Layout 1 Introduction Medicine in South Africa (SA), as in other parts of the world, is becoming an increasingly inclusive and di- verse profession, with growing numbers of women doc- tors (Bates et al., 2016; McKinstry et al., 2006). Greater diversity in medicine has led to improved relations with diverse patient populations and a deeper understanding of their needs and backgrounds (Sullivan 2004), as well as encouraged varied and novel ways of thinking, en- hanced cultural proficiency, and improved patient care and outcomes (Klifto et al., 2020). Nevertheless, surgi- cal disciplines have continued to be dominated by men Operating in the margins: Women’s lived experience of training and working in orthopaedic surgery in South Africa Mari Thiart,1 Megan O’Connor,2 Jana Müller,3 Nuhaa Holland,4 Jason Bantjes,4,5 1Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg, Stellenbosch University; 2Department of Orthopaedic Surgery, Inkosi Albert Luthuli Central Hospital, School of Clinical Medicine, University of KwaZulu-Natal; 3Ukwanda Centre for Rural Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University; 4Institute for Life Course Health Research, Department of Global Health, Stellenbosch University; 5Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa ABSTRACT 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. Correspondence: Mari Thiart, Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg, Stellenbosch University, South Africa. E-mail: marithiart@sun.ac.za Key words: Diversity; medical training; South Africa; women; or- thopaedic surgery. Contributions: MT, MOC, JB conceptualised the study. NH and JM conducted data analysis. All authors were involved in data in- terpretation and preparation of the final manuscript. Conflict of interest: The authors confirm that there are no conflicts to declare. Funding: The work reported herein was made possible through funding by the Fund for Innovation and Research into Learning and Teaching (Finlo) grant through Stellenbosch University (awarded to MT). The content hereof is the sole responsibility of the authors and does not necessarily represent the official views of the Finlo grant. The work was also made possible with funding from the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the MCSP (awarded to JB). The content hereof is the sole responsibil- ity of the authors and does not necessarily represent the official views of the SAMRC. Ethics approval: Ethical clearance for the study was obtained from the Health Sciences Research Ethics Committee at Stellenbosch University (N21/06/054). Informed consent: Informed consent was obtained prior to data col- lection. Availability of data: Availability of data and datasets used and/or analysed during the current study are available from the correspon- ding author on reasonable request. Received: 4 October 2022. Accepted: 8 March 2023. Publisher’s note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2023; 7:10902 doi:10.4081/qrmh.2023.10902 This article is distributed under the terms of the Creative Commons Attribution-NonCommercial International License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduc- tion in any medium, provided the original author(s) and source are credited. [page 12] [Qualitative Research in Medicine & Healthcare 2023; 7:10902] Qualitative Research in Medicine & Healthcare 2023; volume 7:10902 No n- co mm er cia l u se on ly (Wildschut, 2010). In 1960, only 10% of the SA medical profession were women (Digby et al., 2012), but by 2019, women constituted 40.6% of medical doctors, yielding a men-to-women ratio of 1:0.7 (Tiwari et al., 2021). Between 1999 and 2007, enrollment of women in SA medical schools increased from 49.7% to 56.2%. However, during this period, men still made up 80% of specialists, with women constituting only 5% of sur- geons, 4% of cardiothoracic surgeons and 3% of or- thopaedic surgeons (Wildschut, 2010). In SA, as in Canada, the United Kingdom and the US, women still tend to specialise in disciplines such as obstetrics and gynaecology, paediatrics, family medicine, and derma- tology—a phenomenon that has been called “internal segregation” (Wildschut, 2010). Globally, orthopaedic surgery has been particularly reticent resistant to gender transformation and continues to report the greatest sex disparity of all sub-specialities (Rohde et al., 2016; van Heest & Agel, 2012). In the US, for example, the women-to-men ratio in orthopaedics changed marginally from 1:7 to 1:6 between 2007 and 2016 (Klifto et al., 2020). In 2020, SA had only 51 registered women or- thopaedic surgeons, amounting to 5% of the profession (HPCSA, 2022). Studies in Canada, the US, and the United Kingdom have identified several reasons why women choose not to specialise in orthopaedic surgery, including personal pref- erence, the nature and demands of the work, perceptions about the work, tradition, negative experiences of the work environment during training, patients’ attitudes to- wards women surgeons, long working hours, and difficul- ties retaining balance between work and family commitments (Green et al., 2020). Women surgeons in Rwanda report similar challenges and attribute their de- cision to enter the speciality to role models, positive pa- tient encounters, and exposure to surgery (Yi et al., 2018). Women in surgical disciplines more broadly (i.e., be- yond just orthopaedics) experience subtle forms of inter- personal discrimination even when laws are in place to prohibit gender discrimination (Myers et al., 2018). Stud- ies have documented women surgeons’ negative experi- ences in the workplace, including interpersonal microaggressions, environmental invalidations, being treated like a second-class citizen, assumptions about tra- ditional gender roles, sexual objectification, assumptions of inferiority, being forced to “leave gender at the door,” and experiencing sexist language (Sprow et al., 2021). A survey of women’s perceptions of gender-based discrim- ination during surgical training and practice found that 87% of women experienced gender-based discrimination in medical school, 88% in residency, and 91% in practice (Bruce et al., 2015). A qualitative study of 46 women sur- geons and trainees identified four types of bias faced by women surgeons: i) workplace factors such as access to parental leave and role models; ii) epistemic injustices (unfair assessments of women surgeons’ credibility by pa- tients and colleagues); iii) stereotyped expectations that they will carry out more of surgery’s “care work” such as meeting the emotional needs of patients, and iv) objecti- fication (Hutchison, 2020). Furthermore, women surgeons remain grossly underrepresented in leadership positions in academic surgical departments (Jena et al., 2015; Zhuge et al., 2011), creating the impression that, for women surgeons, a “glass-ceiling” exists which is perpet- uated due to prejudices about traditional gender roles, un- conscious assumptions, sexism in medicine, and lack of effective women mentors (Cochran et al., 2013; Colletti et al., 2000; Zhuge et al., 2011). Occupying a historically marginalized identity in the workplace, such as being a woman in a field dominated by men, especially in a field dominated by men, has been associated with discrimination (Crawley, 2006; Pager & Shepherd, 2008; Smith, 2002), compromising mental health, and decreasing work satisfaction (Jansson & Gun- narsson, 2018). A survey of orthopaedic surgery residents across the United States and Canada found higher levels of depression and worse mental health outcomes among women residents (Gosselin et al., 2019). Furthermore, women surgeons in the US are more likely to experience burnout compared to their male colleagues, which has been attributed to work-home conflicts and workplace dis- crimination (Dyrbye et al., 2011). Indeed, women sur- geons’ experiences of marginalisation and discrimination in the workplace are a source of stress that consume en- ergy, which decreases the emotional capacity available for additional roles and negatively impacts their psychologi- cal well-being (Olsen et al., 2022). Women surgeons’ psy- chological health is affected by their perception of other people’s endorsement of stereotypes in the workplace (Salles et al., 2016), and Saudi Arabian scholars have de- scribed the deleterious emotional impact on women when their surgical competence is unfairly questioned (Alwaz- zan & Rees, 2016). Experiencing marginalisation con- tributes to trainee surgeons’ attrition, as well as feelings of depression, depersonalization, and emotional exhaus- tion, which, in turn, compromises patient care and de- pletes the medical workforce (Torres et al., 2019). While studies in SA have explored the experiences of Black doctors’ training as medical specialists (Thackwell et al., 2016, 2017), no studies have described experiences of women orthopaedic surgeons in SA. Understanding the experiences of women orthopaedic surgeons in SA may provide insight into why this corner of medicine continues to be dominated by men and what can be done to promote ongoing transformation and support the well-being of all doctors. Furthermore, understanding the experiences of women orthopaedic surgeons could have important im- plications for protecting and promoting the mental health of women orthopaedic surgeons who occupy a minority position in a historically male dominated work environ- ment. This interpretive qualitative study aims to explore women’s experiences of training and working as or- [Qualitative Research in Medicine & Healthcare 2023; 7:10902] [page 13] Article No n- co mm er cia l u se on ly thopaedic surgeons in SA and identify structures, prac- tices, attitudes, and ideologies that may promote or im- pede the inclusion of women in orthopaedic surgery. Materials and Methods The study was led by two women orthopaedic sur- geons (MT and MOC) who wanted to document their ex- periences and to give voice to other women’s experiences in the profession. Data collection Purposive and snowball sampling were used to recruit women orthopaedic surgeons working in the public and private sector, as well as women undergoing training to be specialists in orthopaedics. Emails inviting women to participate in the study were sent to all members of the South African Orthopaedic Association, heads of depart- ments at the eight SA universities training orthopaedic surgeons, and to members of the South African Female Orthopaedic Surgeons Society. The invitation described the aims of the study and asked women willing to partic- ipate in focus group discussions to contact the principal investigator (MT). Data were collected in December 2021, during three focus groups conducted online via Zoom. A total of 16 women orthopaedic surgeons participated in the focus groups. Each group had between four and six participants and lasted 60 to 90-minutes. The focus groups were facil- itated by a psychologist (JB) using a semi-structured in- terview guide which included questions about motives for choosing this speciality, experience of training and work- ing in this field, and challenges and highlights of being a woman orthopaedic surgeon. MT and MOC attended all focus groups as participant-researchers, asking questions to clarify what other participants were saying and sharing their own experiences. All focus groups were audio recorded and transcribed. Data analysis Data were analysed inductively using thematic analy- sis (Braun & Clarke, 2012). Two researchers (JM and NH), who are not orthopaedic surgeons and had not par- ticipated in the focus groups, worked independently to identify the initial codes using ATLAS.ti and followed the steps outlined by Braun and Clarke (2012). Initial themes were then shared and discussed with the whole research team to gain consensus on a final code book for subse- quent in-depth analysis. JM and NH used the code book to conduct an independent, in-depth analysis of the data using ATLAS.ti. The final list of themes and quotes were then discussed with the research team to gain consensus that participants’ words had been correctly interpreted and to select the most appropriate quotes to illustrate each theme. This process of data analysis triangulation was adopted to enhance the trustworthiness of the findings (Saunders et al., 2018). Member checking (also known as participant or respondent validation), was also used to im- prove the trustworthiness of findings by sending a final draft of the manuscript to participants for them to correct any aspects of the findings that did not represent their ex- perience. Member checking is a technique used in quali- tative research for consulting research participants about the credibility of findings (Birt et al., 2016). Ethical considerations Ethical clearance for the study was obtained from the Health Sciences Research Ethics Committee at Stellen- bosch University (N21/06/054). The online focus groups were password-protected; participants could log in with an alias and keep the video setting off to safeguard their pri- vacy. Informed consent was obtained prior to data collec- tion. De-identified data were securely stored on a password-protected cloud-based server. All identifying in- formation has been removed from the quotes to ensure anonymity. Findings Participants consisted of registrars (n=6) and consult- ants (n=10), from six of the eight universities offering postgraduate orthopaedic training. Registrars are middle- ranking hospital doctors undergoing training as specialists (i.e., the equivalent of a resident). Consultants are senior doctors who are qualified as specialists (i.e., the equiva- lent of an attending physician). Among the consultants, seven worked in the public sector, and three worked in private practice. Participants were between 25 and 59 years old. Five superordinate themes were identified: i) dynamic working environments and the work of transfor- mation, ii) negotiating competing roles of mother and sur- geon, iii) belonging, exclusion and internalised sexism, iv) gaslighting and silencing, and v) acts of resistance – agency and pushing back. Dynamic working environments and the work of transformation Participants described a dynamic and transforming work environment, which was markedly different from the healthcare system prior to 1994, when medicine in SA was still male dominated. They spoke with ambivalence about the use of quota systems and affirmative action to improve gender representation, highlighting how these practices contributed to them questioning whether they had earned their place in the profession. While they cele- brated gender diversification in the workplace, they also talked about the emotional work of being active partici- pants in the transformation process and the impact of being part of a minority group. [page 14] [Qualitative Research in Medicine & Healthcare 2023; 7:10902] Article No n- co mm er cia l u se on ly Participants gave concrete examples of gender trans- formation in the workplace and the strategies used to achieve this. P2, for example, contrasted her current en- vironment to the discrimination experienced as a woman doctor prior to 1994: ...[F]emale medical officers still got salaries two thirds of what the equivalent male doctors got… [and] once you married, you lost your housing sub- sidy…. We also didn’t have paid maternity.… A lot has changed for the better. Participants explained how quota systems and affir- mative action were being used to recruit more women into orthopaedic surgery and promote the career advancement of hitherto underrepresented groups. While they recog- nised the need to increase workplace opportunities for women, they also described how affirmative action un- dermined women by prompting them to question whether they had been selected on merit. P8 explained: … [T]he appointment of registrars has become so much more politicalised…. You kind of have peo- ple saying, “Oh, but you know that you’ll get the post...because they’re short of woman in the de- partment.” And, I think, for our registrars, there’s probably a very strong feeling of, “Am I here be- cause I deserve to be here? Or am I here because I’m not a white boy?” Similarly, P4 described how her self-confidence was un- dermined by colleagues saying that she had only been se- lected for a training program because of affirmative action, going on to explain that she only believed that she had earned her place in the training program once she was affirmed by a man: There were quite a good amount of comments made at many times, like, “Oh, yes, there was only two girls before you. They had to employ another girl. So, you played the girl card, obvi- ously going to get the job.” And I remember be- lieving that for a very long time. Only recently, I was speaking to one of the consultants who was actually in my interviews…and [he said] they were so happy when I interviewed well, when I scored the best.… It would have been wonderful to know that seven years back, and not for seven years think that you really just got the job because you’re a girl. P4’s experiences not only highlight how a quota system exacerbated feelings of self-doubt, but also illustrates men’s enduring role as gatekeepers to the profession and the power they hold to affirm women’s competence. Participants spoke with an acute awareness that they were disrupting an established gender order. They ex- pressed pride in disturbing the status quo, but also said this role was exhausting. They said actively participating in the transformation process imposes additional—often invisible—labor and responsibilities on them, which are not explicitly acknowledged or shared by colleagues who are men. P11 explained: I always feel like I have to first prove myself that I am competent, and that I’m this amazing person, and that I know everything before I can even do something as simple as cutting an incision. I have to first be qualified as an orthopaedic specialist.... I take it personally when that happens to me…. This constant needing to prove myself gets exhausting. Similarly, P15 described the impact, emotional labor, and personal cost of being a minority: You deal with the macroaggression. You go home. You debrief. You reflect. You distract yourself. You do something else. That time could have been used for doing something academic. So, every day you’re taking away because each time you’re angry for 10 minutes is taking away 10 minutes of the time you could be using to be productive…. You’re always on the back foot. Participants said that as part of a minority group, they felt additional self-imposed pressure to perform exceptionally well so as not to confirm any perceptions that women can- not do the work of an orthopaedic surgeon. P6 explained the origin of this internal pressure, saying: I think the problem is when you are a minority of any kind, in a department, if you are only two of you, and one of you is really great, and one of you is average, they’re going to remember that average one. Whereas if there’s 10 men and one is average, you know, it is still only one…. But because you’re compared to your minority group, that then be- comes like a generalisation. Participants used metaphors of war and combat to de- scribe the emotional impact and trauma of participating in the work of transformation. P6 said, “They survived, but I mean, just like in a war, with like bits missing, you know, maybe not sort of like physical wounds, but defi- nitely sort of emotional wounds.” While participants ac- knowledged that progress towards gender diversity had been made, they also said the pace of change was slow and expressed pessimism about the possibility of radical change in the foreseeable future. P15 articulated this say- ing, “I’m now sitting here thinking, ‘It doesn’t get better.’ I thought it would get better.” And P8 concluded, “I don’t see it changing anytime soon.” [Qualitative Research in Medicine & Healthcare 2023; 7:10902] [page 15] Article No n- co mm er cia l u se on ly Negotiating competing roles of mother and surgeon Participants spoke about the challenge of trying to bal- ance the competing roles of surgeon and mother and the sacrifices this entailed. They spoke about the difficult de- cisions they had made to delay motherhood and described how the working environment and the work of orthopaedic surgeons made it difficult to be pregnant, especially during training. They identified structural barriers, such as the na- ture of the work and the physical consequences of being pregnant, which made childbearing difficult, but they also highlighted attitudes and prejudices expressed by men and women colleagues, which exacerbated these structural bar- riers and made it more difficult to be a mother. Participants spoke with sadness and frustration about their decisions to sacrifice or delay motherhood so that they could realize the orthopaedic surgeon’s role, imply- ing that they experienced these two roles as mutually ex- clusive. P15 said, “I’ve had how many ladies in front of me now, about four or five. Only one has been brave enough to have a child during Reg [training], time. It sad- dens me.” And P6 said, “I really feel as much as I love my job, I feel like orthopaedics has robbed me of my fer- tility. And I resent it for that.…” Participants said that the work environment—espe- cially during training—made it almost impossible to be pregnant because work entails frequent and unavoidable exposure to radiation and physical exertion which com- promises maternal health. P16 described the challenges she experienced being pregnant during training, saying: … [T]hen you get to about six or seven months [pregnant], and you’re like really tired. Your back is sore now. I can’t actually push this traction table so well. It’s really heavy and, also, I guess I didn’t realise how much weaker I would feel physically. P13 reiterated the physical demands of pregnancy and the challenges of being a working mother, “It’s really damn difficult being pregnant and working. It’s even harder hav- ing a child or a toddler and trying to study, so it’s really not that easy.” Several participants described reluctance to take ma- ternity leave, being cognizant of the additional workload this would impose on colleagues and the disruption to their own training. They described hostile and unempa- thetic reactions of colleagues when pregnancy prevented them from being on call. P15 said, “I still think there’s an undercurrent of, if you employ a woman, it’s a risk, be- cause she may want to have a baby, you know, and our program is not really structured around that.” And P8 said: [My colleagues said,] “How can she want to stop doing calls at 37 weeks? Now we must pick up her calls!” When I can’t see my feet, and my back’s killing me, and I’m having pre-term contraction. All I wanted was to stop doing calls a month be- fore I popped a human out of my body [but] that was not acceptable. P15 acknowledged that it was similarly difficult for men to take paternity leave and said that men not taking pater- nity leave made it even more difficult for women to assert the right to take time off to during and after pregnancy: “If a man is too scared to take paternity leave, where does that leave a woman?” (P15). Participants described how male colleagues made inap- propriate comments which made it clear that women were expected not to fall pregnant. P6 explained, “Every time he [the head of department] would call me in to discuss some- thing else…unrelated, his parting words to me would al- ways be, “Whatever you do, just don’t fall pregnant.’” Participants expressed sadness and concern about the health and fertility consequences of their decision to delay motherhood until after training. P15 said: I’m much older, and, you know, to now finish and then try to have a child, it’s just not fair physiolog- ically. It’s not fair to ask me to put it off because, you know, for them, for males they can have a child at 90. It doesn’t matter. And P6 described the career sacrifices necessitated by pregnancy and motherhood, saying: I just feel like my professorship or whatever is going to be at least five to seven years delayed [compared to] whoever qualified with me, because I’m still trying to create this family…. I’m behind the men, my peers, because they’re writing articles and like pumping out things because…wife is at home looking after the babies…. I now have to juggle both, and from an academic trajectory, I think we’re on the back foot. This sense of “being on the back foot” (p6) and “making sacrifices” (P15) to be a mother negatively impacted par- ticipants’ job satisfaction and left them feeling robbed of the experience and joy of motherhood. It was explicit in the words of participants that they could not reconcile the role of mother and orthopaedic surgeon and that structural and attitudinal changes in the workplace would be needed to enable reconciliation of the two roles. Belonging, exclusion and internalised sexism While participants spoke of finding their place in or- thopaedic surgery and said they experienced a sense of be- longing in this field of medicine, they also described ongoing systemic barriers which blocked full participation in the profession and left them feeling alienated from col- leagues. The experience of simultaneously finding their place in the profession and being excluded from full par- [page 16] [Qualitative Research in Medicine & Healthcare 2023; 7:10902] Article No n- co mm er cia l u se on ly ticipation, engendered a sense of thwarted belonging. Aside from encountering sexist attitudes from other men doctors, nurses, and patients, they also described how other women expressed sexism and identified ways in which they them- selves had internalised and reproduced sexism. Participants explained how they “belonged” in or- thopaedic surgery and described the joy of discovering a place in medicine that piqued their interests and matched their aptitudes, finding the speciality a “perfect fit” (P1) for them, and “being at home” (P2) doing the work of an orthopaedic surgeon. P1 said, “I started, and I found or- thopaedics a wonderful mix between the engineering, and the building, and the three-dimensional thinking and puz- zle solving that I love, mixed with the humanity of med- icine.” P2 explained, “In my fourth year, we had the experience of being on call in the orthopaedic section of the [name redacted] hospital. And I just totally fell in love and just felt this is my place.” Although participants said they found their work en- vironment demanding and challenging, no one said they regretted choosing this speciality. P14 explained: When we got exposed to what orthopaedics was actually about…it was simply amazing. It’s clean. It’s cleaner than surgery. And you get to be in the- ater all the time, and it’s just a whole lot of fun. So, I don’t think I have any regrets. However, participants also described sexist attitudes and institutional practices that contributed to feeling excluded and marginalised. P10 described the alienating impact of confronting gender stereotypes, saying, “We had to assist for cases in private, and I could hear on the phone, how the guy said, ‘Don’t send me a girl to assist. They can’t do it.’” They described the culture of orthopaedic surgery as an “old boys’ club” that affirmed heteronormative, tra- ditional masculine modes of expression. For example, P9 described feeling marginalised and alienated from men colleagues because she did not share their interest in tra- ditionally “male” sports: The boys would go off and ride their bicycles, or they all seem to go and ride motorbikes.... And I would go, and I’d pick up my tennis racket, and I’d go and hit a few tennis balls or whatever it was.… You always feel separate or alone…. It’s just the way it is. Likewise, a participant reported that a male colleague commented, “You are not one of us” (P15), which rein- forced the perception of being out of place in the or- thopaedic environment. P15 explained: … [I]n an interview he [senior male colleague] let slip that I wasn’t a [white male]... [He said] “We can’t really deal with you yet.” I would just like to be an orthopaedic surgeon. I didn’t know I was of- fending anybody by trying to be that. And so, it be- comes difficult, you know when people say that to you, and it hurts…. All but one participant gave examples of encountering gender expectations and explicit sexist attitudes from other doctors, nursing staff, and patients. For example, P15 described the emotional impact of regularly not being recognised as an orthopaedic surgeon because it is typi- cally assumed that the surgeon would be a man: I walk into a strange theater. Everybody turns. I need to introduce myself. “Hi, this is who I am, I am here to do this [surgical procedure].” It is ex- hausting, as you’ve been doing it [explaining who you are] every day…. You do it when you’re on call. And at 3 a.m. in the morning you get some- body who’s going to say something left ways [derogatory], and you burst out at them because you’ve been carrying this the whole day. Then you get reported, “Oh, she’s being emotional!” But no one understands that was the fifteenth person of that day to undermine you. Participants also articulated a perception that men sur- geons are assumed at face value to be competent, but women are required to demonstrate competence before they are recognised as surgeons. P3 explained: …[A]nd the sisters [nurses] always think I’m ei- ther the rep or the radiographer and never think you’re the surgeon. And you have to also prove yourself to them, that you’re a capable surgeon be- fore they start trusting you with things. Similarly, another participant said: ….[P]atients assume you’re not the doctor—you’re the nurse. Or [they assume] your big burly [man] intern is the orthopaedic surgeon. And you know, [they assume] you’ve got to be the assistant…. And you’re explaining the operation in detail [to the pa- tient]...and then the patient turns to him [the intern] and asks a question that he can’t answer. (P5) These stories highlighted the frequency with which par- ticipants were “not seen” and/or “misrecognised.” They experienced this misrecognition as a recurrent unambigu- ous reminder that women are out of place doing the work of an orthopaedic surgeon and do not belong in this field of medicine. Participants said that some of the most blatant sexism they had experienced came from other women—not only women nurses, but also other women specialists. P6 ex- plained: [Qualitative Research in Medicine & Healthcare 2023; 7:10902] [page 17] Article No n- co mm er cia l u se on ly … [M]yself and another female were both asked in the interview process, whether or not we plan to fall pregnant, during Reg [training] time, which is actually illegal. You’re not allowed to ask that, but we were both asked, and that question came from a senior female in the department. Another participant said: As much as I’ve had a lot of trouble with men in my departments, my worst case was with a female head of department. I don’t know why that hap- pens, and I can’t explain it really…. Maybe it’s be- cause you have your guard down when you’re with the female head of department, and so it hurts more. (P11) Similarly, R13 said: The hospital that I haven’t felt comfortable at is actually because of the senior woman who makes all the other women feel inadequate…. Unfortu- nately, all the registrars or medical officers that have been female have had the same problem with this particular woman, and it’s quite traumatizing. I honestly actually have PTSD [post-traumatic stress disorder] right now from her behaviour so now, when I have to go to the hospital, I, literally, like get anxious and nervous. Some participants acknowledged that they too hold women trainees to a higher standard than their male coun- terparts, with an expectation that women should “do better than men” (P6). They acknowledged that this double stan- dard contributed to increasing the pressure on other women and made the work environment less hospitable for them. These experiences seem to point to internalised sexism and a complex dynamic in which women con- tribute to co-creating and reproducing a work environ- ment with different rules for men and women. P1 said: I really do try and be an advocate for the women, but at the same time, I think, as a woman in the de- partment, I do hold them [women] to a higher level…. It’s about holding them to a higher stan- dard. Because I want to be proud of that minority. I really want to be proud of those girls. I want them to achieve. I want them to be beyond question. Participants also articulated a perception that senior women colleagues were harsh on junior women because they were unconsciously re-enacting their own experience of being treated badly. P8 said: I almost feel like there’s this divide, and as a female consultant or senior, you can either be an absolute bitch or you can be a mentor, and I’ve encountered both…. They think “I’ve had it really hard in getting to where I am, and I’m going to make you work just as hard, because I didn’t have it easy.” Gaslighting and silencing Participants said they experienced gaslighting—i.e., being psychologically manipulated into doubting their own perception of reality and/or memory of events— when they tried to talk about sexist practices, which made it very difficult for them to raise concerns about subtle gender discrimination in the workplace without being po- sitioned as “crazy” (P6) or “emotional” (P15), “imagin- ing” (P6) this transgression or being “too sensitive” (P6). These experiences acted as a prohibition to talking about sexism and left them feeling silenced, unheard, and afraid to raise their concerns. P6 described a scenario where she tried to draw atten- tion to a male colleague’s sexist remark: “…the fact that they did not actually acknowledge it—to go, “Sorry you’re right’…. [Instead, they] don’t seem to want to admit it.” Participants explained that they were sometimes called “combative” (P16) for drawing attention to gendered prac- tices. While they acknowledged that they were assertive and passionate about raising these issues, they did not ex- perience themselves as combative. This incongruence be- tween their experience of themselves and their colleagues’ experience of them was perturbing and contributed to par- ticipants questioning their perception of themselves, in- cluding their sanity and judgement. P16 explained: You know that sometimes these comments can be bounced off because you’re resilient, but if people say things to you—like “you’re combative,” and you don’t experience yourself like that—then those kind of micro-traumas will wear anybody down. And you wouldn’t be human if they didn’t have an impact on your mood or your level of job satisfaction. It’s not nice to be in a situation where people are telling you things that you don’t expe- rience of yourself. Participants said that they felt silenced from gaslighting incidents and were afraid to be too assertive for fear of the consequences. P13 explained, “No one is standing up and saying anything. ‘You want us to lay the complaint? You want us to email Prof [the head of department]? You want us to contact them?’ But we’re too scared.” And P14 said: I’ve seen it around me…. You are trying to obvi- ously change the status quo, while the people who are very happy in the status quo are going to do al- most everything to make sure that the things don’t change. I saw it happen in our…department where this very vocal passionate, intelligent—they might [page 18] [Qualitative Research in Medicine & Healthcare 2023; 7:10902] Article No n- co mm er cia l u se on ly have named her a combative female in that depart- ment—was kind of pushed out because she wanted things done differently. Implicit in the words of participants was a double bind; if they spoke directly about their experiences of sexism, they would run the risk of being gaslit and/or positioned as combative and/or squeezed out of the department, but if they remained silent, they would feel that they were com- plicit in perpetuating sexism and, hence, impeding gender transformation in orthopaedic surgery. This “double bind” created internal tension and frustration which impeded participants’ job satisfaction. Acts of resistance – agency and pushing back Participants described strategies they use to resist and disrupt the status quo. They explained how they affirmed their sense of agency and pushed back against being mar- ginalised through acts of resistance and rebellion which included positioning themselves as stubborn, consulting lawyers to assert their legal rights, taking a stand about sanitary bins in bathrooms, claiming space, wearing boldly colored dresses, insisting on maternity leave, and expressing milk at work when they were breastfeeding. Above all, participants described becoming comfortable with not fitting in and expressed pride at being different. Participants explained how they resisted marginalisa- tion by asserting themselves and playing the role of rebel. P1 described her tenacity and rebellion, identifying her- self as stubborn—a label she reclaimed and wore with pride—saying: I really do believe we are a stubborn lot of women who have really gone out and said, “You know I’m going to do what I love. I’m going to do it well, and… stuff everyone’s opinion about me doing that.” And P4 said: That didn’t sit well with me, to be told that I can’t do something. So, I think that maybe fuelled my rebellious side to the point that I decided, well, I can do it now, and I will do it great! Participants gave examples of the lengths they went to challenge the status quo, including consulting labor lawyers and insisting on sanitary bins being placed in the bathrooms. P13 said, “I went to, I even contacted like labor lawyers to see what the law says, and labor laws for doctors in general….” Another participant explained: There was a big uproar when I had to add a bin for sanitary pads to our one toilet that we had in our hospital. Oh my God, it was like the world is going to end. So, they were like, “Why do we have to have a bin, sanitary pads in our toilet?” and I was like, “Yes because there are now women in our de- partment and get over it.” (P8) Participants reported pushing back against the notion that there is no room for femininity in orthopaedics by wearing dresses and dressing in bold colors, especially at conferences where they expressed feeling particularly marginalised. P6 said: I make a point of when I go to Congress, when all those men are there at the annual meeting, I make sure that I’m wearing something bright, because they’re all in grey and navy and black…just to be sort of like, “Just remember, we are here and we are not going anywhere.” I do it on purpose as an act of rebellion. Similarly, another participant described her defiant re- sponse when she was asked if she planned to fall pregnant: …[W]hen I got there, I was asked [if I was planning to fall pregnant]. So that’s just a little bit ridiculous. So, I asked them if they plan to get into any major accidents or get any major surgery or get cancer, then they should just, please, let me know. (P10) And P12 explained how after having a baby, she used ex- pressing milk as an opportunity to make a point about women doctors’ needs: I had to express breast milk during the day…. I just told the guys like, between cases, “Now, I need twenty minutes to go express. I’ll write the theatre notes, while I’m expressing in the office. I need that office, please. Thank you.” I had to give my one male colleague a lift between the two hospi- tals, so he had to wait outside the car while I set up, and I put a blanket over myself, and I ex- pressed next to him in the car on the way to the other hospital, and he had to deal with it. He didn’t have the guts to say anything about it. Participants also asserted that they felt comfortable with “not fitting in” and challenging established practices. Throughout the interviews, there were implicit assump- tions about the value of diversity and the benefits of ques- tioning traditions. P9 explained how she had become comfortable with challenging conventions and celebrated the benefits of diversity. It’s only as I’ve gotten older that I realised that you shouldn’t fit in. That’s the beauty of it. You con- tribute because you’re different. You see things dif- ferently, you approach patients differently, you handle conflict differently, you handle manage- [Qualitative Research in Medicine & Healthcare 2023; 7:10902] [page 19] Article No n- co mm er cia l u se on ly ment of groups of people differently, you crisis manage differently, you think differently in theatre, and that’s because you are a woman. And I wish I had known that earlier, because it really tormented me, this dire need to fit in, to be able to be one of the boys, but you’re not going to be one of the boys…. You shouldn’t be one of the boys. That’s the beauty of having different races, and different genders, and different identities in a group, is that you can approach it in a different way. Discussion Participants in this explorative qualitative study de- scribe working in a system that is undergoing visible transformation as more space is made for women in a field of medicine traditionally dominated by men. They de- scribe participating in the transformation process and the emotional and often invisible labor this entails. They de- scribe the satisfaction they experience doing the work of an orthopaedic surgeon while also encountering systemic structural and attitudinal barriers to their full participation in the profession. Their experiences of simultaneously finding a perfect fit in this specialty while feeling blocked from fully participating precipitated a sense of thwarted belonging. The experiences draw attention to the painful sacrifices they make to straddle the role of mother and surgeon while resisting and challenging the status quo. Previous studies have described surgery as a “boys club” with fiercely protected boundaries that restrict ac- cess (Gargiulo et al., 2006), which is consistent with how the women in our study experience orthopaedic surgery in SA. Indeed, it is this tightly controlled membership that in part makes the profession exclusive and distinctive. The women in our study are aware that they have crossed the boundary and work hard to affirm their place in this “club,” yet they still sometimes feel that their belonging is thwarted. Previous studies have demonstrated that a lack of belonging contributes to trainee surgeons’ attrition, depression, depersonalization, and emotional exhaustion (Torres et al., 2019). It is thus unsurprising that the women in our study describe the emotional effort and te- diousness of being excluded as they confront sexism, deal with microaggressions, and are misidentified. A scoping review of microaggressions experienced by women in sur- gery identified several common experiences, including encountering assumptions that women have inferior sur- gical skills, attitudes about traditional gender roles, and sexist language (Sprow et al., 2021), all of which are com- mon to the experiences of the women orthopaedic sur- geons who participated in our study. It is remarkable that the women in our study spoke so explicitly about the inability to reconcile the role of mother and surgeon and the struggles they felt to assert basic rights to maternity leave, even though SA has a lib- eral constitution which affirms and protects women’s rights. The role of the mother is closely tied up with social constructions of what it means to be a woman, and preg- nancy is a natural expression of womanhood. In this sense, a work environment that does not make space for motherhood sends an unambiguous message to women that they cannot bring all of themselves to work. Implicit in the words of participants was a perception that to as- sume the role of surgeon, they were encouraged—if not expected—by both men and women colleagues to deny motherhood and thus split off parts of themselves that are deeply entangled with womanhood. Again, these tensions are not new (Morantz-Sanchez, 1985) or unique to SA (Yi et al., 2018). A recent US study found that 84% of female residents did not start a family in their training and that these women experienced bias concerning pregnancy from both senior colleagues and their peers (Mulcahey et al., 2019). Similarly, studies have documented women surgeons’ perceptions that they are expected “to leave gender at the door” when they come to work (Sprow et al., 2021), as is implicit in the words of our participants. It is noteworthy that the women in our study report ex- periencing sexism and gender discrimination from other women—including nurses and senior medical special- ists—as has been reported in previous studies of women surgeons’ experiences in the US (Bruce et al., 2015). However, our participants also explicitly acknowledge that they too sometimes express and enact sexist attitudes by holding other women to a higher standard than men. There is extensive literature describing “mean girls,” “queen bees,” women’s competitiveness with other women, and internalised misogyny in the workplace (Har- ris & Kramer, 2019), particularly in the corporate world (Tosone, 2009). Still, this dynamic has not been widely explored in medicine. Scholars have described how senior women in business environments block and undermine more junior women to prevent them from climbing the hi- erarchy (Johnson & Mathur-Helm, 2011), a practice which is not uncommon in traditionally men-dominated work environments (Abramson, 1975; Davidson & Cooper, 1992; Gini, 2013). Other studies have also de- scribed how senior women working in male-dominated environments are more critical of women subordinates and require more of women subordinates compare to men colleagues (Derks et al., 2011; Moalusi & Jones, 2019). It is theorized that this occurs because women working in environments dominated by men want recognition of their own abilities to have “made it” and wish to remain unique in their environment, maintaining their “queen bee” status (Davidson & Cooper, 1992; Mattis, 1993). It has also been suggested that women in these environments tend to as- sume hyper-masculine leadership characteristics, rejecting their femininity and becoming more brash and aggressive as they assimilate into the dominant culture (Merrick, 2002; Yi et al., 2018). Another interpretation is that the senior women working in these environments are re-en- acting the sexist attitudes they have been subject to be- [page 20] [Qualitative Research in Medicine & Healthcare 2023; 7:10902] Article No n- co mm er cia l u se on ly cause they have unwittingly and unconsciously inter- nalised sexism, in the same way that racism and stigma are internalized (David, Schroeder & Fernandez, 2019; Fernández et al., 2022). The presence of gaslighting among our participants is further evidence of the power imbalance that exists in the historically patriarchal medical profession and is congruent with the findings of other studies describing gaslighting and bullying within the medical profession (Fraser, 2021). Gaslighting is less tangible and more difficult to expose than bullying, but can similarly have a pervasive psycho- logical impact on healthcare workers (Fraser, 2021). Typ- ically, in medicine, gaslighting occurs in doctor-patient interactions when patients experience invalidation, dis- missal, and consequently inadequate care at the hands of doctors (Sebring, 2021; Thompson et al., 2022). However, it also occurs between doctors, particularly when there is a power imbalance, as for example, occurs in training pro- grams. Crucially, our participants describe how their ex- perience of gaslighting makes them anxious about raising their concerns and acts to silence and restrict them. Finally, the women in this study describe clearly the active and conscious role they play in exercising agency and resisting sexism in orthopaedic surgery. They ac- knowledge that they are active participants in a dynamic process where they are not powerless to influence the sta- tus quo. While they acknowledge that this resistance is sometimes emotionally gruelling, they nonetheless ex- press pride at the role they are playing in transforming the profession and speak of their increasing comfort at being different and not having to “fit in.” It is a limitation that the study did not explore inter- secting identities, including how gender intersects with race, ethnicity, sexual orientation, and disability. The study focused narrowly on women’s collective experiences, and the sample was too small to adequately explore intersec- tionality. It would be very helpful, particularly in countries like SA that have a history of discrimination based on gen- der, sexual orientation, and disability, for future studies to focus on the dynamics of intersecting identities, although doing so would probably require an expansion into other surgical disciplines, given the small number of orthopedic surgeons with these social identities. Conclusions The findings of this study draw attention to the ongo- ing process of transformation that is happening in or- thopaedic surgery as more SA women claim their place in a profession historically dominated by men, highlight- ing both the progress that has been made and the work that still needs to be done. Most importantly, the findings remind us of the dynamic process in which both men and women contribute to co-creating, re-producing, and chal- lenging practices which make the profession more inclu- sive and diverse. 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