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Women in Surgery in Brazil

Friday, August 28, 2020  
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Women in Surgery in Brazil 
Fernanda Lage Lima Dantas1, Elizabeth G. Santos2
  
  1.  - MD, MPH, TCBC, FACS, professor, Federal University of Acre, Pediatric Surgeon of the state of Acre, representative of Women Surgeons in the Brazilian chapter of the American College of Surgeons, member of the AWS 
  2.  - MD, PhD, ECBC, FACS, General surgeon – HUCFF- Federal University of Rio de Janeiro, President of the Women's Commission – CBC; President of the Residence Committee – CBC; General Secretary - CBC (Brazilian College of Surgeons) 

 “We will not get there by osmosis. We need attitudes”. 
                                                                             Julie Freischlag 

At the end of the 19th century, surgeons already had everything needed to operate successfully: anatomy knowledge and the control of pain infection and hemorrhage. This period became known as “The surgeons' century1”. However, none of this made it easier for women to enter universities and surgery, as they were still seen as second-class beings, compared to children and foresters. They did not manage their money, they were not admitted to higher education, and they did not have the right to vote, which in Brazil, only happened in 19322.  

University teaching in Brazil was instituted by D. João VI, in 1808. As soon as he arrived in Bahia with his entourage, fleeing from Napoleon's invasion of Portugal. He founded the first medical school in the country, the School of Surgery of Bahia. Later on, in the same year, in November, the royal family moved to Rio de Janeiro and there he founded the National Faculty of Medicine. However, only in 1826 it was authorized by emperor D. Pedro I to issue diplomas and certificates to the doctors who were taking the course. It was once called the University of Brazil, and today it is known as the Faculty of Medicine of the Federal University of Rio de Janeiro (UFRJ)3,4

In 1879, D. Pedro I opened medical schools to women. Up to 1900, five women completed a medical education and  practiced their profession: Rita Lobato Lopes, from Rio Grande do Sul, in 1887; Ermelinda Lopes de Vasconcelos, from Rio Grande do Sul, in 1888; Antonieta Cesar Dias, from Rio Grande do Sul, in 1889; Maria Amélia Cavalcante, from Pernambuco, in 1889, and Judith Adelaide Maurity Santos, from Rio de Janeiro, in 1900. Before 1879, some women who wanted to be doctors had to leave Brazil and study in the United States of North America2

Gradually, the number of women doctors has increased, and today they are the majority in medical schools, although the percentage increase in surgeons has not kept pace with the accelerated growth in the number of doctors trained in the following years. Women accounted for 22.3% and 21.5%, respectively in 1910 and 1920. Since 1970, this proportion of women doctors has grown steadily. In the last Brazilian medical demographics. published in 2018, men were still the majority among doctors, accounting for 54.4% of the total professionals5.  

However, this difference changes every year. Women already predominate among younger doctors, up to 57.4%, in the group up to 29 years old, and 53.7%, in the range between 30 and 34 years old5. This increase in the number of women physicians has not changed the fact that medicine in general is dominated by men, as a result of a patriarchal culture6.  

Women are the majority in five of the six basic specialties Pediatrics (70.0%), Gynecology and Obstetrics (51.5%), Internal Medicine (54.2%), Family and Community Medicine (54.2%) and Preventive Medicine (50.3%), but not in surgery. 

Female doctors have maintained a higher concentration in relation to the number of men, in medical schools, but traditionally, they do not show a preference for the surgical area. Neumayer et al7 reported that only 15% of female doctors choose any surgical specialty. 

Although surgery has undergone many changes in the past two centuries, and women surgeons no longer need to disguise themselves as men to practice the specialty, many people when they think of a surgeon, the image is that of a smart and confident man8. For women the path is always arduous, full of opposition, lack of support, including from family, and varied prejudices. Sometimes discreetly, but often ostensibly, women were pushed back, but have persisted. 

The Brazilian College of Surgeons (CBC), the largest society of surgeons in Latin America, was founded in 1929. After 91 years of existence, in 2020, of 7,072 members in its membership only 1,181 are women9. The first woman to apply was Meriza Garrido, in 1959, thirty years after its foundation. Next came Oldea Bertolazzo, in 1964, Maria Luiza Cavalcanti in 1966, Talita Franco in 1968 and, in 1969, Angelita Habr-Gama, perhaps the most famous woman surgeon in Brazil. A world authority in the field of coloproctology, with several international awards, she was discouraged by her own family. She is an example of strength for all surgeons. In her recently published book, “No, it’s not an answer”, her goal is to encourage women to pursue their dreams, not accepting the “no” that is often presented to them10,11.  

In forty years, only five women surgeons were part of the leadership of CBC. Recently, the numbers of women leaders have increased, but not so much, among women surgeons9. It is noteworthy that in this large organization, since its founding, women belonging to the Board of Governors make up a very small number. The first was Dr. Helga R. Pitta, who in the presidency of Dr. Correntino Paranaguá (1961-1963), was the second secretary. From that time, until the current Directory, only fourteen women occupied positions, such as sectoral vice presidents, board members and the most important, secretary general 9.  

In the history of the first generation of female surgeons, in the 19th century, the need to disguise as males was common for women to be able to practice their profession. In the second generation, there was a need to choose between professional and personal life. It was common then to hear this phrase: "you will ruin your life as a woman if you choose a surgical career". Many chose not to have children or classic marriages. In the third and fourth generation of women, we have been able to identify more frequent reports of satisfactory reconciliation between personal life, marriage and children, and the life of a surgeon. Discrimination and discouragement, as well as bullying based on gender, are still noted. Some are beginning to appear, albeit tenuously, to discuss these issues. The process is still difficult for women. They need to prove many times throughout their lives that they are capable of performing their duties, because they are playing a still masculine role in society12

Explaining why few women want to be surgeons, or if they initially do, but end up deciding on another specialty is not simple, nor does it have a single answer. A variety of factors negatively influence potential candidates. One explanation would be the lack of inspiring models. The gender of the tutor does not impact the quality of training, but the lack of a successful female model that can be “copied”, does6. Another is the search for specialty that allows them to more easily reconcile rewarding professional activity with personal life, including marriage and maternity13. Even though in its early years of medical school surgery has a very strong appeal, this flame goes down, often is even extinguishing, as the candidates become more aware of what being a surgeon means. A third, and perhaps the most important factor, is the strong discouragement that comes from bullying. Women, even when they are more capable than their male counterparts, have to work much harder to prove their worth. Bullying, defamation, disrespect ... One of the phrases they hear the most is: “Surgery is not for women”6.  

On the other hand, most women who decide for surgery report that they had a strong, successful female model, and wanted a specialty that was an intellectual and technical challenge14.  

Surgery is a specialty that consumes and becomes a second skin. To be a surgeon, the individual must be strong but flexible; bending, but never tearing or breaking. We must learn to lead and command12. And, certainly, embracing surgery will impact many personal decisions, such as becoming a mother and starting a family, because for surgeons this is interpreted as punishment. 

The echoes of Lucas-Championnière's defamation are still strong and have an expression in the male world of surgeons. “Women cannot seriously pursue a medical career unless they are no longer women. Due to physiological laws, medical women are ambiguous, hermaphroditic or asexual, monsters from all points of view”15.  

After so many centuries, this prejudice still exists and is intense, although more veiled. It goes hand in hand with blackmail, harassment and devaluation. In a recent survey carried out by the CBC Commission of Women Surgeons, it was found that 50.3% of the interviewees suffered moral harassment, and that 59.9% thought they would not reach the end of their residency. However, 80.7% stated that, despite the difficulties, they would choose surgery as a specialty again9

Being a surgeon means that on a same day you have to be as hard as concrete and as sweet as honey. You must have “nerves of steel”, firm hands, and a keen sense of competition. However, these are qualities that every surgeon must have, whether male or female12

Operating requires surgeon resistance, precision, visual acuity, and integration between cognition and manual ability. Being a surgeon is much more than having the ability to perform a series of operations. Their training is complex because it requires a unique and balanced mix of knowledge, manual dexterity and the ability to make decisions16. However, it is not written in these requirements that the surgeon must be male, as women are also able to develop these attributes without having to lose their femininity. They can be mothers, wives and yet great surgeons - “You may be disappointed if you fail, but you are doomed if you don´t try”. 

It seems incredible that in the 21st century, prejudices against women surgeons are still being discussed. There are several associations of women surgeons created with the aim of helping in this regard. In the United States, Canada, England, Australia, all colleges of surgery have Commissions for Women Surgeons, and all have the same thought: being a woman is no impediment to being “an excellent surgeon”, although surgery is still seen by many, including women, such as “an old boy’s club”. 

In September 2018, at the invitation of ACS presidents, Barbara Bass and Patricia Numann, a dinner of women surgeons took place in Rio de Janeiro. Present at the occasion were Elizabeth Santos, General Secretary of the CBC and first female surgeon in the general surgery service at the UFRJ University Hospital, and Maria Cristina Maya, first female professor of surgery at the State University of Rio de Janeiro (UERJ), in addition to another 30 surgeons from Brazil. On this occasion, Brazilian surgeons were strongly encouraged to create an association of women surgeons, and on November 26 of the same year, the CBC approved the creation of the Commission of Women Surgeons. 

The activities aimed at discussing women's issues have received a large interested audience, at the CBC Congresses, in which there is always room for such discussions and exchanges of experiences. At the regional Congresses in 2017 e 2018, and at the Brazilian Congress of Surgery in 2019, in Brasília, the rooms for these discussions had a record audience. 

The Brazilian College of Surgeons joins all others with the Commission of Women Surgeons, whose objective is to work for equality, share ideas, share difficulties, encourage, and suggest actions that can positively transform the lives of women surgeons.  

“It is a wonderful, but difficult path. Many will try to discourage you and say that it is not "a woman's thing". If that's what you want and like to do, go ahead and don't be discouraged! Being a woman doesn't make you less capable in this area!” - testimony of a surgeon. 

The future is now. Those who pursued their dreams of being a surgeon had a love wedding, with intense fights and very difficult achievements. It is necessary for women to galvanize their energy and self-confidence, to believe in themselves, because they do have the necessary skills. The day will come when such questions will be anecdotal. The balance is still biased. Removing all barriers is a long-term action. Social changes are not simple. It must be understood that opportunities cannot be limited by gender. Female surgeons need to show that it doesn't matter if they are 12, 20 or 50% in number. They will show that they can win, because they want to make their careers a success, and this journey is an exciting adventure12,14

  

"When you know who you are, when your mission is clear, you burn with your inner fire, the ice does not come close to your heart, nothing can make you give up, because you know you are alive". 

Chief Seattle - Suquamish 

  
References 

  1. Thorwald J. O século dos cirurgiões. Hemus - Livraria Editora LTDA. São Paulo – 2002. 
  2. Franco T, Santos EG. Mulheres e Cirurgiãs. Rev. Col. Bras. Cir. 2010;37(1):72 – 77
  3. Faculdade de Medicina da Bahia. Available at:https://pt.wikipedia.org/wiki/Faculdade_de_Medicina_da_Bahia_da_Universidade_Federal_da_Bahia  Acesso em abril de 2020.
  4. Universidade Federal do Rio de Janeiro. Available at:https://www.medicina.ufrj.br/pt/conteudos/paginas/historia/principal
    Acesso em abril 2020. 
  5. Demografia Médica. Conselho Federal de Medicina & Conselho Regional de Medicina de São Paulo - Demografia Médica - Relatório de Pesquisa – 2018. Available at: http://www.cremesp.org.br. Acesso em março de 2020.
  6. Umoctok, f. Van Wyk, JM, Madiba, TE Does gender impact on female doctor`s experiences in the training ans practice of surgery? A single centre styudy. SAJS 2017:55(3):8-12.
  7. Neumayer L, Kaise S, Anderson K at al. Perceptions of woman medica students and their influence on career choice. Am. J Surg. 2002;183(2):146-150.
  8. Dossa E, Baxter, NN Reducing gender bias in surgery. BJS; 2018;1-3:17-7-1709.
  9. Colégio Brasileiro de Cirurgiões. A arte e a técnica da cirurgia no Brasil. Produção Editorial e Projeto Gráfico News Comunicação. 2007 1° Ed. Rio de Janeiro.
  10. Angelita Gama. Available at:  https://saude.estadao.com.br/noticias/geral,angelita-habr-gama-e-uma-historia-feita-de-acaso-e-dedicacao,70003223681  Acesso em abril de 2020.
  11. Angelita Gama. Available at:   http://www.usp.br/espacoaberto/?materia=angelita-habr-gama-dedicada-e-incansavel    Acesso em abril de 2020.
  12. Being a woman surgeon. Gordian Knot Books. 1st edition. Los Angeles, 2015.
  13. Cassel J. in Being a woman surgeon. Gordian Knot Books. Los Angeles, 2015.
  14. Wirtzfeld, DA. The history of womwn in Surgery. Can J Surg. 2009;52(4):317-320
  15. Lucas-Championnière, Just. ‘Article 9997’. J Méd Chir Prat. June 1875 issue. p. 241-2.
  16. Férnandez-Cruz L. Challenging times for General Surgeons. Ann. Surg. 2004; 240(6): 932-938