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ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 4  |  Page : 282-286
 

Challenges and gender-based differences for women in the Indian urological workforce: Results of a survey


1 Department of Urology and Renal Transplant, Kasturba Medical College, Manipal, Karnataka, India
2 Department of Urology, Institute of Nephro Urology, Bengaluru, Karnataka, India

Date of Submission07-May-2022
Date of Decision04-Jul-2022
Date of Acceptance13-Sep-2022
Date of Web Publication1-Oct-2022

Correspondence Address:
Arun Chawla
Department of Urology and Renal Transplant, Kasturba Medical College, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iju.iju_143_22

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   Abstract 


Introduction: Entry of women into urology has not kept pace with that in other surgical branches with only 1% of Urological Society of India (USI) members being female. The objective of this study was to explore the personal and professional challenges, practice barriers, and level of satisfaction among female urologists/urology trainees in India.
Methods: A strictly confidential and anonymous 26-item questionnaire with respect to professional and personal challenges, workplace discrimination, and family satisfaction was circulated as a Google form through email and WhatsApp to all the female members of the USI (full and associate) and trainees (n = 48) based on identification from the USI directory.
Results: Thirty-three out of 48 female urologists responded (68%). Among the respondents (n = 33), majority had <5 years of experience (60.6%), of which 30.3% were residents, which reflected a recent surge in women joining urology. Majority (57.7%) chose to subspecialize, commonly in “female urology”. Many (72.7%) were encouraged to take this subspecialty. Gender discrimination at workplace was reported by 54.5%, commonly by patients and consultants. 68% of respondents had conceived either before or during residency, leading to additional domestic responsibilities. 9.1% suffered a pregnancy-related complication, which they believed was a direct consequence of their work environment. These obstacles led to 30.3% of women reporting that their personal life had compromised their careers. Professional dissatisfaction was reported by 60.1% of women, with common causes being less operative time than male counterparts and lack of mentorship. Despite these challenges given a chance, 78.7% would choose urology again, and 66.7% would encourage their daughter to pursue a career in urology.
Conclusion: Professional and personal challenges as perceived by women responding to our survey include gender discrimination in training and work, lack of mentorship, pregnancy-related compilations, and compromised career due to family responsibilities. Despite these, most would choose this specialty again.



How to cite this article:
Pandit SR, Venugopal P, Keshavamurthy R, Chawla A. Challenges and gender-based differences for women in the Indian urological workforce: Results of a survey. Indian J Urol 2022;38:282-6

How to cite this URL:
Pandit SR, Venugopal P, Keshavamurthy R, Chawla A. Challenges and gender-based differences for women in the Indian urological workforce: Results of a survey. Indian J Urol [serial online] 2022 [cited 2022 Dec 1];38:282-6. Available from: https://www.indianjurol.com/text.asp?2022/38/4/282/357715





   Introduction Top


The entry of Indian women in the medical profession took place only after 1880, Dr. Anandibai Joshi being the first to graduate with a degree in Western medicine.[1] At present, women constitute 51% of students joining medical colleges, 33% at postgraduate levels[1] with only 2.8% of the members of the Association of Surgeons of India[2] being female, and just a meager 1% of members of the Urological Society of India (USI) indicating a lack of adequate representation in surgery and its subspecialties.

Dr. Lakshmi from Chennai was the first Indian female urologist who qualified in 1970 and eventually retired as a Professor of Urology. Since then, there has been an inconsistent rise in female Indian surgeons opting for urology, probably due to a unique set of challenges that they commonly encounter. To minimize this wide gender gap, it is important to understand the issues that might discourage women to opt for urology. Our aim was to explore the current trends of practice, satisfaction level, and personal and professional challenges experienced by the Indian female urological workforce.


   Methods Top


A review of world literature highlighting challenges faced by female urologists was done, and a 26-item questionnaire was designed focusing on their personal and professional experiences [Supplementary Table 1][Additional file 1]. Due to the paucity of Indian data on this subject, evidence from the Western literature was extrapolated with modifications to suit the Indian scenario. After approval from the Institutional Ethics Committee (IEC: 535/2021), strictly confidential and anonymous questionnaire was circulated as a Google form through email and WhatsApp to all the female members of the USI (full and associate) and trainees (n = 48) (USI Directory, May 2021). The survey consisted of multiple choice and open-ended questions, none of which were mandatory.

Demographic data were collected as a categorical or continuous variable where appropriate. Personal and professional obstacles faced were posed as yes/no questions with space for clarification if needed. Questions on satisfaction were presented on a Likert scale, while the main source of dissatisfaction and workplace discrimination was offered as a list of options with space for the participant to add additional replies if desired. As a final question in the survey, participants were invited to share their experiences or add an additional comment.

Demographic data was evaluated using descriptive statistics included academic title, fellowship or specialization training completed, number of years in practice, marital status, number of children, and professional title at the time of the first child. The Chi-square test was used to compare categorical data that had numerical values and percentages. For a two-tailed comparison, P < 0.05 was used to indicate statistical significance. Statistical analyses were performed using the Statistical Package for the Social Sciences, Version 23 (SPSS-23, IBM, Chicago, IL, USA).


   Results Top


Thirty-three out of 48 female urologists (68.75%) responded to the questionnaire, with all participants answering all the questions. The demographic data and details on career satisfaction and professional attributes are summarized in [Table 1] and [Table 2], respectively.
Table 1: Demographic data

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Table 2: Professional satisfaction

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Gender discrimination at work

More than half (54.5%) of the women sensed gender discrimination [Table 3] either from patients and their relatives, male colleagues, and/or nursing and paramedical staff. Respondents perceived that patients tend to take male doctors more seriously and look to them for affirmation. Mentors prefer to assign complex surgeries to male counterparts, while women are assigned simpler and less challenging cases. A general observation is a senior taking over at the slightest difficulty during operating, while it is not so for when a male is operating. Peers and juniors were observed to constantly take a second opinion from male colleagues.
Table 3: Gender discrimination in the workplace

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Challenges in personal life

Most women were married (n = 26) (78.8%) with children (n = 22) (66.7%), having had their first child before joining residency (n = 11). 50% reported taking maternity leave of 6.1 months, ranging from no leave to 15 months. Three women (9.1%) reported a pregnancy-related complication that they believe was triggered by their work. Ten (30.3%) women believe that their personal and family life has compromised their career and work potential, while 11 (33.3%) women feel that their career had compromised their personal and family life. Challenges include less time for research, delay/inability to join fellowship programs, managing family responsibilities while spouse is working, carrying work home, inability to devote time to family and resultant conflicts, and difficulty in finding marriage prospects.

Would you choose urology again or encourage your daughter to take up urology?

Given a chance, most women (78.7%, n = 26) would choose urology again, while 3% (n = 1) stated that they would choose a different surgical specialty, and 18.2% (n = 6) reported that they would choose a career outside of medicine. 66.7% (n = 22) of the respondents stated that they would encourage their daughter to pursue a career in urology. Women who stated that they were given less opportunity to assist/operate/learn compared to their male counterparts were more likely to not choose urology again if given the opportunity (P = 0.001). Women who faced workplace discrimination were more likely to dissuade their daughters from taking up a career in urology (P = 0.0001).


   Discussion Top


Women have been underrepresented in urology compared to other surgical specialties, with only neurosurgery and orthopedics having a lower percentage of female attending physicians.[3] Compared to the USA (9.2% practicing female urologists and 26.3% of female urology residents)[4],[5] and Canada (11.2% female urologists),[6] India ranks low with only 1% of female members (practicing urologists and residents) in USI. The wide gender gap persists in the urological workforce, despite reaching parity with respect to the number of women entering medical training. To find an explanation, this first-ever nationwide survey was carried out to identify the personal and professional challenges faced by women and suggest solutions for the same.

Only two among the 33 respondents had the title of “professor,” and two-third were in the field for <5 years, indicating that women have only recently begun to enter this male-dominated field. This is comparable with world data reporting only 5% of women reaching the rank of “professor.”[7] In India, this discrepancy is more pronounced in the private sector compared to the public sector where promotions would be gender-neutral.[8] Among the respondents who were in an institutional practice for more than 20 years (n = 5), two attained the rank of “professor.” Overtly confident and outgoing behavior of women is traditionally not well accepted by the society, probably causing difficulty in the promotion of enterprising women or women themselves underperforming to avoid social aversion.[9] These factors with the fear to experience backlash or stereotype threats prevent deserving women to excel and attain leadership positions.[10] This, in turn, also deprives female trainees of strong female mentors. It is crucial for young women to be able to find mentors who have previously faced similar hurdles and can offer support and direction in overcoming obstacles, thereby providing additional professional advancement.[11]

Female trainees are motivated to emphasize more on 'female urology' during their training irrespective of their inclination. Twenty-four (72.7%) practicing women in the survey reported domination of 'female urology' subspecialty in their current clinical practice, which could be attributed to the encouragement from peers and seniors during their residency. Conversely, if they do not want to treat a bigger proportion of female urology patients, they may pursue fellowship training in the hopes of being able to tailor the patient group.[12] Andrology and uro-oncology are male-dominated subspecialties, whereas female and pediatric urology have traditionally been considered common among female urologists,[13] as also seen in our survey where none of the women have subspecialized in andrology (Supplementary Table 2)[Additional file 2].

Incidentally, the childbearing age group (20–30 years of age)[14] coincides with surgical and urological training. Ionizing radiation from fluoroscopy and general anesthesia gases have theoretical teratogenic potential. These factors with difficult long working hours and advanced maternal age due to prolonged education, increase risk for pregnant urologists. A similar survey conducted on female urologists in the USA revealed a 25.3% risk of pregnancy-related complications.[15] In our survey, this risk appeared to be lower (9.1%, n = 3) with infertility (n = 2) and threatened preterm labor (n = 1) being the common complications. This means that employers have to be considerate for working hours and strict adherence to ALARA principle and ensuring women are well supported.

In our survey, women expressed that the greatest source of professional dissatisfaction was having less operative work compared to their male counterparts; the reason for this could be multifactorial. Irrespective of their seniority and experience, women are observed to have comparatively lesser surgical referrals.[12] These implicit gender biases and the time-off taken for childbirth have led to decreased operative work compared to male urologists. 'Pigeonholing', that is being assigned to an overtly restrictive category, could be due to the societal enforced norm to pursue female urology, despite other interests which leads to career dissatisfaction.

Gender bias, like in other specialties, affects the salary and a wide wage gap exists between male and female urologists. In 2016, a survey conducted in collaboration with the American Urologic Association found a mean salary difference of $81,578 with female urologists being underpaid compared to male counterparts, despite controlling for age, work hours, and fellowship training.[16] Four (12.5%) female urologists in our survey believed that they were being underpaid compared to their male counterparts with no obvious differences in the services rendered. This divide maybe absent in the Indian public sector where remuneration is based on promotions and is gender-neutral.[8]

In this survey, more than half of the respondents reported discrimination by their consultants, seniors, colleagues, and juniors in the form of being denied the opportunity to operate more complex cases compared to male counterparts, being perceived as incapable of handling intraoperative difficulties, seniors relying more on the clinical findings of a male colleague compared to them, condescending and indifferent colleagues, and insubordinate behavior by juniors due to their gender. Women who enter this field have all suffered subtle forms of emotional or psychological attacks, better labeled as “micro aggressions.”[12] Most women (n = 27/81.8%) reported to have been declined examination by a patient due to their gender. Female physicians are less likely to be addressed as “doctor” in rounds and are often mistaken as nurses.[17] In a large survey of surgical residents, 65.1% reported some form of gender discrimination and 19.9% reported sexual harassment.[18] In this survey, 12.1% (n = 4) of women reported facing some form of sexual harassment at the workplace. Women have reported to have adapted to this discrimination and learned to ignore inappropriate and offensive remarks to conform to the workplace environment.[19] These patterns suggest a resigned acceptance of the status quo, which is deeply rooted in the patriarchal society. The presence of zero-tolerance policies laid down not only by the institution but also by the government should encourage favorable trends in ensuring gender equality.

The struggle of the gender divide continues at home with the additional workload of domestic and childcare responsibilities.[11] These discrepancies persist even among high-achieving career-driven women. According to a survey, a woman physician–scientist with an employed partner spent an average of 8.5 h more per week on domestic activities and childcare than their spouses and were more likely to be assigned to take time-off amid interruptions of the customary childcare arrangements.[20] The stress gap, which highlights the emotional and physical toll women incur, has resulted from the added domestic work in family and home-care tasks on top of professional commitments. Majority of women also were faced with the opposite scenario where they felt that they were unable to devote time to their children due to their work schedule and felt solely responsible for the same. While it may be difficult to change predefined societal norms and cultural biases in our country, we can improve work-life integration by including policies on paid parental leave and on-site childcare.

The choice of the specialty of a female medical graduate is greatly influenced by the opportunities and challenges faced by women in this field. Female urologists who reported fewer opportunities to assist or learn during their training compared to their male counterparts were less likely to choose urology again. Women who faced gender discrimination were more likely to dissuade their daughters from entering urology. This means that a woman who has faced multiple challenges in this particular field is more likely to dissuade other women from joining, and that may explain the immense gender gap.

Compared to other surgical subspecialties, urology offers a diverse practice while also allowing a more flexible lifestyle. Change starts by first identifying that gender-based differences and challenges exist, and actively working toward rectifying these inherent biases. Social media platforms have been pivotal to change the public perception by movements such as #ILookLikeASurgeon, #IlookLikeAUrologist, and @manelWatch. The “HeForShe” track was designed by the University of Michigan Women's Surgical Collaborative to highlight the strategies used by female surgical trainees to navigate a traditionally male-dominated field and to offer suggestions for how our male colleagues might help achieve gender parity.[21] In urology, organizations such as the “Society for Women in Urology” and the “Women in Urologic Oncology” encourage women to network in conventionally male-dominated fields, increase their members' visibility for promotion and leadership opportunities, and bring women together at all stages of their training and careers to find mentors and colleagues.

There are limitations to the current study. The USI directory lacks division of members as per their gender, and only minimal information could be extracted from the zonal directory. As a result, the current sample size may not represent the true USI female community. Our small sample size reflects the meager number of female urologists in India and is a study limitation. Furthermore, lack of a control sample from other specialties and from males may leave some room for doubt regarding the uniqueness of these findings to urology and to the female gender. The questionnaire used in the survey was extrapolated from the western literature and was modified to suit the Indian scenario, and thus is not a validated questionnaire. This survey kick-started a thought process for this under-discussed topic and requires further qualitative studies for an in-depth understanding of the challenges faced by women in the urological workforce.


   Conclusion Top


This first-of-its-kind survey conducted for women in the Indian urological workforce has helped us understand the challenges and obstacles faced by women. Professional and personal challenges for women gathered from this survey include gender discrimination in training and work, lack of mentorship, pregnancy-related compilations, and compromised career due to family responsibilities, in spite of which given a choice, many would not reconsider changing their specialty and would encourage their daughters to take up the same. Policy revisions focusing on gender neutrality and organized programs offering an equal surgical opportunity to all, and merit-based promotions would help in establishing equilibrium and encouraging women to take up this specialty.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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