The history of female surgeons dates back as far as 3500 Before Common Era (BCE). Entombed with the Sumerian queen Shubad of Ur were surgical instruments made of flint and bronze, which have led archaeologists to believe she practiced as an early surgeon [1, 2]. The Queen is not alone; documentation of female surgeons exists in many ancient civilizations. In fact, the abundance of ancient records and artistic depictions of women practicing surgery suggest that female surgeons were relatively commonplace in ancient times. Egyptian records show that there were female students at the medical school of Heliopolis in Egypt as early as 1500 BCE, and detailed portrayals of female surgeons are common on the walls of Egyptian temples and tombs. A small painting of a slave girl operating on a patient has been discovered in a small chapel in Thebes (circa 1420 BCE). The Bible, Talmud, and other Jewish writings provide accounts of Jewish women trained as surgeons, and when the Romans conquered the Greek city-state of Corinth, hundreds of female prisoners were taken to Rome for the slave markets, where women with medical training sold for the highest price [1–3].

One particularly impressive female surgeon of antiquity was Aspasia, a Greek gynecologist (circa fourth century CE). Aspasia’s innovative surgical techniques were compiled by eminent Byzantine physician and medical writer Aeitus in his work the Tetrabiblion (fifth century CE), which served as the main surgical text for the next 600 years [1]. Aspasia developed and performed a variety of surgical operations. Her operation for uterine fibroids was an early form of fibroid surgical excision that was still used in modern times. She also developed a procedure for varicoceles that was – in effect – an open subinguinal varicelectomy, fairly similar to today’s methods. Aspasia’s surgical treatment of hydrocele closely resembles the modern hydrocelectomy, a surgical option still in use today [4].

The formal medical education of women was banned during the Middle Ages, after the fall of the Roman Empire and the rise of the male-dominated Catholic Church. Medical science itself was in a general decline, and most medical care was performed in monasteries. The medical care of the time placed a heavy emphasis on prayer and holy relics, and physical treatments for disease gradually fell out of favor. By the twelfth century, the church had officially banned monks from performing operations. Surgery became the responsibility of tradesmen trained as barbers, and women were generally prevented from practicing surgical procedures unless they inherited the practice from a deceased husband. In the fourteenth century, King Henry VIII decreed “No carpenter, smith, weaver, or woman shall practice surgery” [1]. By the seventeenth century, medicine had become more scientific, but women were still barred from the profession as few women at the time received a formal education [2].

Women in surgery have enjoyed a gradual resurgence in modern times, although they were not always allowed to practice openly. A physician by the name of Dr. James Barry graduated from the prestigious Edinburgh Medical School in 1812 at the age of 17 [3]. After graduation, he joined the British army and served as a surgeon during the Napoleonic wars. Referred to by the moniker “the beardless lad,” Dr. Barry led an illustrious career in the British armed forces. He led public health reform measures in Africa and the West Indies, and is credited with performing the first successful cesarean section in Africa. Over the course of his career, he rose to the rank of Inspector General in charge of military hospitals [5]. During his career there were rumors Dr. Barry was involved in a long term romantic relationship with another man. Upon “his” death, Dr. Barry was revealed to be woman with abdominal findings consistent with a history of pregnancy. After Dr. Barry’s death, a friend commented Dr. Barry “chose to be a military doctor not to fight for the right of a woman to become one, but simply to be one.” [1]

Although male practitioners in colonial America refused to take on female apprentices, women practicing as “doctresses” practiced both medicine and surgery in rural towns prior to the formal establishment of medical schools. The first medical schools established in America refused to admit female students, but by the mid-1800s women began to return to medicine. The first woman to graduate from medical school in the United States was Elizabeth Blackwell, MD. Her initial attempts at gaining admission to medical school were plagued with rejection, and she was denied admission by more than 20 medical schools [1]. Male physicians acquainted with Blackwell and her talents repeatedly advised her to dress as a man, insisting she would be accepted to medical school if not for her gender [6]. Believing women should have the right to openly practice medicine, Blackwell refused to assume a male identity and persisted in her admissions efforts, eventually earning admission to the small Geneva Medical College in New York and graduating in 1849. Dr. Blackwell’s sister, Emily Blackwell followed in her older sister’s footsteps and became the third woman to graduate from an American medical school [6]. The Blackwell sisters were forced to move to Europe for advanced clinical training, as women at the time were unable to obtain clinical experience in the United States [2]. Although it was Elizabeth Blackwell’s ambition to become a surgeon, the loss of her right eye to infection effectively ended her surgical ambitions, and she instead returned to the United States where she would eventually open her own hospital and found America’s first medical school for women [6].

Mary Edwards Walker, MD, was the second woman to graduate from medical school, and the first recognized female surgeon in the United States [3]. Dr. Walker entered into surgical practice with her husband and former classmate, Albert Miller. Their practice was ultimately unsuccessful, and it has been speculated that Dr. Walker’s decision to keep her maiden name and openly practice as a female surgeon contributed to the demise of the couple’s practice [1]. Dr. Walker practiced as a nurse for several years, before enlisting in the military in 1863, where she became the first female surgeon in the United States army [2]. Dr. Walker served in the civil war, and was awarded the Congressional Medal of Honor for her military service. Though the medal was revoked in 1917 – as she had not served on the front lines in battle – it was restored by President Jimmy Carter in 1977. To this day she remains the only female recipient of the Medal of Honor.

Women have made serious advances in the fields of medicine and surgery in the recent past, but 160 years after Elizabeth Blackwell’s graduation from medical school, society is still far from gender parity. Although women now constitute roughly 50 % of American medical students and enter academic medicine as faculty in numbers equal to their male colleagues, women are grossly underrepresented in positions of power and leadership [3, 7]. As of 2011, only 19 % of tenured professors, 17 % of full professors, 12 % of department chairs, and 11 % of deans (A total of 14 deans) were female [7]. If current trends continue, surgical residents will be equal proportions of men and women as early as the year 2028. The same trends, however, indicate that there will not be an equal number of male and female full professors of surgery until the year 2096 [8].

This leadership gap is not limited to medicine or surgery. It was long held that gender parity would be achieved as women entered the workforce in greater numbers. Referred to as the “pipeline effect,” it was believed that women had not been present in sufficient numbers in the professional workforce for long enough to have advanced to senior leadership [7, 9, 10]. It was speculated that as more women entered the workforce they would move along the leadership pipeline, rise through the ranks and take a proportionate share of senior leadership roles. This has yet to happen, despite ample time. Although women have earned more than 50 % of college degrees since the early 1980s, and currently outnumber men in management and professional occupations [7, 10], women make up only 16 % of top executive positions in America’s largest corporations. Only 17 countries in the world (out of 195) are led by women [10]. In the medical field, women are even underrepresented in leadership positions within the specialties dominated by women: for the past 25 years, 50 % or more of psychiatrists, gynecologists and pediatricians have been female, and yet women constitute only 20 % of full professors and 10 % of department chairs within these specialties [7]. As Sheryl Sanberg wrote in Lean In – her Bestselling opus on female leadership – “The blunt truth is that men still rule the world” [10].

Even in a world run largely by men, surgery has long stood out as a particularly male dominated profession. The American College of Surgeons elected its first female chair to the board of regents in 2012, and no woman has ever served as the executive director. The American Surgical Association has only now (2015) elected a female president, and as of 2013 did not have any female council members. Of the eight regional surgical societies, three have never had a female president, and an additional four have had only one [11]. Women in academic surgical departments are ten times more likely to perceive gender discrimination than their male colleagues [12]. One study of 105 medical students indicated that 96 % of female students viewed surgery as “unfavorable” to their gender [7]. Although by 2011 more than a third of general surgery residents were female, only 14 % of full time faculty members were female [12]. Faculty attrition remains substantial, with female surgeons at the assistant professor level being almost six times more likely to report an interest in leaving academia than male colleagues [13].

One study, conducted by Yedida and Bickel, conducted 80 min interviews with medical department chairs, and asked them to discuss the obstacles women face when rising through the ranks of academic medicine. The chairpersons identified three major barriers: traditional gender roles, sexism in the medical environment, and a lack of effective mentors [9].

Adherence to traditional gender roles plays a large part in inhibiting the career advancement of successful women. Sheryl Sandberg notes that “from the moment we are born, boys and girls are treated differently.” Studies have shown mothers will spend more time comforting and coddling female infants while male infants are left to play alone. Similarly, parents will overestimate the crawling ability of male children and underestimate the abilities of female children. In school, teachers interact more with boys and ask them more questions. Boys are more likely to call out answers whereas girls who speak out of turn are chided and reminded to raise their hands without speaking [10]. Women are expected to be submissive, communal, and nurturing, whereas men are held to be strong, independent and action-oriented. These expectations have created a society that drives women towards careers that coincide with these expected traits, including childcare, nursing, and social work, while leaving fields like surgery and engineering dominated by men [7, 9].

The pressure to adhere to traditional gender roles is particularly problematic for female surgeons who aim to balance a career and family life. Women have traditionally been responsible for the majority of housework and childcare, and while male surgeons can often rely on their spouses to take on domestic duties that they are too busy to perform, women are rarely afforded that opportunity [9, 13]. Ninety percent of married female academic surgeons live in a dual career household, whereas only half of their male colleagues have a working spouse [13]. Female academic surgeons without children earn roughly 95 % of the salary of comparatively matched male colleagues, while female academic surgeons with children earned only 75 % the salary of comparative males [7]. Women are aware of this discrepancy, and are more likely to postpone having children until the completion of all surgical training than male colleagues (67 % against 37 %) to compensate [13]. One female medical chair interviewed in the Yedida study asserted: “for many of us as women who got where we were, we got there by delaying our rewards. We got there by not getting married and/or having children while in college or in medical school or even residency” [9]. Female surgeons are far less likely than their male counterparts to marry at all; one survey of 317 academic general surgeons found that 1 in 4 female academic surgeons answered that they had never been married. The never-married rate among male colleagues was only 1 in 25 [13].

Furthermore, academic tenure tracks and senior leadership positions generally require incumbents to work inflexible hours and be willing to relocate geographically. As a result, young mothers who are responsible for the majority of childcare, or who temporarily switch to part time are often at a serious disadvantage. For example, meetings called during off hours often have a larger proportion of male attendees, which leads male faculty to be assigned more responsibilities. Unlike many men, women are often less willing or able to relocate their family, which limits opportunities for career advancement [7, 9, 10].

Sexism – whether conscious or unconscious – has been a major barrier to the success of women in the surgical field. Surgery has long been considered a “boy’s club,” and one survey of medical students found that 54 % of female students reported sexual harassment during their surgical rotation [14]. Sexism is not limited to overt sexual harassment; a perhaps equally detrimental form of sexism is gender discrimination. In one survey of board certified female surgeons, 70 % of respondents indicated that they had experienced gender discrimination. Of the surveyed women, 63 % described being bullied, 29 % were the object of sexist remarks or inappropriate advances, and 42 % reported the presence of sexism and discrimination against women as systematic within the male power structure [14]. Gender discrimination is not always clearly intentional. A common complaint made by female professionals – that is by no means limited to the field of surgery – is that women have less access to the informal networking opportunities that are often necessary for career advancement. Women are rarely invited to social locations like racquetball courts, golf courses and locker rooms where important organizational information and negotiations take place [6]. One study of the gender climate at an academic health center found that 24 % of female faculty members believed informal networking systematically excluded women [15].