Leading the way: A national mixed-methods survey of race, ethnicity, and gender among gynecologic oncology leaders at ACGME-accredited fellowship programs

Abstract

Objective

To describe self-reported demographics of gynecologic oncology leaders at U.S. institutions with an ACGME-accredited fellowship program, examine opinions regarding diversity and inclusion and perceived barriers to increased representation, and explore leaders' identity-related experiences.

Methods

A cross-sectional mixed-methods survey was distributed to gynecologic oncology leaders at NCI-designated cancer centers and institutions with fellowship programs. Associations between gender, race, and ethnicity, and survey responses were explored. Qualitative responses were analyzed using thematic analysis.

Results

Fifty-five leaders responded (45% response rate), and 52.7% identified as female. Gender differed by family structure, with male leaders more likely to report three or more children and female leaders two or fewer (p = 0.045). 70.9% (n = 39) identified as White, 14.5% (n = 8) Asian, 7.3% (n = 4) Black, and 5.5% (n = 3) Hispanic. In exploratory analyses, years of medical practice prior to attaining a leadership position differed by race, with Black leaders reporting a median of 16.3 years [IQR 13.0, 20.3], White leaders 11.0 years [IQR 7.0, 17.0], Asian leaders 6.0 years [IQR 4.0, 7.0], and multiracial/other leaders 10.0 years [IQR 3.0, 10.0] (p = 0.04). Given the small subset of leaders, this finding is exploratory. Thematic analysis identified three major themes including the importance of investing in the leadership pathway; systemic and structural barriers to diversity; and determining the role that diversity should play in leadership positions.

Conclusions

Racial and ethnic diversity among surveyed leaders was limited. Qualitative findings highlighted perceived systemic and structural barriers to leadership advancement. Systemic, institutional, and departmental efforts focused on early mentorship, leadership development, recognition, and work-life integration may support more equitable leadership pathways within gynecologic oncology.

Highlights

• •National survey of demographics and experiences of a cohort of gynecologic oncology leaders at institutions with fellowships.
• •Gender and racial differences were observed in leadership characteristics and experiences.
• •Systemic, structural, and institutional barriers were identified as shaping leadership pathways.
• •Experiences of bias and discrimination were described among some leaders.

1. Background

Leadership within academic medicine shapes clinical priorities, workforce development, mentorship, and research agendas. The individuals in these roles affect faculty advancement, trainee recruitment, institutional culture, and ultimately patient care. As the physician workforce and patient population become increasingly diverse, it is important to identify the leaders in academic gynecologic oncology and the experiences that shape leadership pathways to provide important context for how leadership may change as the field's demographics evolve.

Many surgical specialties remain male-dominated; however, obstetrics and gynecology (OB/GYN) has become numerically dominated by women since 2012, when it was reported that more than half of the American College of Obstetricians and Gynecologists (ACOG) Fellows were women (Rayburn, 2011). The proportion of women versus men going into OB/GYN continues to increase: Talbott and Wasson (2022) found the proportion of OB/GYN residents who were female to have increased from 44% to 81% from 1989 to 2019. This increasing proportion of female OB/GYN residents has translated to an increasing proportion of female OB/GYN subspecialists. The 2020 Society of Gynecologic Oncology (SGO) State of the Society Survey, sent to all SGO members including MD/DO and advanced practice providers, found that a majority of respondents, 54%, self-identified as women, the first time in the history of gynecologic oncology (Society of Gynecologic Oncology, 2020). Although gynecologic oncology has become numerically dominated by women, there are still significant gender disparities among leadership positions.

Prior research has demonstrated racial and ethnic disparities among OB/GYN and gynecologic oncology trainees. Talbott and Wasson (2022) found that between 2012 and 2018, while 54% of OB/GYN residents were White, gynecologic oncology was the subspecialty with the highest proportion of White trainees, at 73%. Additionally, when looking at the class of 2018–2019, 19% of OB/GYN residents identified as Black, while only 6% of gynecologic oncology fellows identified as Black (Talbott and Wasson, 2022). Another study demonstrated that between 2016 and 2019, 40% of all residents/fellows identified as racially or ethnically underrepresented in medicine (URM) (defined in that study as Hispanic, Black, or “Native American”), 35% of OB/GYN trainees identified as URM and only 26% of gynecologic oncology trainees identified as URM (Ngo et al., 2021). To our knowledge, there are no studies of self-reported race and ethnicity within gynecologic oncology leadership at fellowship institutions.

The aims of this study were to 1) examine self-reported demographics of gynecologic oncology leaders at institutions with ACGME-accredited fellowship programs (hereafter, fellowship institutions), 2) explore opinions among leaders regarding diversity and inclusion and perceived barriers to increased diversity, and 3) characterize leaders' identity experiences as leaders.

2. Methods

This study was approved by the Icahn School of Medicine at Mount Sinai institutional review board. An anonymous, mixed-methods survey was developed using a secure online platform (SurveySparrow Inc., 2024) to evaluate demographics, leadership experiences, and perceptions of diversity among gynecologic oncology leaders at fellowship institutions. The survey instrument was designed by the study team based on existing literature on leadership pathways, diversity in academic medicine, and physician workforce studies, and underwent internal review by investigators with expertise in gynecologic oncology and medical education to ensure clarity and relevance prior to distribution.

The survey collected information on demographic characteristics (age, gender, race, ethnicity, income, marital status, number of children, location of practice) and leadership positions (title, years of practice prior to leadership attainment, years of practice within their leadership position). The survey included Likert-scale items assessing perceptions of diversity within OB/GYN and gynecologic oncology, with responses scored from 1 (strongly disagree) to 5 (strongly agree). Optional open-ended questions invited participants to describe perceived barriers to increasing diversity in leadership, strategies to improve representation, and personal experiences related to how their identities influenced their career trajectory and leadership pathway (Supplemental 1).

At the time of survey distribution, there were 63 ACGME-accredited gynecologic oncology fellowship programs in the U.S. All ACGME-accredited programs were eligible for inclusion, regardless of academic or community hospital affiliation. Potential participants were identified through publicly available institutional websites and fellowship program directories. The following leadership positions were included: OB/GYN department chair, gynecologic oncology division director, gynecologic oncology fellowship program director, NCI-designated cancer center director, NCI-designated cancer center deputy director. Positions held by physicians from other specialties or OB/GYN subspecialties were excluded.

All 63 ACGME-accredited gynecologic oncology fellowship programs were included. Because multiple qualifying leadership roles existed at many institutions, more than one leader per institution was eligible and invited to participate. In some cases, a single individual held multiple leadership roles (e.g., division director and fellowship program director). Given the above criteria, 125 eligible gynecologic oncology leaders were identified. All leaders and their contact information were identified through publicly available sources including institutional websites and the SGO directory.

In addition to self-reported survey responses, publicly available institutional biographies and administrative rosters were reviewed by one investigator (JV) to describe the gender, race, and ethnicity composition of the invited cohort. Demographic characteristics inferred from publicly available information may not reflect individuals' self-identification and were used solely to contextualize the invited cohort rather than for inferential analysis.

Between April and September 2023, eligible individuals were contacted via email and invited to complete the survey using a secure one-time access link. To optimize response rate, participants received an initial invitation followed by two reminder emails at 2-month intervals. Informed consent was obtained electronically from all participants prior to starting the survey. Missing data were addressed using complete case analysis, with statistical testing limited to respondents with available data for each variable. Associations between demographic characteristics and survey responses were explored using Mann-Whitney U, Kruskal-Wallis, chi-square, and Fisher's exact tests, as appropriate. Given the modest sample size and small subgroup representation, comparisons by gender and race/ethnicity were considered exploratory, and no adjustments were made for multiple comparisons. Statistical significance was defined as p < 0.05. All analyses were performed using SAS version 9.4 (SAS Institute, 2023).

Qualitative responses were analyzed using thematic analysis (Braun and Clarke, 2006). Two investigators independently reviewed and coded responses using ATLAS.ti® software. After independently coding an initial subset of responses, discrepancies were discussed with a third investigator who was blinded to the study hypothesis, and a shared codebook was developed. The investigators applied the finalized codebook to all write-in responses and iteratively as analysis progressed. Themes were generated through systematic review of coded data across participants.

3. Results

Of 125 eligible leaders, 121 were successfully contacted. To assess potential response bias, the presumed demographics of all eligible leaders were characterized using publicly available data prior to evaluating respondent characteristics. On review of publicly available data, the presumed gender, race, and ethnicity of contacted leaders (n = 121) were as follows: 50.4% female vs 49.6% male; non-Hispanic White 70.2%, Hispanic White 5.0%, Black 7.4%, Asian 17.4%. These estimates do not reflect individuals' self-identification, and were not used for analysis.

Fifty-five responded (45%), including 51 (92.7%) complete and 4 (7.3%) partial surveys. The median respondent age was 52.0 years (IQR 46.0–57.0). Respondent demographics can be found in Table 1. Respondents self-identified as 45.5% male and 52.7% female. Most identified as White (70.9%), followed by Asian (14.5%), Black/African American (7.3%), and multiracial/other (5.5%). Most were non-Hispanic (94.5%) and were married/in a domestic partnership (81.5%). The majority of participants had children (74.1%), and the most commonly reported number of children was two (43.4%). There was a broad geographical distribution of responses. Reported income most often ranged between $450,000 and $750,000, annually. Within this income range, the largest single category was $450,001 and $550,000 (23.1%), followed by $550,001 and $650,000 (19.2%) and $650,001 and $750,000 (13.5%).

Table 1.

Demographic information.

Demographic Variable	n = 55
Age- median (IQR)	52.0 (46.0, 57.0)
Gender- n (%)
Female	29 (52.7)
Male	25 (45.5)
Prefer Not to Answer	1 (1.8)
Race- n (%)
Asian	8 (14.5)
Black	4 (7.3)
White	39 (70.9)
Multiracial/Other	3 (5.5)
Prefer Not to Answer	1 (1.8)
Ethnicity- n (%)
Hispanic	3 (5.5)
Non-Hispanic	52 (94.5)
Marital Status- n (%) among respondents (n = 54)⁎
Married or domestic partnership	44 (81.5)
Multiple responses selected	1 (1.9)
Separate/Divorced	3 (5.6)
Single	6 (11.1)
Prefer Not to Answer	1 (1.9)
Children- n (%) among respondents (n = 54)⁎
No	13 (24.1)
Yes	40 (74.1)
Prefer Not to Answer	1 (1.9)
Number of Children- n (%) among respondents (n = 54)⁎
0	13 (24.5)
1	2 (3.8)
2	23 (43.4)
3	13 (24.5)
4	2 (3.8)
Prefer Not to Answer	1 (1.9)
Region- n (%) among respondents (n = 53)+
Midwestern U.S.	8 (15.1)
Northeastern U.S.	19 (35.8)
Southern U.S.	16 (30.2)
Western U.S.	10 (18.9)
Income- n (%) among respondents (n = 52)^
<$450,001	17 (32.7)
$450,001 $550,000	12 (23.1)
$550,001–$650,000	10 (19.2)
$650,001–$750,000	7 (13.5)
>$750,001	3 (5.8)
Prefer Not to Answer	3 (5.8)

Denominators vary due to missing responses; row-specific denominators are provided.

*1 individual did not respond.

+2 individuals did not respond.

^3 individuals did not respond.

Respondents' leadership characteristics can be found in Table 2. The majority of respondents listed one leadership position (70.9%) and were fellowship directors (45.5%) or division directors (43.6%). For all respondents, the median age at which they were appointed to their current highest leadership position was 40 years old (IQR 38–44). The median number of years at their institution was 10 years (IQR 6–18). The median number of years of medical practice post-fellowship prior to appointment to their current highest leadership position was 10 years (IQR from 6.5 to 16.5). The median number of years in their current highest leadership position was 4 years (IQR 2–7).

Table 2.

Leadership characteristics.

Leadership Characteristics
Leadership Positions (multiple selections allowed), n (%)+
Fellowship Director	25 (45.5)
Division Director	24 (43.6)
Department Chair	5 (9.1)
Cancer Center Director	1 (1.8)
Cancer Center Deputy Director	3 (5.5)
Vice Chair	3 (5.5)
Other (Medical Director, Assistant Fellowship Director; Assistant Resident Program Director; Primary Investigator; Director; Assistant Director; Chair of Education; Associate Dean)	14 (25.5)
Total Number of Leadership Positions- n (%)	n = 55
1	39 (70.9)
2	13 (23.6)
3 or more	3 (5.5)
Age at appointment to current leadership position (years)- median (IQR)⁎	40.0 (38.0, 44.0)
Length of time in current leadership position (years)- median (IQR)‡	4.0 (2.0, 7.0)
Length of time at current institution (years)- median (IQR)‡	10.0 (6.0, 18.0)
Years of medical practice (post fellowship) prior to appointment of current leadership position (years)- median (IQR)⁎	10.0 (6.5, 16.5)

+ Individuals were able to select multiple answers. Percentages calculated out of all respondents (n = 55). Respondents could select more than one leadership position; therefore totals exceed 100%.

* 3 individuals did not respond.

‡ 4 individuals did not respond.

The effect of gender on demographic and leadership responses was examined (Table 3). Number of children differed by gender, with female respondents more likely to report two or fewer children and male respondents more likely to report three or more children (p = 0.045). Gender was also associated with median time in the current leadership position, with women reporting 3 years (IQR 2.0–5.0) and men reporting 5.5 years (IQR 4.0–10.0, p = 0.005) despite similar age. Age at appointment to leadership (p = 0.82) and years of medical practice prior to leadership attainment (p = 0.83) did not differ significantly by gender. Other demographic and leadership characteristics did not differ by gender.

Table 3.

Association of gender on select demographic and leadership characteristics.

Variable	All (n = 54)	Female (n = 29)	Male (n = 24)	p-value
Children- n (%) among respondents (n = 53)+				1.000
Yes	40 (75.5)	22 (75.9)	18 (75.0)
No	13 (24.5)	7 (24.1)	6 (25.0)
Number of Children- n (%) among respondents (n = 53)+				0.045
0	13 (24.5)	7 (24.1)	6 (25.0)
1	2 (3.8)	2 (6.9)	0 (0)
2	23 (43.4)	15 (51.7)	8 (33.3)
3	13 (24.5)	5 (17.2)	8 (33.3)
4	2 (3.8)	0 (0.0)	2 (8.4)
Income- n (%) among respondents (n = 52)⁎				0.311
<$450,001	17 (32.7)	12 (42.9)	5 (20.8)
$450,001 - $750,000	29 (55.8)	13 (46.4)	16 (66.7)
>$750,001	3 (5.8)	2 (7.1)	1 (4.2)
Prefer Not to Answer	3 (5.8)	1 (3.6)	2 (8.3)
Age at appointment to current leadership position (years)- median (IQR)⁎	40.0 (38.0, 44.0)	40.0 (38.0, 44.0)	41.0 (38.0, 43.0)	0.82
Length of time in current leadership position (years)- median (IQR)‡	4.0 (2.0, 7.0)	3.0 (2.0, 5.0)	5.5 (4.0, 10.0)	0.005
Length of time in at current institution (years)- median (IQR)‡	10.0 (6.0, 18.0)	11.0 (6.0, 19.0)	9.5 (5.0, 16.0)	0.53
Years of medical practice (post fellowship) prior to appointment of current leadership position (years)- median (IQR)⁎	10.0 (6.5, 16.5)	10.0 (7.0, 16.0)	11.5 (6.0, 17.0)	0.83

1 individual answered ‘prefer not to respond’ to gender. Denominators vary due to missing responses; row-specific denominators are provided.

+ 1 individual did not respond.

* 3 individuals did not respond.

‡ 4 individuals did not respond.

The effect of self-reported race on demographic and leadership responses was examined as well (Table 4). Years of medical practice before attaining leadership differed by race. Black leaders reported a median of 16.3 years, White leaders 11.0 years, Asian leaders 6.0 years, and multiracial/other leaders 10.0 years (p = 0.04). Other demographic and leadership characteristics did not differ by race. When examining the effect of self-reported ethnicity on respondent demographics and leadership characteristics, there were no statistically significant findings.

Table 4.

Association of race on select demographic and leadership characteristics.

Variable	All (n = 54)	White (n = 39)	Black (n = 4)	Asian (n = 8)	Multiracial/Other Race (n = 3)	p-value
Children- n (%) among respondents (n = 53)+						0.21
Yes	40 (75.5)	30 (76.9)	2 (50.0)	5 (62.5)	3 (100.0)
No	13 (24.5)	8 (20.5)	2 (50.0)	3 (37.5)	0 (0.0)
Number of Children- n (%) among respondents (n = 53)+						0.42
0	13 (24.5)	8 (20.5)	2 (50.0)	3 (37.5)	0 (0)
1	2 (3.8)	1 (2.6)	1 (25.0)	0 (0)	0 (0)
2	23 (43.4)	19 (48.7)	1 (25.0)	2 (25.0)	1 (33.3)
3	13 (24.5)	8 (20.5)	0 (0)	3 (37.5)	2 (66.7)
4	2 (3.8)	2 (5.1)	0 (0)	0 (0)	0 (0)
Income- n (%) among respondents (n = 52)0						0.53
<$450,001	17 (32.7)	13 (33.3)	0 (0)	3 (37.5)	1 (33.3)
$450,001 - $750,000	29 (55.8)	20 (51.3)	3 (75.0)	3 (37.5)	2 (66.7)
>$750,001	3 (5.8)	2 (5.1)	1 (25.0)	0 (0.0)	0 (0.0)
Prefer Not to Answer	3 (5.8)	3 (7.7)	0 (0.0)	0 (0.0)	0 (0.0)
Age at appointment to current leadership position (years)- median (IQR)⁎	40.0 (38.0, 44.0)	40.5 (38.0, 44.0)	39.0 (39.0, 45.0)	40.0 (35.0, 43.0)	44.0 (38.0, 49.0)	0.7
Length of time in current leadership position (years)- median (IQR)‡	4.0 (2.0, 7.0)	5.0 (3.0, 7.0)	2.0 (2.0, 4.0)	4.5 (4.0, 7.0)	5.0 (2.0, 10.0)	0.36
Length of time in at current institution (years)- median (IQR)‡	10.0 (6.0, 18.0)	10.0 (6.0, 15.0)	15.0 (10.0, 20.0)	11.5 (4.0, 18.0)	16.0 (6.0, 23.0)	0.79
Years of medical practice (post fellowship) prior to appointment of current leadership position (years)- median (IQR)⁎	10.0 (6.5, 16.5)	11.0 (7.0, 17.0)	16.3 (13.0, 20.3)	6.0 (4.0, 7.0)	10.0 (3.0, 10.0)	0.04

1 individual answered ‘prefer not to respond’ to race. Denominators vary due to missing responses; row-specific denominators are provided.

Counts may not sum to group totals due to missing responses.

+ 1 individual did not respond.

0 3 individuals did not respond.

* 3 individuals did not respond.

‡ 4 individuals did not respond.

Among 55 total respondents, 51 individuals responded to Likert-scale questions assessing their views about diversity/representation, race/ethnicity, and gender in the field of OB/GYN and gynecologic oncology. The frequencies of answers among all respondents per Likert question can be found in Supplemental Table 1.

A majority of respondents disagreed that there is adequate diversity and representation among MD/DO providers within GO (52%). A greater majority disagreed that there is adequate diversity and representation among leadership within GO (56%). Full response distributions are reported in Supplemental Table 1. Further analysis explored the impact of gender, race, and ethnicity on responses. Gender differences were observed across nearly all Likert items assessed. Women more frequently perceived inadequate diversity and representation within GO, within leadership of OB/GYN and GO (p < 0.05). Men more frequently disagreed that their own gender, race, or ethnicity had influenced their leadership opportunities (p < 0.05) (Table 5). White and Black respondents were more likely than Asian and multiracial/other respondents to disagree that there is adequate diversity among leadership within OB/GYN (median 2.0 for both White and Black vs 3.0 for Asian and 4.0 for multiracial/other respondents; p = 0.04) (Supplemental Table 2a). There were no significant impacts of ethnicity on Likert responses (Supplemental Table 2b).

Table 5.

Likert questions by gender.

Variable	All (n = 51)	Female (n = 28)	Male (n = 23)	p-value*
There is adequate diversity and representation among all MD/DO providers within the field of gynecologic oncology- Median (IQR)	2.0 (2.0, 3.0)	2.0 (2.0, 3.0)	3.0 (2.0, 4.0)	0.005
There is adequate diversity and representation among all MD/DO providers within the field of Obstetrics and Gynecology- Median (IQR)	3.0 (2.0, 3.0)	2.5 (2.0, 3.0)	3.0 (3.0, 3.0)	0.06
There is adequate diversity and representation among leadership within the field of gynecologic oncology- Median (IQR)	2.0 (1.0, 3.0)	2.0 (1.0, 3.0)	3.0 (2.0, 4.0)	0.02
There is adequate diversity and representation among leadership within the field of obstetrics and gynecology- Median (IQR)	2.0 (2.0, 3.0)	2.0 (1.0, 3.0)	3.0 (2.0, 4.0)	0.02
I feel my race/ethnicity influenced my leadership opportunities in gynecologic oncology- Median (IQR)	3.0 (1.0, 3.0)	3.0 (1.0, 3.0)	2.0 (1.0, 3.0)	0.03
I feel my race/ethnicity influenced my leadership opportunities at my institution- Median (IQR)	3.0 (1.0, 3.0)	3.0 (2.0, 4.0)	1.0 (1.0, 3.0)	0.03
I feel my race/ethnicity influenced my leadership opportunities nationally- Median (IQR)	3.0 (1.0, 3.0)	3.0 (2.0, 4.0)	2.0 (1.0, 3.0)	0.02
I feel my gender influenced my leadership opportunities in gynecologic oncology- Median (IQR)	3.0 (1.0, 3.0)	3.0 (2.0, 4.0)	2.0 (1.0, 3.0)	0.02
I feel my gender influenced my leadership opportunities at my institution.	3.0 (1.0, 4.0)	3.0 (2.0, 4.0)	2.0 (1.0, 3.0)	0.02
I feel my gender influenced my leadership opportunities nationally- Median (IQR)	3.0 (1.0, 3.0)	3.0 (3.0, 4.0)	2.0 (1.0, 3.0)	0.006

*p-values represent comparisons between female vs male responses.

Utilizing the technique of thematic analysis (Braun and Clarke, 2006), qualitative responses were analyzed with the identification of three major themes. The first major theme was systemic and structural barriers, with sub-themes of institutions and organizations as a barrier or facilitator to improving diversity, and unconscious bias and discrimination. Within this theme, several women leaders described being told they must choose between professional advancement and family, alongside reports of being overlooked for promotion and limited recognition of their abilities as surgeons and leaders. The second major theme was investing in the pathway with sub-themes of growth opportunities, the role of mentorship, and a perceived shortage of candidates. The third major theme was determining the role that diversity should play in leadership positions, with sub-themes of ambivalence about prioritizing diversity, and incentivization of participation in leadership positions. Fig. 1 highlights commentary from each theme and its sub-themes.

Fig. 1.

Thematic analysis themes and selected quotes.

4. Discussion

This study examined the demographics and perspectives of gynecologic oncology leaders at U.S. fellowship institutions and NCI-designated cancer centers. Women reported fewer years in their current leadership roles, which may reflect that the transition to more women in gynecologic oncology leadership has been relatively recent. This may be a result of a steadily increasing number of women in gynecologic oncology as evidenced by the SGO State of the Society survey which had previously reported women made up 33% of gynecologic oncology providers in 2010, 46% in 2015 (Society of Gynecologic Oncology, 2015), 54% in 2020 (Society of Gynecologic Oncology, 2020) and 63% in 2025 (Society of Gynecologic Oncology, 2025).

Female leaders in this study reported fewer children than their male counterparts. Qualitative responses provided additional context, with multiple women describing perceived systemic and structural barriers, including unconscious bias and discrimination, and the expectation that they need to “choose” their role, leader versus mother. This difference may reflect broader concerns regarding the impact of family responsibilities on leadership trajectories, including the timing of childbearing and career progression. Prior research has described similar patterns. A 2000 survey of women gynecologic oncologists found that 74% of respondents believed delaying childbearing until after fellowship was most appropriate, citing concerns related to workplace discrimination, negative perceptions from colleagues, and institutional barriers such as inadequate maternity leave policies and limited access to convenient childcare (Gordinier et al., 2000). Over two decades later, respondents in the present study described similar challenges, including navigating bias, balancing professional and family obligations, and working within larger systems perceived as inadequately supporting physician mothers. These persistent themes suggest that, despite increased attention to gender equity in medicine, structural and cultural barriers may continue to influence leadership pathways.

These challenges are not unique to gynecologic oncology. Prior research across medical and surgical specialties demonstrates that women physicians frequently encounter similar barriers including pay disparities, implicit bias, lack of mentorship and sponsorship, limited recognition, caregiving responsibilities, reduced work-life integration, and institutional expectations (Bering et al., 2018; Chesak et al., 2021; Lerner et al., 2009; Pham et al., 2014; Rangel et al., 2018; Temkin et al., 2020). A 2020 study found that though women represent the majority of gynecologic oncology faculty at 66%, they represented only 38% of gynecologic oncology division directors and 48% of gynecologic oncology fellowship directors (Temkin et al., 2020). Barriers to higher levels of career advancement have previously been described as the “leaky pipeline” and “glass ceiling” (Temkin et al., 2020). Participants in this study emphasized the importance of institutional support for leadership participation including greater incentivization and support among physicians balancing clinical, administrative, and familial responsibilities. Structural strategies identified as potentially supportive included increased control over scheduling; on-site or easily accessible childcare; competitive compensation that aims to close gender gaps (Jerg-Bretzke and Limbrecht, 2012; Scully et al., 2017; Tawfik et al., 2021).

The 2025 SGO State of the Society Survey reported 70% White, 13% Asian, 5% Black, 3% Hispanic, 6% multiracial, and 3% other race/ethnicity among respondents (Society of Gynecologic Oncology, 2025). In this survey, 7.3% of respondents identified as Black and 5.5% identified as Hispanic, broadly consistent with these national estimates. Review of publicly available data for all contacted leaders demonstrated similar distributions, though these data are less reliable than self-reported identification. Survey respondents frequently identified a perceived shortage of URM candidates as a barrier to increased representation. Workforce data suggest that representation declines across successive stages of training. While 11.7% and 12.2% of OB/GYN residents identified as Black or Hispanic, respectively, only 6.2% and 7.7% of gynecologic oncology fellows identified as Black or Hispanic (Association of American Medical Colleges, 2025). This pattern is consistent with attrition across the academic pathway and underscores the importance of sustained efforts to support URM physicians throughout training and career advancement. Prior work has demonstrated that leadership diversity is associated with increased diversity among faculty and trainees, highlighting the potential influence of leadership composition on broader workforce representation (Dreachslin and Hobby, 2008; Lewis et al., 2020; Okike et al., 2019). Improving representation within leadership may have downstream implications for recruitment, mentorship, and retention within gynecologic oncology.

While fewer URM candidates may partially account for the lack of representation among leadership, the issue is likely multifactorial. In exploratory analyses, Black leaders in this study reported more years of practice prior to attaining leadership positions when compared to their non-Black counterparts. Qualitative responses and prior literature suggest that barriers, including underrepresentation, limited mentorship and sponsorship, and experiences of overt and implicit bias, may influence advancement to leadership roles (Pololi et al., 2010; Rodríguez et al., 2015; Serafini et al., 2020). The small sample size of this study limits definitive interpretation; further research is needed to better understand how these factors interact across the leadership pathway.

Findings from this study highlight the importance of continued evaluation and intentional development of leadership pathways within gynecologic oncology. Respondents frequently emphasized the value of early mentorship, leadership training, and structured opportunities for career advancement. Programs such as the SGO's Leadership, Engagement and Active in Diversity (LEAD) program, which creates opportunities for URM mentorship, represent examples of efforts to support mentorship and professional development of URM physicians. Continued investment in early mentorship and leadership development may strengthen equitable leadership pathways within gynecologic oncology.

Multiple respondents described experiences of gender, racial and ethnic discrimination. Women leaders recounted being told they must choose between professional advancement and family, being overlooked for promotions, and experiencing limited recognition of their abilities as surgeons and leaders. URM leaders recounted experiences of bias and exclusion, such as colleagues making little effort to pronounce their name correctly. Respondents described experiences reflecting the intersection of racism and sexism, underscoring how overlapping identities may compound barriers to leadership, for example, one respondent recounted being referred to as a “Spanish beauty queen”. These narratives are consistent with prior literature demonstrating that experiences of bias and discrimination can influence career satisfaction, advancement, and leadership aspirations among URM physicians (Chapman et al., 2018; Dellasega et al., 2022; Criddle et al., 2017). Participants emphasized the importance of cultural and institutional change to address these challenges, including efforts to identify and mitigate unconscious bias, promote accountability for unprofessional behavior, and foster inclusive work environments. Organizational, institutional, and departmental initiatives aimed at improving equity and inclusion have been identified as important components of efforts to strengthen diversity within leadership (Cantor et al., 1996; Gomez and Bernet, 2019; Perdomo et al., 2019).

While many leaders acknowledged the importance of diversity within gynecologic oncology and its leadership, others expressed ambivalence regarding its prioritization. 43.1% of respondents were neutral or agreed with the statement that diversity within gynecologic oncology leadership is already sufficient. This finding may itself reflect selection bias, as respondents in leadership positions may hold different views than non-respondents or those who have not reached leadership positions. This variability in perspective may reflect differing views on the role of diversity in leadership selection and institutional priorities. Some leaders expressed concern that an increased emphasis on diversity could be perceived as detracting from other institutional goals, highlighting ongoing tensions in how diversity initiatives are interpreted and implemented.

Prior research suggests that leadership diversity is associated with increased diversity among the entire healthcare team, and may influence institutional culture, recruitment, and patient care environments, particularly for minority and underserved populations (Simms, 2013; Wooding et al., 2020). Together, these findings highlight the importance of continued dialogue and institutional engagement to support inclusive, transparent pathways to advancement within gynecologic oncology.

This study has several limitations. Selection bias is possible, as participation was voluntary and respondents may differ from non-respondents in their perspectives and experiences. Because the survey was anonymous, we could not determine the number of unique institutions represented among respondents or assess potential clustering of responses by institution. The overall sample size was modest and subgroup representation, particularly among racially and ethnically underrepresented leaders, was small, limiting statistical power and the ability to draw definitive conclusions. Leadership roles varied in scope and seniority and were not analyzed hierarchically, which may influence the interpretation of leadership experiences. The sample size also limited our ability to examine intersectionality or the experience of non-binary individuals. In addition, this survey did not capture other aspects of identity that may influence leadership pathways, including sexual orientation, gender identity beyond the binary, disability status, or religion. The study targeted individuals currently serving in a subset of leadership roles at fellowship institutions and therefore may not be generalizable to non-fellowship institutions, or other leadership structures. Former leaders were not included, which may limit historical perspective, and individuals aspiring to leadership but not currently in leadership positions were not surveyed, limiting insight into barriers to leadership attainment. Additionally, this study reflects a single point in time and cannot capture changes in diversity, representation, or perceptions over time.

Despite these limitations, this study provides novel insight into the demographics, experiences, and perceptions of gynecologic oncology leaders at fellowship institutions and identifies important areas for future research and intervention. Strengths include a national sampling approach, a 45% response rate, and broad geographical representation. Furthermore, this study examined self-reported gender, race, and ethnicity, data that have been limited in prior literature, and integrated quantitative and qualitative findings to better characterize findings.

In the context of increasing attention to diversity and inclusion in medicine, this survey highlights the lived experiences of a small cohort of leaders in gynecologic oncology. These leaders face ongoing experiences of bias, discrimination, and structural barriers to advancement. Participants emphasized the importance of systemic, institutional, and departmental initiatives to support equitable leadership pathways, including early mentorship, leadership development opportunities, recognition of professional contributions, and policies that promote sustainable work-life integration. Continued efforts at the systemic, institutional, and departmental levels may help foster more inclusive leadership structures and strengthen diversity within gynecologic oncology.

CRediT authorship contribution statement

Jessica Velasquez: Writing – review & editing, Writing – original draft, Visualization, Investigation, Formal analysis, Data curation, Conceptualization. Caroline Gellman: Writing – review & editing, Methodology, Formal analysis. Sara Wetzler: Writing – review & editing, Methodology, Data curation. Mona Saleh: Writing – review & editing, Methodology, Investigation, Conceptualization. Kelly Wang: Formal analysis. Stephanie V. Blank: Writing – review & editing, Validation, Supervision, Methodology, Investigation, Conceptualization.

Funding

The authors state that they have not received any funding for this study.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

Supplementary material 1

Likert Responses Among Overall Cohort.

Supplementary material 2

Likert Questions Among Overall Cohort