‘old boys club’’ of surgery [38] and that women felt the
need to adjust their physical appearance to fit in [14]. One
US female consultant surgeon recalled, ‘‘Surgery is par-
ticularly cruel to individuals who show… non-masculine
communication patterns [36].’’ Women felt that they must
leave feminine aspects of themselves at home, with one
woman from the US reporting that she ‘‘tried to avoid
looking or acting like a sexual object’’ [14], and another
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World J Surg (2021) 45:1409–1422
woman from the United Kingdom stating that she had to
‘‘become a man in a man’s world [47].’’
Furthermore, microaggressions affected female sur-
geons’ perceptions on family planning; for example, in the
US, coaching about the negative effects of pregnancy on
women’s careers had the ability to induce reticence about
becoming pregnant [51]. A study of South African surgical
trainees reported that women are often not taken seriously
once they become pregnant [19]. This causes some women
to feel like they must leave gender at the door by delaying
pregnancy, an idea that is underscored by reports in the US
where the age at first pregnancy for thoracic surgeons was
nine years later than the national average [51] and that US
urologists were ten times more likely to use assisted
reproductive technology [35, 51].
Experiencing sexist language
Six studies described instances of sexist language [11, 19,
29, 31, 38, 41]. Women were the recipients of lewd com-
ments made in the operating room, which one US female
postgraduate surgical trainee interpreted as her colleague’s
attempt to ‘‘assert their authority or develop some sort of
power structure in the operating room to say ‘I am in
charge.’’’[14] Women in South Africa and the US were
also subject to defaming statements and abusive language,
often made by male consultant surgeons [19, 31].
World J Surg (2021) 45:1409–1422
Table 3 Themes, descriptions, and examples of sexist microaggressions
Theme Description Example
Sexual ‘‘A woman is treated as a sexual Witness or experience sexual
objectification object’’ [50] harassment by a physician-teacher
Inappropriate touching or comments in
the operating room
Being asked sexually explicit questions
Second-class ‘‘A woman is overlooked and/or a Women felt that they were held to
citizen man is given preferential higher standards for academic
treatment’’ [50] advancement or career promotion
Female students and residents were not
given equal training opportunities as
their male counterparts
Assumptions of ‘‘A woman is assumed to be less ‘‘All residents, surgical or otherwise,
inferiority competent than a man’’[50] perceived the general public to
believe that men are better surgeons
than women’’[20]
‘‘55.6% of female residents compared
to 8.3% of male residents
experienced physicians disregarding
their credentials.’’[11]
Assumptions of ‘‘An individual assumes a woman Assuming women will only work part-
traditional should maintain traditional time after residency to raise a family
gender roles gender roles’’[50] Experiencing chauvinistic attitudes
from male surgeons
‘‘50% of respondents were told that
surgery is not for females’’[19]
Use of sexist ‘‘Language is used to degrade, Discussion of sexual discourse in the
language dismiss, or humiliate women’’ OR
[50] Defaming statements spoken by male
registrars
Experiencing negative comments about
one’s sex
Environmental ‘‘Macro-level aggressions that Resentment towards pregnant female
invalidations occur on systemic and residents or poor maternity leave
environmental levels’’[50] policies
Lack of female mentors
Exclusion of women from networking
events
1417
Quote
‘‘So a nice silk shirt, and as I rushed in, you
know, with my, you know, really nice,
really like crisp kind of… and he just
stared at my, my chest and said, er, ‘Oh
cold out there, is it?’ I just thought, that’s
my boss and he can’t even hold it in, you
know. And he, he… just, you know, and
I’m still referring him patients; he’s still in
the same neck of the woods.’’ [47]
‘‘There is incredible discrimination from
attendings and some residents. I am the
only female in my residency, and the
chauvinism encountered is unbelievable! I
sometimes wonder why they even ranked
females if they truly dislike them in the
program!’’ [38]
‘‘I was...told that they had absolutely no
intention of ever accepting a woman into
their program.’’ [26]
‘‘‘There was a specific instance recently
where another resident called himself
doctor and then introduced me by my first
name. It stood out to me. It was very
noticeable’ -Female, PGY2’’ [11]
‘‘The obvious one is gender prejudice. I am
[petite].... and I was pretty good looking
when I was a young woman and those
actually counted against me, eliciting
comments like ‘oh you are too cute to be a
surgeon’, ‘you got your husband, why
don’t you quit now’, ‘you just are taking a
place that should be occupied by a man’,
and ‘you are too little’, ‘you are not strong
enough’ etc.’’ [14]
‘‘‘Yes, (the introduction of sexual discourse)
in the operating room has happened to me
countless times. I think that part of it is
about power and the aggressor, or
inappropriate person, trying to assert their
authority or develop some sort of power
structure in the operating room to say ‘I
am in charge.’ -Female, PGY5’’ [11]
‘‘At another program, I was blatantly told
that the only reason I was being
interviewed was to meet a quota. At yet
another program I was told I should pick a
better specialty for women like peds or
ob.’’ ‘‘I was...told that they had absolutely
no intention of ever accepting a woman
into their program.’’ [26]
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Table 3 continued
Theme Description Example Quote

Leaving gender ‘‘Women are expected to keep
at the door feminine aspects of themselves
out of a given scenario (e.g.
work, school)’’ [50]
Avoiding acting or looking feminine in ‘‘For the most part I learned to keep a low
the workplace
Women are deterred from surgery as it
is an ‘‘old boys club’’
Women must act like a man in a
‘‘man’s world’’
profile so as to not target myself. I used to
try to make things better in my work
environment; however my observations
were treated primarily as annoyance’’ [36]
‘‘Surgery is particularly cruel to individuals
who show weakness, self-doubt, or non-
masculine communication patterns’’ [36]
‘‘I tried to avoid acting or looking like a
sexual object. The conflict, of course, is
that you know it’s great to feel feminine
and sexual... those aren’t bad things. It’s
just you can’t do it in the workplace. The
message should be you have to look
professional and then beyond that, you...
want some freedom [and].some latitude.’’
[14]
’’Women are not taken seriously, as they
may soon get pregnant’’ [19]
‘‘Good old boys club, left out of the loop,
lack of mentoring, and morale issues—
horrible, but worth it in the end.’’ [38]

Discussion not the sole perpetrators of inequity against women; in fact,

This scoping review highlights a spectrum of microag-
gressions faced by female surgeons, trainees, and medical
students using the previously validated Sexist MESS
framework [52]. Environmental invalidations were the
most common microaggression reported, suggesting that
women in surgery face ongoing microaggressions at the
systemic level. Additionally, women across all levels of
training—female consultant surgeons, residents, and med-
ical students—experienced microaggressions. This pattern
of bias is concerning and has created many barriers to
advancement. Reducing gender-based microaggressions is
essential to achieving gender equity in the surgical field.
Microaggressions can be emotionally challenging for
women in training and create a sense of inequity with male
colleagues. In 2016, 61% of US women were asked inap-
propriate interview questions about relationships and
childbearing compared to only 8% of men [53]. In com-
parison to surgical trainees who do not experience
mistreatment, women in the US who regularly encountered
discrimination and harassment, two examples of microag-
gressions, were more likely to exhibit symptoms of burnout
and suicidal ideation [54].
To achieve gender equity in surgery, people of all
genders must reevaluate their beliefs and actions. Men are
cultural norms about traditional gender roles are deeply
ingrained and subconsciously influence behavior. Research
shows a strong persistence of implicit gender bias despite
efforts to change overtly biased actions and language.
Implicit bias can manifest in microaggressive actions such
as by overlooking women for positions of power or offer-
ing challenging cases to male colleagues who are believed
to be more capable than their female counterparts. This
same bias can also be seen in microaggressive language
such as highlighting nurturing caregiver qualities in letters
of recommendation instead of capacity for leadership. In
order to reduce microaggressions in the surgical workplace,
these actions must be acknowledged as a remaining bastion
of gender inequity, even in professional settings that have
set goals to eliminate such practice. Shifting cultural norms
in surgery will require deliberate action to educate team
members about microaggressions and setting norms to
reduce this behavior; reducing microaggressions is essen-
tial to achieving gender equity.
Surgical leaders can also look to other historically male-
dominated fields that have novel approaches to achieving
gender equity by reducing microaggressions. In business
professions, studies have shown that teams that include
women are more profitable [55] and promote equal
opportunities for advancement in the workplace [56].

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World J Surg (2021) 45:1409–1422
Surgeons should look to this success as inspiration to
advance similar measures within surgery. The field of
surgery must prioritize changes in national and depart-
mental policy, interpersonal interactions, and individual
bias if women can ever be expected to thrive; reducing
these microaggressions is essential to achieving gender
equity.
Until microaggressions are systematically eliminated,
we encourage women to support one another and to nurture
and advocate for the careers of younger women. Several
initiatives and interventions have been designed to
accomplish this. For example, the United Nations’ move-
ment HeForShe has exhibited that support groups engender
support while encouraging men to reject microaggressive
behavior. Further efforts to advance this cause include
creating hotlines for reporting microaggressions and using
advocacy (e.g., presentations, opinion editorials, etc.) to
raise awareness of the challenges that women in surgery
face.
Strengths/limitations
This study has certain methodological limitations with only
internationally indexed English-language articles in three
databases were referenced, potentially limiting the inclu-
sion of relevant grey literature and articles catalogued in
databases commonly used in LMICs. This limits the gen-
eralizability of our findings. Research on gender-based
microaggressions, particularly in LMICs, must be priori-
tized to better understand its scope and characteristics.
Further, we must acknowledge the unbalanced power
1419
dynamic that frequently surrounds microaggressions and
potential deterrents to reporting, including stigma and fear
of repercussion. This could result in the systematic exclu-
sion of certain countries or environments where the con-
sequences can outweigh the benefits of reporting
microaggressions. Despite these limitations, the strength of
this scoping review is its novel summary of gender-based
microaggressions in surgery and its negative consequences.
Conclusion
Gender-based microaggressions against women in surgery
are a barrier to gender equity in the field. While progress
over the last century in dismantling systemic inequity and
overt gender discrimination against women has opened the
door for more women to pursue careers in surgery, this
study demonstrates that inequity persists in the form of
gender-based microaggressions. This calls on all to work
together to recognize and mitigate these transgressions to
make the surgical workplace a more welcoming environ-
ment for persons of all genders.
Compliance with ethical standards
Conflict of interest None of the authors have conflicts of interest to
disclose.
Appendix: Search strategy and search terms
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World J Surg (2021) 45:1409–1422
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