Female insertion in neurosurgery: Evolution of a stigma break

Brazil

Notably, the total number of Brazilian neurosurgeons is 3298 (248 females and 2638 males), and their average age is 49.4 representing than 1% of all medical physicians in the country.[13] In Brazil, 57.4% of physicians under 30 years of age are women who go into, in descending order, pediatrics, gynecology and obstetrics, medical clinic, and dermatology.[13-16] In 2017, women comprised 45.6% of all doctors, but only 8.6% of all neurosurgeons [Figure 2].

In 2017, there were about 813 5-year neurosurgical residency spots offered in Brazil, but only 508 s were filled[13] [Table 3]. Indeed, in 2017, neurosurgery was the first choice of residency positions for less than 1% of newly graduated both female and male medical student’s neurosurgical residency training slots.

Table 3:: Quantitative distribution of the number and occupation of vacancies in neurosurgery in Brazil (2017).

United States

In the USA, in 2016, women represented less than 20% of all residents in neurosurgery, and about 6% (259/4178) of all neurosurgeons certified by the American Board of Neurological Surgery.[1,3,4,7,11] The main obstacles to becoming neurosurgeons included; the lack of adequate mentoring, inadequacy of many training programs, unique obstacles encountered for women in training, and prejudice/discrimination against women.[3,5,6,11,18] Women in Neurosurgery (WINS), and James Beane M.D. on behalf of the American Association of Neurological Surgeons (AANS), proposed in a 2008 a White Paper for neurosurgery (the future of neurosurgery: a white paper on the recruitment and retention of WINS, Japan Neurosurgical Society [JNS] 2008). In that, Dr. Beane stated that it was critical to recruit and retain female neurosurgical residents; the goal would be for 20% of all neurosurgical residents and faculty to be female by 2012.[2,10,19]

However, Dr. James Beane in 2018 spearheaded the Professional Conduct Committee (PCC) in a discriminatory grievance against the 12^th board certified female neurosurgeon in the USA, Nancy E. Epstein, M.D the Editor-in-Chief of Surgical Neurology international, on the Editorial Boards of Spine (since 1990), Journal Spinal Disorders/Techniques now Clinical Spine Surgery (since 1990), The Spine Journal (since 2003), Past President of the Cervical Spine Research Society, and author of over 400 peer reviewed publications.[2] They went after Dr. Epstein for being a plaintiff ’s expert in a case in which a 66-year-old female was unnecessarily subjected to a Transforaminal Lumbar Interbody Fusion (TLIF) by a neurosurgeon’s partner who had never spoken to, never examined, or obtained informed consent from the patient prior to the TLIF. After the partner performed the surgery, she was left with a new, permanent right-sided foot drop.[2] After multiple presentations/appeals, the PCC, the AANS’ Board, the outgoing President Shelley D. Timmons M.D., and incoming President Christopher I. Shaffrey M.D, voted to suspend Dr. Nancy E. Epstein for a period of 6 months.[2]

Europe

At present, almost half of the doctors in Europe are women.[18,20] In 2016, the European Association of Neurosurgical Societies (EANS) database, including information from 39 member countries, observed that women accounted for just 12% of all neurosurgeons (1565 females vs. 12,985 males).[13] Interestingly, 36% of neurosurgeons in Italy were female, while there were none in Kosovo and Cyprus.[17] The European WINS Project in 2016 observed that the distribution of female neurosurgical residents was 32% (477 out of 1479 residents), and attending female neurosurgeons were just in 24 of 39 countries 11% (467/4439).[17] Here, likely explanations for this poor showing included; the paucity of neurosurgical female mentors, active gender, and cultural discrimination.[6,17,20] At present, in the EANS and the 15 centers of excellence in neurosurgical training in the European Union of Medical Specialists, not one is chaired by a woman.[12,17,20]

India

The number of female neurosurgeons in India is small; only 73 of 2500 certified neurosurgeons including female residents in training.[8] The first female neurosurgeon in India/Asian Continent was Thanjavur Santhanakrishna Kanaka (1968). If took until 1980 for an additional two female neurosurgeons to appear in the country.[8,21] Since then, an additional 33 females (2017 data) have been added to the neurosurgical roster in India.[8] Most female Indian neurosurgeons are now between the ages of 30 and 50, are married, have children, and are satisfied with the profession. Nevertheless, approximately 40% document additional sex-based problems/discrimination in their neurosurgical careers.[8]

Japan

In 2018, only 12% of new members of the JNS were women and their total number was <5% of all members.[9] Among the 94 hospitals that offered training in neurosurgery, the majority had about one to four women enrolled and seven of them had none.[9] Notably, however, in Japan, about 17% of female neurosurgeons leave the profession because of pregnancy and/ or marriage.[9] Regarding discriminatory practices, lack of mentoring, and other factors stacked against Japanese women entering the field of neurosurgery were difficult to obtain.