Gender Disparities and Neurosurgical Training Among Residents From the Andean Community in Latin America

Abstract

BACKGROUND AND OBJECTIVES:

This study investigated gender disparities in neurosurgical training among residents in Andean Latin America, focusing on operative autonomy, case experience, and barriers to academic and professional development.

METHODS:

A total of 132 neurosurgical residents and early-career neurosurgeons from the Andean Community in Latin America participated in this study. An electronic survey assessed neuroanatomy knowledge, self-reported operative autonomy, and case volumes and identified limitations to academic excellence. Anatomy survey responses were graded at baseline and postintervention. Participants engaged in educational interventions, including a hands-on simulation course, traditional lectures, and web-based tools, focusing on the critical operative anatomy of various approaches.

RESULTS:

Participants included 21 women and 111 men. Women reported less supratentorial experience than men (median [IQR], 10 [1-20] cases vs 20 [5-50] cases; mean [SD], 15.9 [21.6] vs 35.7 [40.8], P < .01, 95% CI: 9.15-30.45) and lower rates of operative autonomy (57% vs 77%). Despite these challenges, female and male participants had comparable levels of neuroanatomic knowledge. Before the intervention, 17 (81%) women were classified in the subpar group, decreasing to 8 (38%) after the intervention (P = .04, 95% CI: 0.00-0.29). The lack of anatomy courses was identified as a limitation by a significantly greater proportion of women than men (15 of 21 [71%] vs 44 of 111 [40%]; P = .04, 95% CI: 10.4%-53.2%).

CONCLUSION:

This study highlights significant gender disparities in neurosurgical training within the Andean region. Although female and male residents demonstrate comparable academic performance, women face substantial barriers in operative experience and autonomy. Addressing these disparities through targeted educational interventions is essential for fostering equity in neurosurgical training and enhancing opportunities for female residents in low- and middle-income countries.

ABBREVIATION:

LMIC

low- or middle-income country.

The global neurosurgical workforce is estimated to be 49 940,¹ including both neurosurgeons and trainees. However, the distribution of neurosurgeons is notably unequal, with severe shortages in low- and middle-income countries (LMICs) and over 30 countries reporting having no neurosurgeons at all.^1,2 Despite the clear and growing need for neurosurgeons, gender disparities in training remain a significant issue, complicating the workforce deficit. A recent systematic review encompassing studies from 55 countries revealed consistently fewer female neurosurgeons than male neurosurgeons.³ This gender imbalance varies across regions, with Italy reporting the highest proportion of female neurosurgeons (36%) and Kosovo reporting none (0%).³ In South America, the gender distribution also fluctuates; Uruguay has the highest proportion of female neurosurgeons (25%) and Paraguay the lowest (5%), whereas Peru reports that fewer than 9% of neurosurgeons are women.³ To the best of our knowledge, there are limited data on the gender distribution of neurosurgical residents and the impact of gender disparities on neurosurgical training in Latin America.

The representation of women in neurosurgery remains disproportionately low, although the number of female medical students entering neurosurgery residencies continues to rise.⁴ Neurosurgery, like many surgical specialties, remains male-dominated despite women beginning to enter the field in the 20th century.^3,5,6 Several factors contribute to uneven female-to-male ratios among those applying for a neurosurgical residency or enrolling in the specialty. First, concerns about balancing professional responsibilities with family obligations may deter women from pursuing the specialty.³ For example, in many LMICs, cultural expectations often place the primary responsibility for child-rearing on women.^7,8 Second, the scarcity of female neurosurgery attending physicians reduces the availability of female role models and mentors, which limits guidance and networking opportunities for prospective trainees.⁸ The lack of mentorship has been shown to influence career decisions, with female medical students less likely to enter specialties in which they see few women in leadership roles.^3,9 Efforts to address this disparity have been made, such as the founding of the Women in Neurosurgery Society in 1989.¹⁰ Women in Neurosurgery has since played a key role in promoting gender equality within neurosurgery by providing mentorship opportunities to female trainees and organizing events aimed at equalizing training opportunities for female neurosurgeons globally.^8,10,11 Nevertheless, gender-based disparities persist, particularly in LMICs.

Given the predominance of men in neurosurgical leadership roles in Andean Latin America, women tend to be displaced from roles that can actively change these disparities.^12,13 Despite this, the number of female neurosurgeons has been increasing globally and in Latin America.^13,14 In addition, studies have found that female neurosurgeons perform on par with or surpass their male counterparts in academic domains. Unfortunately, this is not the case for operative autonomy, despite evidence indicating that operative autonomy is essential for residents' future independent practice. Many female residents across various surgical specialties experience less autonomy in the operating room than their male counterparts.¹⁵ Addressing these issues will help reduce the training gap encountered by female residents and consequently enhance the appeal of the specialty to female medical students.

The extent to which gender disparities specifically impact neurosurgical training in the Andean Community in Latin America remains unexplored. Therefore, this study aimed to assess gender inequalities in neurosurgical training in LMICs, focusing on Andean Latin America. We also examined associations between gender, operative autonomy, and case experience, as well as residents' reported barriers to academic and professional development. By examining these disparities, we hope to contribute to a deeper understanding of how sociocultural and structural factors influence the neurosurgical workforce in this region.

METHODS

Participants

This study included neurosurgical residents and early-career neurosurgeons from the Andean Community in Latin America (Peru, Bolivia, Colombia, and Ecuador). The inclusion criteria comprised internet access and less than 5 years of professional experience. Individuals with more than 5 years of professional practice and those not affiliated with a Latin American LMIC as their main practice location were excluded from participation.

Settings

Our study was conducted within the Andean Community in Latin America. In May 2022, the Sociedad Peruana de Neurocirugía (Peruvian Neurosurgical Society) initiated contact with participants through an official announcement on their website and social media platforms. Comparable announcements were also issued to the neurosurgical communities in Colombia, Bolivia, and Ecuador. This outreach was specifically aimed at all neurosurgery residents and attending physicians in the Andean region.

Intervention

Before any educational intervention, participants completed an electronic survey in Spanish. The survey included questions related to operating room autonomy, supratentorial experience, and factors limiting the achievement of higher levels of academic excellence. Specific questions included “How many supratentorial craniotomies have you performed in total?,” “How many craniotomies have you performed independently to date?,” and “In your opinion, what is the greatest limitation preventing you from reaching your next level of technical competence?” For the latter, participants were allowed to select from among responses that included lack of a structured educational curriculum, scarcity of educational courses in advanced neuroanatomy and neurosurgical techniques, lack of technically complex cases at their hospital, lack of surgical instruments at their hospital, and others. An additional operative neuroanatomy knowledge survey was administered before any intervention to establish a baseline assessment of each participant's neuroanatomic knowledge.

Subsequently, participants were assigned to different neuroanatomy educational interventions as part of a 2-day course, which included a hands-on simulation course, traditional lectures, and web-based educational tools. The interventions focused on the operative anatomy involved in the pterional, far-lateral, orbitozygomatic, and retrosigmoid approaches. After the intervention, participants completed the same neuroanatomy survey, allowing for an evaluation of subspecialty interest at 1 and 3 months after the educational intervention. Detailed methodology regarding the survey instruments, tier classifications, cohort allocation, and intervention content has been described elsewhere.¹⁶

Variables

This study followed Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Participants were asked to provide basic demographic information, and gender was analyzed in relation to each variable. Regarding autonomy and supratentorial experience, we examined how many participants reported being autonomous and having experience with supratentorial pathologies. Participants were then asked to report the number of cases in which they acted as the lead surgeon (autonomy) and the number of cases involving supratentorial pathologies. Subsequently, we calculated the mean number of cases (both autonomous and supratentorial) for each gender.

Additionally, participants were divided into different cohorts based on the type of educational intervention they received. Cohort 1 was given access to a website, whereas cohort 2 received website access and lectures. Cohort 3 participated solely in lectures, cohort 4 had access to the website along with both the hands-on course and lectures, and cohort 5 received a hands-on course and lectures without access to the website. Following the educational intervention, each participant was assigned a specific tier of excellence based on their responses to the neuroanatomy survey. Surveys were graded by percentage of correct responses (51%-100%) and assigned to tiers (subpar, basic, advanced, or connoisseur). Although not based on validated benchmarks, this tiering system reflected progressive levels of anatomic knowledge complexity, consistent with Bloom taxonomy. These tiers, along with cohort assignment, were later analyzed for correlations with gender. Case numbers and autonomy levels were self-reported without independent verification because no unified case log system exists in the region, potentially introducing recall and reporting bias.

Statistical Analysis

Statistical analysis methods such as t-tests, χ² tests, Fisher exact test, and the Kruskal-Wallis test were used to compare scores among cohorts. A P-value <.05 was used for statistical significance. Both means and medians were reported for case numbers because of skewed distributions; medians provide a more robust measure of central tendency when outliers are present, whereas means facilitate comparison with other published studies.

Ethical Approval

Institutional review board approval was given by “Hospital de la policía Nacional de Peru,” Ministry of Health, Peru (NZ06072022SD/2022). All participants gave informed consent to this study.

RESULTS

There were 132 participants (111 [84%] men and 21 [16%] women) who ranged from first-year residents to attending physicians with 5 years of independent practice. Women's representation within each training year was similar (P = .50). The distribution of gender throughout training years was similar. Chief year (postgraduate year 5) was the year with the most participants for both men (n = 32) and women (n = 6). In addition, there were no women in attending positions with more than 2 years of independent practice (Table 1).

TABLE 1.

Baseline Characteristics of Study Participants, by Gender

Variable	Male participants (n = 111)	Female participants (n = 21)	P value	95% CI
Age, y, mean (SD)	33.3 (4.6)	31.4 (4.1)
Junior residents (PGY 1-2)	21 (19)	8 (38)	.20	0.37-5.71
Senior residents (PGY 3-4)	41 (37)	5 (24)	.20	0.39-4.31
Chief residents (PGY 5)	29 (26)	6 (29)	.20	0.42-3.51
Attending physicians	20 (18)	2 (10)	.20	0.34-6.71
Residents reporting autonomous operations	86 (77)	12 (57)
Autonomous cases overall	1378	70	<.01a	1.01-6.47
Autonomous cases per resident among those reporting autonomous operations, mean (SD); median (IQR)	16 (22.9); 5 (1-15)	5.8 (8.2); 1 (0-3)
Residents reporting supratentorial experience	107 (96)	19 (86)
Supratentorial cases overall	3823	303	<.01a	9.15-30.45
Supratentorial cases per resident among those reporting supratentorial experience, mean (SD); median (IQR)	35.7 (40.8); 20 (5-50)	15.9 (21.6); 10 (1-20)
Intervention
Website only	45 (41)	10 (48)
Website plus lectures	16 (14)	3 (14)
Lectures only	15 (14)	3 (14)
Website, hands-on training, and lectures	17 (15)	3 (14)
Hands-on training and lectures	18 (16)	2 (10)

PGY, postgraduate year.

^aStatistically significant (P < .05).

Data are presented as n (%) unless otherwise specified. Percentages represent proportions within each gender group.

Caseloads and Operative Autonomy

A total of 126 participants (107 men and 19 women) reported supratentorial experiences. Female participants had less supratentorial experience than male participants (mean difference: 19.8 cases per resident, 95% CI: 9.15-30.45, P < .01). Among the male participants, 107 of 111 (96%) reported supratentorial experience, contributing to a total of 3823 supratentorial cases, resulting in a median (IQR) of 20 (5-50) cases per male participant. In contrast, 19 of 21 (90%) female participants reported supratentorial experiences. The total number of supratentorial cases reported by women was 303, yielding a median (IQR) of 10 (1-20) cases per female participant.

Overall, female participants reported having less autonomy in the operating room than male participants (95% CI: 1.01-6.47, P < .01). Twelve of 21 (57%) female participants reported having performed autonomous operations. The total number of operations performed autonomously by these 12 female participants was 70, with a median (IQR) of 1 (0-3) cases per participant. Of 111 male participants, 86 (77%) reported performing autonomous operations. The total number of autonomous operations reported by the 86 male participants was 1378, with a median (IQR) of 5 (1-15) cases per individual.

Preintervention and Postintervention Survey Tiers

Overall, 108 of 132 (82%) participants were categorized as having subpar or basic proficiency. However, despite women having fewer training opportunities, women and men achieved similar tiers of excellence in neurosurgical anatomy (95% CI: 0.00-0.29, P = .04). Before the intervention, 70 of 111 (63%) men were classified as having subpar proficiency, and 39 (35%) were classified as having basic proficiency. Only 2 (2%) of the male participants had achieved the advanced tier, and none were classified as having attained the connoisseur level. Among women, 17 (81%) were classified in the subpar tier, 4 (19%) in the basic tier, and none had attained advanced or connoisseur levels (Table 2).

TABLE 2.

Preintervention and Postintervention Survey Tiers of Excellence, by Gender

Tier	Male participants (n = 111)	Female participants (n = 21)	P value	95% CI
Preintervention			.33	0.00-0.29
Subpar	70 (63)	17 (81)
Basic	39 (35)	4 (19)
Advanced	2 (2)	0 (0)
Connoisseur	0 (0)	0 (0)
Postintervention			.04	0.02-0.37
Subpar	17 (15)	8 (38)
Basic	85 (77)	11 (52)
Advanced	9 (8)	2 (10)
Connoisseur	0 (0)	0 (0)

Data are no. (%) within each gender group.

There was a statistically significant improvement in participant tiers of excellence on the postintervention survey (95% CI: 0.02-0.37, P = .04). The number of men classified in the subpar tier decreased from 70 (63%) to 17 (15%), and the number of women classified in the subpar tier decreased from 17 (81%) to 8 (38%). Conversely, the number of female participants in the basic tier increased from 4 (21%) to 11 (52%). Additionally, 9 (8%) men and 2 (10%) women achieved the advanced tier. No participants reached the connoisseur tier after the intervention (Table 2).

Reaching the Next Tier of Excellence

Compared with male residents, female residents expressed greater consensus regarding the limitations on their ability to reach the next tier. Specifically, the majority of female residents (15 [71%] of 21) identified a lack of anatomy courses as a major limitation, compared with 44 of 111 (40%) male residents (difference: 31.8%, 95% CI: 10.4%-53.2%, P = .04). In contrast, a higher proportion of men than women reported that clinical overload was a limitation (35 of 111 [32%] vs 4 of 21 [19%]), although this difference was not statistically significant (difference: −12.5%, 95% CI: −31.4%-6.4%, P = .13) (Table 3).

TABLE 3.

Limitations on Reaching the Next Tier of Excellence

Limitation	Male participants (n = 111)	Female participants (n = 21)	P value	95% CI
Lack of anatomy courses	44 (40)	15 (71)	.04a	10.4-53.2
Lack of technology	5 (5)	2 (10)
Lack of complex cases	6 (5)	0 (0)
No academic culture	21 (19)	0 (0)
Clinical overload	35 (32)	4 (19)

^aStatistically significant (P < .05).

Data are no. (%) within each gender group.

DISCUSSION

This study is the first to capture the gender-based disparities in neurosurgical training within the Andean region of Latin America, providing critical insight into the challenges female residents face. In this study, we examined key areas of concern, including unequal access to operative experience, differences in academic proficiency, and barriers to professional growth associated with the gender of neurosurgical trainees. Among the 132 neurosurgical trainees included, only 21 were women, reflecting an underrepresentation of females in the neurosurgical field. Moreover, female residents reported less operative autonomy and fewer supratentorial cases compared with their male counterparts but demonstrated comparable levels of neurosurgical anatomical knowledge.

Female residents and attendings comprised only 15% of the study participants, and notably, there were no female neurosurgeons with more than 2 years of independent practice. Their representation across different residency years was found to be uniform and consistent. Currently, the scarcity of female neurosurgeons extends worldwide. In a systematic review of 87 studies, Lulla et al³ found that, although the degree of gender disparities varied by country, there were consistently far more male than female neurosurgeons throughout the world. High-income countries are not spared from this disparity; in 2017, only 8.4% of US neurosurgeons were women.⁵ Our results highlight this gender disparity in low-resource settings, such as those found in Andean Latin America. Given reports indicating an increasing number of female neurosurgeons in Latin America,¹² our findings can serve as a baseline for future research. Addressing this disparity is essential, with equal access to operative opportunities, educational resources, and mentorship playing a pivotal role in fostering a more equitable professional environment.

Although the total number of surgical cases was expected to be lower among female trainees due to their smaller representation in the study, it is noteworthy that female participants, on average, performed significantly fewer cases than their male counterparts. Additionally, female participants had a mean (SD) of 15.9 (21.6) (median [IQR], 10 [1-20]) supratentorial cases per neurosurgeon, compared with 35.7 (40.8) (median [IQR], 20 [5-50]) supratentorial cases per neurosurgeon for male participants. This finding supports previous research that highlights the barriers women face with respect to operative autonomy in surgical specialties. Meyerson et al¹⁷ found that female general surgery residents reported having less operative autonomy than their male counterparts. Moreover, our findings indicate that, despite facing challenges related to the lack of supratentorial experience and operative autonomy, female residents had academic proficiency in neurosurgical anatomy comparable to that of their male counterparts, as reflected by their preintervention and postintervention tiers of excellence. Extensive literature exists demonstrating that there is no difference in academic productivity among female and male neurosurgery residents. Khan et al¹⁸ have shown no difference in academic productivity (evaluated by the h-index) between male and female neurosurgeons adjusted by rank. Moreover, over a recent 15-year period, the proportion of first authors of neurosurgery-related scientific articles who were women increased from 12% to 16.5%.¹⁹ Nonetheless, institutional discrimination on the basis of gender could be obscured.²⁰ For example, when a female neurosurgical resident makes a mistake, her error is more likely to be associated with her gender despite the fact that gender was not a contributing factor to the mistake, and errors committed by female neurosurgeons may be more likely to draw attention than those committed by male neurosurgeons.

Finally, a high proportion of female participants identified the lack of anatomy courses as a significant limitation in achieving the next tier of excellence, with 71% citing this barrier compared with 40% of male respondents. Notably, female and male residents demonstrated comparable performance on the anatomy knowledge section of both the preintervention and postintervention assessments, despite many women identifying the lack of courses as a major obstacle to reaching a higher tier of excellence. It is imperative that proactive measures be taken to address residents' reports of inadequate anatomy courses and resources, particularly given today's readily accessible technology. Kelly et al²¹ conducted a scoping review that detailed educational interventions such as conferences, hands-on training, mentorships, and bootcamps and assessed the impact of these interventions on neurosurgery resident training worldwide.

Limitations

This study has several limitations. First, the self-reported data on surgical autonomy and case volume are subject to recall and reporting bias. However, there are no other objective data sources in this field because there is no unified case log system. Second, the small number of female participants (n = 21, 16%) limited statistical power and subgroup analyses, likely underestimating true gender disparities. Notably, the differences we observed in operative experience (P < .01) emerged despite this constraint. Ironically, this low representation underscores the very issue under study—the profound underrepresentation of women in neurosurgery. Third, recruitment through professional societies and online platforms may have introduced selection bias, overrepresenting residents with better institutional resources and professional networks and potentially excluding those from underserved areas, who face the greatest training disparities. This could underestimate the true extent of inequalities, particularly for female residents, who may experience greater professional isolation and have limited access to these communication channels. Finally, the study's short follow-up period may not fully capture the long-term effects of the educational interventions, although it maximized the engagement of participants for a delayed assessment.

CONCLUSION

Understanding gender disparities in neurosurgical training is crucial for fostering equity in the field, particularly in low-resource settings. Despite facing challenges, female residents demonstrated academic knowledge comparable to that of their male counterparts. However, female residents had fewer opportunities for operative autonomy and supratentorial experience. Future research should explore how to increase surgical opportunities for female residents and address resource-related barriers in LMICs.

Funding

This study received funding from the Barrow Neurological Foundation.

Disclosures

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this manuscript.