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To the Editor: Women neurosurgeons around the world have made significant advances over the last decades, but recent data confirm that a great deal of work is still needed. Benchmarks, such as the number of women graduating from neurosurgery residency programs and the number of board-certified women neurosurgeons, have markedly increased (Figures 1 and 2).1-3 However, these numbers remain disproportionate compared to those of men in the field (Figure 3).1-3 Analysis of this topic reveals that for all working women, parity remains elusive.1-4 Gathering precise data on the challenges faced by women, specifically in neurosurgery, is therefore essential. Toward this aim, the Congress of Neurological Surgeons (CNS) hosted the first International Female Neurosurgical Think Tank at the 2018 annual meeting in Houston. The results of this meeting are presented.FIGURE 1.: Number of women graduating from US neurosurgery residency programs from 1951 to 2010 (data points accrued from Benzil et al, Appendix 21).FIGURE 2.: Number of ABNS board-certified women neurosurgeons from 1961 to 2010 (data points from Renfrow et al2).FIGURE 3.: Gender Distribution of US neurosurgery residents and ABNS board-certified neurosurgeons in 2016 (numbers attained from Renfrow et al2).Fourteen women neurosurgeons from around the world (Table) were joined by 2 male colleagues and 3 non-neurosurgeon female professionals. The purpose of the meeting was to reflect on: The current standing of international women neurosurgeons The ideal status of international women neurosurgeons Strategies to bridge identified gaps TABLE. - Countries Represented at CNS International Female Neurosurgical Think Tank Total female neurosurgeons Department chairs US 9 1 Brazil 1 0 Netherlands 1 0 Portugal 2 0 Spain 1 1 SWOT (Strengths, Weaknesses, Opportunities, and Threats) analyses suggest that the appropriate emphasis on organizational change must be paired with changing individual behavior. Thus, a SWOT format was used to guide discussion. The results of a pre-meeting survey also served as a foundation for dialogue, shedding more insight into the professional gender gap that still exists (Figures 4–7).FIGURE 4.: Questions 1 and 2 (Q1, Q2) from pre-meeting survey.FIGURE 5.: Questions 3 and 4 (Q3, Q4) from pre-meeting survey.FIGURE 6.: Questions 5 and 6 (Q5, Q6) from pre-meeting survey.FIGURE 7.: Question 7 (Q7) from pre-meeting survey.“STRENGTHS” IDENTIFIED BY WOMEN NEUROSURGEONS Beginning a discussion of perceived gender-based strengths and weaknesses creates a sense of unease, given the question of these being biological, cultural or a combination. The data suggest that social and/or communicative differences between genders do exist,4-6 although these characteristics are likely conditioned.6,7 Additionally, many personal qualities are observed across genders. Even the terms “strengths” and “weaknesses” are open to interpretation. One behavioral trait might be considered positive in a given environment, profession, or context, while that same quality might be viewed less favorably under different circumstances. For instance, surgeons regardless of gender manifest personality traits serving them within the hospital setting but may be negatively viewed outside of work.5 Accepting such pitfalls, participants listed “strengths” traditionally identified as “female behavior” that served them well professionally and benefited their patients. The most common responses were as follows: Empathy Communication skills Willingness to collaborate Diversity of perspective It should be noted that the intent of this exercise was not to perpetuate gender-based stereotypes, which can undermine gender equality and promote discriminatory views.7 Instead, the purpose was to acknowledge that learned differences in behavior between men and women may impact self-perception, which in turn can affect one's own actions. This is corroborated by studies examining personality differences between genders and their effects on the delivery of healthcare.4,8,9 In addition to the above “strengths,” participants discussed other “advantages” to being women neurosurgeons. First, women patients may feel more comfortable with surgeons who are also women. Numerous studies evaluating patient satisfaction substantiate that women patients often prefer same-sex physicians.2,8-11 Second, training and practicing in a clearly disadvantageous male-dominated environment, likely generates strength and resilience as a result of overcoming these obstacles. Most women queried have, on many occasions, literally been the only female at the table, so the women felt they offered a distinct perspective from their male peers. This contributes to a diversity of thought that can be valuable clinically and academically. “WEAKNESSES” IDENTIFIED BY WOMEN NEUROSURGEONS Three significant vulnerabilities were overwhelmingly identified by the women as negative “female” behavior: Insecurity Impostor syndrome Professional altruism (one's hard work and efforts being handed or credited to another) Every member of the group recalled instances where they questioned themselves or felt inadequate, even when knowing this not to be true. These feelings of self-doubt are not unique to the women participants questioned. In analyzing gender differences among students of science, technology, engineering, and mathematics (STEM), females are consistently found to exhibit more anxiety and negative self-worth than males, even when outperforming them,12,13 perhaps contributing to the higher attrition rates of female STEM students.12,14 Likewise, women medical students have been found to devalue their performances on clinical rotations,4,10 potentially deterring them from pursuing competitive surgical specialties.15 European data evaluating the impact of neurosurgical training on career planning and anxiety between genders also support this phenomenon.16 In a survey of European neurosurgeons completing their training, women tended to feel less confident to work on their own and were twice as likely as men to experience anxiety about their future careers.16 The men participating were quick to acknowledge that they also suffered from insecurities, particularly the impostor syndrome. This suggests that perhaps the impostor syndrome differs in some important way for men and women neurosurgeons. Some possibilities regarding the syndrome include the following: Incidence General impact Specific impact on career choices (including withdrawal from the specialty) Studies have shown that gender highly influences how individuals react to criticism, challenges, and mistakes.1,4,12,15,17 This could shape the effects of the impostor syndrome. Together, such factors contribute to and influence a woman's reaction to such self-doubt, resulting in the higher rates of attrition seen in women across all surgical specialties, particularly neurosurgery.18 The lack of role models and mentors for women may further aggravate this condition, particularly if the learning style of women differs from that of men, as data suggest.1,4,12,18 Undoubtedly, women neurosurgeons suffer a paucity of mentors of any gender perpetuating the cycle of self-deprecation.1,2,4,18,19 Limitations of support for women are likely compounded by a tendency of women to see successes as a team effort and to allow others to take credit for their ideas and accomplishments. Participants became animated in relating multiple episodes when a woman's ideas were usurped by a man who was a colleague. Both behaviors serve to veil the successes of women from their peers, superiors, and sometimes even from themselves. THREATS IDENTIFIED BY WOMEN NEUROSURGEONS The threats identified by the women neurosurgeons were remarkably universal for women across all professions. These threats were as follows: Fewer opportunities for promotion and leadership Unequal pay for equal work Overcoming prejudices against women by patients and peers Limited role-models and mentors Navigating work-life challenges, particularly during pregnancy and when raising small children A common refrain in the meeting was that women felt they had to work and study harder, complete more fellowships, and/or receive more degrees just to be recognized as an equal to their men counterparts. These concerns have been frequently reported in other studies evaluating women in a male-dominated environment.1,2,4,10,15,18-20 This is perhaps due to awareness that promotions for women are slower and rates of attrition are higher, despite more women pursuing careers in STEM and medicine.1,2,14,16,18,20,21 However, even with increased efforts by women to strengthen their credibility, women authorship in scientific journals around the world remains notably lower than that of men.4,20 This disparity is even greater in higher impact journals.20 Such trends are similarly seen with NIH funding for women investigators.7,9 Intensifying these barriers, European data indicate that women start their careers with fewer research-related resources than men in academic medical careers, thus setting up women for decreased scientific productivity.16 Gender disparities also extend to salary differences between working men and women, in both medical and nonmedical professions.1,4,19 Promotional opportunities are also affected. There are only 4 neurosurgical programs in the US, as of recently, with women serving as Neurosurgery Chairs, yet this is still too few. Outside the US, some women neurosurgical participants stated that while there is little or no public pay discrepancy across genders in their country, implicit patient bias (choosing men surgeons more frequently) does play a role. This indirectly impacts income and promotion, and is also a well-described phenomenon.10,14,22 Women discussants from all countries felt that male colleagues also unwittingly displayed unconscious bias. These sentiments are corroborated by evidence suggesting that men may be more actively sought for collaborative endeavors by their peers, maintaining a “boys’ club” environment that promotes the professional advancement of men.4,15 Interestingly, several women described that their experience of discrimination by their peers changed when they became mothers. As a result of this milestone, they began to be held to different standards, another frequently reported experience.4,23,24 It was enlightening to learn that in some countries, the neurosurgery match is blind to gender, which dramatically reduces unconscious bias. In these systems, candidates’ scores in prioritized categories are available for program review rather than individual applications. Based on recent data, this approach will more likely support meritocracy for the residency match, as applicant gender may negatively impact neurosurgical matching for women.25 Despite such innovative strategies, universally, there are still not enough neurosurgeons of either sex who are willing to mentor women, and far too few women in the field to change the unconscious biases of neurosurgeons and patients.1,4,10,12,15,19,20,23,24,26 The challenges of work-life harmony/integration generated significant discussion. This challenge is felt for women across the training and practice spectrum, experienced even in high school and college.10 It also extends across countries to varying degrees, though some are more effective than others in addressing this. For example, in Portugal, all working women are offered maternity leave for up to 6 months, which may make neurosurgery more appealing to young women. Female neurosurgeons who have families during their residency training can make up this 6-months, period later, resulting in critical flexibility. Disappointingly, child care support is not readily available nor supported by any of the hospitals of the women discussants from any country. This pervasive problem of work-life balance affects females across medical specialties and STEM disciplines,1,4,10,14,15,18,24 with limits to child care being a key element. The differential hours, particularly for women in medicine, aggravates this issue. Moreover, women who are primary wage earners or with substantial professional demands often still serve as primary care givers at home and shoulder a disproportionate burden of home responsibilities.23 These family circumstances greatly impact the chances of promotion and leadership for women that might otherwise happen at critical stages of their careers. Better systems to protect free time and family life, for both men and women neurosurgeons, will benefit all. Ultimately, such gender imbalance leads to poor self-esteem, reduced resilience, and less career satisfaction for women.1,4,10,15,18,24 This may, in part, explain why the board certification rates for women in neurosurgery remain lower than for men in the US and Europe.1,2,16,19 While there may never be an equal representation of women in the workforce,24 without the presence and visibility of more women achieving success as neurosurgeons, such as promotion and leadership, it will remain exceedingly difficult to overcome the discriminations of colleagues and patients described above. OPPORTUNITIES IDENTIFIED BY WOMEN NEUROSURGEONS Despite extensive discussion surrounding the challenges faced by women in neurosurgery, participants remained hopeful and excited when the conversation shifted into opportunities for improvement. Agreed upon strategic efforts for the group moving forward included: Recruiting more women into neurosurgery Promoting mentorship for women Developing women leadership opportunities Engaging women in neurosurgery globally Supporting women Among the many initiatives resulting from the CNS International Female Think Tank will be efforts to recruit more women into the field. Young girls and women will be targeted in a “This Is Neurosurgery” social media campaign to build awareness and to showcase the many faces of women neurosurgeons around the world. There are substantial data demonstrating that an absence of role models for women plays a role in the self-doubt of women in pursuit of medical and STEM specialties, discouraging them away from such professions, while also fostering further bias in both genders.1,4,10,12,15,19,21-24 Thus, this campaign may help break down preconceptions, while allowing young girls and women to imagine themselves as neurosurgeons too. Reaching girls as early as elementary or high school would effectively increase the number of females who pursue careers in neurosurgery and other traditionally male-dominated careers. Additionally, as a result of the meeting, several efforts are underway to better connect women in neurosurgery internationally utilizing social media. Networking events will be held to help women find professional resources, connections, and friendships that may result in opportunities not otherwise possible. These efforts are intended to help establish a critical mass of female neurosurgeons, potentially further encouraging more women to pursue the field. Mentorship for women was also felt to be paramount in overcoming bias and discrimination and was another agenda item resulting from the meeting. Mentorship is needed for women who are considering a career in neurosurgery, as well as for those in residency susceptible to attrition and those who are faculty striving for professional advancement. Men and women must both serve as mentors for women neurosurgeons, and both genders should be encouraged to fulfill this role. This unmet need for the mentorship of women is ubiquitous.1,2,10,15,19,26 Any concerns raised by men mentoring women as a result of the #MeToo type issues should be easily dealt with through systemic organization of appropriate mentoring and coaching programs. Over the years, Women in Neurosurgery (WINS) in the US successfully established several mentorship efforts for women. WINS has also recently collaborated with the CNS and the American Association of Neurological Surgeons to further promote these programs at each society's annual meeting. Online resources, such as webinars, are available through the CNS and through the Joint Section of Women in Neurosurgery (http://www.neurosurgerywins.org), as are awards and other opportunities for women globally to apply throughout the year. The CNS International Female Summit aims to partner with WINS in the US and with women in other countries to strengthen these mentoring efforts and to make them accessible to young girls and women worldwide. It is also imperative that women pursue leadership courses and education to become more effective at promoting themselves and leading others. Only when women hold seats as leaders, next to men who are regarded as leaders, can prejudices truly be overcome. As such, attendees from the CNS Female International Think Tank have pledged to work with the CNS to develop a leadership course and curriculum geared towards women neurosurgeons. Another mechanism that can foster the promotion and leadership of women is the establishment of WINS sections within organized neurosurgical societies in countries around the world. Although some countries, such as Brazil, already have a formal WINS organization, many other countries do not. Launching such associations would generate more opportunities for women to hold positions of leadership and to have their voices heard amongst their men colleagues. WINS is also vital in protecting, supporting, and advancing women in the field, irrespective of the number of women neurosurgeons in the region. Thus, helping to create WINS globally is likewise an objective arising from the meeting. Finally, it is vital to eliminate barriers for women in neurosurgery. Transparency and equity in pay across genders is a key component of this equation, as this reaffirms the worth of female neurosurgeons and would represent a tangible first step in equality of labor.2,16,19 Similarly, developing a mechanism across organized neurosurgery in all countries to allow women to report true harassment and sexual discrimination without backlash and with an appropriate response. This would help to ensure the protection of women throughout their careers.1,4 Lastly, devising approaches that support women who have families, such that they can simultaneously be successful neurosurgeons, are also needed. Hence, institutions and training programs should find creative solutions to allow a work-life integration, which would likely improve the quality of life for both men and women in the field. REFLECTIONS The 30th anniversary of WINS will be celebrated in 2020, representing an impressive milestone to reach. It also offers a chance to reflect on the progress achieved by women in neurosurgery around the world. Yet, still, much work remains. Open conversations and thoughtful strategies for gender equality are essential for the betterment of the field. These efforts require the help of both men and women to generate meaningful change for the future of neurosurgery. Disclosures This publication was made possible by the Clinical and Translational Science Collaborative of Cleveland, KL2TR002547 from the National Center for Advancing Translational Sciences (NCATS) component of the National Institutes of Health and NIH roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Dr support from the National Institutes of Health and on the scientific board of Young Dr also on the Congress of Neurological Surgeons and is on the Neurosurgery Dr is the of the Congress of Neurological Surgeons and is on the Neurosurgery Dr is the of the Congress of Neurological Surgeons and is on the Neurosurgery Dr is the of the Congress of Neurological Surgeons and is on the Neurosurgery Dr Benzil is a partner in Benzil and on an for The Congress of Neurological Surgeons Female International Neurosurgical Think Tank was by but they had no role in
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