**Abstract**

Despite progress and advancements made to achieve gender equality, a glass ceiling still exists for women in surgery. Women remain largely underrepresented in academic surgery, with appointments to only 18% of surgery program director roles and 6.3% of surgical chair positions in the United States as of 2018. Inequities across various surgical subspecialties are also significant, especially in the areas of neurosurgery, orthopedic surgery, otolaryngology, and plastic and reconstructive surgery. Additional barriers exist for women in academics, including lack of high-quality female mentorship, implicit bias within letters of recommendation, and a greater incidence of reported moral injury and burn-out. Further efforts to address these inequities are necessary to retain the talents and contributions of women in surgery. Interventions that may counterbalance the continued gender gap within surgical fields include the implementation of implicit bias training, increasing institutional support, establishing formal mentorship initiatives, the introduction of early exposure programs during medical training, transparent institutional promotion policies, childcare support, and accommodation of maternity leave. The purpose of this chapter is to educate the reader regarding gender inequality in surgery and related fields and to highlight key issues central to the propagation of gender biases specifically as they relate to female surgeons across various roles and responsibilities (e.g., clinical practice, education/training, and leadership) within the contemporary academic landscape.

**Keywords:** academic surgery, equity and inclusion, gender equity, surgical education, women in academic medicine

## **1. Introduction**

In 2019 women comprised about 52% of medical school graduates as compared to approximately 48% in 2009, which is a milestone for parity efforts in medicine [1]. Although medical school classes are roughly half female, women in surgery continue to be significantly underrepresented. For example, recent reports indicate that only 12.4% of active physicians and 29.1% of residents over five surgical fields (general surgery, plastic surgery, thoracic surgery, neurosurgery, and orthopedic surgery) were females [2–4]. Of note, this represents a slight improvement from

**Figure 1.** *Word cloud providing a graphical representation of key topics discussed in the current chapter.*

2007 when women comprised only about 10.4% of the active surgical specialists and 18.3% of the residents in the same five surgical fields [2–4]. Over this time period, the largest increases in female participation were seen in general surgery (active physicians 13.6–22%, residents 30.8–43.1%) and plastic surgery (active physicians 11.9– 17.2%, residents 22.2–40.9%), reflecting ongoing efforts to achieve gender parity. At the same time, orthopedic surgery (active physicians 3.6–5.8%, residents 12.4–16%) and neurosurgery (active physicians 5.6–9.2%, residents 11.3–19.5%) have made little to no progress [2–4]. In light of looming surgeon shortages [5], it is more important to recruit and retain the best and brightest into surgical fields to meet the projected demands. Addressing the barriers to women in surgery, and academic medicine in general, could help with physician shortages and foster a more diverse and inclusive medical team. Consequently, we set out to create this narrative review of key issues surrounding the emergence and propagation of gender-specific biases in surgery and related specialties. Our goals are to educate the reader and to provide evidence-based approaches to addressing the persistence of gender inequity in surgery. Key concepts discussed in this chapter are summarized in a dedicated word cloud (**Figure 1**).
