Intersectionality: Understanding the Interdependent Systems of Discrimination and Disadvantage

Abstract

The fight for gender equity in surgery extends well beyond the simplistic binary construct of man versus woman. Professor Kimberlé Crenshaw coined the term “intersectionality,” which is used to describe the dynamic associations between the concepts of race, class, gender, and other individualized characteristics and their real-time interaction with one another in our society. Our review of intersectional identities among medical professionals attempts to examine the trends of difficulties at the intersections of an individual's identity within academic surgery, leadership in academic surgery, and the effects on patient outcomes in the United States. Specifically, we will focus on the interaction of race, ethnicity, religion, sexual orientation, family, disability, and international status. Much more research focused specifically on intersectional groups is required to statistically identify to what degree overlapping identities impact professional and patient care outcomes. Recognition of the problem and candid discussions will allow for vast improvements not only in surgical culture, but also in surgical care.

Keywords

diversity - intersectionality - LGBTQ - women in surgery

The fight for gender equity in surgery extends well beyond the simplistic binary construct of man versus woman [Fig. 1]. If this were the case, Black, Indigenous, and Hispanic women would share the same disadvantages as their male counterparts. Intersectionality was first described by Kimberlé Crenshaw in The University of Chicago Legal Forum in 1989 and her analytic framework is currently defined as “the complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups.”[1] [2] In the United States, there is a slight female predominance, 97 men per every 100 women.[3] The current data available from the 2020 United States Census reveal the percentage of White, non-Hispanics in the United States has decreased from 63.7% in 2010 to 57.8% in 2020. During this same period, the Diversity Index, which describes the chances that two persons picked at random would be from different ethnic/racial groups, increased from 54.9 to 61.1%.[4] Unfortunately, the current surgical workforce does not reflect the national trends in diversity, and leadership in surgery is less diverse. This study seeks to explore how intersectionality compounds the discrimination and disadvantage of some women in the field of surgical specialties. We also gained input from Dr. Pringl Miller, founder and executive director of Physician Just Equity (PJE), for testimonial authority on unique examples of intersectionality and the challenges suffered as a result (see Appendix).

Fig. 1 Intersectionality word cloud created by Erin King-Mullins, MD.

Testimonials

We asked Dr. Pringl Miller how she has seen intersectionality affect a physician's ability to participate in the workforce in her experience with PJE. She indicated women who claim intersectional identities are more likely to be subjected to harassment, discrimination, and retaliation, which directly impairs and impedes their ability to function in the workforce. Women with intersectional identities are a vulnerable subset of physicians (and surgeons) who are not afforded due process and the same rights and protections that the White cis male majority command and are privileged to receive. Included below are a few anonymous testimonials from women who sought counsel from PJE:

Medical Student

I'm a fourth-year medical student facing retaliation for reporting sexual harassment. I'm interested in any help you all could provide as well as working to change the culture of medicine into a safer, more supportive environment. (This medical student was dismissed from medical school.)

Resident

I'm a resident physician. I was sexually harassed and subsequently sexually assaulted while operating on a patient, then retaliated against for reporting it. Two independent investigators confirmed mistreatment of women and retaliation by the university, and the ACGME [Accreditation Council for Graduate Medical Education] investigated and sanctioned the program as well as the institution as a whole. However, the university and program refuse to correct my record, seriously harming my chances at matching into fellowship or future employment.

Attending

I am an early career surgeon who is being blocked from working at any US hospital in the country due to discriminatory acts by a former employer.

What Intersections Are the Focus of This Article?

Abelson et al published that at the current rate women will not reach gender parity at the rank of full professors until 2136.[5] In the Association of American Medical Colleges (AAMC) 2017 report, the breakdown of women chairs of surgical departments was as follows: White women 3%, Asian women 0.5%, and no Black or Hispanic women. This statistic underscores how the intersection of race and gender, and undoubtedly other identities, is compounded in the careers of women surgeons as this breakdown does not mirror the ratio of women of these various racial/ethnic groups in surgery, medicine, or society as a whole. As previously stated, Professor Kimberlé Crenshaw coined the term “intersectionality,” which is used to describe the dynamic associations between the concepts of race, class, gender, and other individualized characteristics and their real-time interaction with one another in our society.[6] As a professor at Columbia University and the University of California Los Angeles, Crenshaw drew attention to the variability of personal and professional life experiences from the lens determined by one's position within society. For instance, a Black woman who is trained as a medical doctor, who also belongs to the LGBTQIA+ community, can experience her societal interactions as a Black person, and/or a woman, and/or physician, and/or LGBTQIA+ person in a dynamic fashion, rather than each one existing independently. Crenshaw spent her career bringing attention to important sociological differences among people. In a world messaging of “equality” and “color-blindness,” Crenshaw challenges a society that is ignoring the possibility that equity does not exist due to structural barriers of sexism, racism, and other -isms.

Our review of intersectional identities among medical professionals attempts to examine the trends that demonstrate the difficulties at the intersections of an individual's identity within academic surgery, leadership in academic surgery, and the effects on professional and patient care outcomes. Specifically, we will focus on the interaction of race, ethnicity, religion, sexual orientation, family, disability, and international status.

What Is the Current State of Women with Intersectional Identities in Medicine and Surgery?

[Table 1] provides the demographic breakdown of women in certain surgical subspecialties.[7]

Table 1 Demographic breakdown of women in certain surgical subspecialties

	Ethnicity/race
Specialty	American Indian/Alaska Native	Asian	Black	Native Hawaiian/Pacific Islander	Hispanic, Latino, or of Spanish origin	Multiracial/ethnicity	White	Other	Unknown
Neurological surgery	0	85	15	0	8	28	171	9	2
Plastic surgery (standard and integrated)	0	117	19	0	16	47	283	11	0
Colorectal surgery	0	7	2	0	0	4	27	1	2
Orthopaedic surgery	0	88	30	0	24	61	521	6	8
General surgery	3	801	242	4	211	328	2246	80	62

Source: Adapted from ACGME Data Resource Book.[19]

Race/Ethnicity

The AAMC describes an “underrepresented minority” in medicine as a person from a racial or ethnic group that is underrepresented in the medical profession as compared with their numbers in the general population. This is a simplistic view of this topic. Physicians of African descent who immigrated to the United States after high school do not view themselves so much in racial terms, but rather in terms of their country of origin. It appears the traditional findings related to underrepresented in medicine (URiM) really only pertain to U.S.-born persons. Those born in the United States oftentimes have unique struggles in ascertaining access to education and resources, as well as internalizing certain racial biases, in contrast to those arriving in the United States later than their early developmental stages.[7]

In 2019, there were 15,653 U.S. surgical faculty, including 3,876 women (24.8%), listed in the AAMC faculty roster derived from the Faculty Administrative Management Online User System (FAMOUS) database. Although the longitudinal trend from 2013 to 2019 indicates an increase in the number of non-White women surgeons, this increase was largely due to an increase in people identifying as Asian. The percentage of Black women surgeons remained constant, while Hispanic/Latina women representation decreased, a trend consistent with data from National Institutes of Health (NIH) funding allocation to surgeon scientists, surgical residency acceptances, and graduates, all of which are contributors to maintaining URiM in the surgical sciences.[8] It would take 1,000 years for the population of Black doctors to reflect current population demographics.[9]

According to the most recent data, 77.7% of full professors and 77.4% of department chairs are held by White males. It was not until 2015 that there was a female surgery department chair from any racial and ethnically underrepresented group. Only one Black and one Hispanic/Latina woman ascended to chair from 2013 to 2019. In 2021, Drs. K. Marie King and Andrea Hayes-Dixon were the first Black women chairs of surgery in the United States, hired at Albany Medical Center in Albany, NY, and Howard University in Washington, DC, respectively. Prior to their appointments, Black faculty represented 13 of 380 department chair positions (3.4%). Black and Hispanic men have demonstrated small increases in the number of professor positions held; however, they remain at risk for leaking from the pipeline.

Most of the data available and cited in this article refer to medicine as a collective. Very little data look at women in surgery with intersectional identities. In a Canadian study by Mocanu et al, the intersection of female gender and visible racial and/or ethnic status in surgical trainees was explored. “Visible minority” (VM) status was self-reported via a nonvalidated survey distributed to all general surgery residents in Canada during the 2017–2018 academic year. The 2016 census categories were used to select VM status (African/Caribbean, Asian origin, Latin/Central/South American origin, other North American) with only a 12.7% response of “prefer not to answer.” Survey questions centered around five themes related to diversity and interpersonal relationships in the program, mentorship, training opportunities, perception of competence, and perceived level of support and discrimination. Key findings included that greater than 30% of respondents disagreed or strongly disagreed that their program staff was diverse in race/ethnicity or sexual orientation. Almost 50% of women who identified as a VM strongly disagreed they had a mentor to help them throughout residency.[10] Ultimately, this study reveals the paucity of representation that would support women in surgery who claim intersectional identities.

Religion

Another potential form of VM is religion. Those who abide by a certain faith may have outward facing signs such as identifying garments. Examples include the hijab for followers of the Muslim faith, or the yarmulke for followers of the Jewish faith. Dr. Qaali Hussein has shared her experience as a hijab-wearing woman of the Muslim faith and being dismissed from the operating room as a third-year resident for not succumbing to the pressure to remove her head covering.[11] A UK-based study evaluated the decision of female Muslim health professionals not to enter the surgical field due to the “dress code.” This looked at the hijab and the bare below the elbows policies. With greater than 50% of women reporting difficulty trying to wear a head covering in the operating room, the breakdown of their experience was as follows: 23% felt embarrassed, 37% experienced anxiety, and 36.5% reported being bullied. Over half of the women also reported a lack of respect for their religious tradition to cover their arms below the elbow. Some women chose other medical specialties as a direct result of their religious mandates not being respected in the operating theater.[12] This study may not exactly reflect the challenges faced by women who identify as Muslim in the United States; however, it is an important reflection of how underrepresentation can directly impact a woman's decision to pursue a surgical career.

LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual)

Somewhere between 4.8 and 11% of trainees in surgery identify as a member of the LGBTQIA+ community.[13] The term LGBTQIA+ appears to be all encompassing and is quite complex. It is often used to address the full breadth of gender identity and sexual orientation. While attempts in surgical academia have been made to create a more inclusive environment, many of the statistics are staggering. In a 2019 survey that included over 6,000 surgical residents, 75% reported some form of bullying. Respondents identifying as LGBTQIA+ had a greater than 8% chance of having suicidal thoughts over the past year, twice that of their counterparts at 4%. Thoughts of leaving the program were also twice as high in the LGBTQIA+ group. Challenges were noted to occur even prior to matriculation into residency. A previous survey conducted in 2014 revealed 30% of respondents did not disclose their identity during the interview process. The transition to the virtual interview platform during the pandemic created new obstacles. Without being able to physically see and experience a program and its facilities, it was difficult for applicants to identify safe spaces and persons with whom to discuss their identity. Unless a program explicitly stated policies and endeavors to create an inclusive environment for members of the LGBTQIA+ community, or interviewers provided visible cues (using pronouns in their on-screen title, wearing an inclusive garment/pin, etc.), the onus was on the applicant to research and seek out support systems available.[14] Although the subject of this study addresses the difficulty of women and the intersections of their other self-described identities, the complexities of identity and sexual orientation are more difficult to subcategorize in a purely binary fashion.

Family

Testimonial from the Coauthor

I began surgery internship as one of three women in a class of four. Each woman was separately pulled into the program coordinator's office early in that training year and specifically told not to get pregnant. No such conversation occurred with the only male intern.

A daunting career can be difficult for women who aspire to motherhood. Medicine and surgery have their own unique challenges. The stage of training also impacts the types of challenges faced. As one could imagine, bearing a child during medical school differs from doing so during training or as an attending. JAMA Surgery published an article in 2018 entitled “Pregnancy and motherhood during surgical training.” A cognitive testing approach was used to create a 74-question survey. It was distributed to members of the Association of Women Surgeons, members of the Association of Program Directors in Surgery, and various social media platforms. Data points collected were demographic information, program information regarding formal parental leave, lactation facilities, and childcare support. The survey targeted the perceptions of maternity leave policies, being pregnant while working, stigma, breastfeeding, and satisfaction. Inclusion criteria were women completing an ACGME-accredited general surgical residency program after 2007 (or were scheduled to complete training after 2007 if they left early) and had at least one pregnancy during training. Overwhelmingly, the respondents worried about being perceived negatively, causing resentment, and being seen as noncommitted. Regarding maternity leave itself, many felt the time off was inadequate and the decision to take less time than desired was based upon the American Board of Surgery policy for leave. Well over 60% of respondents reported that if they had it all to do over, they would have chosen a career more conducive to motherhood.[15] [16] Becoming a mother is a different journey for all. Increasingly, in vitro fertilization is utilized to assist in difficulties conceiving for many, including those who have deferred childbearing, are deciding to conceive in the absence of a partner, or those who identify as LGBTQIA+ with a “nontraditional” family. The medical demands of this process can create limited access to women surgeons. Adoption and foster parenting can also be arduous tasks with difficulties arising from the legal appointments and processes required to verify qualifications to do so.

In an opinion piece for STAT News, Dr. Qaali Hussein shares her story of becoming a trauma surgeon and her journey to and through motherhood along the way. She chronicles how she never made the decision to be one over the other, while simultaneously facing outside pressure to “choose one.” Interviewing for her first job while pregnant, a surgical department chair said her focus was on the wrong place. All too often, she shares, male physicians who become fathers are celebrated, while women surgeons are seen as selfish.[11] Dr. Hussein has also contributed to the arena of being a Muslim woman wearing a Hijab in the operating room as noted earlier.

Disability

In a 2018 report, contributors from the University of California San Francisco (UCSF) and AAMC extensively outlined the challenges and the current status of physicians and trainees with disabilities. Not all disabilities are visible, thus adding varying levels of complexity in stating accommodations needed. The report's executive summary opens with a quote by Dr. Harvey Cushing: “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.” Formally defined as “physical, mental, cognitive, or developmental condition that impairs, interferes with, or limits a person's ability to engage in certain tasks or actions or participate in typical daily activities and interactions,” disability in medical education traditionally focuses on physical and sensory disabilities. With that as the frame of reference, historical studies document a range of 0.19 to 0.56% U.S. and Canadian medical students with disability. When encompassing the full definition, which further includes physical, sensory, learning, psychological, and chronic health conditions as accepted by the Americans with Disabilities Act Amendments Act (ADAAA) of 2008, it was found that up to 2.7% of medical students reported a disability. This figure is likely woefully inaccurate given the fear of reporting secondary to stigmas associated with disabilities. With the increased inclusivity of the ADAAA, it became obvious that many suffered from “invisible” disabilities and thus were going without appropriate accommodations. Coupling a disability with the existing preconceived notions regarding the physical ability of women in surgery can further negatively impact attrition, matriculation, and career success. Meeks and Jain provided further clarity about the proportions of students with disabilities in U.S. allopathic programs, reporting the categorical makeup of disability as shown in [Fig. 2].[17]

Fig. 2 Categorization of medical students with disabilities. Accessibility, inclusion, and action in medical education: lived experiences of learners and physicians with disabilities.[17]

International Training

Testimonial from the Coauthor

As an international medical graduate (IMG), I have had to do far more work to complete medical school than my American graduate counterparts due to discriminatory, gatekeeping practices. I have had to expend additional resources for inequitable access to clinical training and complete additional licensing requirements and have been subjected to delays in residency application submission. When United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) was cancelled due to the pandemic, American medical graduates (AMGs) were able to submit their own validation of clinical competencies completed during their clinical rotations. IMGs were required to enter a pathway system and pay to complete additional competencies, which were logistically challenging to accomplish. I flew to another state to complete a week of clinical requirements with the help of a family friend who was a physician. One of the biggest barriers is the difference in the residency application process. The Educational Commission for Foreign Medical Graduates (ECFMG) is the governing/accrediting body for all IMGs. While letters of recommendation can be uploaded and immediately used by AMGs, letters written for IMG applicants need to be reviewed for validity prior to being made available to upload, which can cause a delay of 1 to 2 weeks.

Some of the difficulties experienced by IMGs are discussed earlier in relation to their visible and/or religious minority status; however, this may intersect with other challenges. To train in a U.S. graduate medical education (GME) program, noncitizens must be granted one of two available forms of a visa, the J1 or H1B. The latter must be funded by the individual training institution, and the 2016 Medicare GME funding cuts led to a decline in the number of programs sponsoring these visas. Two major events also hindered certain trainees access to visas and U.S.-based training: the September 11 attacks in 2001, and the 2017 executive order banning travelers from countries with a Muslim majority. Beyond the difficulties in obtaining a visa, a major challenge for IMGs is the difficulty in traveling to their home country during training for fear of being unable to return.[18] As of the 2020–2021 academic year, the nuclear medicine specialty held the largest percentage of IMGs at 75.4%; general surgery and colorectal surgery were at 15.7 at 15.5%, respectively.[19]

After training, the type of visa held impacts where a foreign medical graduate can practice. Those on a J1 visa must obtain a waiver from the Department of State before being able to apply for a green card. Getting this waiver typically comes with practicing in an underserved area for at least 3 years before they are eligible to apply. Graduates with an H1B visa have no geographic restrictions. The challenging decision is deciding which hurdle you want to leap. Getting a J1 visa to train may be easier since the program will not have to financially support it. On the other hand, finding a program to support an H1B visa alleviates the geographic restrictions upon graduation.[18]

Humanity

The authors would be remiss if the intersection of womanhood and humanity was not discussed. In the case of Dobbs versus Jackson's Women's Health Organization decided by the U.S. Supreme Court on June 24, 2022, it was decided that only in the case of a severe fetal abnormality or a medical emergency can a fetus be intentionally aborted beyond 15 weeks gestation.[20] This decision overturned the previous precedent set by the Roe versus Wade decision of 1973, which established the legality of elective abortions under the 14th Amendment, or the right to privacy.[21] The complexities of the ruling are many, but its relevance to this study is the discussion of bodily autonomy and women's rights. At its core, this decision sparks an argument that a woman cannot make her own health decisions, which then bears the question of her ability to control what does or does not happen to her body and when. Women in medicine and surgery may be negatively impacted by potentially limiting the capacity to delay childbearing. Discussions above highlight the many hardships women trainees and practicing physicians face on their journey to motherhood; thus, this topic becomes increasingly important among women surgeons. Combined the lack of sufficient parental support and leave policies, limiting the ability to defer childbearing, and limiting the ability to decrease personal health consequences in high-risk pregnancies, the following are distinct possibilities:

• A decline in the number of women surgical applicants.

• A decline in the number of women applicants to training programs and jobs in certain states.

• Increasing attrition rates among women surgeons and trainees.

• Decreased access to medical care for women physicians and trainees due to a decline in the number of obstetric providers.

Another all-too-common experience for women in medicine and surgery is sexual abuse, assault, and harassment. Specific data and details can be found in the Narrative Inquiry in Bioethics issue featuring the stories of the women of the #MeToo movement.[22] The objectification of women and the oft lack of recourse creates a toxicity that permeates the culture of surgery. This too can limit the desire to pursue the surgical specialties or increase rates of attrition.

Is the Current State of Diversity of Surgery Affecting Patient Care?

Our discussion of the difficulties in identifying with various identities can ultimately impact patient care. Disparities in health care outcomes between races are a widely recognized historical occurrence. When considered independently, African Americans consistently have the poorest outcomes lending to lowest life expectancies of any race or ethnicity.[23] Largely due to increased morbidity and mortality associated with higher incidence of chronic health problems, African Americans are more likely to be diagnosed later, suffer more complications, and die earlier than any other race from preventable chronic health problems such as diabetes, hypertension, and malignancy.[23] A longstanding history of institutionalized racism and discriminatory practices contributes to African Americans being more closely associated with lower socioeconomic standing, thus resulting in increased distrust of the medical system, lower rates of health literacy, insurance coverage, inadequate disease surveillance, absence of prevention, and delayed treatment interventions.[24] Furthermore, men and members of the LGBTQIA+ community are also disproportionately less likely to participate in preventive health practices, such as regular primary care and routine health screening.[25] An example of this consequence is a transgender woman failing to receive prostate cancer screening at the appropriate age, resulting in a later stage at diagnosis.

Gender discrimination is not unique to medical training and practice in the United States. An article from 2018 discusses the deliberate sabotage of female medical school applicants in Tokyo, Japan. Medical school admission test scores were purposely altered by subtracting from the female applicants and adding points to male applicants to decrease the percentage of women in medical school.[26] Beyond the obvious adulteration of a competence-based process, such practices can prove detrimental to patient care. Considering our topic of discussion, it is evident that when evaluated independently, race, gender, and sexual orientation are all risk factors for negative health outcomes. However, when the intersection of each characteristic is considered, it is evident that as an individual holds membership to more categories, there is a compounded risk for negative health outcomes.

The Institute of Medicine (IOM), along with various professional medical societies, such as the American Medical Association (AMA), the National Medical Association (NMA), and the AAMC, has recognized that an effective strategy to improve health care outcomes among marginalized populations involves increasing the representation of such groups among the physician demographics. African Americans comprise approximately 13% of the U.S. population yet represent only 4% of physicians and less than 7% of recent medical school graduates. Consequently, this results in a disproportionately underrepresented population of African Americans in medical practice.[27] Representation is even less for other intersections such as LGBTQIA + , those of Hispanic descent, and IMGs.[9] Research has revealed that patient outcomes are associated with concordant patient/physician relationships; this demonstrates the importance of increasing diversity among medical practitioners.[28] When surveyed, African American patients who saw African American doctors for their care had longer and more satisfying interactions. This was true particularly among higher risk groups. For instance, a cohort of African American males were more likely to participate in preventative health services after discussing them with their African American doctor.[9] When a group of African American men in Oakland, California, was randomized to seeing a concordant race physician, they too were more likely to participate in preventive health practices they previously declined after seeing a concordant physician.[23] [29] It is important to emphasize that being a member of a marginalized population alone in of itself is not a genetic precursor to poor health outcomes. A marginalized person intersecting with biased medical and societal infrastructures does, however, create an accumulation of risk factors lending to increased rates of disparate health outcomes, which extends through multiple generations.

Female gender concordance was found to correlate with improved postoperative outcomes. Wallis et al demonstrated female patients had worse postoperative outcomes when operated on by male surgeons. Male patients, however, did not experience the same increased risk when operated on by a woman surgeon.[30]

Conclusion

After a discussion of the current state of poor representation of intersectional women populations, determining causation is the next step to identifying effective improvement strategies. Riner et al identified recruitment processes, lack of mentorship, implicit biases, NIH funding disparities, and systemic racism or bias as significant contributors to disproportionate representation in medicine. When specific barriers preventing women from achieving success in academic surgery were assessed, organizational culture, institutional policies, mentorship, colleague and staff interactions, and individual characteristics all contributed significantly.[9]

What are some ways to mitigate the harm inflicted upon underrepresented intersectional groups? Establish a culture of inclusiveness. Simply appointing a leader for DEI (diversity, equity, and inclusion) initiatives and creating a committee can further ostracize those trying to make an impact. These goals must be incorporated in all endeavors, hires, and content creation. Utilizing external boards and resources can also be a way to avoid something called the “minority/cultural tax,” and creates a level of independent accountability for a program or institution. The minority tax refers to the responsibilities placed upon minorities to be mentors, sponsors, and leaders in creating a diverse environment at their institution.[31] Many medical organizations have guidelines and resources for creating a diverse and inclusive environment, so there is no need to “re-invent the wheel.” The Association of Program Directors in Surgery created a Diversity and Inclusion Toolkit that is free and available on their Web site.[32] The AAMC's Group on Diversity and Inclusion provides an extensive array of resources dedicated to diversity and inclusion in career development, research, training, etc.[33] Much more research focused specifically on intersectional groups is required to statistically identify to what degree overlapping identities impact professional and patient care outcomes. Recognition of the problem and candid discussions will allow for vast improvements not only in surgical culture but also in surgical care.

Appendix

Physician Just Equity is a diverse and distinguished collaborative of physicians and surgeons who saw a need and came together to form the Founding Partners and Advisory Board now restructured as the Board and Peer Supporters. Physician Just Equity exists to provide peer support to physicians and surgeons in the United States who experience workplace conflicts, through education, research, empowerment, and advocacy—Championing a Balanced Resolution—while facilitating institutional culture change that optimizes patient care. Physician Just Equity is dedicated to achieving diversity, equity, and inclusion in the medical profession. We have personal knowledge and experience with the investment and hardships that lead to attrition and the tragic loss of talent from the profession. To accept the current culture of medicine is to deny a safe, equitable, and dignified workplace to valued clinicians and withholding higher quality patient care.[34]

Conflict of Interest

None declared.

Acknowledgments

We would like to extend our gratitude to the brave souls who provided their anonymous testimony to make this study relevant and real.

• References

• 1 Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chic Leg Forum 1989:8. Accessed May 10, 2022 at: https://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8/
• 2 Merriam-Webster. . Intersectionality. Accessed May10, 2022 at: https://www.merriam-webster.com/dictionary/intersectionality
• 3 US Census Bureau. . DP05 ACS demographic and housing estimates. Accessed June 10, 2022 at: https://data.census.gov/cedsci/table?q=United%20States&table=DP05&tid=ACSDP1Y2017.DP05&g=0100000US&lastDisplayedRow=29&vintage=2017&layer=state&cid=DP05_0001E
• 4 US Census Bureau. . 2020 U.S. population more racially, ethnically diverse than in 2020. Accessed June 10, 2022 at: https://www.census.gov/library/stories/2021/08/2020-united-states-population-more-racially-ethnically-diverse-than-2010.html
• 5 Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg 2016; 212 (04) 566-572
• 6 Coaston J. . The intersectionality wars. Vox [serial online] 2019; 1–8. Accessed September 18, 2022 at: https://www.salisbury.edu/administration/diversity-and-inclusion/_files/anti-racism/the-intersectionality-wars.pdf
• 7 Merchant JL, Omary MB. Underrepresentation of underrepresented minorities in academic medicine: the need to enhance the pipeline and the pipe. Gastroenterology 2010; 138 (01) 19-26.e1-3
• 8 Lewit RA, Black CM, Camp L. et al. Association of sex and race/ethnicity with National Institutes of Health funding of surgeon-scientists. JAMA Surg 2021; 156 (02) 195-197
• 9 Riner AN, Herremans KM, Neal DW. et al. Diversification of academic surgery, its leadership, and the importance of intersectionality. JAMA Surg 2021; 156 (08) 748-756
• 10 Mocanu V, Kuper TM, Marini W. et al. Intersectionality of gender and visible minority status among general surgery residents in Canada. JAMA Surg 2020; 155 (10) e202828
• 11 Hussein Q. Motherhood and medicine should mix. So why is it such a struggle? Statnews.com. October 18, 2019. Accessed September 19, 2022 https://www.statnews.com/2019/10/18/motherhood-medicine-struggle/
• 12 Malik A, Qureshi H, Abdul-Razakq H. et al. ‘I decided not to go into surgery due to dress code’: a cross-sectional study within the UK investigating experiences of female Muslim medical health professionals on bare below the elbows (BBE) policy and wearing headscarves (hijabs) in theatre. BMJ Open 2019; 9 (03) e019954
• 13 Cortina CS, Williamson AJ, Goulet ND. Progress, barriers, and the future of LGBTQ+ surgeons in academic surgery. Am J Surg 2022; 224 (1 Pt B): 294-295
• 14 Awe A, Ai A. Interviewing for residency as an LGBTQ+ applicant: compounded problems with virtual interviewing. J Surg Educ 2022; 79 (02) 279-282
• 15 Rangel EL, Smink DS, Castillo-Angeles M. et al. Pregnancy and motherhood during surgical training. JAMA Surg 2018; 153 (07) 644-652
• 16 American Board of Surgery. Leave policy - general surgery. Updated June 2022. Accessed October 10, 2022 at: https://www.absurgery.org/default.jsp?policygsleave
• 17 Meeks LM, Jain NR. . Accessibility, inclusion and action in medical education: lived experiences of learners and physicians with disabilities. March 2018. Accessed October 9, 2022 at: https://store.aamc.org/downloadable/download/sample/sample_id/249/
• 18 Al Ashry HS, Kaul V, Richards JB. The implications of the current visa system for foreign medical graduates during and after graduate medical education training. J Gen Intern Med 2019; 34 (07) 1337-1341
• 19 ACGME Data Resource Book.. Table 1. Accessed October 4, 2022 at: https://www.acgme.org/globalassets/pfassets/publicationsbooks/2020-2021_acgme_databook_document.pdf
• 20 Read: The Supreme Court's Dobbs Decision.. National Review. June 24, 2022. Accessed October 4, 2022 at: https://www.nationalreview.com/news/read-the-supreme-courts-dobbs-decision/
• 21 Roe V Wade. History.com. June 24, 2022. Accessed October 4, 2022 at: https://www.history.com/topics/womens-rights/roe-v-wadekground-HISTORY
• 22 Miller P. #MeToo in surgery: narratives by women surgeons. Narrat Inq Bioeth 2019; 9 (03) 179-183
• 23 Alsan M, Garrick O, Graziani G. Does diversity matter for health? Experimental evidence from Oakland. American Economic Review 2019; 109 (12) 4071-4111 https://doi.org/10.1257/aer.20181446
• 24 Priest N, Paradies Y, Trenerry B, Truong M, Karlsen S, Kelly Y. A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people. Soc Sci Med 2013; 95 (95) 115-127
• 25 Aleshire ME, Ashford K, Fallin-Bennett A, Hatcher J. Primary care providers' attitudes related to LGBTQ people: a narrative literature review. Health Promot Pract 2019; 20 (02) 173-187
• 26 Aleshire ME, Ashford K, Fallin-Bennett A, Hatcher J. Primary care providers' attitudes related to LGBTQ people: a narrative literature review. Health Promot Pract 2019; 20 (02) 173-187
• 27 Myers CG, Sutcliffe KM. . How discrimination against female doctors hurts patients. Harvard Business Review. August 30, 2018. Accessed September 27, 2022 at: https://hbr.org/2018/08/how-discrimination-against-female-doctors-hurts-patients
• 28 Silver JK, Bean AC, Slocum C. et al. Physician workforce disparities and patient care: a narrative review. Health Equity 2019; 3 (01) 360-377
• 29 Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race?. Health Aff (Millwood) 2000; 19 (04) 76-83
• 30 Wallis CJD, Jerath A, Coburn N. et al. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surg 2022; 157 (02) 146-156
• 31 Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: what of the minority tax?. BMC Med Educ 2015; 15: 6
• 32 Association of Program Directors in Surgery.. APDS Diversity and Inclusion Toolkit. June 2020. Accessed October 9, 2022 at: https://apds.org/program-directors/apds-diversity-and-inclusion-toolkit/
• 33 American Association of Medical Colleges. . Group on Diversity and Inclusion (GDI). Accessed October 9, 2022 at: https://www.aamc.org/career-development/affinity-groups/gdi
• 34 Physician Just Equity.. About Us. Accessed October 9, 2022 at: https://physicianjustequity.com/about/

Publication History

Article published online:
15 March 2023