- Email: [email protected]
Female Neurosurgeons in Europe—On a Prevailing Glass Ceiling
Women in Neurosurgery
Female Neurosurgeons in Europe—On a Prevailing Glass Ceiling Christina Wolfert, Veit Rohde, Dorothee Mielke, Silvia Herna´ndez-Dura´n
BACKGROUND: Almost one half of currently practicing physicians in Europe are women. Despite advances in access to training positions and the entry of women into neurosurgery, it has remained a male-dominated field, with an underrepresentation of female leaders. We designed a 2-part study to better understand the current situation of European female neurosurgeons.
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METHODS: The European Association of Neurosurgical Societies and its member societies were analyzed for female participation in leadership positions. Additionally, an online survey was designed, containing 33 questions about career choice, mentorship, family planning, and perceived obstacles, for women in neurosurgery.
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RESULTS: A total of 116 responses were received. Most female neurosurgeons lacked same-gender role models (76%), although most reported that having a female mentor would be important (58%). An overwhelming majority (86%) believe family planning takes on a more important role for women, and 72% reported worrying their career prospects could be negatively affected by their desire to have children. The greatest obstacle perceived was the prevailing inequality in opportunities (30%) and attaining leadership positions (24%). Most (81%) reported that women have different concerns regarding their career from men, and 72% also reported feeling at a disadvantage as a woman. Most (66%) also believe should be a “Women in Neurosurgery” committee within the European Association of Neurosurgical Societies.
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CONCLUSIONS: Unfortunately, a gender gap still exists in European neurosurgery. The extent thereof has not yet been systematically analyzed. Our project offers a glimpse
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into the inequalities and obstacles women perceive in our field; however, more comprehensive data are required.
INTRODUCTION
G
ender parity is fundamental to the prosperity of societies. The appropriate development and use of female talent, which constitutes one half of the world’s workforce pool, is key to the advancement of global economies. According to the Global Gender Gap Report, Western Europe was the highest performing region in 2017.1 The latter presupposes low gender gaps in economic, education, health, and political criteria. According to Eurostat,2 almost one half of currently practicing physicians in Europe are women. Between 2005 and 2015, the total number of female physicians in the European Union increased, with the Baltic Member States, Romania, Slovenia, and Croatia reporting 60% of their physician workforce were women. Nevertheless, the Global Gender Gap Report showed great imbalances between the number of women employed in the healthcare sector compared with those in leadership roles,1 which is in line with several studies in the United States that have highlighted the presence of a glass ceiling in academic medicine.3-5 Does this imbalance extend to neurosurgery? Neurosurgery has traditionally been a male-dominated field. Despite advances in access to training positions and the increased entry of women into the field, a gross underrepresentation of women in leadership roles remains. In the United States, the number of women in neurosurgery has remained at <15%. Furthermore, women only account for w6% of faculty members.6 However, no data are available on the current gender distribution of neurosurgical trainees and specialists in Europe. Thus, the neurosurgery department of Göttingen University Hospital, in collaboration
To whom correspondence should be addressed: Silvia Hernández-Durán, M.D. [E-mail: [email protected]]
Key words EANS - Glass ceiling - Women in medicine - Women in neurosurgery - Women in surgery -
Christina Wolfert and Dorothee Mielke equally contributed to the manuscript. Citation: World Neurosurg. (2019) 129:460-466. https://doi.org/10.1016/j.wneu.2019.05.137 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com
Abbreviations and Acronyms EANS: European Association of Neurological Societies
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Department of Neurological Surgery, Göttingen University Hospital, Göttingen, Germany
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with their office for gender equality, designed a 2-part study to better understand the current situation of female neurosurgeons in Europe, including their perspectives and attitudes and their perceived professional challenges and obstacles. METHODS The European Association of Neurosurgical Societies (EANS) website was analyzed for female participation in leadership positions within the organization and its committees.7 Furthermore, the national neurosurgical societies affiliated to the EANS were reviewed regarding female participation in their boards of directors, as noted on their respective websites.8-30 When the provided web hyperlinks were unavailable, the information provided on the EANS website was used. Additionally, an online survey was designed using GoogleDocs, which contained 33 questions about key fields, such as career choice, mentorship, family planning, and perceived obstacles (Table 1). The full survey is presented in Appendix 1. It was distributed among female neurosurgeons with the aid of the EANS and the national societies of the Netherlands and the United Kingdom. Other national societies were approached; however, no responses were received. The survey was available online for 6 weeks. Participation was voluntary, and no incentives were offered. RESULTS Female Neurosurgeons in Leadership Positions in Europe From an organizational perspective, the EANS has never had a female president. Currently, the Board of Officers, which determines the strategic direction of the EANS, is comprised solely of men. Among the 9 EANS subspecialist sections, only 1 is chaired by a woman. Of the 15 training centers accredited by the Joint Residency Advisory and Accreditation Committee and certified by the European Union of Medical Specialists and EANS as a Center of Excellence in Neurosurgical Training, none is chaired by a woman. This underrepresentation can also be seen in the different national societies, for which the boards of officers are predominantly constituted by men (Figure 1). Survey A total of 116 responses were received. The survey was sent to 482 individuals, either self-identifying as women or with a nondisclosed sex, for a response rate of 24%. Of these, 11 were excluded because they were located outside of Europe. Most of the responses were obtained from the United Kingdom and Germany. Single responses were obtained from Eastern European countries, such as Czechia, Estonia, Latvia, Poland, Russia, Serbia, and the Ukraine (Table 2). The mean age of the respondents was 36 years (range, 24e59). Most women were married (52%) and did not have any children (58%). More than 70% of the responders selfidentified as Caucasian or white. Most of the women worked at academic institutions (76%). On average, 34% of trainees and 23% of the consultants were women at the reported institutions. Gender quotas were not used in 77% of the reported institutions. However, 17% of the surveyed women did not know whether their institutions had such quotas. Thus, a statement regarding whether these gender quotas influenced women’s careers
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or biased the employed workforce was not possible because of the low number of centers reporting the use of gender quotas. Our survey showed that most women (>90%) reported neurosurgery as their first choice of specialization, with the opportunity to treat challenging clinical and surgical cases their main reason for choosing neurosurgery (84%). Our survey also revealed that most survey participants lacked role models at their institutions and that their role models were not of their own gender, although most reported that having a female mentor was important (Figure 2). An overwhelming majority (86%) of the surveyed women reported that family planning takes on a more important role for women in neurosurgery than for men. Most (82%) also expressed a desire to have children. However, 72% of women reported worrying that their career prospects might be negatively affected by their desire to have a family. However, an extended maternity leave and/or a reduction of work hours after having children were not desired by most of the women (Table 3). Although most institutions (65%) reportedly had established policies regarding parental leave, only a few (24%) have offered logistical support to parents, such as nurseries or daycare facilities at the workplace. The largest obstacle the surveyed women perceived in their careers as neurosurgeons is the prevailing inequality in opportunities and attaining leadership positions (Figure 3). Most (81%) of the surveyed women believed that women have different concerns regarding their career in neurosurgery from men, and 72% also reported feeling at a disadvantage as a woman in neurosurgery compared with their male counterparts. Anecdotal recounts entered in a free-text field are summarized in Figure 4. Finally, most of the surveyed women (66%) reported that a “Women in Neurosurgery” committee within the EANS should be created. DISCUSSION The first part of our project revealed that the most influential, policy-determining positions in European neurosurgery are almost exclusively occupied by men. This finding was not surprising, because it has also been exhaustively documented in other medical specialties.31-33 In U.S. neurosurgery, Benzil et al.34 documented a stagnant entry of women into neurosurgery from 1998 to 2006, despite the increased number female medical graduates. Woodrow et al.35 analyzed the reasons for this lack of female participation in neurosurgery and found limited mentorship, outdated career programs, and deep-seated societal beliefs were the main contributors deterring women from entering the field. To counteract this disproportionate trend, a white paper was published in 2008 describing strategies for future progress.6 Despite these efforts, a gross underrepresentation of women remains in leadership positions in U.S. neurosurgery.36 This phenomenon has been termed “glass ceiling,” a metaphor used to denote the lower likelihood of women to be promoted to higher hierarchical positions despite equal seniority and productivity.3 Ash et al.37 also suggested that women of minority ethnic groups are the most vulnerable to these inequalities. It has been postulated that the lack of progression in female careers has resulted from organizational male-oriented cultures, with women excluded from the necessary networking and mentoring required for professional advancement.38 In addition, a cumulative
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Table 1. Items in the Women in European Neurosurgery Multinational Survey Variable Demographic data Age Marital status Children Ethnicity Country of practice Institutional characteristics Type of institution Number of neurosurgeons at department Number of neurosurgical trainees at department and proportion of women Number of neurosurgical consultants at department and proportion of women Institutional gender quotas Influence of gender quotas Career choice Neurosurgery as first choice of specialization Factors influencing the choice for neurosurgery Mentorship Presence of a mentor/role model Gender of role model Importance of having a role model of same gender Family planning Desire to have children Length of desired maternity leave Desired workload after having children Role of family planning for women vs. men Fear of influence of desire to have family on career prospects Institutional policies regarding maternity leave Institutional logistical support for parents Obstacles Perceived disadvantage as female vs. male neurosurgeon Obstacles perceived as a female neurosurgeon Perceived differences between female and male neurosurgeons Committee Necessity to establish a committee for female neurosurgeons within the EANS EANS, European Association of Neurological Societies.
54% of survey respondents identified prevailing inequality in opportunities and attaining a leadership position as their greatest obstacles. Evidently, these answers are not unfounded, for they reflect the current organizational and multinational
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Figure 1. Female representation in European national and multinational neurosurgical societies. Data obtained from their respective websites and the European Association of Neurological Societies website.
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Table 2. Responses Obtained Stratified by Country, Listed Alphabetically Country
Response (n)
Austria
2
Belgium
8
Croatia
2
Czech Republic
1
Estonia
1
France
3
Germany
15
Greece
3
Ireland
2
Italy
5
Latvia
1
Netherlands
8
Poland
1
Portugal
5
Russia
1
Serbia
1
Spain
7
Sweden
6
Switzerland
5
Turkey
3
United Kingdom
24
Ukraine
1
situation across Europe. To date, no studies have been conducted to specifically investigate the issues pertaining to female career advancement in neurosurgery in Europe. The reported data have shown that women frequently prefer female mentors and strive to identify with role models of their own gender. A recently reported study by Faucett et al.39 illustrates the importance of same-gender mentorship in encouraging women to pursue surgery. In their survey of 160 U.S. medical students, most female respondents regarded same-gender role models as a positive influence. Similarly, Seemann et al.40 found that female surgeons in Canada have a desire for same-gender mentors who could guide them both academically and personally in their efforts to achieve harmony between their careers and family obligations. The relevance of such mentorship even extends into leadership positions and academic surgery. In their survey of 149 female U.S. surgeons, Schroen et al.41 found that attrition in academia largely resulted from the lack of mentoring. This phenomenon has also been observed in other fields of academic medicine42 and has been attributed to a sense of isolation in a male-dominated institutional culture. The results of our survey are in accordance with these observations from other surgical fields. Women in European neurosurgery have also experienced the lack of female mentorship, although most of the survey participants considered same-gender role models as important. Another factor that constrains women’s career advancement is stereotype-based cognitive bias.43,44 Women are thought to be more likely to leave surgical specialties to raise a family, because it is assumed they will become the main bearers of family duties, in charge of child rearing and other domestic affairs.45,46 These stereotypes not only influence career advancement, but also shape social expectations and play a role in deterring women from entering surgical fields altogether, because they worry about balancing their familial obligations and their professional obligations.47-49 However, empirical data have provided different information. In the WTS
Figure 2. Presence of role models among surveyed female neurosurgeons and importance of same-sex mentors.
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Table 3. Answers Regarding Desired Work Hours After Having Children and Length of Maternity Leave Category
%
Desired work hours after having children Full-time
66
Part-time
21
Retirement
0
Do not know/no answer
12
Desired length of maternity leave None
11
<6 months
36
6 months to 1 year
33
1 year
14
>1 year
5
(women in thoracic surgery) report on the current status of women in cardiothoracic surgery, the attrition rate of women was similar to that of their male counterparts and was unrelated to the raising of children.50 Brown et al51 further demonstrated no association between female gender and/or child rearing and attrition or training quality in a general surgery program. Our survey has clearly evinced that although most of the women desired to have a family, they did not intend to retire from their profession to do so, rendering the cited concerns an unfounded stereotype. Nevertheless, most of the survey respondents worried that their career prospects might be negatively affected by their desire to have a family, which also suggests that these gender-based prejudices are prevalent. Strategies such as cognitive behavioral programs to break the gender bias habit appear to be needed to create a more equitable environment.49 Studies have shown that women rank the presence of organizations that support women in surgery as important.39 A fine example is the Women in Neurosurgery organization, founded in 1989 in the United States, which has played a pivotal role in guiding policy-making and implementing strategies to foster recruitment, retention, and career advancement of female neurosurgeons in North America.6,36 Similarly, the Asian Women’s
Figure 3. Obstacles perceived by European women in neurosurgery.
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Figure 4. Anecdotal recounts from survey respondents regarding the inequalities perceived.
Neurosurgical Association, founded in 1996, has served to promote excellence in female neurosurgeons across Asia.52 However, a sister society does not exist in Europe. Our survey showed that most female neurosurgeons believe that such a committee should be created within the EANS. As Robert F. Spetzler said, “. Institutional accountability must be evaluated to ensure that the best and brightest candidates, regardless of gender, are recruited to neurosurgical programs to promote the health of our challenging but most satisfying profession.”53 We have, therefore, submitted a proposal to the EANS board of directors for the creation of a committee for women in European neurosurgery. The goal of the committee would be to counteract the glass ceiling effect in an institutionalized fashion by 1) identifying the issues and obstacles female neurosurgeons face across Europe, 2) creating a mentoring platform to pair young female neurosurgeons with senior female consultants in leadership positions to enhance their motivation in their own professional journeys, 3) providing strategies and solutions for the issues identified, and 4) monitoring female career advancement in European neurosurgery and providing hard data on which to base future policy-making.
Study Limitations Our study was subject to selection bias, because not all European female neurosurgeons are included in the EANS mailing list and not all of those from that list replied to the survey. Furthermore, we obtained a relatively low response rate of 24%. Nevertheless, this should be interpreted with caution. First, it is unknown whether all 482 individuals were indeed women. Second, some might have been at locations outside of Europe and, thus, did not respond. Furthermore, studies have estimated the response rates for online surveys at 11%, which relativizes our results.54 By approaching national societies, we attempted to overcome this possible bias. However, because many did not respond, the bias was possibly even enhanced by skewing the responses to certain geographic regions. Eastern European countries were especially underrepresented in our results.
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Most survey responders were relatively young, with a mean age of 36 years. This could have also skewed the results, with an underrepresentation of older female neurosurgeons. A postal distribution of the survey could have increased the response rate of older female neurosurgeons. However, no databases exist reporting the actual number of practicing female neurosurgeons in Europe and their postal addresses. Therefore, the responses portrayed in the present study are representative of the individuals who participated, although possibly not generalizable to all female neurosurgeons in Europe. Thus, the acquisition of more data regarding female participation and female career perceptions in European neurosurgery becomes pivotal in further understanding of this subject. CONCLUSIONS Unfortunately, a gender gap still exists in European neurosurgery. To date, the extent has not been systematically analyzed. Our
REFERENCES 1. World Economic Forum. The Global Gender Gap Report 2017. Available at: https://www.weforum. org/reports/the-global-gender-gap-report-2017. Accessed September 30, 2018. 2. European Commission e Eurostat. Physicians by sex and age. Available at: https://ec.europa.eu/ eurostat/search?p_auth¼k2Uh3dql&p_p_id¼estats earchportlet_WAR_estatsearchportlet&p_p_lifecy cle¼1&p_p_state¼maximized&p_p_mode¼view&_ estatsearchportlet_WAR_estatsearchportlet_action ¼search&text¼physician. Accessed September 30, 2018.
ACKNOWLEDGMENTS The authors would like to thank Stella Müller from the Göttingen University Hospital’s Bureau for Gender Equality for her continued support in the conception and development of this project. We would also like to thank Petra Koubova and Amy Pinchbeck-Smith from the European Association of Neurosurgical Societies for their logistic support in the distribution of the survey, and Carole Turner from the Society of British Neurological Surgeons, and the Dutch Association for Neurosurgery.
10. Bulgarian Society of Neurosurgery. Available at: https://www.neurosurgery.bg. Accessed September 30, 2018.
21. Romanian Society of Neurosurgery. Board of Directors. Available at: http://rsn.ro/board/. Accessed September 30, 2018.
11. Czech Neurosurgical Society. Committee. Available at: http://czech-neurosurgery.com/members/. Accessed September 30, 2018.
22. Serbian Neurosurgical Society. About. Available at: http://snss.rs/o-nama/. Accessed September 30, 2018.
12. Danish Neurosurgical Society. Board of directors. Available at: http://www.dnks.dk/index.php?id¼4. Accessed September 30, 2018.
23. Slovak Neurosurgical Society. Committee and members of SNCHS. Available at: http:// neurosurgery.sk/o-nas/. Accessed September 30, 2018.
13. Finnish Neurosurgical Society. Front Page. Available at: http://www.snky.fi/. Accessed September 30, 2018. 14. French Neurosurgical Society. Scientific and Administrative Counsel. Available at: http://www. neurochirurgie.fr/spip.php?article50. Accessed September 30, 2018.
4. Carnes M, Morrissey C, Geller S. Women’s health and women’s leadership in academic medicine: hitting the same glass ceiling? J Womens Health (Larchmt). 2008;17:1453-1462.
15. German Neurosurgical Society. Board of Directors. Available at: https://www.dgnc.de/gesellschaft/ueberuns/organe-und-personalia/vorstand/. Accessed September 30, 2018.
5. Longo P, Straehley C. Whack! I’ve hit the glass ceiling! Women’s efforts to gain status in surgery. Gend Med. 2008;5:88-100.
16. Hellenic Neurosurgical Society. Board of directors. Available at: http://www.enxe.gr/%CE% B4%CE%B9%CE%BF%CE%B9%CE%BA%CE% B7%CF%84%CE%B9%CE%BA%CE%BF-%CF% 83%CF%85%CE%BC%CE%B2%CE%BF%CF%85% CE%BB%CE%B9%CE%BF/. Accessed September 30, 2018.
7. European Association of Neurosurgical Societies. Societies of the European Association of Neurosurgical Societies. Available at: https:// www.eans.org/pages/about-us/societies. Accessed September 30, 2018. 8. Austrian Neurosurgical Society. Board of Directors of the ÖGNC. Available at: http://www.neurochirurgie. ac.at/ueberuns/vorstand/. Accessed September 30, 2018. 9. Belgian Society of Neurosurgery n.p.o. Board. Available at: http://www.bsn.be/about.php. Accessed September 30, 2018.
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project offers a glimpse into the obstacles women perceive in our field. However, more comprehensive data are required, especially from Eastern European countries. A problem unacknowledged is destined to remain unsolved. We hope that our study and the proposal submitted to the EANS will constitute the spark that ignites an organizational and multinational change toward a more equitable European neurosurgery.
3. Zhuge Y, Kaufman J, Simeone D. Is there still a glass ceiling for women in academic surgery? Ann Surg. 2011;253:637-643.
6. Benzil DL, Abosch A, Germano I, et al. The future of neurosurgery: a white paper on the recruitment and retention of women in neurosurgery. J Neurosurg. 2008;109:378-386.
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17. Italian Neurosurgical Society. Board of Directors. Available at: http://www.sinch.it/pag/consigliodirettivo20182020-53. Accessed September 30, 2018. 18. Latvian Society of Neurosurgeons. LNB Board. Available at: http://www.neirokirurgija.lv/valde/. Accessed September 30, 2018. 19. Ludvig Puusepa Society for Neurology and Neurosurgery. Board. Available at: http://www. enns.ee/juhatus/. Accessed September 30, 2018. 20. Portuguese Society of Neurosurgery. Society Organization. Available at: http://www.spnc.pt/ officers_page_160. Accessed September 30, 2018.
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24. Spanish Neurosurgical Society. Board of Directors. Available at: https://senec.es/juntadirectiva. Accessed September 30, 2018. 25. Swedish Neurosurgical Society. Home. Available at: http://www.swedishneurosurgicalsociety.se/ english/. Accessed September 30, 2018. 26. Swiss Neurosurgical Society. Board of Directors. Available at: https://www.swissneurosurgery.ch/ Vorstand. Accessed September 30, 2018. 27. The Association of Neurosurgeons in Bosnia and Herzegovina e Udruga neurokirurga u BiH. Executive Committee. Available at: http://www.neurohirurgija. org/?page_id¼101. Accessed September 30, 2018. 28. The Netherlands Association for Neurosurgery. About the NVvN. Available at: http://www.nvvn. org/over-de-nvvn/. Accessed September 30, 2018. 29. The Society of British Neurological Surgeons. Council & Committees. Available at: https://www.sbns.org. uk/index.php/councils/. Accessed September 30, 2018. 30. Turkish Neurosurgical Association. Board members. Available at: https://www.turknorosirurji.org.tr/ yonetim-kurulu?menu¼14. Accessed September 30, 2018. 31. Morahan P, Voytko M, Abbuhl S, Means L, Wara D, Thorson J. Ensuring the success of women faculty at AMCs: lessons learned from the National Centers of Excellence in Women’s Health. Acad Med. 2001;76:19-31.
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32. Morton M, Sonnad S. Women on professional society and journal editorial boards. J Natl Med Assoc. 2007;99:764-771.
41. Schroen A, Brownstein M, Sheldon G. Women in academic general surgery. Acad Med. 2004;79: 310-318.
50. Donington J, Little V, Sesti J, Colson Y. The WTS report on the current status of women in cardiothoracic surgery. Ann Thorac Surg. 2012;94:452-459.
33. Jonasson O. Leaders in American surgery: where are the women? Surgery. 2002;131:672-675.
42. Pololi L, Krupat E, Civian J, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative US medical schools. Acad Med. 2012;87:859-869.
51. Brown E, Galante J, Keller B, Braxton J, Farmer D. Pregnancy-related attrition in general surgery. JAMA Surg. 2014;149:893-897.
34. Benzil D, von der Schmidt E. Toward harnessing forces of change: assessing the neurosurgical workforce. AANS Bull. 2006;15:7-11. 35. Woodrow S, Gilmer-Hill H, Rutka J. The neurosurgical workforce in North America: a critical review of gender issues. Neurosurgery. 2006;59: 749-758. 36. Renfrow J, Rodriguez A, Wilson T, Germano I, Abosch A, Quintero Wolfe S. Tracking career paths of women in neurosurgery. Neurosurgery. 2018;82:576-582. 37. Ash C, Carr P, Goldstein R. Compensation and advancement of women in academic medicine: is there equity? Ann Intern Med. 2004;5:205-212. 38. Voytko M, Barrett N, Courtney-Smith D. Positive value of a women’s junior faculty mentoring program: a mentor-mentee analysis. J Womens Health (Larchmt). 2018;27:1045-1053. 39. Faucett E, McCrary H, Milinic T, Hassanzadeh T, Roward S, Neumayer L. The role of same-sex mentorship and organizational support in encouraging women to pursue surgery. Am J Surg. 2017;214:640-644. 40. Seemann N, Webster F, Holden H, et al. Women in academic surgery: why is the playing field still not level? Am J Surg. 2016;211:343-349.
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43. National Academy of Sciences, National Academy of Engineering, Institute of Medicine of the National Academies. Beyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering. Washington, DC: National Academies Press; 2006. 44. Carnes M, Bartels C, Isaac C, Kaatz A, Kolehmainen C. Why is John more likely to become department chair than Jennifer? Trans Am Clin Climatol Assoc. 2015;126:197-215. 45. Bern S. The measurement of psychological androgyny. J Consult Clin Psychol. 1974;42:544-548. 46. Eagly A, Karau S. Role congruity theory of prejudice toward female leaders. Psychol Rev. 2002;109: 573-598. 47. Keizer M. Gender and careers in medicine. Neth J Soc Sci. 1997;33:94-115. 48. Williams C, Cantillon P. A surgical career? The views of junior women doctors. Med Educ. 2000;34: 602-607.
52. Kato Y, Mihara C, Matsuyama J, et al. Role of women in medicine: a look at the history, the present condition and the future status of women in the surgical field, especially neurosurgery. Minim Invasive Neurosurg. 2004;47:65-71. 53. Spetzler R. Progress of women in neurosurgery. Asian J Neurosurg. 2011;6:6-12. 54. Yan Z, Fan W. Factors affecting response rates of the web survey: a systematic review. Comput Human Behav. 2010;26:132-139.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 17 March 2019; accepted 16 May 2019 Citation: World Neurosurg. (2019) 129:460-466. https://doi.org/10.1016/j.wneu.2019.05.137 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com
49. Kerr HL, Armstrong L, Cade J. Barriers to becoming a female surgeon and the influence of female surgical role models. Postgrad Med J. 2016; 92:576-580.
1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.137
Female Neurosurgeons in Europe—On a Prevailing Glass Ceiling Christina Wolfert, Veit Rohde, Dorothee Mielke, Silvia Herna´ndez-Dura´n
BACKGROUND: Almost one half of currently practicing physicians in Europe are women. Despite advances in access to training positions and the entry of women into neurosurgery, it has remained a male-dominated field, with an underrepresentation of female leaders. We designed a 2-part study to better understand the current situation of European female neurosurgeons.
-
METHODS: The European Association of Neurosurgical Societies and its member societies were analyzed for female participation in leadership positions. Additionally, an online survey was designed, containing 33 questions about career choice, mentorship, family planning, and perceived obstacles, for women in neurosurgery.
-
RESULTS: A total of 116 responses were received. Most female neurosurgeons lacked same-gender role models (76%), although most reported that having a female mentor would be important (58%). An overwhelming majority (86%) believe family planning takes on a more important role for women, and 72% reported worrying their career prospects could be negatively affected by their desire to have children. The greatest obstacle perceived was the prevailing inequality in opportunities (30%) and attaining leadership positions (24%). Most (81%) reported that women have different concerns regarding their career from men, and 72% also reported feeling at a disadvantage as a woman. Most (66%) also believe should be a “Women in Neurosurgery” committee within the European Association of Neurosurgical Societies.
-
CONCLUSIONS: Unfortunately, a gender gap still exists in European neurosurgery. The extent thereof has not yet been systematically analyzed. Our project offers a glimpse
-
into the inequalities and obstacles women perceive in our field; however, more comprehensive data are required.
INTRODUCTION
G
ender parity is fundamental to the prosperity of societies. The appropriate development and use of female talent, which constitutes one half of the world’s workforce pool, is key to the advancement of global economies. According to the Global Gender Gap Report, Western Europe was the highest performing region in 2017.1 The latter presupposes low gender gaps in economic, education, health, and political criteria. According to Eurostat,2 almost one half of currently practicing physicians in Europe are women. Between 2005 and 2015, the total number of female physicians in the European Union increased, with the Baltic Member States, Romania, Slovenia, and Croatia reporting 60% of their physician workforce were women. Nevertheless, the Global Gender Gap Report showed great imbalances between the number of women employed in the healthcare sector compared with those in leadership roles,1 which is in line with several studies in the United States that have highlighted the presence of a glass ceiling in academic medicine.3-5 Does this imbalance extend to neurosurgery? Neurosurgery has traditionally been a male-dominated field. Despite advances in access to training positions and the increased entry of women into the field, a gross underrepresentation of women in leadership roles remains. In the United States, the number of women in neurosurgery has remained at <15%. Furthermore, women only account for w6% of faculty members.6 However, no data are available on the current gender distribution of neurosurgical trainees and specialists in Europe. Thus, the neurosurgery department of Göttingen University Hospital, in collaboration
To whom correspondence should be addressed: Silvia Hernández-Durán, M.D. [E-mail: [email protected]]
Key words EANS - Glass ceiling - Women in medicine - Women in neurosurgery - Women in surgery -
Christina Wolfert and Dorothee Mielke equally contributed to the manuscript. Citation: World Neurosurg. (2019) 129:460-466. https://doi.org/10.1016/j.wneu.2019.05.137 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com
Abbreviations and Acronyms EANS: European Association of Neurological Societies
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Department of Neurological Surgery, Göttingen University Hospital, Göttingen, Germany
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with their office for gender equality, designed a 2-part study to better understand the current situation of female neurosurgeons in Europe, including their perspectives and attitudes and their perceived professional challenges and obstacles. METHODS The European Association of Neurosurgical Societies (EANS) website was analyzed for female participation in leadership positions within the organization and its committees.7 Furthermore, the national neurosurgical societies affiliated to the EANS were reviewed regarding female participation in their boards of directors, as noted on their respective websites.8-30 When the provided web hyperlinks were unavailable, the information provided on the EANS website was used. Additionally, an online survey was designed using GoogleDocs, which contained 33 questions about key fields, such as career choice, mentorship, family planning, and perceived obstacles (Table 1). The full survey is presented in Appendix 1. It was distributed among female neurosurgeons with the aid of the EANS and the national societies of the Netherlands and the United Kingdom. Other national societies were approached; however, no responses were received. The survey was available online for 6 weeks. Participation was voluntary, and no incentives were offered. RESULTS Female Neurosurgeons in Leadership Positions in Europe From an organizational perspective, the EANS has never had a female president. Currently, the Board of Officers, which determines the strategic direction of the EANS, is comprised solely of men. Among the 9 EANS subspecialist sections, only 1 is chaired by a woman. Of the 15 training centers accredited by the Joint Residency Advisory and Accreditation Committee and certified by the European Union of Medical Specialists and EANS as a Center of Excellence in Neurosurgical Training, none is chaired by a woman. This underrepresentation can also be seen in the different national societies, for which the boards of officers are predominantly constituted by men (Figure 1). Survey A total of 116 responses were received. The survey was sent to 482 individuals, either self-identifying as women or with a nondisclosed sex, for a response rate of 24%. Of these, 11 were excluded because they were located outside of Europe. Most of the responses were obtained from the United Kingdom and Germany. Single responses were obtained from Eastern European countries, such as Czechia, Estonia, Latvia, Poland, Russia, Serbia, and the Ukraine (Table 2). The mean age of the respondents was 36 years (range, 24e59). Most women were married (52%) and did not have any children (58%). More than 70% of the responders selfidentified as Caucasian or white. Most of the women worked at academic institutions (76%). On average, 34% of trainees and 23% of the consultants were women at the reported institutions. Gender quotas were not used in 77% of the reported institutions. However, 17% of the surveyed women did not know whether their institutions had such quotas. Thus, a statement regarding whether these gender quotas influenced women’s careers
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or biased the employed workforce was not possible because of the low number of centers reporting the use of gender quotas. Our survey showed that most women (>90%) reported neurosurgery as their first choice of specialization, with the opportunity to treat challenging clinical and surgical cases their main reason for choosing neurosurgery (84%). Our survey also revealed that most survey participants lacked role models at their institutions and that their role models were not of their own gender, although most reported that having a female mentor was important (Figure 2). An overwhelming majority (86%) of the surveyed women reported that family planning takes on a more important role for women in neurosurgery than for men. Most (82%) also expressed a desire to have children. However, 72% of women reported worrying that their career prospects might be negatively affected by their desire to have a family. However, an extended maternity leave and/or a reduction of work hours after having children were not desired by most of the women (Table 3). Although most institutions (65%) reportedly had established policies regarding parental leave, only a few (24%) have offered logistical support to parents, such as nurseries or daycare facilities at the workplace. The largest obstacle the surveyed women perceived in their careers as neurosurgeons is the prevailing inequality in opportunities and attaining leadership positions (Figure 3). Most (81%) of the surveyed women believed that women have different concerns regarding their career in neurosurgery from men, and 72% also reported feeling at a disadvantage as a woman in neurosurgery compared with their male counterparts. Anecdotal recounts entered in a free-text field are summarized in Figure 4. Finally, most of the surveyed women (66%) reported that a “Women in Neurosurgery” committee within the EANS should be created. DISCUSSION The first part of our project revealed that the most influential, policy-determining positions in European neurosurgery are almost exclusively occupied by men. This finding was not surprising, because it has also been exhaustively documented in other medical specialties.31-33 In U.S. neurosurgery, Benzil et al.34 documented a stagnant entry of women into neurosurgery from 1998 to 2006, despite the increased number female medical graduates. Woodrow et al.35 analyzed the reasons for this lack of female participation in neurosurgery and found limited mentorship, outdated career programs, and deep-seated societal beliefs were the main contributors deterring women from entering the field. To counteract this disproportionate trend, a white paper was published in 2008 describing strategies for future progress.6 Despite these efforts, a gross underrepresentation of women remains in leadership positions in U.S. neurosurgery.36 This phenomenon has been termed “glass ceiling,” a metaphor used to denote the lower likelihood of women to be promoted to higher hierarchical positions despite equal seniority and productivity.3 Ash et al.37 also suggested that women of minority ethnic groups are the most vulnerable to these inequalities. It has been postulated that the lack of progression in female careers has resulted from organizational male-oriented cultures, with women excluded from the necessary networking and mentoring required for professional advancement.38 In addition, a cumulative
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Table 1. Items in the Women in European Neurosurgery Multinational Survey Variable Demographic data Age Marital status Children Ethnicity Country of practice Institutional characteristics Type of institution Number of neurosurgeons at department Number of neurosurgical trainees at department and proportion of women Number of neurosurgical consultants at department and proportion of women Institutional gender quotas Influence of gender quotas Career choice Neurosurgery as first choice of specialization Factors influencing the choice for neurosurgery Mentorship Presence of a mentor/role model Gender of role model Importance of having a role model of same gender Family planning Desire to have children Length of desired maternity leave Desired workload after having children Role of family planning for women vs. men Fear of influence of desire to have family on career prospects Institutional policies regarding maternity leave Institutional logistical support for parents Obstacles Perceived disadvantage as female vs. male neurosurgeon Obstacles perceived as a female neurosurgeon Perceived differences between female and male neurosurgeons Committee Necessity to establish a committee for female neurosurgeons within the EANS EANS, European Association of Neurological Societies.
54% of survey respondents identified prevailing inequality in opportunities and attaining a leadership position as their greatest obstacles. Evidently, these answers are not unfounded, for they reflect the current organizational and multinational
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Figure 1. Female representation in European national and multinational neurosurgical societies. Data obtained from their respective websites and the European Association of Neurological Societies website.
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Table 2. Responses Obtained Stratified by Country, Listed Alphabetically Country
Response (n)
Austria
2
Belgium
8
Croatia
2
Czech Republic
1
Estonia
1
France
3
Germany
15
Greece
3
Ireland
2
Italy
5
Latvia
1
Netherlands
8
Poland
1
Portugal
5
Russia
1
Serbia
1
Spain
7
Sweden
6
Switzerland
5
Turkey
3
United Kingdom
24
Ukraine
1
situation across Europe. To date, no studies have been conducted to specifically investigate the issues pertaining to female career advancement in neurosurgery in Europe. The reported data have shown that women frequently prefer female mentors and strive to identify with role models of their own gender. A recently reported study by Faucett et al.39 illustrates the importance of same-gender mentorship in encouraging women to pursue surgery. In their survey of 160 U.S. medical students, most female respondents regarded same-gender role models as a positive influence. Similarly, Seemann et al.40 found that female surgeons in Canada have a desire for same-gender mentors who could guide them both academically and personally in their efforts to achieve harmony between their careers and family obligations. The relevance of such mentorship even extends into leadership positions and academic surgery. In their survey of 149 female U.S. surgeons, Schroen et al.41 found that attrition in academia largely resulted from the lack of mentoring. This phenomenon has also been observed in other fields of academic medicine42 and has been attributed to a sense of isolation in a male-dominated institutional culture. The results of our survey are in accordance with these observations from other surgical fields. Women in European neurosurgery have also experienced the lack of female mentorship, although most of the survey participants considered same-gender role models as important. Another factor that constrains women’s career advancement is stereotype-based cognitive bias.43,44 Women are thought to be more likely to leave surgical specialties to raise a family, because it is assumed they will become the main bearers of family duties, in charge of child rearing and other domestic affairs.45,46 These stereotypes not only influence career advancement, but also shape social expectations and play a role in deterring women from entering surgical fields altogether, because they worry about balancing their familial obligations and their professional obligations.47-49 However, empirical data have provided different information. In the WTS
Figure 2. Presence of role models among surveyed female neurosurgeons and importance of same-sex mentors.
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Table 3. Answers Regarding Desired Work Hours After Having Children and Length of Maternity Leave Category
%
Desired work hours after having children Full-time
66
Part-time
21
Retirement
0
Do not know/no answer
12
Desired length of maternity leave None
11
<6 months
36
6 months to 1 year
33
1 year
14
>1 year
5
(women in thoracic surgery) report on the current status of women in cardiothoracic surgery, the attrition rate of women was similar to that of their male counterparts and was unrelated to the raising of children.50 Brown et al51 further demonstrated no association between female gender and/or child rearing and attrition or training quality in a general surgery program. Our survey has clearly evinced that although most of the women desired to have a family, they did not intend to retire from their profession to do so, rendering the cited concerns an unfounded stereotype. Nevertheless, most of the survey respondents worried that their career prospects might be negatively affected by their desire to have a family, which also suggests that these gender-based prejudices are prevalent. Strategies such as cognitive behavioral programs to break the gender bias habit appear to be needed to create a more equitable environment.49 Studies have shown that women rank the presence of organizations that support women in surgery as important.39 A fine example is the Women in Neurosurgery organization, founded in 1989 in the United States, which has played a pivotal role in guiding policy-making and implementing strategies to foster recruitment, retention, and career advancement of female neurosurgeons in North America.6,36 Similarly, the Asian Women’s
Figure 3. Obstacles perceived by European women in neurosurgery.
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Figure 4. Anecdotal recounts from survey respondents regarding the inequalities perceived.
Neurosurgical Association, founded in 1996, has served to promote excellence in female neurosurgeons across Asia.52 However, a sister society does not exist in Europe. Our survey showed that most female neurosurgeons believe that such a committee should be created within the EANS. As Robert F. Spetzler said, “. Institutional accountability must be evaluated to ensure that the best and brightest candidates, regardless of gender, are recruited to neurosurgical programs to promote the health of our challenging but most satisfying profession.”53 We have, therefore, submitted a proposal to the EANS board of directors for the creation of a committee for women in European neurosurgery. The goal of the committee would be to counteract the glass ceiling effect in an institutionalized fashion by 1) identifying the issues and obstacles female neurosurgeons face across Europe, 2) creating a mentoring platform to pair young female neurosurgeons with senior female consultants in leadership positions to enhance their motivation in their own professional journeys, 3) providing strategies and solutions for the issues identified, and 4) monitoring female career advancement in European neurosurgery and providing hard data on which to base future policy-making.
Study Limitations Our study was subject to selection bias, because not all European female neurosurgeons are included in the EANS mailing list and not all of those from that list replied to the survey. Furthermore, we obtained a relatively low response rate of 24%. Nevertheless, this should be interpreted with caution. First, it is unknown whether all 482 individuals were indeed women. Second, some might have been at locations outside of Europe and, thus, did not respond. Furthermore, studies have estimated the response rates for online surveys at 11%, which relativizes our results.54 By approaching national societies, we attempted to overcome this possible bias. However, because many did not respond, the bias was possibly even enhanced by skewing the responses to certain geographic regions. Eastern European countries were especially underrepresented in our results.
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Most survey responders were relatively young, with a mean age of 36 years. This could have also skewed the results, with an underrepresentation of older female neurosurgeons. A postal distribution of the survey could have increased the response rate of older female neurosurgeons. However, no databases exist reporting the actual number of practicing female neurosurgeons in Europe and their postal addresses. Therefore, the responses portrayed in the present study are representative of the individuals who participated, although possibly not generalizable to all female neurosurgeons in Europe. Thus, the acquisition of more data regarding female participation and female career perceptions in European neurosurgery becomes pivotal in further understanding of this subject. CONCLUSIONS Unfortunately, a gender gap still exists in European neurosurgery. To date, the extent has not been systematically analyzed. Our
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ACKNOWLEDGMENTS The authors would like to thank Stella Müller from the Göttingen University Hospital’s Bureau for Gender Equality for her continued support in the conception and development of this project. We would also like to thank Petra Koubova and Amy Pinchbeck-Smith from the European Association of Neurosurgical Societies for their logistic support in the distribution of the survey, and Carole Turner from the Society of British Neurological Surgeons, and the Dutch Association for Neurosurgery.
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project offers a glimpse into the obstacles women perceive in our field. However, more comprehensive data are required, especially from Eastern European countries. A problem unacknowledged is destined to remain unsolved. We hope that our study and the proposal submitted to the EANS will constitute the spark that ignites an organizational and multinational change toward a more equitable European neurosurgery.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 17 March 2019; accepted 16 May 2019 Citation: World Neurosurg. (2019) 129:460-466. https://doi.org/10.1016/j.wneu.2019.05.137 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com
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