Why so slow? The advancement of females in neurosurgery: a 30-year analysis.

Objective: As gender parity in medicine improves, neurosurgery lags behind. In pediatric neurosurgery, considered the most "female-friendly" subspecialty, determining the extent to which gender disparity has evolved over time, and how it compares to other subspecialties, can serve as an important benchmark for neurosurgery altogether. This study analyzed gender parity across different neurosurgical and subspecialty training stages to understand how female representation varies with training level and leadership positions.

Methods: Data spanning from 1990 to 2023 were extracted from Association of American Medical Colleges (AAMC), Accreditation Council for Graduate Medical Education (ACGME), Accreditation Council for Pediatric Neurosurgical Fellowships (ACPNF), American Board of Neurological Surgery (ABNS), and American Board of Pediatric Neurological Surgery (ABPNS) databases and American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) subspecialty websites to examine the proportions of female-identifying trainees and neurosurgeons. Information regarding females in leadership roles was gathered from publicly available sources.

Results: Over the last 30 years, the proportion of female medical school graduates increased from 34.0% in 1990 to 51.9% in 2023 (0.45 graduates/year, R2 = 0.813). Female neurosurgery residency applicants increased from 10.5% in 1990 to 27.9% in 2023 (0.48 applicants/year, R2 = 0.694). Female neurosurgical residents increased from 7.3% in 1990 to 23.7% in 2023 (0.46 residents/year, R2 = 0.909). Female neurosurgeons obtaining ABNS certification increased from 5.0% in 1990 to 17.0% in 2023 (0.23 surgeons/year, R2 = 0.476). Female pediatric neurosurgery fellows increased from 0.0% in 1990 to 25.0% in 2023 (0.74 applicants/year, R2 = 0.369). The number of females obtaining ABPNS certification increased at a rate of 0.42 surgeons/year (R2 = 0.067). In neurosurgical academic leadership, female representation remains low: Society of Neurological Surgeons presidents at 0.98%, AANS presidents at 3.3%, CNS presidents at 0.0%, and departmental chairs at 1.5%. In pediatric neurosurgery, only 10% of division chiefs at top US News & World Report children's hospitals are female. Only 13.3% of past presidents of the AANS/CNS Section on Pediatric Neurosurgery were female; all American Society of Pediatric Neurosurgeons presidents have been male. There are higher proportions of female directors within ABPNS (33%) and the ACPNF board (43%). Other subspecialties have comparable female leadership representation, with 5.3% in spine, 5.1% in cerebrovascular, 5.9% in tumor, and 14.3% in functional/stereotactic.

Conclusions: Despite encouraging growth in the number of females entering neurosurgery over the past 3 decades, there continues to be significant gender disparity that is most pronounced at advanced career stages-in both academic organized neurosurgery and pediatric neurosurgery. Pediatric neurosurgery, due to a separate fellowship accreditation and board certification, provides the most accurate view within the subspecialties. Because pediatric neurosurgery exhibits the lowest gender disparity among subspecialties, these findings suggest more pronounced female underrepresentation across the stages of other neurosurgical subspecialty trainings.