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Original Investigation
November 10, 2021

Sex Differences in the Pattern of Patient Referrals to Male and Female Surgeons

Author Affiliations
  • 1Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 3Berglas School of Economics, Tel Aviv University, Tel Aviv, Israel
  • 4Institute of Labor Economics, Bonn, Germany
  • 5ICES, Toronto, Ontario, Canada
  • 6Division of Minimally Invasive Gynecologic Surgery, University of Toronto, Toronto, Ontario, Canada
  • 7Department of Obstetrics and Gynecology, St Michael’s Hospital, Toronto, Ontario, Canada
  • 8Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
  • 9Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
JAMA Surg. Published online November 10, 2021. doi:10.1001/jamasurg.2021.5784
Key Points

Question  Does a surgeon’s sex influence the number and types of referrals received from physicians?

Findings  In this cross-sectional study of nearly 40 million referrals to surgeons, female surgeons received nonoperative referrals more often than male surgeons. Male physicians had a strong preference for referring patients to male surgeons; female physicians were less influenced by surgeon sex when making referral decisions, differences that were associated with physician choice rather than with differences in surgeon or patient characteristics.

Meaning  These results suggest that when referring patients to surgeons, male physicians may have biases toward same-sex referrals, thereby disadvantaging female surgeons.


Importance  Studies have found that female surgeons have fewer opportunities to perform highly remunerated operations, a circumstance that contributes to the sex-based pay gap in surgery. Procedures performed by surgeons are, in part, determined by the referrals they receive. In the US and Canada, most practicing physicians who provide referrals are men. Whether there are sex-based differences in surgical referrals is unknown.

Objective  To examine whether physicians’ referrals to surgeons are influenced by the sex of the referring physician and/or surgeon.

Design, Setting, and Participants  This cross-sectional, population-based study used administrative databases to identify outpatient referrals to surgeons in Ontario, Canada, from January 1, 1997, to December 31, 2016, with follow-up to December 31, 2018. Data analysis was performed from April 7, 2019, to May 14, 2021.

Exposures  Referring physician sex.

Main Outcomes and Measures  This study compared the proportion of referrals (overall and those referrals that led to surgery) made by male and female physicians to male and female surgeons to assess associations between surgeon, referring physician, or patient characteristics and referral decisions. Discrete choice modeling was used to examine the extent to which sex differences in referrals were associated with physicians’ preferences for same-sex surgeons.

Results  A total of 39 710 784 referrals were made by 44 893 physicians (27 792 [61.9%] male) to 5660 surgeons (4389 [77.5%] male). Female patients made up a greater proportion of referrals to female surgeons than to male surgeons (76.8% vs 55.3%, P < .001). Male surgeons accounted for 77.5% of all surgeons but received 87.1% of referrals from male physicians and 79.3% of referrals from female physicians. Female surgeons less commonly received procedural referrals than male surgeons (25.4% vs 33.0%, P < .001). After adjusting for patient and referring physician characteristics, male physicians referred a greater proportion of patients to male surgeons than did female physicians; differences were greatest among referrals from other surgeons (rate ratio, 1.14; 95% CI, 1.13-1.16). Female physicians had a 1.6% (95% CI, 1.4%-1.9%) greater odds of same-sex referrals, whereas male physicians had a 32.0% (95% CI, 31.8%-32.2%) greater odds of same-sex referrals; differences did not attenuate over time.

Conclusions and Relevance  In this cross-sectional, population-based study, male physicians appeared to have referral preferences for male surgeons; this disparity is not narrowing over time or as more women enter surgery. Such preferences lead to lower volumes of and fewer operative referrals to female surgeons and are associated with sex-based inequities in medicine.

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