Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13112 Challenges faced by female oral and maxillofacial surgeons in conservative societies: a gender-based analysis Najla Dar-Odeh,1 Osama Abu-Hammad,1 Hanan Reda,2 Monther Alsharif,3 Shadia Elsayed,2 Mohammad Al-Shayyab,1 Ashraf Abu-Karaky,1 Soukaina Ryalat1 1School of Dentistry, University of Jordan, Amman, Jordan; 2Faculty of Dental Medicine for Girls, Al-Azhar University, Cairo, Egypt; 3Faculty of Dentistry, University of Benghazi, Libya Abstract Oral and Maxillofacial Surgeons (OMFSs) face peculiar chal- lenges that may hinder surgical careers and jeopardize job sati- sfaction. More data are necessary on these challenges, particularly among females in conservative societies and politically unstable areas. This study aimed to perform a gender-based analysis of social and professional challenges faced by OMFSs in Egypt, Jordan, Libya, and Saudi Arabia. An online questionnaire was distributed among OMFSs to explore career-hindering factors, factors influencing OMFS career choice by female surgeons, and surgeons’ preferences for online educational platforms. The results showed that male professionals performed more surgical procedures under general anesthesia and identified “financial revenues” as a significant career obstacle (p≤0.05). Regarding the most important factors that impact female surgeons’ choice of OMFS career, significantly more females cited “lack of mentors” (p=0.012), while significantly more males cited “marriage” and “having children” (p=0.001). Further, significantly more males stated that “males are better suited for leadership positions” (p<0.001). Female OMFSs in conservative societies encounter challenging social and professional barriers, which may adversely affect job stability and career aspirations. Adopting policies that promote a work-family balance for female surgeons and providing institutions with a sufficient number of mentors may be crucial in mitigating the obstacles and challenges they face. Further leader- ship opportunities should be made accessible to women, supported by establishing an inclusive and unbiased environment that enga- ges all stakeholders, regardless of their gender. Introduction Oral and Maxillofacial Surgery (OMFS) is an interdisciplinary specialty between dentistry and surgery. Oral and Maxillofacial Surgeons (OMFSs) perform versatile procedures that address challenging diseases affecting the head and neck region, such as cancer, trauma, and developmental malformations. Moreover, close collaboration between surgical and non-surgical teams is required to enhance overall treatment outcomes inherently direc- ted toward patients’ functional and aesthetic needs. Gender diversity in surgical workforces promotes favorable treatment outcomes and increases patients’ satisfaction and quality of life. Increasing women’s participation in surgical careers is pro- jected to enhance and sustain healthcare resources, thereby miti- gating the global surgical burden.1 Female physicians were descri- bed as being more careful, better communicators, and adherent to the clinical guidelines.2 They are also preferred to male surgeons among a substantial proportion of the female patient population who feel more comfortable when seeking healthcare from female surgeons3 and who were reported to have several health disparities in low-resource settings.4 Further, recent studies highlight a high rate of adverse surgery outcomes when female patients are treated by male surgeons, a trend that was not identified when female sur- geons treat male patients.5 While the overall healthcare sector has made major steps towards inclusivity and gender equity, disparities still persist in various medical fields, especially in surgical disciplines.6,7 In con- servative cultures such as those in Arabic societies, understanding gender diversity is particularly important. It highlights the need to assess the interplay between gender dynamics, societal expecta- tions, and professional experiences to enhance the understanding and appreciation of the features of this surgical subspecialty.7 For many decades, the Arabic region has experienced protrac- Correspondence: Najla Dar-Odeh, School of Dentistry, University of Jordan, Amman, Jordan. E-mail: najla@ju.edu.jo Key words: career; conservative; gender; oral and maxillofacial surgery; perceptions. Contributions: NDO, conceptualization, methodology, writing – original draft, writing – review & editing; OAH, conceptualization, methodology, formal analysis; HR, MA, MAS, AAK, SR, data curation, validation; SE, investigation, methodology, writing – review & editing. All the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: ethics approval was obtained from the Faculty of Dental Medicine, Al Azhar University, Egypt (Protocol # EEPI-IB 201). The study was carried out in accordance with the World Medical Declaration of Helsinki. Consent for publication: written informed consent was obtained from the participants of this study. Availability of data and materials: all data generated or analyzed are included in this published article. Received: 16 September 2024. Accepted: 17 January 2025. Early access: 19 March 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13112 doi:10.4081/hls.2025.13112 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s1):13112] [page 89] ted political instability and armed conflicts, triggering numerous difficulties for healthcare systems, particularly surgical disciplines such as OMFS. These low-resource settings are further jeopardized by the increasing rates of migration of highly qualified surgeons who aspire to more prosperous careers in politically stable coun- tries.8 Previous research highlighted several challenges and obsta- cles faced by OMFSs, particularly female surgeons.9 Globally, a biased, less welcoming work environment and sexual harassment were perceived as major obstacles.10 On the other hand, in conser- vative countries, female surgeons highlighted “lack of mentors” and “long working hours” as the major career obstacles.3 More follow- up studies are warranted to provide an in-depth analysis of these challenges, particularly the perceptions of male surgeons, who con- stitute the largest proportion of the surgical workforce and who occupy more influential leadership positions.11 Therefore, we con- ducted this study in four Arabic countries using a gender-specific approach to evaluate challenges that face OMFSs, assess factors that influence female surgeons’ career choices, identify training pre- ferences for online educational platforms, and lastly, explore per- ceptions of female representation in leadership positions. Materials and Methods Study design This study employed a cross-sectional survey utilizing an onli- ne questionnaire created with Google Forms, based on a previous similar study.8 A pilot test was performed to ensure clarity and reproducibility. Ten male and female surgeons from each country were invited to complete the questionnaire on two separate occa- sions, one week apart. Calculated Cronbach’s alpha (0.72) and Kappa (0.79) were considered acceptable. The questionnaire was composed of an introductory section on the objectives of the study and the anonymous nature of participation. This was followed by 37 closed-ended questions on socio-professional characteristics (age, gender, marital status, parental status, specialization country, work country, years of experience, professional setting, weekly number of in-patients, and weekly number of out-patients); percei- ved socio-professional factors that may hinder career (financial revenues, peer appreciation, uncooperative boss, patient respect, patient flow, spouse career, spouse appreciation, family responsi- bilities, medical illness, physical complaints, time for professional development); perceptions on factors influencing the OMFS career choice by female surgeons (lack of mentors, long working hours, marriage, children, society); perceptions on gender-specific leader- ship roles; and preferences on surgical topics for which YouTube platform is consulted. Study participants A convenient sample of OMFSs was invited to participate by co-authors who were members of local dental associations through local professional social networks as follows: HR and SE in Egypt, SR in Jordan, SE in Saudi Arabia, and MA in Libya. Participants were invited to complete the questionnaire during May 2023. A second round of invitations was performed in June 2023. Participants were included if they were Arabic surgeons practicing OMFS in one of the four participating countries. Participants who were identified as working outside these countries were excluded. A total of 137 surgeons participated, with 74 males (54.0%) and 63 females (46.0%). Data analysis Statistical analysis was conducted using IBM SPSS software for Windows (SPSS version 25, Armonk, NY: IBM Corp) to calcu- late descriptive data, including range, mean, and standard devia- tion of age and years of experience, frequencies, and percentages of socio-professional groups. Descriptive data were also calculated for surgeons’ preferences for professional development on various surgical topics using the YouTube platform. Participating countries were divided into two groups according to the income level as defi- ned by the World Bank. The first category constituted Saudi Arabia (High income), Jordan, and Libya (upper middle income), and the second category constituted Egypt (lower middle income). The chi-square test was used to assess the significance of the associa- tion between gender and socio-professional characteristics, socio- professional career factors, and socio-professional factors percei- ved by participants to influence females’ choice of the OMFS care- er. A p-value of ≤0.05 was considered significant. Ethics approval Ethics approval was obtained from the Faculty of Dental Medicine, Al Azhar University, Egypt (Protocol #EEPI-IB 201). The study was carried out in accordance with the World Medical Declaration of Helsinki. Results Data were analyzed to describe the socio-professional charac- teristics of participants, career barriers, and factors that influence female surgeons’ preference for OMFS career path. The socio-pro- fessional characteristics of participants are presented in Table 1. Males were more likely to be married, have children, and larger families (p<0.05). In contrast, females were more likely to receive training and work in lower-income countries (p<0.001). Additionally, males tended to perform a greater number of proce- dures under general anesthesia each week (p=0.018). Table 2 revealed that most male and female surgeons confirmed the important influence of all socio-professional factors, except “spouse career”, which was considered “not important”. “Financial revenues” was the most highly cited career obstacle among males (97.3%), in contrast to “family responsibilities”, which was the most highly cited factor among females (95.2%). A statistically significant higher proportion of males considered “financial reve- nues” as a barrier to their career (p=0.044). Participants indicated which factors influence female surgeons’ choice of OMFS career (Table 3); significantly, more females identified “lack of mentors” as an important factor in their choice of OMFS career (p=0.012). While more males perceived that “marriage” and “having children” are important factors in females’ OMFS career choice (p=0.001). When exploring perceptions of women’s professional representa- tion and participation in leadership positions, females were more likely to feel under-represented in the profession. However, the dif- ference was not statistically significant (p>0.05). Further, signifi- cantly more females perceived that “both genders can equally be leaders” (p<0.001), while significantly more males stated that “males are better suited in leadership positions”, and that there are “none or fewer female leaders than males” (p<0.05) (Table 4). The study also conducted a gender analysis of continuous education using YouTube as an important platform in surgical training. There were no statistically significant differences between genders in their referral to YouTube platform (p>0.05). Further, the most frequently cited disciplines were aesthetic surgery and oncology, while dento- Special issue Pathways of Change [page 90] [Healthcare in Low-resource Settings 2025;13(s1):13112] alveolar surgery was the least cited (Figure 1). The last section of the questionnaire presented an open space for surgeons to express their feelings about the status quo of the profession and their asses- sment of the future. Only 21 participants (9 males and 12 females) provided comments, which were summarized in five themes. The first three themes were cited by males as follows: (1) OMFS is inhe- rently associated with tension and effort; (2) I feel passionate and content with the OMFS career; (3) all genders are suitable for this profession, and nowadays we see more participation from female surgeons. The last two themes were cited by females as follows: (1) challenges for female surgeons are mainly children’s responsibili- ties and poor society acceptance of female surgeons; (2) more con- tinuing education activities are desirable, however, there are some obstacles, such as lack of mentorship, costly courses, and the inabi- lity to obtain specialization abroad. Discussion Including a diverse, sustainable, and integrated workforce in the OMFS specialty is expected to fulfill the professional outco- mes of surgeons and the treatment needs of patients. As the profes- sion of OMFS continues to evolve, an essential aspect worthy of careful exploration is gender analysis of social and professional challenges faced by surgeons. This study utilized a gender-based approach to investigate social and professional career obstacles faced by OMFSs in four Arabic countries as an example of conser- vative societies that have similar cultural backgrounds and social perspectives. Understanding the complex interplay between gen- der, social dynamics, and professional experiences is crucial not only for advancing diversity but also for fostering an environment that allows all practitioners to thrive and contribute to the advan- cement of the profession. Several studies have investigated career obstacles in the field of OMFS globally and regionally.3,7,8,12 Regionally, previous rese- arch estimated that males had higher career satisfaction, perceiving that it was the right career path.7 Females, on the other hand, were confident that they had what it took to be more suitable than males for the OMFS career;7 however, they cited specific social factors as Special issue Pathways of Change Table 1. Socio-professional characteristics of participating oral and maxillofacial surgeons. Socio-professional Gender p characteristics of participants Male (%) Female (%) Age (years) <40 38 (51.4) 36 (57.1) 0.606 ≥40 36 (48.6) 27 (42.9) Marital status Single 8 (10.8) 18 (28.6) 0.038* Married 62 (83.8) 41 (65.1) Divorced 4 (5.4) 3 (4.8) Widow 0 (0.0) 1 (1.6) Ever married Single 12 (16.2) 22 (34.9) 0.017* Married 62 (83.8) 41 (65.1) Have children No 14 (18.9) 25 (39.7) 0.008* Yes 60 (81.1) 38 (60.3) Number of children No children 13 (17.6) 25 (39.7) 0.010* 1-2 children 21 (28.4) 17 (27.0) >2 children 40 (54.1) 21 (33.3) Work country UIC/UMIC 63 (85.1) 14 (22.2) 0.000* LIC 11 (14.9) 49 (77.8) Specialization country UIC/UMIC 47 (63.5) 11 (17.5) 0.000* LIC 27 (36.5) 52 (82.5) Professional setting Academic 23 (31.1) 27 (42.9) 0.258 Public sector 31 (41.9) 25 (39.7) Private sector 20 (27.0) 11 (17.5) Years of experience <10 43 (58.1) 42 (66.7) 0.378 ≥10 31 (41.9) 21 (33.3) Weekly procedures under GA ≤5 55 (74.3) 52 (82.5) 0.018* >6 19 (25.7) 11 (17.5) Weekly number of out-patients <20 15 (20.3) 19 (30.2) 0.101 20-30 20 (27.0) 19 (30.2) 31-40 15 (20.3) 4 (6.3) >40 24 (32.4) 21 (33.3) *Statistically significant difference; UIC, upper-income country; UMIC, upper-middle- income country; LIC, lower-income country; GA, general aesthesia. Table 2. Socio-professional factors perceived by participants to be limiting to their careers. Socio-professional Gender p career factors Male (%) Female (%) Financial revenues Not important 2 (2.7) 8 (12.7) 0.044* Important 72 (97.3) 55 (87.3) Peer appreciation Not important 4 (5.4) 4 (6.3) 1.000 Important 70 (94.6) 59 (93.7) Uncooperative boss Not important 10 (13.5) 7 (11.1) 0.797 Important 64 (86.5) 56 (88.9) Time for professional development Not important 4 (5.4) 7 (11.1) 0.345 Important 70 (94.6) 56 (88.9) Patient flow Not important 7 (9.5) 8 (12.7) 0.592 Important 67 (90.5) 55 (87.3) Patients’ respect Not important 5 (6.8) 11 (17.5) 0.064 Important 69 (93.2) 52 (82.5) Medical illness Not important 9 (12.2) 6 (9.5) 0.785 Important 65 (87.8) 57 (90.5) Physical complaints Not important 8 (10.8) 11 (17.5) 0.324 Important 66 (89.2) 52 (82.5) Spouse appreciation Not important 3 (4.1) 4 (6.3) 0.703 Important 71 (95.9) 59 (93.7) Spouse career Not important 45 (60.8) 33 (52.4) 0.387 Important 29 (39.2) 30 (47.6) Family responsibilities Not important 7 (9.5) 3 (4.8) 0.342 Important 67 (90.5) 60 (95.2) *Statistically significant difference. [Healthcare in Low-resource Settings 2025;13(s1):13112] [page 91] obstacles to their career progress.8 Analysis of the semi-professio- nal characteristics of participants in this study gives an insight into their perceptions and sheds light on the current professional envi- ronment. Similar to other studies conducted among surgeons in other disciplines, males were more likely to be married and to have larger families with more children.13 A study conducted in Jordan, Saudi Arabia, and Egypt estimated that a substantial proportion of female surgeons were either single or divorced, in contrast to most male surgeons who were married.8 A similar trend was identified in more modernized societies. Most female surgeons want children; however, they often perceive workplace bias against pregnant female trainees. Consequently, they postpone or refrain from having children, trying to mitigate the conflict with the surgical career.14 For those who manage to become pregnant during training years, a substantial proportion may experience miscarriage or other adverse pregnancy outcomes, which may increase the need for assisted reproductive therapy in the future.14,15 Therefore, more stu- dies are now calling for adopting policies that conform with the “basic human nature” of having a family even during surgical trai- ning years.12 Other sociodemographic characteristics were noted in this study. Participants from Egypt were mostly females, contrary to other countries. This likely represents the current predominance of male surgeons in these countries, particularly in Saudi Arabia, where a large proportion of the OMFS workforce is made up of non-national male surgeons. In contrast to Egypt, the country’s large female surgical workforce may face various social con- straints that prevent them from working abroad. Special issue Pathways of Change Table 3. Socio-professional factors perceived by participants to influence the choice of females to pursue a career in oral and max- illofacial surgery. Semi-professional Gender p factors influencing OMFS career choice of females Male (%) Female (%) Lack of mentors Not important 18 (24.3) 5 (7.9) 0.012* Important 56 (75.7) 58 (92.1) Long working hours Not important 5 (6.8) 6 (9.5) 0.745 Important 69 (93.2) 57 (90.5) Physical exertion Not important 12 (16.2) 19 (30.2) 0.066 Important 62 (83.8) 44 (69.8) Hostile work environment Not important 17 (23.0) 16 (25.4) 0.842 Important 57 (77.0) 47 (74.6) Sexual harassment Not important 31 (41.9) 26 (41.3) 1.000 Important 43 (58.1) 37 (58.7) Sexism by colleagues Not important 31 (41.9) 23 (36.5) 0.600 Important 43 (58.1) 40 (63.5) Sexism by patients Not important 27 (36.5) 24 (38.1) 0.861 Important 47 (63.5) 39 (61.9) Marriage Not important 4 (5.4) 16 (25.4) 0.001* Important 70 (94.6) 47 (74.6) Having children Not important 3 (4.1) 15 (23.8) 0.001* Important 71 (95.9) 48 (76.2) Society impact Not important 15 (20.3) 20 (31.7) 0.169 Important 59 (79.7) 43 (68.3) *Statistically significant difference. Figure 1. Gender distribution of oral and maxillofacial surgeons in consulting YouTube platform to enhance skills in various surgical disciplines. [page 92] [Healthcare in Low-resource Settings 2025;13(s1):13112] Table 4. Perceptions of oral and maxillofacial surgeons on gender- specific leadership roles and female representation. Perceptions Gender p on leadership gender roles Males Females Female surgeons in leadership positions None or fewer than males 71 (95.9) 50 (79.4) 0.003* Equal or more than males 3 (4.1) 13 (20.6) Males are better suited in leadership positions No 16 (21.6) 33 (52.4) 0.000* Yes 58 (78.4) 30 (47.6) Both genders can be equally leaders No 28 (37.8) 7 (11.1) 0.000* Yes 46 (62.2) 56 (88.9) Females are under-represented in OMF surgery No 32 (43.2) 17 (27.0) 0.052 Yes 42 (56.8) 46 (73.0) *Statistically significant differences. Several potential social and professional obstacles were exami- ned in this study. Among these, “financial revenues” stands out as the only obstacle that showed a significant difference between gen- ders, with males being more concerned about this aspect. This is further affirmed by the fact that male surgeons, in this study, per- form a higher number of financially rewarding procedures, such as procedures conducted under general anesthesia. This may highlight the social stereotype of the Arab male as being the “pro- vider” and “breadwinner” for the family. It may also indicate that patients and/or institutions consider male surgeons more experien- ced and trustworthy to perform more complicated surgical proce- dures.16 However, it should be noted that several studies reported interesting findings linking better surgical outcomes with the female gender. Female surgeons were more likely to have longer operation times;17 however, they demonstrated more favourable surgical outcomes.18 This was explained by the inherent properties of women in using a patient-centered approach in decision- making, being selective of their patients for surgery, and being more willing to collaborate.19 The above observations are consi- stent with the findings of this study, which showed that “family responsibilities” was the most highly cited career obstacle among females. However, when asked about the factors that influence their career choice, the most highly cited factor among females was “lack of mentors”. This, together with their preference for obtaining specialization abroad, confirms the diligent and, proba- bly, conscientious approach of females, who were more concerned about prospects of professional development and mentor availabi- lity. Role models or mentors have a significant influence on female surgical career choice.20 Female mentors, in particular, have a significant role in motivating female trainees to move forward and overcome obstacles in the profession.21,22 Participating male surgeons in this study believed that “marria- ge” and “having children” are the most important factors that influence female surgeons’ career choice. These perceptions seem to be consistent with the current views in conservative societies, which consider that women, regardless of their career stage, are expected to fulfill society’s expectations of getting married to esta- blish a family and have children. Work-family balance is important for surgeons, irrespective of gender and geographic setting.23 It should be noted that achieving this balance is not only the respon- sibility of surgeons themselves but also institutions and the heal- thcare system in general. Examples of such required support inclu- de the provision of maternity/paternity leave, childcare facilities, allowing time for breastfeeding, and improving access to medical care.24 There were also significant differences between males and females in their views regarding leadership roles. Significantly more males perceived that females are not fit for leadership, con- trary to females who perceived that “both genders can be equal lea- ders”. The lack of confidence in assuming leadership roles by females should be further investigated to explore the reasons behind these perceptions. It should be noted that lower participa- tion of females in leadership positions is reported in many profes- sions, mainly because leaders are seen to demonstrate masculine traits.25–27 Within the context of OMFS, however, female and male surgeons were in agreement that there are no physical or mechani- cal disadvantages associated with female gender.28 Specific strate- gies may be implemented to assist women in leadership, such as identifying potential leaders early on, establishing mentorship pro- grams, and training men and women in management to provide support.29–31 It was important in this study to assess the surgeons’ continuous education activities using popular platforms32,33 such as YouTube. Almost seven in ten surgeons stated that they refer to YouTube for professional development. Males and females were comparable in referring mostly to aesthetic surgery- and oncology- related content. These two disciplines are highly advanced; there- fore, training years may be insufficient for obtaining the required competencies. This highlights the importance of revising surgical training curricula to accommodate advanced competencies. More recently, several oral, head, and neck oncologic and reconstructive surgery fellowships were established in an effort to increase traine- es’ exposure to ablative and reconstructive head and neck surge- ry.34 This experience can be replicated in other countries, particu- larly Middle Eastern countries, where the vulnerable political atmosphere and armed conflicts increase the demand for recon- structive surgery, including microvascular reconstruction. The study has limitations represented by the convenient sam- pling method and low participation rate, particularly from Saudi Arabia. Two rounds of data collection were performed to minimize this deficiency. Future studies should recruit larger and more ran- domized samples to improve representativeness and generalizabi- lity of results. While it was not possible to accurately determine the number of OMFSs practicing in the participating countries, the number of participants exceeded that of previous relevant studies conducted in this geographic area. Future longitudinal studies may be conducted to track career progression and advancement. Other recommendations include employing qualitative methods that explore personal experiences, which could complement and enrich the quantitative data. Conclusions Male oral and maxillofacial surgeons in the Arabic region show approval of female participation in the surgical career; howe- ver, their uncertainty towards female contribution to leadership roles should be assessed further in future studies. Factors influen- cing females’ decision to delay starting a family should be addres- sed, particularly for trainees. 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