RESEARCH • RECHERCHE

Surgical sexism in Canada: structural bias

in reimbursement of surgical care for women
Michael Chaikof, MD Background: It is well established that female physicians in Canada are reimbursed
Geoffrey W. Cundiff, MD at lower rates than their male counterparts. To explore if a similar discrepancy exists
in reimbursement for care provided to female and male patients, we addressed this
Fariba Mohtashami, MD question: Do Canadian provincial health insurers reimburse physicians at lower
Alexi Millman, MD rates for surgical care provided to female patients than for similar care provided to
male patients?
Maryse Larouche, MD
Methods: Using a modified Delphi process, we generated a list of procedures per-
Marianne Pierce, MD
formed on female patients, which we paired with equivalent procedures performed on
Erin A. Brennand, MD male patients. We then collected data from provincial fee schedules for comparison.
Colleen McDermott, MD Results: In 8 out of 10 Canadian provinces and territories studied, we found that
surgeons were reimbursed at significantly lower rates (26.7%) for procedures
Presented at the annual meetings of the ­p erformed on female patients than for similar procedures performed on male
Canadian Society for Pelvic Medicine, Apr. patients.
30, 2022, Toronto, Ont., and the Interna- Conclusion: The lower reimbursement of the surgical care of female patients than
tional Urogynecological Association, June
14–18, 2022, Austin, Tex.
for similar care provided to male patients represents double discrimination against
both female physicians and their female patients, as female providers predominate
in obstetrics and gynecology. We hope our analysis will catalyze recognition and
Accepted Oct. 12, 2022 meaningful change to address this systematic inequity, which both disadvantages
female physicians and threatens the quality of care for Canadian women.
Correspondence to:
M. Chaikof Contexte : Il est de notoriété publique qu’au Canada les femmes médecins sont
Sunnybrook Health Sciences Centre moins rémunérées que leurs collègues masculins. Pour vérifier s’il existe un écart
Toronto ON M4N 3M5 similaire selon que la patientèle est féminine ou masculine, nous avons posé la
michael.chaikof@mail.utoronto.ca question suivante : les régimes d’assurance provinciaux canadiens rémunèrent-ils
les médecins à un taux moindre pour les traitements chirurgicaux dispensés à la
Cite as: Can J Surg 2023 July 4;66(4). patientèle féminine comparativement à la patientèle masculine?
doi: 10.1503/cjs.022121 Méthodes : À l’aide d’une méthode de Delphi modifiée, nous avons généré une liste
d’interventions visant des patientes, que nous avons appariées à des interventions
équivalentes visant des patients. Nous avons ensuite recueilli à des fins comparatives
les données sur les barèmes d’honoraires provinciaux versés.
Résultats : Dans 8 provinces et territoires sur 10 étudiés, nous avons constaté que
les chirurgiens recevaient une rémunération significativement moindre (26,7 %) pour
les interventions visant la patientèle féminine comparativement à la patientèle
­masculine.
Conclusion : La rémunération moindre pour des traitements chirurgicaux dis-
pensés à la patientèle féminine comparativement à la patientèle masculine
représente une double discrimination à l’endroit des médecins et de la patientèle
de sexe féminin, car les femmes sont plus nombreuses à exercer en obstétrique et
gynécologie. Nous espérons que notre analyse servira de catalyseur pour une
meilleure reconnaissance et pour la correction de cette inégalité systématique
qui désavantage les femmes médecins et menace la qualité des soins prodigués
aux Canadiennes.

G
ender bias is prevalent in medicine worldwide, and women
experience poorer health than men as a result.1,2 The disparities
in the health outcomes of men and women are due to a variety
of issues, including missed diagnoses, minimized symptoms, greater bur-
dens of specific diseases and poorly targeted treatment.3 Health care sys-
tems continually disadvantage their female patients by under­estimating

© 2023 CMA Impact Inc. or its licensors Can J Surg/J can chir 2023;66(4) E341
RECHERCHE

their pain and down­playing other symptoms.4 Women Methods

are also under-represented in clinical trials and there is
inadequate incorporation of sex- and gender-based We created a study committee of Canadian clinicians to
analyses into research.5 Recently, attention has turned perform a cross-sectional analysis of data obtained from
to the effect of gender bias on medical practitioners. provincial physician fee schedules. Members of the com-
There is a persistent and substantial gender-based gap mittee were recruited to ensure a mix of Canadian clin­
in physician remuneration, both in Canada and inter- icians trained in the specialties of obstetrics and
nationally. An Ontario study of physician reimburse- gyne­­­­co­logy and of urology, with representation across
ment showed that female surgeons are reimbursed 24% provinces and work environments.
less than male surgeons on an hourly basis, even within We created a list of common gynecologic procedures
the same surgical discipline. 6 A 2021 study that used performed exclusively on female reproductive anatomy,
Ontario billing and administrative health data found a which would correspond to a patient population of pre-
daily payment gap of 13.5% between female and male dominantly cisgender women, as well as nonbinary ­people,
physicians after controlling for practice characteristics, transgender men and transgender women with ovaries, a
region and specialty.7 uterus, a vagina and/or a vulva. We then analyzed the pro-
While the proportion of female physicians in Canada cedures to identify a comparable procedure performed
has increased substantially over time, inequity in exclusively on male reproductive anatomy. Through an
medicine still exists for women. Female physicians still expert review process, the committee identified procedural
earn less than their male counterparts, are under- pairs for analysis in this study. First, they were asked to
represented in the highest paying medical specialties and independently review a list of gynecologic surgeries and a
tend to enter specialties with lower rates of compensa- list of urologic surgeries. The panellists considered each
tion.8,9 Even within the same specialty, women earn less surgery according to the following factors: surgical com-
than their male colleagues, as they are more likely to plexity, type of anesthesia required (general v. regional v.
perform procedures that are less well compensated. 10 local), surgical time, whether or not a major body cavity
Indeed, in other highly skilled professions, as the pro- was entered and whether or not the surgeon typically
portion of women increases, remuneration correspond- required subspecialty training to perform the procedure.
ingly declines.11 This phenomenon has been observed in We then engaged in a 2-step modified Delphi process. In
obstetrics and gynecology12 in the United States, where the first step, the list of gynecologic procedures was con-
overall reimbursement has fallen as women have filled a firmed and a list of paired procedures was generated sepa-
higher proportion of positions.13 Thus, there is a preva- rately by each participant and then collated by the group.
lent systemic remuneration bias against female phys­ In the second step, the collated list was reviewed in 2 sepa-
icians in the fee-for service system. rate meetings, where the pairs were discussed according to
This systemic bias against female physicians has the above criteria and disagreements were resolved by con-
important implications for patient care. Almost 60% of sensus. After these meetings, a finalized list of 23 proced­
Canadian obstetrician–gynecologists (OB/GYNs) are ural pairs was generated by consensus.
female, compared with 29% of all surgical specialists and Our data source was publicly available provincial fee
11% of all urologists.14 As female physicians are more schedules in the year 2020; we sought compensation details
highly represented in obstetrics and gynecology, the care to record total physician fees for the relevant billing codes
of female patients could suffer because of the wage dis- for each procedure on a provincial and territorial basis. We
crimination against female physicians. Data from the did not include data for the Northwest Territories or
United States have shown that procedures performed on Nunavut, as there were no fee-for-service specialists in
female patients are systematically valued at lower relative obstetrics and gynecology or urology practising there.
value units (RVUs) than equivalent procedures per- There was a published fee code for the Yukon, so data
formed on male patients,15 and a recent analysis showed were included despite the territory having an alternative
that the use of biased surgeon-reported data has further payment plan. Most of our procedural pairs involved
contributed to a relative undercompensation of the sur­ single-code procedures (e.g., hysterectomy as opposed to
gical time of American gynecologists compared with that hysterectomy plus oophorectomy) so that we could collect
of urologists.16 An informal comparison by Dossa and consistent data across jurisdictions. When multiple billing
colleagues of surgical procedures in Ontario demon- codes were associated with a procedure, the total fee was
strated an analogous trend, although similar analyses for recorded, with appropriate adjustments for each jurisdic-
other provinces are lacking.6 Our objective in this study tion’s fee schedule. For example, in Ontario, any additional
was to determine whether Canadian provincial health code beyond the main procedure code was paid at a rate of
insurers reimburse physicians at lower rates for surgical 85%. The data from each province and the Yukon were
care provided to female patients than for similar care pro- either collected or reviewed by a phys­ician with experience
vided to male patients. with that jurisdiction’s fee code schedule. If the data for a

E342 Can J Surg/J can chir 2023;66(4)

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Table 1. Paired gynecologic and urologic procedures

Procedures for female patients Procedures for male patients

Vulvar biopsy Penile or scrotal biopsy

Excision of Bartholin gland Excision of hydrocele
Vestibulectomy Adult circumcision
Hymenectomy Pediatric circumcision
Excision of condyloma (vulva) Excision of condyloma (penis)
Endometrial ablation Transurethral resection of the prostate
Dilation and curettage Urethral dilation
Diagnostic hysteroscopy Diagnostic cystoscopy
Hysteroscopic polypectomy Transurethral resection of bladder tumour
Simple vulvectomy Scrotal resection
Radical vulvectomy Radical penectomy
Revision of perineal scar (obstetric or FGM) Distal hypospadias repair
Midurethral sling (female) Urethral sling (male)
Cystocele repair Simple Peyronie repair
Ovarian detorsion Testicular detorsion
Salpingectomy Varicocelectomy
Oophorectomy Radical orchiectomy
Sacrospinous vaginal or uterine suspension Placement of penile implant
Vesicovaginal fistula repair Urethrocutaneous fistula repair
Rectovaginal fistula repair Rectourethral fistula repair
Abdominal hysterectomy Simple abdominal prostatectomy
Pelvic and para-aortic lymph node dissection (ovarian cancer) Retroperitoneal lymph node dissection (testicular cancer)

FGM = female genital mutilation.

given procedure were not available within the jurisdiction’s payment plan there, the overall difference for all of Canada
fee schedule, then the procedural pair was excluded from decreased from 28.1% to 26.7%.
the analysis of fees for that jurisdiction. Figure 2 shows the mean reimbursement difference for
After data collection, the fees for each pair were com- all paired procedures by jurisdiction. In most jurisdic-
pared and differences were calculated in dollars and as tions, reimbursement was significantly lower for proced­
percentages. The mean percentage difference between ures for female patients than for the matched procedure
reimbursement for procedures for female patients and for male patients. The provinces with the largest discrep-
those for male patients was then calculated for each juris- ancies were Saskatchewan (mean percentage difference in
diction. The mean difference in fees within each pro­ fees of 67.3% [SD 18.4%]) and British Columbia (61.2%
cedural pair across all jurisdictions was also calculated. [SD 30.1%]). Smaller but still significant differences were
seen in Alberta, Manitoba, Ontario, New Brunswick and
Results Prince Edward Island. Notably, there were no statistically
sig­nificant differences in the average fees in Nova Scotia,
Through the modified Delphi process, we developed a list of Newfoundland and Labrador or Quebec.
paired surgical procedures exclusive to female and male
reproductive anatomy (Table 1). This list included pairs rep- Discussion
resenting all surgical approaches across the surgical spec-
trum, including 2 ambulatory procedures, 7 minor surgical Our study revealed a trend toward devaluation of the
procedures, 7 major surgeries performed with same-day dis- health care provided to female patients across Canada.
charge and 6 major surgeries performed with overnight stay. This trend was pervasive across the country, with
Figure 1 shows the mean reimbursement difference 7 provinces and 1 territory out of the 11 jurisdictions in
within each procedural pair for all of the study jurisdictions. the study showing a significant difference between the
For 70% of the procedural pairs, the procedure for female mean reimbursement for comparable procedures per-
patients was reimbursed at a lower rate; the average billing formed for the female and male reproductive tracts.
fee for procedures for female patients was 28.1% (standard Specifically, we have shown that across Canada, phys­
deviation [SD] 11.1%) lower than the fee for the correspond- icians performing procedures on female patients were
ing procedure for male patients. This corresponds to a mean remunerated at a lower rate than their colleagues per-
difference of Can$43.91 for pro­cedures for female versus forming comparable procedures on male patients. The
male patients. After removing Yukon data from the analysis provinces with the largest discrepancies were Saskatch­
of paired procedures by jurisdiction owing to the alternative ewan (mean percent different in fees of 67.3% [SD

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RECHERCHE

Vulvar biopsy Penile or scrotal biopsy

Excision of Bartholin gland Excision of hydrocele
Vestibulectomy Adult circumcision
Hymenectomy Pediatric circumcision
Excision of condyloma on vulva Excision of condyloma on penis
Endometrial ablation Transurethral resection of the prostate
Dilation and curettage Urethral dilation
Diagnostic hysteroscopy Diagnostic cystoscopy
Hysteroscopic polypectomy Transurethral resection of bladder tumour
Simple vulvectomy Scrotal resection
Radical vulvectomy Radical penectomy
Revision of perineal scar (obstetrical or FGM) Distal hypospadias repair
Midurethral sling (female) Urethral sling (male)
Cystocele repair Simple Peyronie repair
Ovarian detorsion Testicular detorsion
Salpingectomy Varicocelectomy
Oopherectomy Radical orchiectomy
Sacrospinous vaginal or uterine suspension Placement of penile implant
Vesicovaginal fistula repair Urethrocutaneous fistula repair
Rectovaginal fistula repair Rectourethral fistula repair
Abdominal hysterectomy Simple abdominal prostatectomy
Pelvic and para-aortic lymph node Retroperitoneal lymph node dissection
dissection (ovarian cancer) (testicular cancer)
-200 -15 0 -10 0 -50 0 50 100 150 200 250

Mean reimbursement difference (%)

Fig. 1. Mean reimbursement differences across Canada within each procedural pair. Negative values indicate higher reimbursement
of procedures for male patients; positive numbers indicate higher reimbursement of procedures for female patients. FGM = female
genital mutilation.

Canada
YT
PEI
NL
NB
NS
Qu e.
On t.
Man .
Sask .
Alta.
BC

-10 0 -80 -60 -40 -20 0 20 40 60 80 1 00

Mean difference in reimbursement by province (%)

Fig. 2. Mean reimbursement difference for all paired procedures in each province or territory. Negative values indicate higher
re­imbursement of procedures for male patients; positive values indicate higher reimbursement of procedures for female patients.

18.4%]) and British Columbia (61.2% [SD 30.1%]). tory’s fee schedule was set at a different time using
Smaller but still significant differences were seen in different processes. Across Canada, the average billing fee
Alberta, Manitoba, Ontario, New Brunswick and Prince for a procedure for female patients was 26.7% lower than
Edward Island. There were no differences in the average the corresponding fee for male patients. While some of
fees in Nova Scotia, Newfoundland and Labrador or the procedural pairs may reflect different surgical
Quebec. The variation between jurisdictions reflects the approaches (e.g., ovarian detorsion is performed lapara-
fact that in Canada, health care is administered on a pro- scopically whereas testicular detorsion is typically per-
vincial and territorial basis, and each province or terri­ formed with a transscrotal approach), we felt it was

E344 Can J Surg/J can chir 2023;66(4)

 RESEARCH

important to look at the financial value assigned to a pro- the US. 23 Cohen and Kiran found a similar trend in
cedure to save female versus male gonads. Canada, where female specialists earned 40% less than
OB/GYNs, who operate exclusively on the female their male counterparts.8 This gender bias may reflect
reproductive tract, constitute 3.2% of Canadian physicians inherent biases in the various provincial fee schedules, as
and earn 3.2% of total service fees. In contrast, urologists, suggested by previous studies.6,7 The authors emphasized
who provide similar care for men and some of whom care that double discrimination is at play. While female phys­
for women, constitute 1.0% of Canadian physicians but icians are devalued by provincial fee schedules, those who
earn 1.3% of total service fees.14 The findings in the care for female patients are even further devalued. As
pre­sent study indicate that this discrepancy is probably a female providers predominate in obstetrics and gynecol-
structural gender bias reflected in provincial and terri­ ogy, this may reflect one form of structural sexism leading
torial remuneration schedules, rather than evidence that to decreased compensation for female surgeons.
physicians operating on the male reproductive tract work More than just disadvantaging female physicians, this
harder or work longer hours. The fact that reimburse- systematic oppression threatens the quality of care for
ments for OB/GYNs are lower than for urologists does women. A recent commentary in Obstetrics & Gynecology
not reflect less rigorous training or lower practice showed that poor reimbursement of gynecologic surgeons
expenses. OB/GYNs are surgical specialists who undergo disproportionately affects female surgeons and also leads to
the same length of training and have the certification a higher prevalence of low-volume surgeons and higher
requirements per the Royal College of Physicians and complication rates for their patients.24
Surgeons of Canada17,18 as urologists. Moreover, gynecol-
ogists who also practise obstetrics pay the Canadian Limitations
Medical Protective Agency nearly 400% higher premiums
for malpractice insurance than urologists or most other Because our study relied on publicly available data, we
surgical specialists.19 The high premiums reflect in part could not analyze individual patient and health system
the high-risk nature of the conditions and care of data when comparing procedural pairs. We relied on a
OB/GYNs’ patients, but this is not at all reflected in the Delphi protocol, rather than operating room data, to
remuneration OB/GYNs receive for the high-risk pro­ determine equivalency between procedures, especially
cedures they perform. Instead, the lower reimbursements with respect to complexity. Surgical complexity, which
for OB/GYNs indicate a devaluation of the health care can be further compounded by patient complexity, is a
provided to female patients and, ultimately, a relative subjective measure, and no empiric data on this are
underevaluation of women’s health. available. Furthermore, we did not have access to phys­
In a 2007 Norwegian survey, medical trainees were ician payment or salary data at an individual level, so we
asked to rank different medical conditions according to the could not confirm that our findings reflect an actual dif-
relative prestige of treating them and found that ovarian ference in overall income between physicians who pro-
cancer was considered a less prestigious disease than tes­ vide care for female patients and those who provide care
ticular cancer.20 Fibromyalgia, a condition that is more for male patients.
commonly diagnosed in women, was ranked as having the The mechanism by which fee schedules are established
lowest prestige among 38 conditions. These findings are varies by province and territory, but it usually includes
echoed in the American literature, which has demonstrated some influence by individual medical or surgical disci-
a substantial difference in the relative value units (RVUs) plines, known as sections. In some provinces, like Alberta
assigned to procedures specific to female versus male and British Columbia, the section receives an allocation
patients.21 Although the Canadian health care system does sum and then determines how it is allocated for specific
not code procedures according to RVUs, the data presented codes unique to that section. The relative allocation per
here suggest that a similar pattern exists in Canada. section is 1 place where bias can occur. The sections also
Certainly, this trend is influenced not only by patient often “own” specific shared codes that are billed most fre-
sex but also by physician gender. Like Canada, in the US, quently by that section. For example, a urology section
obstetrics and gynecology has the highest proportion of may own the code for midurethral sling and therefore
female physicians among the surgical specialties, and it also determine the level of compensation for this procedure in
has the lowest remuneration rate of all procedural special- both urology and gynecology. Similarly, a family
ties.22 Moreover, in the last 5 years there has been a medicine section may own the code for vaginal delivery.
15%–20% decrease in fee-for-service fees for common If that section increases the compensation for this to
procedures in obstetrics and gynecology.16 Indeed, there is encourage family physicians to offer primary maternity
a strong negative relationship between the proportion of care, there will be an impact on the obstetrics and gyne-
female physicians in a specialty and the mean salary in that cology section, which must allocate more of its total sum
specialty, with gender composition correlated with 64% of to vaginal delivery, leaving less for gynecologic pro­
the variation in salaries among the medical specialties in cedures. While the details of these policies clearly affect

Can J Surg/J can chir 2023;66(4) E345

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C. McDermott acquired the data, which M. Chaikof, G. Cundiff,

how reimbursements are determined, they should not F. Mohtashami, A. Millman, M. Pierce, E. Brennand and
detract from the underlying message of systemic bias in C. McDermott analyzed. M. Chaikof, G. Cundiff, F. Mohtashami,
the provincial and territorial Canadian health care systems E. Brennand and C. McDermott wrote the article, which G. Cundiff,
F. Mohtashami, A. Millman, M. Larouche, M. Pierce, E. Brennand and
that has a negative impact on women and the providers C. McDermott critically revised. All authors gave final approval of the
who serve them. The mechanisms of this bias are compli- version to be published.
cated and they vary across Canada, but nevertheless this Content licence: This is an Open Access article distributed in
bias seems to be the norm. accordance with the terms of the Creative Commons Attribution
(CC BY-NC-ND 4.0) licence, which permits use, distribution and
The devaluation of health care provided to women reproduction in any medium, provided that the original publication
should be further explored, starting with a focus on the is properly cited, the use is noncommercial (i.e., research or
individual provincial and territorial fee schedules. There educational use), and no modifications or adaptations are made. See:
https://creativecommons.org/licenses/by-nc-nd/4.0/
should be investigations into how these were established,
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