Women in neurosurgery: Why is the field still male-dominated?

Factors including representation, a lack of mentoring, and discrimination have been among the issues cited by female neurosurgeons as contributing to gender disparity in the field. This is according to a study published in the Journal of Neurosurgery by Tina Lulla (Rutgers New Jersey Medical School, Newark, USA) et al, who conducted a systematic literature review of studies pertaining to women in neurosurgery. 

Authors note in their introduction, “An increase in the neurosurgical workforce is necessary to meet the growing burden of neurosurgical diseases, such as cerebrovascular accidents and traumatic brain injury.” They further comment that despite 50.7% of medical students in the USA being female, according to the American Medical Colleges (AAMC) in 2017 only 8.4% of neurosurgeons in the USA are women. 

Researchers looked at 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practising female neurosurgeons in a single or in multiple countries. The majority of these studies were from the past five years. 

Factors in lack of representation 

The paper identified eight factors which they report were contributing to the gender disparity in the field. These included: conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden. 

Through their analysis, investigators saw 55 countries represented, with North America being the most researched region. They note that Asia and Europe were also well represented, but they could not find any analysis of Africa or Australia. 

According to the authors, the most frequently cited factor was mentorship, with 22 (56.4%) of studies finding it impactful. They also note that mentorship was mentioned as a factor even from the earliest study, in 2004, and was mentioned across multiple continents. Researchers comment, “Female medical students are more likely to enter programmes with a higher proportion of female residents. Mentorship has also been shown to improve recruitment as well as retention of women into neurosurgery.” 

The second most cited factor—mentioned across 19 (48.7%) studies—was lifestyle, such as work, family goals, and personal goals. Similar to mentorship, this factor was mentioned consistently and across multiple continents which, according to researchers, indicated this is not a culture-specific concern. Authors cite a number of studies, including one from Japan, in which women had reported leaving their neurosurgery careers due to difficulty balancing their career and motherhood, and a study which reported that both male and female residents were leaving surgery due to lifestyle reasons. The authors comment that “In conjunction with our analysis, these data suggest that work-life balance is of increasing importance to incoming surgical trainees regardless of gender.” 

Other consistently–cited factors were unequal opportunities and discrimination. Researchers report that a questionnaire assessing the barriers faced by Indian women in 2017 saw 74.5% of respondents claim they felt supported by their male colleagues, yet, 40% reported they faced discrimination for their gender. On this factor investigators comment, “It is vital to encourage men in the field to mentor women at every stage of their careers. Having both genders actively involved in nurturing and encouraging women as they progress in their neurosurgical careers can propel women forward professionally.” 

Global representation of women 

Overall it was found that Italy had the highest proportion of female neurosurgeons, at 36%. Countries with similarly high proportions include El Salvador (29.33%), Denmark (26%), Uruguay (25.81%), and Finland (25%). It should be noted that these countries all vary in their number of neurosurgeons; Italy has 1,320 whereas Uruguay only has 31. 

The authors also found some indications of a growing enrolment of women in neurosurgery. For example, they found that in Italy 55% of neurosurgery residents were women, in Denmark this was 40%. 

The countries with the lowest proportion of female neurosurgeons were Kosovo (0%), Cyprus (0%), South Korea (1.7%), and Kazakhstan (2%). Authors note that Kosovo and Cyprus report overall fewer neurosurgeons, 20 and 22 respectively. However, South Korea reported 3,169 neurosurgeons and Kazakhstan over 300, which investigators observe is “on par” with countries with higher representation. 

Further to this point, the authors report that the number of female neurosurgery residents was lower in these countries also. In South Korea of the 335 neurosurgery residents in 2018, 21 (6.3%) were female. 

Authors return to the factor of mentorship with regard to this point, commenting, “Fostering a large network of women neurosurgeons across the globe may help to create a strong network of mentorship and learning opportunities. Efforts to increase the global neurosurgical workforce can be made in conjunction with efforts to achieve gender equity in neurosurgery; expanding mentorship opportunities within the field and mitigating barriers to entering the field may benefit individuals of many backgrounds.” 

Conclusion 

For the authors, a limitation of their study was the lack of information on 140 countries. However, they also note that they were limited by the “inherent dichotomous use of gender characterisation” within the studies they used. For researchers, this means that they did not have the distinction between surgeon-identified sex and surgeon-ascribed gender. They further note that they only included two genders, and had no information on nonbinary or transgender neurosurgeons. 

Investigators found that while there are women performing neurosurgery across the world, “there is a great benefit to fostering global connections for neurosurgeons of all genders.” Authors further comment that they “firmly believe the pursuit of gender equity in neurosurgery need not conflict with broader efforts to increase the global neurosurgical workforce.” 

Lulla commented, “Our goal with this study was to determine the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities. In order to start strides towards gender equity in the field, it is essential to understand what has led to our current distribution. Our analysis revealed eight factors across multiple continents that contributed to gender disparities in neurosurgery. Addressing these factors will enable us to grow the global neurosurgical workforce while simultaneously moving towards gender equity.”