Operating in the margins: Women’s lived experience of training and working in orthopaedic surgery in South Africa


Submitted: 4 October 2022
Accepted: 8 March 2023
Published: 27 April 2023
Abstract Views: 1061
PDF: 277
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Authors

  • Marí Thiart Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg, Stellenbosch University, South Africa.
  • Megan O’Connor Department of Orthopaedic Surgery, Inkosi Albert Luthuli Central Hospital, School of Clinical Medicine, University of KwaZulu-Natal, South Africa. https://orcid.org/0000-0001-8864-4916
  • Jana Müller Ukwanda Centre for Rural Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa. https://orcid.org/0000-0002-3225-6268
  • Nuhaa Holland Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, South Africa.
  • Jason Bantjies Institute for Life Course Health Research, Department of Global Health, Stellenbosch University; Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa. https://orcid.org/0000-0002-3626-9883

Medicine in South Africa (SA), as in other parts of the world, is becoming an increasingly gender diverse profession, yet orthopaedic surgery continues to be dominated by men, with women constituting approximately 5% of the profession in SA. The aim of this descriptive qualitative study was to explore women’s experiences of training and working as orthopaedic surgeons in SA and identify structures, practices, attitudes, and ideologies that may promote or impede the inclusion of women. Data were collected via focus group discussions with women orthopaedic surgeons (n=16). Grounded in phenomenology, data were analysed using thematic analysis following a data-driven inductive approach to making sense of participants’ experiences. Five main themes emerged: i) dynamic working environments and the work of transformation; ii) negotiating competing roles of mother and surgeon; iii) belonging, exclusion and internalised sexism; iv) gaslighting and silencing; and v) acts of resistance – agency and pushing back. The findings highlight the dynamic process in which both men and women contribute to co-creating, re-producing, and challenging practices that make medicine more inclusive.


Abramson, J. (1975). Invisible woman: Discrimination in the academic profession. Jossey-Bass, San Francisco, USA.

Alwazzan, L., & Rees, C. E. (2016). Women in medical education: views and experiences from the Kingdom of Saudi Arabia. Medical Education, 50(8), 852–865.

Bates, C., Gordon, L., Travis, E., Chatterjee, A., Fivush, B., Gulati, M., Jagsi, R., Sharma, P., & Gillis, M. (2016). Striving for gender equity in academic medicine careers: A call to action. Academic Medicine, 91(8), 1050-1052.

Birt, L., Scott, S., Cavers, D., Campbell, C., & Walter, F. (2016). Member checking: A tool to enhance trustworthiness or merely a nod to validation? Qualitative Health Research, 26(13), 1802–1811.

Braun, V., & Clarke, V. (2012). Thematic analysis. In H. M. Cooper (Ed.), APA handbook of research methods in psychology. Volume 2, Research designs: Quantitative, qualitative, neuropsychological, and biological (pp. 57–71). Washington, DC, US: American Psychological Association.

Bruce, A. N., Battista, A., Plankey, M. W., Johnson, L. B., & Blair Marshall, M. (2015). Perceptions of gender-based discrimination during surgical training and practice. Medical Education Online, 20(1).

Cochran, A., Hauschild, T., Elder, W. B., Neumayer, L. A., Brasel, K. J., & Crandall, M. L. (2013). Perceived gender-based barriers to careers in academic surgery. The American Journal of Surgery, 206(2), 263–268.

Colletti, L. M., Mulholland, M. W., & Sonnad, S. S. (2000). Perceived obstacles to career success for women in academic surgery. Archives of Surgery, 135(8), 972–977.

Crawley, R. (2006). Diversity and the marginalisation of Black women’s issues. Policy Futures in Education, 4(2).

David, E. J. R., Schroeder, T. M., & Fernandez, J. (2019). Internalized racism: A systematic review of the psychological literature on racism’s most insidious consequence. Journal of Social Issues, 75(4), 1057–1086.

Davidson, M. J., & Cooper, C. L. (1992). Shattering the glass ceiling: The woman manager. Paul Chapman Publishing, London.

Derks, B., van Laar, C., Ellemers, N., & de Groot, K. (2011). Gender-bias primes elicit Queen-Bee responses among senior policewomen. Psychological Sciences, 22(10), 1243–1249.

Digby, A., Browde, J., Mokhobo, P., & Jassat, E. (2012). Wits. The open years. A history of the University of Witwatersrand. Natal Medical School. Reconciliation Graduation Booklet, 57(2), 1918–1948.

Dyrbye, L. N., Shanafelt, T. D., Balch, C. M., Satele, D., Sloan, J., & Freischlag, J. (2011). Relationship between work-home conflicts and burnout among American surgeons: A comparison by sex. Archives of Surgery, 146(2), 211–217.

Fernández Vega, D., Grandón, P., López-Angulo, Y., Vielma-Aguilera, A. V., & Peñate, W. (2022). Systematic review of explanatory models of internalized stigma in people diagnosed with a mental disorder. International Journal of Mental Health and Addiction, 20(6),1–24.

Fraser, S. (2021). The toxic power dynamics of gaslighting in medicine. Canadian Family Physician 67(5), 367–368.

Gargiulo, D. A., Hyman, N. H., Hebert, J. C., Kirton, O., Gawande, A., Tseng, J., Donahoe, P., & vander Salm, T. (2006). Women in surgery: Do we really understand the deterrents? Archives of Surgery, 141(4), 405–408.

Gini, A. (2013). My Job, My Self: Work and the Creation of the Modern Individual. Routledge, UK.

Gosselin, M. M., Alolabi, B., Dickens, J. F., Li, X., Mesfin, A., Miller, A. N., & Spraggs-Hughes, A. (2019). Cross-sectional survey results on mental health among orthopedic surgery residents across North America. Journal of Surgical Education, 76(6), 1484–1491.

Green, J. A., Chye, V. P., Hiemstra, L. A., Felländer-Tsai, L., Incoll, I., Weber, K., ... & Hing, C. B. (2020). Diversity: women in orthopaedic surgery–a perspective from the International Orthopaedic Diversity Alliance. Journal of Orthopaedic Trauma, 8(1), 44-51.

Harris, A. B., & Kramer, A. S. (2019). It’s not you, it’s the workplace : women’s conflict at work and the bias that built it. Nicholas Brealey Publishing. Boston, USA.

HPCSA. (2022). iRegister Home Page. Health Professions Council of South Africa (HPCSA).

Hutchison, K. (2020). Four types of gender bias affecting women surgeons and their cumulative impact. Journal of Medical Ethics, 46(4), 236–241.

Jansson, I., & Gunnarsson, A. B. (2018). Employers’ views of the impact of mental health problems on the ability to work. Work, 59(4), 585–598.

Jena, A. B., Khullar, D., Ho, O., Olenski, A. R., & Blumenthal, D. M. (2015). Sex differences in academic rank in US medical schools in 2014. Journal of the American Medical Association, 314(11), 1149–1158.

Johnson, Z., & Mathur-Helm, B. (2011). Experiences with Queen Bees: A South African study exploring the reluctance of women executives to promote other women in the workplace. South African Journal of Business Management., 42(4), 47-55.

Klifto, K. M., Payne, R. M., Siotos, C., Lifchez, S. D., Cooney, D. S., Broderick, K. P., Aliu, O., Manahan, M. A., Rosson, G. D., & Cooney, C. M. (2020). Women continue to be under-represented in surgery: A study of AMA and ACGME data from 2000 to 2016. Journal of Surgical Education, 77, 362–368.

Mattis, M. C. (1993). Women directors: Progress and opportunities for the future. Business and the Contemporary World, 5(3), 140-56.

McKinstry, B., Colthart, I., Elliott, K., & Hunter, C. (2006). The feminization of the medical work force, implications for Scottish primary care: A survey of Scottish general practitioners. BMC Health Services Research, 6, 56.

Merrick, B. G. (2002). The ethics of hiring in the new workplace: Men and women managers face changing stereotypes discover correlative patterns for success. Competitiveness Review, 12(1), 94–114.

Moalusi, K. P., & Jones, C. M. (2019). Women’s prospects for career advancement: Narratives of women in core mining positions in a South African mining organisation. South African Journal of Industrial Psychology, 45(1), 1-11.

Morantz-Sanchez, R. (2005). Sympathy and science: Women physicians in American medicine. Univ of North Carolina Press, North Carolina, USA.

Mulcahey, M. K., Nemeth, C., Trojan, J. D., & O’Connor, M. I. (2019). The perception of pregnancy and parenthood among Female orthopaedic surgery residents. Journal of the American Academy of Orthopaedic Surgeons, 27(14), 527–532.

Myers, S. P., Hill, K. A., Nicholson, K. J., Neal, M. D., Hamm, M. E., Switzer, G. E., Hausmann, L. R. M., Hamad, G. G., Rosengart, M. R., & Littleton, E. B. (2018). A qualitative study of gender differences in the experiences of general surgery trainees. Journal of Surgical Research, 228, 127–134.

Olsen, B. C., Barron, S. L., Gutheil, C. M., Blazick, E. A., Mayo, S. W., Turner, E. N., & Whiting, J. F. (2022). Understanding the effect of bias on the experience of women surgeons: A qualitative study. Journal of the American College of Surgeons, 234(6), 1064–1072.

Pager, D., & Shepherd, H. (2008). The sociology of discrimination: Racial discrimination in employment, housing, credit, and consumer markets. Annual Review of Sociology, 34(1), 181–209.

Rohde, R. S., Wolf, J. M., & Adams, J. E. (2016). Where are the women in orthopaedic surgery? Clinical Orthopaedics and Related Research, 474(9), 1950–1956.

Salles, A., Mueller, C. M., & Cohen, G. L. (2016). Exploring the relationship between stereotype perception and residents’ well-being. Journal of the American College of Surgeons, 222(1), 52–58.

Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., ... & Jinks, C. (2018). Saturation in qualitative research: exploring its conceptualization and operationalization. Quality & quantity, 52, 1893-1907

Sebring, J. C. H. (2021). Towards a sociological understanding of medical gaslighting in western health care. Sociology of Health & Illness, 43(9), 1951–1964.

Smith, R. A. (2002). Race, gender, and authority in the workplace: Theory and research. In Annual Review of Sociology, 28, 509–542.

Sprow, H. N., Hansen, N. F., Loeb, H. E., Wight, C. L., Patterson, R. H., Vervoort, D., Kim, E. E., Greving, R., Mazhiqi, A., Wall, K., Corley, J., Anderson, E., & Chu, K. (2021). Gender-based microaggressions in surgery: A scoping review of the global literature. World Journal of Surgery, 45, 1409–1422.

Sullivan, L.W. (2004). Missing persons: Minorities in the health professions, A report of the Sullivan Commission on Diversity in the Healthcare Workforce.

Thackwell, N., Chiliza, B., & Swartz, L. (2017). Race ethnicity and education mentorship experiences during registrar training: reflections of Black African specialists in the Western Cape. Race Ethnicity and Education, 21(6), 791–807.

Thackwell, N., Swartz, L., Dlamini, S., Phahladira, L., Muloiwa, R., & Chiliza, B. (2016). Race trouble: Experiences of Black medical specialist trainees in South Africa. BMC Internationa Health and Human Rights, 16(31), 1–6.

Thompson, C. M., Babu, S., & Makos, S. (2022). Women’s Experiences of health-related communicative disenfranchisement. Health Communication, 25, 1-12.

Tiwari, R., Mash, R., Karangwa, I., & Chikte, U. (2021). A human resources for health analysis of registered family medicine specialists in South Africa: 2002–19. Family Practice, 38(2), 88–94.

Torres, M. B., Salles, A., & Cochran, A. (2019). Recognizing and reacting to microaggressions in medicine and surgery. Journal of the American Medical Association Surgery, 154(9), 868–872.

van Heest, A. E., & Agel, J. (2012). The uneven distribution of women in orthopaedic surgery resident training programs in the United States. Journal of Bone & Joint Surgery, 94(e9), 1–8.

Wildschut, A. (2010). Exploring internal segregation in the South African medical profession. Journal of Workplace Learning, 22(1–2), 53–66.

Yi, S., Lin, Y., Kansayisa, G., & Costas-Chavarri, A. (2018). A qualitative study on perceptions of surgical careers in Rwanda: A gender-based approach. PLoS One, 13(5), e0197290.

Zhuge, Y., Kaufman, J., Simeone, D. M., Chen, H., & Velazquez, O. C. (2011). Is there still a glass ceiling for women in academic surgery? Annals of Surgery, 253(4), 637–643.

Thiart, Marí, Megan O’Connor, Jana Müller, Nuhaa Holland, and Jason Bantjies. 2023. “Operating in the Margins: Women’s Lived Experience of Training and Working in Orthopaedic Surgery in South Africa”. Qualitative Research in Medicine and Healthcare 7 (1). https://doi.org/10.4081/qrmh.2023.10902.

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