Explicit bias refers to the conscious attitudes and beliefs one has about a person or a group. Historical bias against women in surgery is well documented, and women were discouraged and often not permitted to pursue surgical training. For instance, it was not until 1940 when the first woman attained board certification in surgery. At that time, women who graduated surgery residencies were not permitted to sit for the boards.¹⁰ While explicit bias is no longer overtly tolerated within the United States, elements of explicit bias still exist. A recent cross-sectional study assessing explicit bias related to gender and surgery demonstrated the persistence
of certain fixed beliefs.¹¹ Assessment of almost 1 million records from persons who took the Gender-Career Implicit Association Test (IAT) demonstrated a significant association of men with career and women with family. Persons taking the Gender-Career IAT who self-identified as healthcare professionals exhibited more explicit bias than non-healthcare professionals, and all categories of healthcare professionals exhibited this bias. Interestingly, comparison of categories of healthcare professionals demonstrated that those professionals who were diagnosing and treating patients were more likely to explicitly associate men with career and women with family than were nursing and home healthcare assistants and other healthcare support.

Another mechanism by which explicit bias persists is in revelations of the persistence of sexual harassment in the workplace and within academic settings. A recent report by the National Academies of Sciences, Engineering and Medicine demonstrated the persistence of sexual harassment and its extent on negatively impacting recruitment, retention, and advancement of women within STEM (Science, Technology, Engineering, and Mathematics) fields.¹² Other data corroborate this finding. In a sample of 1719 K-award recipient clinician-researchers, 30% of women reported having experienced sexual harassment as compared with 4% of men.¹³ Moreover, women who experienced harassment reported that these experiences negatively impacted their career advancement.

Women in surgical fields are more likely than men to have a partner who is employed full-time and bear family responsibilities such as disruption in childcare disproportionately.^14,15 While not specific to surgery, studies reveal high-achieving women in academic medicine on average spend 8.5 hours more per week on domestic activities than male counterparts.¹⁴ These hours are often at the expense of academic development time and may account for differential achievement. Work-life challenges may also be perpetuated in nonwhite women (e.g., black American, Latino American) who are often alone within their social networks to achieve high socioeconomic status and more likely to rely on network caregiving and economic care.¹⁶

Unconscious assumptions (bias) of traits and behaviors men and women are expected to display form prescriptive gender norms that impact career advancement.¹⁷ Behaviors such as assertiveness and confidence that are traditionally associated with the “model surgeon” and leader are often incongruent with gender role expectations of women and can have significant consequences. For instance, assertive behavior in a woman often has a paradoxical effect where she is perceived to be unlikeable, hostile, and “not leadership material.” Gender norm biases are also believed to perpetuate well-known disparities in salary, start-up packages for new hires, retention packages, and service expectations.^18,19,20 The impact of prescriptive expectations associated with race/ethnicity on gender is largely unexplored in academic surgery but likely very significant. Studies demonstrate that belonging to a group subject to racialization increases the exposure one has to distal stressors such as prejudice, discrimination, and rejection that are then internalized into proximal stressors that may interfere with achievement.²¹

Career advancement in academic surgery is highly dependent on publications, citations, and external research funding, especially from the National Institutes of Health (NIH). Studies demonstrate gender disparity in applicant award probability for R01 external research funding, which is accentuated in minority women.²² When success is achieved, women on average receive less funding and are underrepresented among the top 1% of award winners. In surgery, even when controlling for achievement, gender gaps remain in academic opportunities needed for promotion including editorial board positions and authorship.^23,24,25

There is clear benefit of mentorship on career advancement, yet a lack of same-sex mentors and role models exists for women in academic surgery, and gender-race/ethnicity group matches are likely rare.^26,27 While many women find male mentors within the field, data suggest women may be hesitant to discuss gender-specific issues impeding their advancement with mentors of the opposite gender. Moreover, women in academic medicine are less likely than men to benefit from sponsorship. While mentors provide advice, feedback, and coaching, sponsors advocate in positions of authority and use their influence to help others advance. Studies demonstrate that sponsorship is critical to academic success and to the development of future leaders in academic medicine.

Organizational change toward gender equality in surgery, science, and medicine, broadly, is only part of the broader societal challenge of reducing gender stereotyping of girls and boys and empowering men to embrace gender equality as a goal that also serves their interests.²⁹ Leaders, policy makers, and male colleagues are critical to affecting this change. Inclusive leaders attempt to normalize diversity, not limited to gender.³¹ Consider the following strategies: