Occupational gender segregation is a contributing factor to gender pay inequity in medicine but has not been thoroughly characterised. We assessed the historical relationship between surgeon sex, type of work and value of procedural payments. We hypothesised that female surgeons perform lower-paying procedures as a group, and that this could be seen both with broad historical overview and with focused analysis of major operative procedures in a specific year.

We conducted repeated cross-sectional studies using public payment data from the Canadian Institute for Health Information. We calculated average payment per service by sex and service category and used linear regression to assess the association between proportion of female surgeons performing a procedure and payment value per procedure for 41 major procedures in 2019–2020.

Surgeons in 10 Canadian jurisdictions from 1996 to 1997 (5459) to 2019–2020 (8069).

The proportion of female surgeons increased over the study period from 10.5% (n=575) in 1996–1997 to 28.7% (n=2314) in 2019–2020. The sex gap in the average payment per service narrowed but persisted. A greater proportion of women’s earnings came from non-procedural work in consultation and visits (43% for women vs 36% for men in 2019–2020) while a greater proportion of men’s earnings was from procedural work in major surgery (23% for women vs 38% for men in 2019–2020). There was an inverse relationship between proportion of women performing a procedure and payment value such that for one percent increase in female proportion, the procedural payment was CAD$1.77 lower.

Our findings suggest that women receive fewer procedural payments than men and tend to perform lower paying procedures. Reforms to referral systems and billing codes can help address root causes for the gender pay gap in surgery.