The female autistic surgeon

Part one: the woman and the scalpel

I have been postponing this subject for a while now, not only because it is deeply unpleasant and uncomfortable, but also because I am still not sure where to start, especially since there is more than one contributing factor to this already unlikely situation all of which consist parts of a nightmarish vicious circle. For starts, we need to acknowledge the fact that general surgery is not yet a professional field that women have been broadly accepted and recognised in. Traditionally male dominated, based on the principles and hierarchy one observes at the army ranks, hasn’t much evolved since the ‘60s . The current ratio of male to female consultant surgeons in the UK is approximately 8:1. Sure, there are some women around, but they are not even close to as many as they should be and they admittedly suffer all through their training career but also later as consultants as well.

It is hard to analyse this situation without imagining the doubt on the faces of some that will be reading these lines. The reason is more fundamental than we would like to think. There are many that deny there is sexism at work places. Everything is part of what some ‘consider’ to be a well meant humorous approach to the gender differences, for an example : ‘we need two women to do the job of one man’. Humour…Indeed… If any female voice dares to express any objection, she will immediately either be shut up by louder and heavier voices, ignored as if nothing was said or attacked for daring to speak up in her silly high pitched voice and in some cases she will also be labeled as a feminazi or worse.

Looking beyond the above objective hurdle of peoples’ difficulty to embrace equality between genders the same way they are at least trying to embrace equality between races, ethnicity etc., I will try and demonstrate the problem as I have personally encountered it in the field of surgery but most importantly as it has been so far reported in the scientific literature. The stereotyping of women surgeons has historically been pigeon holing their careers and placing a glass ceiling on them. Female surgeons often feel held back and treated unfairly based on their sex. Unfortunately this feeling among women surgeons is justified by a significant amount of evidence including the low number of women in high surgical jobs, such as professorship, program directors and consultant positions.

The sexist comments are always there, coming mostly from male surgeons who are often patronising and consciously or unconsciously discriminating. A senior female trainee is not as senior compared to a promising young and preferably white male trainee. It happens on all levels, not only trainers are prejudiced, but also nurses, junior doctors and patients most importantly. How often have I heard the line: ‘but you are so young to be a surgeon!’, while my male colleague, who they addressed thinking they are the person in charge, is at least fifteen years younger than me with many less years of medical experience as well… I once answered with a blunt: do you mean I look too female? The problem has immense societal dimensions and is not an easy one to address in the first place. The truth is that it is harder for some doctors, patients and nurses to trust a female surgeon, something that has its roots in ancient societal archetypes and that often makes our lives miserable and our work more difficult than it already is.

I think one of the issues that are specifically related to male and female surgeon/trainee balance is trust and allowing hands on during the years of training. My personal experience is that female trainers were more trusting in general and treated me as a grown up more often, rather than a clumsy child they fear is going to destroy their operation. I find it that male trainers have more often taken instruments out of my hands, including endoscopes when I first started to train in colonoscopies. I was working with a male trainer for a whole year and it eventually took a session with a female nurse endoscopist to perform my first complete colonoscopy. Was it a coincidence? No, because on that day I did three complete colonoscopies, not one. I had been ready for a while but the opportunity was simply never given to me before. My claims are supported by the claims of many female surgeons around the world that have been struggling with the boys club mentality for a long time now. The medical community has slowly been making some steps to acknowledge the problem and perhaps at some point we will hopefully be able to actually address and solve it.

There are many stories like that that describe the inequality, the disrespect and lack of support for female surgeons. I know most of my female colleagues had similar experiences but they rarely talk about them. It is quite often the case that we like to pretend we are one of the guys, an illusion that helps us feel like we belong. There is a catch from coming out or whistle-blowing, they assume that your female nature doesn’t let you cope with the challenges that come with a job like this. I once complained to the educational director of the surgical department I was working about a consultant that was routinely bullying me and he didn’t even bother to investigate this. All he had to say was: if you cannot tolerate this maybe this job is too stressful for you to do! That is a line I heard in 2015 UK. Yes… ‘Go home to look after your babies’ is all some people think and even if they don’t say it out loud you can see it in their eyes, in their moves and their decisions to occasionally ignore the rules and treat you as the weak link and a push around.

The autistic woman and the scalpel

Now imagine on top of all these you are also autistic. An autistic heterosexual female surgeon… As if not fitting in as a female member of the team was not enough of a challenge on its own. Facing extra social challenges as an autistic individual massively amplifies the issues of (not) being part of the team. As a woman, some people are already treating you as if they are doing you a favour ‘accepting’ you as almost one of them. Why aren’t you being nice and grateful? Why aren’t you respectfully accepting your boss’s wrong comments without objecting? We are expected to be nice in order to fit in. Polite, apologetic and pleasant to the eye. Fully obedient and conforming to the patriarchal stereotypes especially designed for us thousands of years ago. Difficult personalities in high achieving professions are for men only. Not that I believe we have the right to be assholes. We don’t. But there is zero tolerance for autistic women. They are not fuzzy and nurturing, often quirky, unfamiliar and difficult. Who gave them the right to be this eccentric anyway?

I recently read an article on a subject very much related that literally gave me goosebumps. The story was about a Canadian thoracic surgeon, Irene Cybulsky, who after having faced numerous difficulties during her training years and later in her career as the lead thoracic surgeon in the hospital she was working, she was eventually dismissed for not complying with the traditional gender standards. After her dismissal, she didn’t remain quiet though. She went to law school and after graduated she ended up representing herself in a human rights case against her former hospital. Her claims were recognised by the court and she is currently waiting on changes to happen. After reading the whole article, I couldn’t help but wonder if Cybulsky is actually autistic. The author of the article describes her as a pragmatic person who likes to solve problems, a direct communicator with total commitment to surgery, very high standards and a meticulous attention to detail. This description in combination with the fact that she was pretty much fired over communication issues and especially for not being ‘a fluffy and hand-holding person’ but rather an assertive, firm and sometimes authoritarian female surgeon, hated by her male colleagues is almost diagnostic…

We do have the right to not be ‘fluffy’ and nurturing. A male surgeon is successful if assertive and firm, often respected for his eccentricities. Why are people appalled when they come across the same personality type in a woman? Why do female surgeons not have the right to be in charge? There is only one ‘boss’ in theatre, however I cannot really count the times that as a senior trainee I was asked by my male boss to ‘do the case together’ with a junior male trainee. Or in some cases not being addressed at all although present and more senior. We cannot do the case together, can we? I can do the case and he can’t yet because he is still learning. Although I am happy to train someone that listens and is safe in the operating room, I am definitely not happy for my authority and leadership to be doubted when a patient’s life is at stake. It is simply not safe…

Gaslighted to believe we are not worthy enough, female and in particular autistic female surgeons live a difficult professional life. We nevertheless need to defend ourselves and speak up. Complying will never benefit autistic individuals. We were never good at it and this won’t change now. Why compromise and loose regardless? I say we fight back. We talk back with our usual annoying to to patriarchal figures audacity. Because we are excellent and committed doctors and we need to defend our medical opinion against any nonsense we hear regardless of which mouth it comes out of. We have the right to defend ourselves when just because of our poor PR skills we are downgraded to do a job way beneath us. We need to speak up if we are being abused by working overtime and being denied not only training but also the psychological and technical support from mentors necessary to advance our career. We need to find the words to describe all these indescribable passive aggressive behaviours that we have been tolerating just because we are very good at masking and very bad at seeking help. It is unfortunately all about fitting in and PR, something that autistic individuals are usually not that great at. Besides all that, nobody will look into how we are experiencing burn out because we have been working at the top of our speed for years now.

So, they have to like us in order to help us. But we are not like ‘them’. There is a massive difference of a whole chromosome between us plus a few tens of autistic genes. It is not our choice to be likeable or not. Even Hecate knows we have been trying hard without good results. But see, we don’t have to be your friend or the ‘next door girl’ type, you wouldn’t respect us anyway. We don’t have to be ‘fuzzy’ to be good doctors and surgeons just because we are female and we don’t have to be invited to your clubs and golf games, although it would be nice if we were sometimes. But we expect to be respected for our hard work and service to the community, our integrity as people and scientists, our loyalty to our patients and the profession. Because we are not like you, but us, your quirky, menstruating, antisocial colleagues, we have too much to offer to be denied access to progression and high responsibility positions…